Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem

Abstract

Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We (1) propose a novel streamlined pathophysiological classification of OH; (2) review the relationship between the cardiovascular disease continuum and OH; (3) discuss OH-mediated end-organ damage; (4) provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; (5) identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.

Orthostatic Hypotension in Parkinson Disease

“…Untreated motor symptoms can also lead to immobility and physical deconditioning, which in turn further worsen the severity of OH. 2 Mild noradrenergic impairment can exist in PD without OH; in these individuals, levodopa may contribute to further impairment in blood pressure regulation, which can become clinically relevant in some cases. Further research is needed with a detailed investigation of the blood pressure in the same patients tested on and off levodopa.…”

Atrial Fibrillation as a Prognostic Indicator in Patients With Orthostatic Hypotension: Nationwide Inpatient Sample Analysis

“…While arterial stiffness has been independently associated with OH [43] and AF [44], it may also potentially increase the risk of cardiac arrest [45]. It has been proposed that the development of OH is secondary to autonomic nervous system dysregulation [17], and the development of AF occurs further downstream in the CVD continuum [17,46]. Therefore, it is very likely that the presence of AF in OH patients indicates the severity of autonomic nervous system dysregulation to increase the risk of cardiac arrest.…”

Use of Multimodal Therapies to Treat Severe Orthostatic Hypotension From Autonomic Failure

“…To better guide therapeutic strategies, a stepwise approach has been recommended in addition to the utilization of clinically proven grading scales such as the Orthostatic Hypotension Questionnaire (OHQ) [ 5 ]. Prior to treatment, a comprehensive medication review is essential to identify medications that may exacerbate orthostatic symptoms [ 7 , 8 ]. Dose reduction and discontinuation of diuretics, vasodilators, and negative chronotropic agents such as beta-blockers are imperative.…”

“…Dose reduction and discontinuation of diuretics, vasodilators, and negative chronotropic agents such as beta-blockers are imperative. Ensuring adequate hydration by encouraging generous fluid intake is key to achieving intravascular volume repletion [ 8 ]. Salt intake is also recommended, however, should be closely monitored in patients with heart failure or severe congestion.…”

“…Salt intake is also recommended, however, should be closely monitored in patients with heart failure or severe congestion. Compression garments and physical conditioning, particularly of the lower extremities, are key to preventing venous pooling and improving venous return to the heart [ 3 , 8 ].…”