Orthostatic hypotension is an independent predictor of mortality and the cause of significant morbidity associated with falls.
A common problem in frail older people. Orthostatic hypotension-related hospitalizations increase markedly with age.
Common causes include drugs (e.g., alpha-blockers, including tamsulosin [used for treating conditions such as benign prostatic hypertrophy], central sympatholytics, including tizanidine [used as a muscle relaxant], and diuretics), diseases causing peripheral neuropathy (e.g., diabetes mellitus), Parkinson disease, and dementia with Lewy bodies.
Primary neurodegenerative disorders of the autonomic nervous system (pure autonomic failure, and multiple system atrophy or Shy-Drager syndrome) are less common, but cause severe orthostatic hypotension.
Acute or subacute onset should suggest an autoimmune or paraneoplastic disorder.
Treatment consists of addressing any underlying pathology, when possible, followed by discontinuing or reducing the dose of aggravating drugs, and nonpharmacologic countermeasures (e.g., liberalization of salt intake, use of abdominal binders or compression stockings). Volume expansion (using mineralocorticoid therapy), short-acting vasopressors, or norepinephrine precursor therapy with droxidopa are adjunctive therapies when nonpharmacologic measures are insufficient.
Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing. When orthostatic hypotension has an underlying neurogenic cause (e.g., peripheral neuropathy) it is associated with a blunted increase in heart rate, typically less than 15 bpm. Orthostatic hypotension becomes clinically significant if it is accompanied by symptoms of cerebral hypoperfusion, which can lead to syncope and falls. Orthostatic hypotension is associated with increased risk of dementia and cardiovascular disease, and is an independent risk factor for all-cause mortality. This topic concentrates on orthostatic hypotension caused by autonomic problems.
History and exam
Key diagnostic factors
- older adult age
- use of high-risk medications
- underlying medical condition
- postural lightheadedness, 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
- older adult age
- frailty and physical deconditioning
- medications that impair sympathetic tone
- volume depletion/anemia
- autonomic neuropathy (e.g., diabetes mellitus)
- Parkinson disease
- dementia with Lewy bodies
- multiple system atrophy
1st investigations to order
- posture test
Investigations to consider
- tilt-table test
- plasma norepinephrine
- deep breathing
- Valsalva maneuver
- nerve conduction studies and electromyogram (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
Italo Biaggioni, MD
Professor of Medicine and Pharmacology
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
Department of Physiology and Neuroscience
NYU Langone Medical Center
LNK is a board member of the American Autonomic Society and has received grant support from Theravance Biopharma, PTC Therapeutics, National Institutes of Health, Michael J. Fox Foundation, and the Familial Dysautonomia Foundation. 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
HK is editor in chief of Clinical Autonomic Research and serves as principal investigator of a clinical trial sponsored by Biogen MA Inc. HK has received consultancy fees from Lilly USA LLC, Biohaven Pharmaceuticals Inc, Takeda Pharmaceutical Company Ltd, Ono Pharma UK Ltd, Lundbeck LLC, and Theravance Biopharma US Inc. HK is an author of a number of references cited in this topic.
Phillip A. Low, MD
Robert D. and Patricia E. Kern Professor of Neurology
Mayo Clinic College of Medicine
PAL is an author of a reference cited in this topic.
William P. Cheshire, MD
Professor of Neurology
WPC declares that he has no competing interests.
Alan Moore, MB, FRCPI
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.
- Neurally mediated (vasovagal) syncope
- Nonspecific falls in older people
- Consensus statement on the definition of neurogenic supine hypertension
- Guidelines on the diagnosis and management of syncope
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