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A Practical Guide to the Treatment of Neurogenic Orthostatic Hypotension

Published online by Cambridge University Press:  23 September 2014

Michael J. Berger  and
Kurt Kimpinski
Michael J. Berger
Affiliation:
Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia
Kurt Kimpinski*
Affiliation:
Department of Clinical Neurological Sciences, London Health Sciences Centre and Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
*
London Health Sciences Centre, University Hospital, 339 Windermere Road, London, Ontario, N6A 5A5, Canada, Email: kurt.kimpinski@lhsc.on.ca
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Abstract

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Neurogenic orthostatic hypotension (NOH) is a debilitating condition associated with many central and peripheral neurological disorders. It has a complex pathophysiology and variable clinical presentation, which makes diagnosis and treatment difficult. Neurogenic orthostatic hypotension is often confused with other disorders of orthostatic intolerance, hypovolemic states and systemic conditions. Diagnosis is usually made by an autonomic specialist following characteristic responses to head-up tilt. Symptom control can be achieved through a combination of patient education, nonpharmacologic and pharmacologic therapy. The purpose of this review is to provide the clinician with a practical approach to the diagnosis and management of NOH.

Type
Review Article
Information
Canadian Journal of Neurological Sciences , Volume 41 , Issue 2 , March 2014 , pp. 156 - 163
Copyright
Copyright © The Canadian Journal of Neurological 2014

References

1.Rose, KM, Eigenbrodt, ML, Biga, RL, et al. Orthostatic hypotension predicts mortality in middle-aged adults: the Atherosclerosis Risk In Communities (ARIC) Study. Circulation. 2006;114(7):630–6.Google Scholar
2.Cordeiro, RC, Jardim, JR, Perracini, MR, Ramos, LR.Factors associated with functional balance and mobility among elderly diabetic outpatients. Arq Bras Endocrinol Metabol. 2009;53(7):834–43.CrossRefGoogle ScholarPubMed
3.Bendini, C, Angelini, A, Salsi, F, et al. Relation of neurocardiovascular instability to cognitive, emotional and functional domains. Arch Gerontol Geriatr. 2007;44 Suppl 1:69–74.Google Scholar
4.Freeman, R, Wieling, W, Axelrod, FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69–72.CrossRefGoogle ScholarPubMed
5.Low, PA, Singer, W.Management of neurogenic orthostatic hypotension: an update. Lancet Neurol. 2008;7(5):451–8.CrossRefGoogle ScholarPubMed
6.Low, PA, Fealy, RD.Managment of neurogenic orthostatic hypotension. In: Low, PA, Benarroch, EE, editors. Clinical autonomic disorders. 3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008. p. 547–59.Google Scholar
7.Freeman, R.Clinical practice: neurogenic orthostatic hypotension. N Eng J Med. 2008;358:615–24.Google Scholar
8.Metzler, M, Duerr, S, Granata, R, Krismer, F, Robertson, D, Wenning, GK.Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management. J Neurol. 2013;260(9):2212–19.CrossRefGoogle ScholarPubMed
9.Smit, AA, Halliwill, JR, Low, PA, Wieling, W.Pathophysiological basis of orthostatic hypotension in autonomic failure. J Physiol. 1999;519 Pt 1:1–10.Google Scholar
10.Masaki, KH, Schatz, IJ, Burchfiel, CM, et al. Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program. Circulation. 1998;98(21):2290–5.Google Scholar
11.Ooi, WL, Barrett, S, Hossain, M, Kelley-Gagnon, M, Lipsitz, LA.Patterns of orthostatic blood pressure change and their clinical correlates in a frail, elderly population. JAMA. 1997;277(16):1299–304.Google Scholar
12.Lanier, JB, Mote, MB, Clay, EC.Evaluation and management of orthostatic hypotension. Am Fam Physician. 2011;84(5):527–36.Google Scholar
13.Poon, IO, Braun, U.High prevalence of orthostatic hypotension and its correlation with potentially causative medications among elderly veterans. J Clin Pharm Ther. 2005;30(2):173–8.Google Scholar
14.Mathias, CJ, Mallipeddi, R, Bleasdale-Barr, K.Symptoms associated with orthostatic hypotension in pure autonomic failure and multiple system atrophy. J Neurol. 1999;246(10):893–8.Google Scholar
15.Low, PA, Opfer-Gehrking, TL, McPhee, BR, et al. Prospective evaluation of clinical characteristics of orthostatic hypotension. Mayo Clin Proc. 1995;70(7):617–22.Google Scholar
16.Freeman, R.Current pharmacologic treatment for orthostatic hypotension. Clin Auton Res. 2008;18 Suppl 1:14–18.Google Scholar
17.Freeman, R.Treatment of orthostatic hypotension. Semin Neurol. 2003;23(4):435–42.Google Scholar
18.Fujimura, J, Camilleri, M, Low, PA, Novak, V, Novak, P, Opfer-Gehrking, TL.Effect of perturbations and a meal on superior mesenteric artery flow in patients with orthostatic hypotension. J Auton Nerv Syst. 1997;67(1–2):15–23.Google Scholar
19.Gupta, V, Lipsitz, LA.Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. 2007;120(10):841–7.Google Scholar
20.Cooke, J, Carew, S, O’Connor, M, Costelloe, A, Sheehy, T, Lyons, D.Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension. QJM. 2009;102(5):335–9.Google Scholar
21.Wieling, W, Krediet, CT, van Dijk, N, Linzer, M, Tschakovsky, ME.Initial orthostatic hypotension: review of a forgotten condition. Clin Sci (Lond). 2007;112(3):157–65.CrossRefGoogle ScholarPubMed
22.Gibbons, CH, Freeman, R.Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance. Neurology. 2006;67(1): 28–32.Google Scholar
23.Fedorowski, A, Melander, O.Syndromes of orthostatic intolerance: a hidden danger. J Intern Med. 2012;273(4):322–35.Google Scholar
24.Logan, IC, Witham, MD.Efficacy of treatments for orthostatic hypotension: a systematic review. Age Ageing. 2012;41(5):587–94.Google Scholar
25.Omboni, S, Smit, AA, van Lieshout, JJ, Settels, JJ, Langewouters, GJ, Wieling, W.Mechanisms underlying the impairment in orthostatic tolerance after nocturnal recumbency in patients with autonomic failure. Clin Sci (Lond). 2001;101(6):609–18.CrossRefGoogle ScholarPubMed
26.Wieling, W, Colman, N, Krediet, CT, Freeman, R.Nonpharmacological treatment of reflex syncope. Clin Auton Res. 2004;14 Suppl 1:62–70.Google Scholar
27.Bouvette, CM, McPhee, BR, Opfer-Gehrking, TL, Low, PA.Role of physical countermaneuvers in the management of orthostatic hypotension: efficacy and biofeedback augmentation. Mayo Clin Proc. 1996;71(9):847–53.Google Scholar
28.Ten Harkel, AD, van Lieshout, JJ, Wieling, W.Effects of leg muscle pumping and tensing on orthostatic arterial pressure: a study in normal subjects and patients with autonomic failure. Clin Sci (Lond). 1994;87(5):553–8.Google Scholar
29.Wieling, W, van Lieshout, JJ, van Leeuwen, AM.Physical manoeuvres that reduce postural hypotension in autonomic failure. Clin Auton Res. 1993;3(1):57–65.Google Scholar
30.Wieling, W, Van Lieshout, JJ, Hainsworth, R.Extracellular fluid volume expansion in patients with posturally related syncope. Clin Auton Res. 2002;12(4):242–9.Google Scholar
31.El-Sayed, H, Hainsworth, R.Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope. Heart. 1996;75(2):134–40.Google Scholar
32.Mtinangi, BL, Hainsworth, R.Early effects of oral salt on plasma volume, orthostatic tolerance, and baroreceptor sensitivity in patients with syncope. Clin Auton Res. 1998;8(4):231–5.Google Scholar
33.Naschitz, JE, Slobodin, G, Elias, N, Rosner, I.The patient with supine hypertension and orthostatic hypotension: a clinical dilemma. Postgrad Med J. 2006;82(966):246–53.Google Scholar
34.World Health Organization. Global status report on noncommunicable diseases. 2010:16–21.Google Scholar
35.Jordan, J.Acute effect of water on blood pressure. What do we know? Clin Auton Res. 2002;12(4):250–5.CrossRefGoogle ScholarPubMed
36.Jordan, J, Shannon, JR, Grogan, E, Biaggioni, I, Robertson, D. A potent pressor response elicited by drinking water. Lancet. 1999;353(9154):723.Google Scholar
37.Jordan, J, Shannon, JR, Diedrich, A, Black, B, Robertson, D, Biaggioni, I.Water potentiates the pressor effect of ephedra alkaloids. Circulation. 2004;109(15):1823–5.Google Scholar
38.Henry, R, Rowe, J, O’Mahony, D.Haemodynamic analysis of efficacy of compression hosiery in elderly fallers with orthostatic hypotension. Lancet. 1999;354(9172):45–6.Google Scholar
39.Smit, AA, Wieling, W, Fujimura, J, et al. Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction. Clin Auton Res. 2004;14(3):167–75.Google Scholar
40.Denq, JC, Opfer-Gehrking, TL, Giuliani, M, Felten, J, Convertino, VA, Low, PA.Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension. Clin Auton Res. 1997;7(6):321–6.Google Scholar
41.Mtinangi, BL, Hainsworth, R.Effects of moderate exercise training on plasma volume, baroreceptor sensitivity and orthostatic tolerance in healthy subjects. Exp Physiol. 1999;84(1):121–30.Google Scholar
42.Mtinangi, BL, Hainsworth, R.Increased orthostatic tolerance following moderate exercise training in patients with unexplained syncope. Heart. 1998;80(6):596–60.Google Scholar
43.Low, DA, da Nobrega, AC, Mathias, CJ.Exercise-induced hypotension in autonomic disorders. Auton Neurosci. 2012;171(1–2):66–78.Google Scholar
44.Wright, RA, Kaufmann, HC, Perera, R, et al. A double-blind, dose-response study of midodrine in neurogenic orthostatic hypotension. Neurology. 1998;51(1):120–4.CrossRefGoogle ScholarPubMed
45.Low PA, GJ, Freeman, R, Sheng, KN, McElligott, MA.Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double-blind multicenter study. Midodrine Study Group. JAMA. 1997;278(5):388.Google Scholar
46.Singer, W, Opfer-Gehrking, TL, Nickander, KK, Hines, SM, Low, PA.Acetylcholinesterase inhibition in patients with orthostatic intolerance. J Clin Neurophysiol. 2006;23(5):476–81.Google Scholar
47.Singer, W, Sandroni, P, Opfer-Gehrking, TL, et al. Pyridostigmine treatment trial in neurogenic orthostatic hypotension. Arch Neurol. 2006;63(4):513–18.Google Scholar
48.Gales, BJ, Gales, MA.Pyridostigmine in the treatment of orthostatic intolerance. Ann Pharmacother. 2007;41(2):314–18.Google Scholar
49.van Lieshout, JJ, ten Harkel, AD, Wieling, W.Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure. Clin Auton Res. 2000;10(1):35–42.CrossRefGoogle ScholarPubMed
50.Chobanian, AV, Volicer, L, Tifft, CP, Gavras, H, Liang, CS, Faxon, D.Mineralocorticoid-induced hypertension in patients with orthostatic hypotension. N Engl J Med. 1979;301(2):68–73.Google Scholar
51.Kaufmann, H, Oribe, E, Miller, M, Knott, P, Wiltshire-Clement, M, Yahr, MD.Hypotension-induced vasopressin release distinguishes between pure autonomic failure and multiple system atrophy with autonomic failure. Neurology. 1992;42(3 Pt 1):590–3.Google Scholar
52.Sakakibara, R, Matsuda, S, Uchiyama, T, Yoshiyama, M, Yamanishi, T, Hattori, T.The effect of intranasal desmopressin on nocturnal waking in urination in multiple system atrophy patients with nocturnal polyuria. Clin Auton Res. 2003;13(2):106–8.Google Scholar
53.Sasaki, E, Kitaoka, H, Ohsawa, N.Postprandial hypotension in patients with non-insulin-dependent diabetes mellitus. Diabetes Res Clin Pract. 1992;18(2):113–21.Google Scholar
54.Armstrong, E, Mathias, CJ.The effects of the somatostatin analogue, octreotide, on postural hypotension, before and after food ingestion, in primary autonomic failure. Clin Auton Res. 1991;1(2):135–40.Google Scholar
55.Hoeldtke, RD, Streeten, DH.Treatment of orthostatic hypotension with erythropoietin. N Engl J Med. 1993;329(9):611–15.CrossRefGoogle ScholarPubMed
56.Perera, R, Isola, L, Kaufmann, H.Effect of recombinant erythropoietin on anemia and orthostatic hypotension in primary autonomic failure. Clin Auton Res. 1995;5(4):211–13.CrossRefGoogle ScholarPubMed