The patient with supine hypertension and orthostatic hypotension: a clinical dilemma

Abstract

Coexistent supine hypertension and orthostatic hypotension (SH-OH) pose a particular therapeutic dilemma, as treatment of one aspect of the condition may worsen the other. Studies of SH-OH are to be found by and large on patients with autonomic nervous disorders as well as patients with chronic arterial hypertension. In medical practice, however, the aetiologies and clinical presentation of the syndrome seem to be more varied. In the most typical cases the diagnosis is straightforward and the responsible mechanism evident. In those patients with mild or non-specific symptoms, the diagnosis is more demanding and the investigation may benefit from results of the tilt test, bedside autonomic tests as well as haemodynamic assessment. Discrete patterns of SH-OH may be recognisable. This review focuses on the management of the patient with coexistent SH-OH.

Syndrome of Supine Hypertension with Orthostatic Hypotension. A Nightmare for Physicians

“…In this way, autonomic failure is a significant risk factor for SH/OH. 5 Long-term hypertension leads to desensitization of the baroreceptor reflex, which might also contribute to the pathogenesis of SH/OH. Another contributing factor to SH/ OH could be residual sympathetic tone acting on postsynaptic adrenergic receptors that have become hypersensitive.…”

“…OH itself occurs in about 40% of patients with Parkinson's disease and most often as a result of nervous system dysfunction. 5 Sharabi and Goldstein examined patients with OH and Parkinson's and revealed that these patients (''PD þ OH'') exhibited baroreflex sympathoneural and cardiovagal failure. 5 These patients were also found to have significant ''sympathetic noradrenergic denervation'' especially in the left ventricular myocardium.…”

“…5 Sharabi and Goldstein examined patients with OH and Parkinson's and revealed that these patients (''PD þ OH'') exhibited baroreflex sympathoneural and cardiovagal failure. 5 These patients were also found to have significant ''sympathetic noradrenergic denervation'' especially in the left ventricular myocardium. 8 According to Sharabi and Goldstein, these patients also have decreased levels of norepinephrine in their plasma compared with patients with Parkinson's without OH.…”

“…Additionally, patients can have very different responses to standard therapy, so outcomes can vary greatly from case to case. Naschitz et al 5 described the variability of SH/OH presentations and proposes a classification system for SH/OH syndrome, characterized by clinical presentation (e.g. acute or chronic, typical, or atypical), pathophysiology (e.g.…”

“…These medications must be strictly monitored to minimize any undesired side effects that may worsen SH or OH. 5 They strongly recommend the use of 24-hour blood pressure monitoring as a means to identify the timing and magnitude of daily fluctuations. This practice can further help to guide treatment.…”