Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- postural light-headedness, syncope, and other symptoms of cerebral hypoperfusion
Other diagnostic factors
- parkinsonian features
- cerebellar ataxia
- weight loss
- resting tachycardia or impaired heart rate variation
- abnormal gastrointestinal motility
- erectile dysfunction and lack of ejaculation
- anhidrosis, heat intolerance, dry skin, focal hyperhidrosis
- urinary frequency, urgency, nocturia
Risk factors
- older adult age
- frailty and physical deconditioning
- medications that impair sympathetic tone
- volume depletion/anaemia
- autonomic neuropathy (e.g., diabetes mellitus)
- Parkinson's disease
- Lewy body dementia
- multiple system atrophy
Diagnostic investigations
1st investigations to order
- posture test
Investigations to consider
- tilt-table test
- plasma noradrenaline (norepinephrine)
- deep breathing
- Valsalva manoeuvre
- nerve conduction studies and EMG
- quantitative sudomotor axon reflex test (QSART)
- heart rate variability
- 24-hour blood pressure monitoring
- autoimmune antibodies
- chest CT
- serum and urine electrophoresis
- fat-pad biopsy
- genetic testing
Treatment algorithm
all patients
Contributors
Authors
Italo Biaggioni, MD
Professor of Medicine and Pharmacology
Vanderbilt University
Nashville
TN
Disclosures
IB is a consultant for Theravance Biopharma and has received grant support from NIH, Theravance Biopharma, and Biohaven. IB holds a patent for an automated binder for the treatment of orthostatic hypotension. IB is an author of a number of references cited in this topic.
Lucy Norcliffe-Kaufmann, PhD
Assistant Professor
Dysautonomia Center
Department of Physiology and Neuroscience
NYU Langone Medical Center
New York
NY
Disclosures
LNK is a board member of the American Autonomic Society. LNK is an author of a number of references cited in this topic.
Horacio Kaufmann, MD
Professor of Neurology
Medicine and Pediatrics
New York University School of Medicine
New York
NY
Disclosures
HK has received compensation from Theravance Biopharma and Lundbeck as a consultant/advisory board member. HK is an author of a number of references cited in this topic.
Peer reviewers
Phillip A. Low, MD
Robert D. and Patricia E. Kern Professor of Neurology
Mayo Clinic College of Medicine
Rochester
MN
Disclosures
PAL is an author of a reference cited in this topic.
William P. Cheshire, MD
Professor of Neurology
Mayo Clinic
Jacksonville
FL
Disclosures
WPC declares that he has no competing interests.
Alan Moore, MB, FRCPI
Consultant Geriatrician
Beaumont Hospital
Dublin
Ireland
Disclosures
AM has received payment from Shire Pharmaceuticals, manufacturer of midodrine, for providing educational talks, and the department in which he works has received unrestricted educational grants from Shire Pharmaceuticals.
Differentials
- Neurally mediated (vasovagal) syncope
- Vertigo
- Non-specific falls in older people
More DifferentialsGuidelines
- Consensus statement on the definition of neurogenic supine hypertension
- Guidelines on the diagnosis and management of syncope
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