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Orthostatic Hypotension: II. Clinical Diagnosis, Testing, and Treatment

Orthostatic Hypotension: II. Clinical Diagnosis, Testing, and Treatment Abstract • The clinical diagnosis of orthostatic hypotension (OH) is straightforward and usually does not require extensive laboratory testing. Symptoms of cerebral hypoxia may not occur even with low BP because of compensatory cerebral vascular autoregulation. Autonomic function tests may pinpoint the lesion in OH, but they should be selected carefully. Heart rate response to standing, the valsalva maneuver, the cold pressor test, and plasma norepinephrine levels are the most useful. General measures in management, eg, nocturnal head up tilt and use of a pressure-support garment, often will provide major relief of symptoms. The mainstay of drug therapy is fludrocortisone acetate, but edema, supine hypertension, and heart failure occur frequently. Other agents (eg, vasopressors, prostaglandin inhibitors, and β-adrenergic blockers) may enhance effectiveness of therapy when combined with fludrocortisone acetate. (Arch Intern Med 1984;144:1037-1041) References 1. Hines S, Houston M, Robertson D: The clinical spectrum of autonomic dysfunction. Am J Med 1981;70:1091-1096.Crossref 2. Robertson D, Wade D, Robertson RM: Postprandial alterations in cardiovascular hemodynamics in autonomic dysfunctional states. Am J Cardiol 1981;48:1048-1052.Crossref 3. Hilsted J: Pathophysiology in diabetic autonomic neuropathy. NY State J Med 1982;82:892-902. 4. Henrich WL: Autonomic insufficiency. Arch Intern Med 1982;142:339-344.Crossref 5. Thomas JE, Schirger A, Fealey RD, et al: Orthostatic hypotension. Mayo Clin Proc 1981;56:117-125. 6. Zerbe RL, Henry DP, Robertson GL: Vasopressin response to orthostatic hypotension. Am J Med 1983;74:265-271.Crossref 7. Godden JO, Roth GM, Hines EA Jr: The changes in the intra-arterial pressure during emersion of the hand in ice cold water. Circulation 1965;12: 963-973.Crossref 8. Polinsky RJ, Kopin IJ, Ebert MH, et al: Pharmacologic distinction of different orthostatic hypotension syndromes. Neurology 1981;31:1-7.Crossref 9. Bannister R: Treatment of progressive autonomic failure , in Bannister R (ed): Autonomic Failure . Oxford, England, Oxford University Press, 1983, pp 316-334. 10. Sheps SG: Use of an elastic garment in the treatment of orthostatic hypotension. Cardiology 1976;61( (suppl 1) ):271-279.Crossref 11. Schatz IJ: Current management concepts in orthostatic hypotension. Arch Intern Med 1980;140:1152-1154.Crossref 12. Schatz IJ, Miller MJ, Frame B: Corticosteroids in the management of orthostatic hypotension. Cardiology 1976;61( (suppl 1) ):280-289.Crossref 13. Davies B: Adrenergic receptors in autonomic failure , in Bannister R (ed): Autonomic Failure . Oxford, England, Oxford University Press, 1983, pp 174-200. 14. Thomas JE, Schirger A, Fealey RD, et al: Orthostatic hypotension. Mayo Clin Proc 1981;56:117-125. 15. Schirger A, Sheps SG, Thomas JE, et al: Midodrine: A new agent in the management of idiopathic orthostatic hypotension and Shy-Drager syndrome. Mayo Clin Proc 1981;56:429-433. 16. Diamond MA, Murray RH, Schmid PG: Idiopathic postural hypotension: Physiologic observations and report of a new mode of therapy. J Clin Invest 1970;49:1341-1348.Crossref 17. Chobanian AV, Tifft CP, Faxon DP, et al: Treatment of chronic orthostatic hypotension with ergotamine. Circulation 1983;67:602-609.Crossref 18. Jennings G, Esler M, Holmes R: Treatment of orthostatic hypotension with dihydroergotamine. Br Med J 1979;11:307-308.Crossref 19. Bobik A, Jennings G, Skeur H, et al: Low oral bioavailability of dihydroergotamine and first pass extraction in patients with orthostatic hypotension. Clin Pharmacol Ther 1981;30:673-679.Crossref 20. Kochar MS, Itskovitz HD: Treatment of idiopathic orthostatic hypotension (Shy-Drager syndrome) with indomethacin. Lancet 1978;1:1011-1014.Crossref 21. Davies B, Bannister R, Hensby C, et al: The pressor actions of noradrenaline and angiotensin II in chronic autonomic failure treated with indomethacin. Br J Clin Pharmacol 1980;10:223-229.Crossref 22. Chobanian AV, Volicer L, Liang CS, et al: Use of propranolol in the treatment of idiopathic orthostatic hypotension. Trans Assoc Am Physicians 1977;90:324-334. 23. Man in't Veld AJ, Schalekamp MADH: Pindolol acts as β-adrenoceptor agonist in orthostatic hypotension: Therapeutic implications. Br Med J 1981;282:929-931.Crossref 24. Davies B, Bannister R, Mathias C, et al: Pindolol in postural hypotension: The case for caution. Lancet 1981;2:982-983.Crossref 25. Man in't Veld AJ, Boomsma F, Schalekamp MADH: Effects of β-adrenoceptor agonists and antagonists in patients with peripheral autonomic neuropathy. Br J Clin Pharmacol 1982;13:3675-3745. 26. Robertson D, Goldberg MR, Hollister AS, et al: Clonidine raises blood pressure in severe idiopathic orthostatic hypotension. Am J Med 1983;74:193-200.Crossref 27. Kuchel O, Buu NT, Gutkowska J, et al: Treatment of severe orthostatic hypotension by metoclopramide. Ann Intern Med 1980;93:841-843.Crossref 28. Moss AJ, Glaser W, Topol E: Atrial tachypacing in the treatment of a patient with primary orthostatic hypotension. N Engl J Med 1980;302: 1456-1457.Crossref 29. Stackpoole PW, Robertson D: Combination H1- and H2-receptor antagonist therapy in diabetic autonomic neuropathy. South Med J 1982;75: 634-635.Crossref 30. Polinsky RJ, Samaras GM, Kopin IJ: Sympathetic neural prosthesis for managing orthostatic hypotension. Lancet 1983;1:901-904.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Orthostatic Hypotension: II. Clinical Diagnosis, Testing, and Treatment

Archives of Internal Medicine , Volume 144 (5) – May 1, 1984

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Publisher
American Medical Association
Copyright
Copyright © 1984 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1984.00350170203031
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Abstract

Abstract • The clinical diagnosis of orthostatic hypotension (OH) is straightforward and usually does not require extensive laboratory testing. Symptoms of cerebral hypoxia may not occur even with low BP because of compensatory cerebral vascular autoregulation. Autonomic function tests may pinpoint the lesion in OH, but they should be selected carefully. Heart rate response to standing, the valsalva maneuver, the cold pressor test, and plasma norepinephrine levels are the most useful. General measures in management, eg, nocturnal head up tilt and use of a pressure-support garment, often will provide major relief of symptoms. The mainstay of drug therapy is fludrocortisone acetate, but edema, supine hypertension, and heart failure occur frequently. Other agents (eg, vasopressors, prostaglandin inhibitors, and β-adrenergic blockers) may enhance effectiveness of therapy when combined with fludrocortisone acetate. (Arch Intern Med 1984;144:1037-1041) References 1. Hines S, Houston M, Robertson D: The clinical spectrum of autonomic dysfunction. Am J Med 1981;70:1091-1096.Crossref 2. Robertson D, Wade D, Robertson RM: Postprandial alterations in cardiovascular hemodynamics in autonomic dysfunctional states. Am J Cardiol 1981;48:1048-1052.Crossref 3. Hilsted J: Pathophysiology in diabetic autonomic neuropathy. NY State J Med 1982;82:892-902. 4. Henrich WL: Autonomic insufficiency. Arch Intern Med 1982;142:339-344.Crossref 5. Thomas JE, Schirger A, Fealey RD, et al: Orthostatic hypotension. Mayo Clin Proc 1981;56:117-125. 6. Zerbe RL, Henry DP, Robertson GL: Vasopressin response to orthostatic hypotension. Am J Med 1983;74:265-271.Crossref 7. Godden JO, Roth GM, Hines EA Jr: The changes in the intra-arterial pressure during emersion of the hand in ice cold water. Circulation 1965;12: 963-973.Crossref 8. Polinsky RJ, Kopin IJ, Ebert MH, et al: Pharmacologic distinction of different orthostatic hypotension syndromes. Neurology 1981;31:1-7.Crossref 9. Bannister R: Treatment of progressive autonomic failure , in Bannister R (ed): Autonomic Failure . Oxford, England, Oxford University Press, 1983, pp 316-334. 10. Sheps SG: Use of an elastic garment in the treatment of orthostatic hypotension. Cardiology 1976;61( (suppl 1) ):271-279.Crossref 11. Schatz IJ: Current management concepts in orthostatic hypotension. Arch Intern Med 1980;140:1152-1154.Crossref 12. Schatz IJ, Miller MJ, Frame B: Corticosteroids in the management of orthostatic hypotension. Cardiology 1976;61( (suppl 1) ):280-289.Crossref 13. Davies B: Adrenergic receptors in autonomic failure , in Bannister R (ed): Autonomic Failure . Oxford, England, Oxford University Press, 1983, pp 174-200. 14. Thomas JE, Schirger A, Fealey RD, et al: Orthostatic hypotension. Mayo Clin Proc 1981;56:117-125. 15. Schirger A, Sheps SG, Thomas JE, et al: Midodrine: A new agent in the management of idiopathic orthostatic hypotension and Shy-Drager syndrome. Mayo Clin Proc 1981;56:429-433. 16. Diamond MA, Murray RH, Schmid PG: Idiopathic postural hypotension: Physiologic observations and report of a new mode of therapy. J Clin Invest 1970;49:1341-1348.Crossref 17. Chobanian AV, Tifft CP, Faxon DP, et al: Treatment of chronic orthostatic hypotension with ergotamine. Circulation 1983;67:602-609.Crossref 18. Jennings G, Esler M, Holmes R: Treatment of orthostatic hypotension with dihydroergotamine. Br Med J 1979;11:307-308.Crossref 19. Bobik A, Jennings G, Skeur H, et al: Low oral bioavailability of dihydroergotamine and first pass extraction in patients with orthostatic hypotension. Clin Pharmacol Ther 1981;30:673-679.Crossref 20. Kochar MS, Itskovitz HD: Treatment of idiopathic orthostatic hypotension (Shy-Drager syndrome) with indomethacin. Lancet 1978;1:1011-1014.Crossref 21. Davies B, Bannister R, Hensby C, et al: The pressor actions of noradrenaline and angiotensin II in chronic autonomic failure treated with indomethacin. Br J Clin Pharmacol 1980;10:223-229.Crossref 22. Chobanian AV, Volicer L, Liang CS, et al: Use of propranolol in the treatment of idiopathic orthostatic hypotension. Trans Assoc Am Physicians 1977;90:324-334. 23. Man in't Veld AJ, Schalekamp MADH: Pindolol acts as β-adrenoceptor agonist in orthostatic hypotension: Therapeutic implications. Br Med J 1981;282:929-931.Crossref 24. Davies B, Bannister R, Mathias C, et al: Pindolol in postural hypotension: The case for caution. Lancet 1981;2:982-983.Crossref 25. Man in't Veld AJ, Boomsma F, Schalekamp MADH: Effects of β-adrenoceptor agonists and antagonists in patients with peripheral autonomic neuropathy. Br J Clin Pharmacol 1982;13:3675-3745. 26. Robertson D, Goldberg MR, Hollister AS, et al: Clonidine raises blood pressure in severe idiopathic orthostatic hypotension. Am J Med 1983;74:193-200.Crossref 27. Kuchel O, Buu NT, Gutkowska J, et al: Treatment of severe orthostatic hypotension by metoclopramide. Ann Intern Med 1980;93:841-843.Crossref 28. Moss AJ, Glaser W, Topol E: Atrial tachypacing in the treatment of a patient with primary orthostatic hypotension. N Engl J Med 1980;302: 1456-1457.Crossref 29. Stackpoole PW, Robertson D: Combination H1- and H2-receptor antagonist therapy in diabetic autonomic neuropathy. South Med J 1982;75: 634-635.Crossref 30. Polinsky RJ, Samaras GM, Kopin IJ: Sympathetic neural prosthesis for managing orthostatic hypotension. Lancet 1983;1:901-904.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: May 1, 1984

References