Last reviewed: 25 Oct 2020
Last updated: 29 Jul 2020

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

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
More investigations to consider

Treatment algorithm

Contributors

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.

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.

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 reviewersVIEW ALL

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.

Professor of Neurology

Mayo Clinic

Jacksonville

FL

Disclosures

WPC declares that he has no competing interests.

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.

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