The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension

Abstract

Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson’s disease, multiple system atrophy, pure autonomic failure, dementia with Lewy bodies, and peripheral neuropathies including amyloid or diabetic neuropathy. Due to the frequency of nOH in the aging population, clinicians need to be well informed about its diagnosis and management. To date, studies of nOH have used different outcome measures and various methods of diagnosis, thereby preventing the generation of evidence-based guidelines to direct clinicians towards ‘best practices’ when treating patients with nOH and associated supine hypertension. To address these issues, the American Autonomic Society and the National Parkinson Foundation initiated a project to develop a statement of recommendations beginning with a consensus panel meeting in Boston on November 7, 2015, with continued communications and contributions to the recommendations through October of 2016. This paper summarizes the panel members’ discussions held during the initial meeting along with continued deliberations among the panel members and provides essential recommendations based upon best available evidence as well as expert opinion for the (1) screening, (2) diagnosis, (3) treatment of nOH, and (4) diagnosis and treatment of associated supine hypertension.Electronic supplementary materialThe online version of this article (doi:10.1007/s00415-016-8375-x) contains supplementary material, which is available to authorized users.

Diagnosis of multiple system atrophy

“…Supine hypertension appears to be slightly more severe in MSA compared to PD (Pilleri et al, 2014; Schmidt et al, 2009a; Vichayanrat et al, 2017). In addition, AMBP can be useful to detect hypotensive episodes not found during a regular clinic visit, for example after meals (i.e., postprandial hypotension), and to further define treatment of OH and supine hypertension (Fanciulli et al, 2016; Gibbons et al, 2017; Jordan et al, 2002; Norcliffe-Kaufmann et al, 2014; Palma et al, 2017; Pavelic et al, 2017; Umehara et al, 2016). …”

Orthostatic heart rate changes in patients with autonomic failure caused by neurodegenerative synucleinopathies

“…1, 5 A recent consensus panel proposed an increase in HR of <15 beats per minute (bpm) to support the diagnosis of neurogenic OH but this proposed range was based on experts’ clinical experience rather than scientific evidence. 6 …”

A New Player in Circulatory Adaptation to Orthostatism

“…Treatments are not always satisfactory. 4,5 The sympathetic nervous system (SN) plays a major role in circulatory adaptation to orthostatism. The system can indeed be activated quickly through arterial baroreceptors and act quickly through noradrenaline release increasing arteriolar resistance and heart rate and restoring cardiac output and organ perfusion pressure.…”