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Diagnosing and treating neurogenic orthostatic hypotension in primary care.
Postgrad Med. 2015; 127(7):702-15.PM

Abstract

In response to a change in posture from supine or sitting to standing, autonomic reflexes normally maintain blood pressure (BP) by selective increases in arteriovenous resistance and by increased cardiac output, ensuring continued perfusion of the central nervous system. In neurogenic orthostatic hypotension (NOH), inadequate vasoconstriction and cardiac output cause BP to drop excessively, resulting in inadequate perfusion, with predictable symptoms such as dizziness, lightheadedness and falls. The condition may represent a central failure of baroreceptor signals to modulate cardiovascular function, a peripheral failure of norepinephrine release from cardiovascular sympathetic nerve endings, or both. Symptomatic patients may benefit from both non-pharmacologic and pharmacologic interventions. Among the latter, two pressor agents have been approved by the US Food and Drug Administration: the sympathomimetic prodrug midodrine, approved in 1996 for symptomatic orthostatic hypotension, and the norepinephrine prodrug droxidopa, approved in 2014, which is indicated for the treatment of symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure (Parkinson's disease, multiple system atrophy and pure autonomic failure). A wide variety of off-label options also have been described (e.g. the synthetic mineralocorticoid fludrocortisone). Because pressor agents may promote supine hypertension, NOH management requires monitoring of supine BP and also lifestyle measures to minimize supine BP increases (e.g. head-of-bed elevation). However, NOH has been associated with cognitive impairment and increases a patient's risk of syncope and falls, with the potential for serious consequences. Hence, concerns about supine hypertension - for which the long-term prognosis in patients with NOH is yet to be established - must sometimes be balanced by the need to address a patient's immediate risks.

Authors+Show Affiliations

a 1 Department of Community Health and Family Medicine, University of Florida , Gainesville, FL, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Review

Language

eng

PubMed ID

26012731

Citation

Kuritzky, Louis, et al. "Diagnosing and Treating Neurogenic Orthostatic Hypotension in Primary Care." Postgraduate Medicine, vol. 127, no. 7, 2015, pp. 702-15.
Kuritzky L, Espay AJ, Gelblum J, et al. Diagnosing and treating neurogenic orthostatic hypotension in primary care. Postgrad Med. 2015;127(7):702-15.
Kuritzky, L., Espay, A. J., Gelblum, J., Payne, R., & Dietrich, E. (2015). Diagnosing and treating neurogenic orthostatic hypotension in primary care. Postgraduate Medicine, 127(7), 702-15. https://doi.org/10.1080/00325481.2015.1050340
Kuritzky L, et al. Diagnosing and Treating Neurogenic Orthostatic Hypotension in Primary Care. Postgrad Med. 2015;127(7):702-15. PubMed PMID: 26012731.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Diagnosing and treating neurogenic orthostatic hypotension in primary care. AU - Kuritzky,Louis, AU - Espay,Alberto J, AU - Gelblum,Jeffrey, AU - Payne,Richard, AU - Dietrich,Eric, Y1 - 2015/05/27/ PY - 2015/5/28/entrez PY - 2015/5/28/pubmed PY - 2015/12/15/medline KW - Neurogenic orthostatic hypotension KW - reduction of falls KW - supine blood pressure KW - supine hypertension SP - 702 EP - 15 JF - Postgraduate medicine JO - Postgrad Med VL - 127 IS - 7 N2 - In response to a change in posture from supine or sitting to standing, autonomic reflexes normally maintain blood pressure (BP) by selective increases in arteriovenous resistance and by increased cardiac output, ensuring continued perfusion of the central nervous system. In neurogenic orthostatic hypotension (NOH), inadequate vasoconstriction and cardiac output cause BP to drop excessively, resulting in inadequate perfusion, with predictable symptoms such as dizziness, lightheadedness and falls. The condition may represent a central failure of baroreceptor signals to modulate cardiovascular function, a peripheral failure of norepinephrine release from cardiovascular sympathetic nerve endings, or both. Symptomatic patients may benefit from both non-pharmacologic and pharmacologic interventions. Among the latter, two pressor agents have been approved by the US Food and Drug Administration: the sympathomimetic prodrug midodrine, approved in 1996 for symptomatic orthostatic hypotension, and the norepinephrine prodrug droxidopa, approved in 2014, which is indicated for the treatment of symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure (Parkinson's disease, multiple system atrophy and pure autonomic failure). A wide variety of off-label options also have been described (e.g. the synthetic mineralocorticoid fludrocortisone). Because pressor agents may promote supine hypertension, NOH management requires monitoring of supine BP and also lifestyle measures to minimize supine BP increases (e.g. head-of-bed elevation). However, NOH has been associated with cognitive impairment and increases a patient's risk of syncope and falls, with the potential for serious consequences. Hence, concerns about supine hypertension - for which the long-term prognosis in patients with NOH is yet to be established - must sometimes be balanced by the need to address a patient's immediate risks. SN - 1941-9260 UR - https://www.unboundmedicine.com/medline/citation/26012731/Diagnosing_and_treating_neurogenic_orthostatic_hypotension_in_primary_care_ L2 - https://www.tandfonline.com/doi/full/10.1080/00325481.2015.1050340 DB - PRIME DP - Unbound Medicine ER -