Management of neurogenic orthostatic hypotension: an update

Abstract

Orthostatic hypotension (OH) is common in elderly people and in patients with disorders such as diabetes and Parkinson's disease. Grading of the severity of OH and its effect on the patient's quality of life are important. The symptoms vary with orthostatic stress, and subtle symptoms such as tiredness and cognitive impairment should be recognised. Standard drug treatment for OH is effective but worsens supine hypertension, whereas pyridostigmine can improve OH slightly but significantly without worsening of supine hypertension. Because orthostatic stress varies from moment to moment and drug treatment is suboptimal, drug treatment of OH needs to be combined with non-pharmacological approaches, such as compression of venous capacitance beds, use of physical counter-manoeuvres, and intermittent water-bolus treatment.

Figures

Figure 1

Baroreceptor afferents synapse at nucleus of tractus solitarius. From this nucleus vagal baroreflex (baroreflex_v) and adrenergic baroreflex (baroreflex_a) loops diverge. Baroreflex_v pathways synapse at nucleus of tractus solitarius and send efferents to sinoatrial node (SA). Baroreflex_a is mediated by connections to rostroventrolateral nucleus of medulla (RVLM) with preceding connection at caudal VLM. Sympathetic efferents from RVLM travel to intermediolateral column and thence synapse at autonomic ganglia then innervate the heart and arterioles and venules.

Figure 2

Examples of some physical countermaneuvers that can raise orthostatic BP. a. Toe-raise; b. Leg-cross; c. forward lean; d. step up; e. genuflection-contraction; f. squat

Figure 3

Diastolic blood pressure (DBP) before and after administration of study drug. Each group (placebo, pyridostigmine bromide, pyridostigmine and 2.5 mg of midodrine hydrochloride, pyridostigmine and 5.0 mg of midodrine hydrochloride) averaged for the supine position and standing position. Asterisk indicates P_.05; dagger, P_.01. Error bars represent mean±SD. (From Singer W, Sandroni P, Opfer-Gehrking TL, Suarez GA, Klein CM, Hines S, O'Brien PC, Slezak J, Low PA. Pyridostigmine treatment trial in neurogenic orthostatic hypotension. Arch Neurol 63:513-518, 2006. Reproduced with permission.)

Figure 4

Regression of change in diastolic blood pressure (DBP) with symptom score. The regression equation is as follows: symptom score=0.524_0.0272_DBP increase (R=0.34). Pyridostigmine was administered as pyridostigmine bromide. (From Singer W, Sandroni P, Opfer-Gehrking TL, Suarez GA, Klein CM, Hines S, O'Brien PC, Slezak J, Low PA. Pyridostigmine treatment trial in neurogenic orthostatic hypotension. Arch Neurol 63:513-518, 2006. Reproduced with permission.)