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Orthostatic hypotension (OH) is defined as a significant decrease in blood pressure (BP) during the first 3 minutes of standing or a head up on a tilt table. Symptoms of OH are highly variable, ranging from mild light-headedness to recurrent syncope. OH occurs due to dysfunction of one or more components of various complex mechanisms that interplay...
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Citations
... PWV reflects the degree of vascular stiffness. It was believed that the failure of lower limbs and visceral vessels to contract in time during the body position change of OH patients was related to the damage of sympathetic adrenergic system (29), but this mechanism could not fully explain the reason that the prevalence of OH in the elderly was much higher than that in the young and middle-aged. In this study, PWV of OH patients was significantly longer than that of the control group, indicating that the vasoconstriction disorder of OH patients was also related to the increase of vascular elasticity and stiffness, which was a good supplement to the above mechanism. ...
Background: Orthostatic hypotension (OH) is a common disease of the elderly. It is generally believed that the pathogenesis of OH is related to the impairment of autonomic nerve function and the decreased vascular capacity regulation. This study aims to explore the relationship between OH and heart rate variability (HRV) parameters, which reflects autonomic nerve function; ankle-brachial pressure index (ABI), which reflects the degree of vascular stenosis; pulse wave velocity (PWV) index, which reflects vascular stiffness; and frailty index (FI), which reflects the overall health status of the elderly.
Methods: From January to September 2018, 24-h HOLTER monitoring, PWV, and ABI were performed in 108 elderly patients with OH and 64 elderly patients who underwent physical examination in our hospital. Analysis software was used to record the subject's standard deviation of the cardiac cycle (SDNN), the standard deviation of the 5-min average cardiac cycle (SDANN), the square root of the average square sum of consecutive n-interval differences (rMSSD), the percentage of the number of adjacent cardiac interval differences >50 ms (pNN50), low frequency (LF), high frequency (HF), very low frequency (VLF), and low frequency/high frequency ratio (LF/HF). Then, FI was evaluated qualitatively and quantitatively in the form of a scale.
Results: There was no statistical difference between the two groups on the basis of age, sex, body mass index (BMI), low-density lipoprotein (LDL), resting heart rate, blood pressure, fasting blood glucose, long-term medication, etc. There were significant differences in PWV, SDNN, LF, VLF, and LF/HF between the two groups ( P < 0.05). The risk factor of OH in the qualitative ( P = 0.04) and quantitative ( P = 0.007) index FI was higher in the OH group than in the control group. The risk factors of OH were PWV, SDNN, VLF, LF/HF, and FI, where FI was positively correlated and LF/HF was negatively correlated.
Conclusions: The pathogenesis of OH is related to vascular stiffness, imbalance of autonomic nerve regulation, and its comprehensive health status in the elderly. However, arteriosclerosis has not been confirmed as an independent risk factor.
Clinical Trial Registration: Retrospectively registered, http://www.chictr.org.cn .
... 66 It is an oral pro-drug that is converted both peripherally and centrally to norepinephrine by decarboxylation. 78 Droxidopa can exert a pressor effect in 3 ways: as a central stimulator of sympathetic activity, as a peripheral sympathetic neurotransmitter and as a circulating hormone. 79 Kaufman et al evaluated the use of droxidopa in 162 patients with symptomatic nOH due to PD, MSA, PAF, or nondiabetic autonomic neuropathy. ...
... 83,87 Droxidopa can exacerbate conditions such as ischemic heart disease, arrhythmias, and congestive heart failure. 78 In the short term studies, were no CV events; in the intermediate term studies, CV event rates were 4.4% and 1.8% (droxidopa vs placebo). 88 In long-term studies, CV events occurred in 10.8% of droxidopa patients (open-label studies, no placebo arm was available for comparison). ...
... 26 Hypokalemia is dose dependent and is seen in 25% of patients. 78 Chronic use can cause cardiac hypertrophy and worsening heart failure. It increases the warfarin effect and may require a dose reduction of concomitant warfarin therapy. ...
Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension in which patients have impaired regulation of standing blood pressure due to autonomic dysfunction. Several primary and secondary causes of this disease exist. Patients may present with an array of symptoms making diagnosis difficult. This review article addresses the epidemiology, pathophysiology, causes, clinical features, and management of nOH. We highlight various pharmacological and non-pharmacological approaches to treatment, and review the recent guidelines and our approach to nOH.
... Remarkably, no association was found in our study between the hemodynamic parameters and orthostatic hypotension. This could be due to the fact that orthostatic hypotension is a more heterogeneous entity, which comprises a wide range of demonstrated mechanisms, from volume depletion to autonomic failure (17)(18)(19)(20). These different phenomena have distinct patternssometimes opposedin the impedance cardiography and patients with different underlying mechanisms for their orthostatic hypotension may have coexisted in our study. ...
Methods:
In treated hypertensive patients, we measured the cardiac index (CI), systemic vascular resistance index (SVRI), blood pressure (BP), and heart rate (HR) in the supine and standing (after 3 minutes) positions, defining three groups according to BP variation: 1) Normal orthostatic BP variation (NOV): standing systolic BP (stSBP)-supine systolic BP (suSBP) between -20 and 20 mmHg and standing diastolic BP (stDBP)-supine diastolic BP (suDBP) between -10 and 10 mmHg; 2) orthostatic hypotension (OHypo): stSBP-suSBP≤-20 or stDBP-suDBP≤-10 mmHg; 3) orthostatic hypertension (OHyper): stSBP-suSBP≥20 or stDBP-suDBP≥10 mmHg. We performed multivariable analyses to determine the association of hemodynamic variables with EOV.
Results:
We included 186 patients. Those with OHyper had lower suDBP and higher orthostatic SVRI variation compared to NOV. In multivariable analyses, orthostatic HR variation (OR = 1.06 (95%CI 1.01-1.13), p = 0.03) and orthostatic SVRI variation (OR = 1.16 (95%CI 1.06-1.28), p = 0.002) were independently related to OHyper. No variables were independently associated with OHypo.
Conclusion:
Patients with OHyper have a distinct hemodynamic pattern, with an exaggerated increase in SVRI and HR when standing.
Background and Purpose
Currently, there are no formal guidelines describing rehabilitation interventions for those with amyloidosis. This case report explores the application of physical and edema therapy interventions, including external compression, for a patient with a diagnosis of light-chain (AL) amyloidosis and functionally limiting orthostatic hypotension in the acute care setting.
Case Description
A 52-year-old man with a diagnosis of immunoglobulin AL amyloidosis presented to the acute care setting with progressed orthostatic hypotension, bilateral lower extremity edema, and episodes of syncope. The patient spent 17 days in the inpatient setting and received physical therapy (PT) and edema therapy through the inpatient lymphedema service. Rehabilitation focused on exercise, compression, and behavioral and educational interventions over the course of 9 PT sessions and 7 edema therapy sessions.
Outcomes
Before interventions, the patient was unable to safely ambulate at home due to syncope. He progressed to being able to ambulate 1560 ft with seated rests. The patient demonstrated decreased limb circumferential measurements, improved performance on the 6-Minute Walk Test, improved ability to self-manage orthostatic hypotension and edema, and increased participation in activities of daily living.
Discussion
The combination of physical and edema therapy services may have compensated for orthostatic hypotension and improved standing tolerance. The patient's blood urea nitrogen and brain natriuretic peptide levels may have improved because of the application of external compression. Overall, the patient experienced decreased limb size, increased exercise tolerance, decreased syncopal episodes, and improved quality of life without changes in pharmacologic management or adverse events.
Review question:
The question of this review is: what is the effectiveness of droxidopa compared to midodrine on standing blood pressure and orthostatic intolerance symptoms in adults with neurogenic orthostatic hypotension?
Both hypertension and orthostatic hypotension (OH) are strongly age associated and are common management problems in older people. However, unlike hypertension, management of OH has unique challenges with few well established treatments. Not infrequently they both coexist, further compounding the management. This review provides comprehensive information on OH, including pathophysiology, diagnostic workup and treatment, with a view to provide a practical guide to its management. Special references are made to patients with supine hypertension and postprandial hypotension, and older hypertensive patients.
