How should I manage hypertension in my patient with neurogenic orthostatic hypotension?

The frequent concurrence of supine hypertension (SH) and neurogenic orthostatic hypotension (nOH)1 makes treatment of SH in these patients particularly challenging.

To begin with, your threshold for treatment of SH in patients with neurogenic orthostatic hypotension (nOH) may need to be higher than that commonly recommended by national guidelines for treatment of essential hypertension to avoid exacerbation of nOH.  Although SH in nOH patients is often arbitrarily defined as a systolic BP ≥150 mmHg or diastolic BP≥90 mmHg, a supine systolic BP of up to 160 mmHg may not warrant treatment, particularly if the symptoms of nOH have improved.2

A 2017 consensus panel recommends treatment of SH in the setting of nOH if systolic BP exceeds the range of 160-180 mmHg or diastolic BP exceeds 90-100 mmHg.  “Permissive” approach to SH in this setting may be reasonable, particularly in those with the largest drops in BP upon standing ( >80 mmHg drop). 2

Regardless, all patients with nOH and SH should be advised to avoid supine posture during the day and elevate the head of the bed as tolerated during the night.

If necessary, significant SH may be treated with short acting agents, including2:

  • Captopril 25 mg qhs
  • Clonidine 0.2 mg with evening meal
  • Hydralazine 10-25 mg qhs
  • Losartan 50 mg qhs
  • Nitroglyerine patch 0.1 mg/h patch qhs (remove patch in am)

Long acting antihypertensive agents and diuretics should be avoided given their inherent risk of significant exacerbation of nOH.

 

References

  1. Goldstein DS, Pechnick S, Holmes C, et al. Association between supine hypertension and orthostatic hypotension in autonomic failure. Hypertension 2003; 42:136-142. https://www.ncbi.nlm.nih.gov/pubmed/12835329
  2. Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a concensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol 2017;264:1567-82. https://www.ncbi.nlm.nih.gov/pubmed/28050656
How should I manage hypertension in my patient with neurogenic orthostatic hypotension?

How can I be sure that my patient truly has orthostatic hypotension (OH)?

OH is a sustained reduction of systolic blood pressure (SBP) of ≥ 20 mm Hg or diastolic BP ≥ 10 mm Hg within 3 min of standing or head-up tilt to at least 60° on a tilt table (1); symptoms are not part of the criteria. In patients with supine hypertension, a reduction in SBP of 30 mm Hg has been suggested (1).  

The Centers for Disease Control and Prevention (CDC) recommends BP measurements when patient is supine for 5 min, and after standing for 1 and 3 min (2).  Preference for mercury column sphygmomanometer due to its reliability and simplicity, with arm at the level of the heart has been stressed (3). 

OH is more common and more severe during mornings and after meals, and is exacerbated by large meals, meals high in carbohydrate, and alcohol intake (1). In some patients symptomatic OH occurs beyond 3 minutes of standing (1).

 

  1. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Autonomic Neuroscience: Basic and Clinical 2011;161: 46–48.
  2. http://www.cdc.gov/steadi/pdf/measuring_orthostatic_blood_pressure-a.pdf , accessed Dec 13, 2015.
  3. Naschitz J, Rosner I. Orthostatic hypotension: framework of the syndrome . Postgrad Med J 2007; 83:568-574. http://pmj.bmj.com/content/83/983/568
How can I be sure that my patient truly has orthostatic hypotension (OH)?