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Holder AC, Dylewski A, Brown JN. Pyridostigmine for the Management of Neurogenic Orthostatic Hypotension: A Systemic Review. J Geriatr Psychiatry Neurol 2024:8919887241266800. [PMID: 39043171 DOI: 10.1177/08919887241266800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND Pyridostigmine is hypothesized to improve neurogenic orthostatic hypotension (nOH) symptoms without causing or exacerbating supine hypertension. The objective of this review was to evaluate the safety and efficacy of pyridostigmine for management of nOH. METHODS A literature search of PubMed, Embase, and CENTRAL was performed in December 2023 for prospective trials with a placebo or active comparator. RESULTS Four randomized and two non-randomized studies were reviewed. Three studies utilizing a single dose, crossover design found significant differences of orthostatics using adjunctive pyridostigmine. Two studies assessing longer-term endpoints demonstrated conflicting efficacy of pyridostigmine with one trial finding significant improvement in orthostatics and symptoms after three months of therapy. Use of pyridostigmine did not lead to supine hypertension with most adverse effects being cholinergic. CONCLUSION Pyridostigmine may be considered as an adjunctive medication in individuals with nOH refractory to standard treatment options as it carries a favorable safety profile with low risk for supine hypertension.
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Affiliation(s)
- Amanda C Holder
- Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Angela Dylewski
- Geriatric Research Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Jamie N Brown
- Pharmacy Service, Durham VA Health Care System, Durham, NC, USA
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2
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Kulkarni S, Wilkinson IB. Adrenoceptors and Hypertension. Handb Exp Pharmacol 2024. [PMID: 38890192 DOI: 10.1007/164_2024_719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Hypertension is a very prevalent condition associated with high mortality and morbidity, secondary to changes resulting in blood vessels and resultant end-organ damage. Haemodynamic changes, including an initial rise in cardiac output followed by an increase in total peripheral resistance, denote the early changes associated with borderline or stage 1 hypertension, especially in young men. Increased sodium reabsorption leading to kidney damage is another mechanism proposed as one of the initial triggers for essential hypertension. The underlying pathophysiological mechanisms include catecholamine-induced α1- and ß1-adrenoceptor stimulation, and renin-angiotensin-aldosterone system activation leading to endothelial dysfunction which is believed to lead to persistent blood pressure elevation.α1 blockers, α2 agonists, and ß blockers were among the first oral anti-hypertensives. They are no longer first-line therapy after outcome trials did not demonstrate any benefits over and above other agents, despite similar blood pressure reductions. Angiotensin-converting enzyme inhibitors (or angiotensin receptor blockers), calcium channel blockers, and thiazide-like diuretics are now considered the first line of therapy, although adrenoceptor agents still have a role as second- or third-line therapy. The chapter also highlights hypertension in specific medical conditions such as pregnancy, phaeochromocytoma, hyperthyroidism, portal hypertension, pulmonary arterial hypertension, and ocular hypertension, to provide an overview for clinicians and researchers interested in the role of adrenoceptors in the pathophysiology and management of hypertension.
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Affiliation(s)
- Spoorthy Kulkarni
- Department of Experimental Medicine and Immunotherapeutics, Vascular Research Clinic, ACCI Level 3, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ian B Wilkinson
- Department of Experimental Medicine and Immunotherapeutics, Vascular Research Clinic, ACCI Level 3, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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Peltier AC. Autonomic Dysfunction from Diagnosis to Treatment. Prim Care 2024; 51:359-373. [PMID: 38692780 DOI: 10.1016/j.pop.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Autonomic disorders can present with hypotension, gastrointestinal, genitourinary symptoms, and heat intolerance. Diabetes is the most common causes of autonomic failure, and management should focus on glucose control to prevent developing autonomic symptoms. The most prevalent cause of dysautonomia, or autonomic dysfunction, is Postural Orthostatic Tachycardia Syndrome (POTS). Autonomic testing characterizes causes for nonspecific symptoms but is not necessary in patients with classic presentations. Treatment for autonomic dysfunction and failure focus on discontinuing offending medications, behavioral modification, and pharmacologic therapy to decrease symptom severity. Autonomic failure has no cure; therefore, the focus remains on improving quality of life.
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Affiliation(s)
- Amanda C Peltier
- Department of Neurology, Vanderbilt University Medical Center, 1611 21st Avenue South, Nashville, TN 37232, USA; Department of Medicine, Vanderbilt University Medical Center, 1611 21st Avenue South, Nashville, TN 37232, USA.
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Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e16-e30. [PMID: 38205630 PMCID: PMC11067441 DOI: 10.1161/hyp.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.
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Vidal-Petiot E, Pathak A, Azulay JP, Pavy-Le Traon A, Hanon O. Orthostatic hypotension: Review and expert position statement. Rev Neurol (Paris) 2024; 180:53-64. [PMID: 38123372 DOI: 10.1016/j.neurol.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20mmHg or a drop in diastolic blood pressure of at least 10mmHg within 3minutes of standing. It is a common disorder, especially in high-risk populations such as elderly subjects and patients with neurological diseases, and is associated with markedly increased morbidity and mortality. Its management can be challenging, particularly in cases where supine hypertension is associated with severe orthostatic hypotension. Education of the patient, non-pharmacological measures, and drug adaptation are the cornerstones of treatment. Pharmacological treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions. First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases.
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Affiliation(s)
- E Vidal-Petiot
- Service de physiologie, ESH Excellence Center, hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; INSERM U1148, Université Paris-Cité and Université Sorbonne Paris Nord, LVTS, 75018 Paris, France.
| | - A Pathak
- Service de cardiologie, ESH Excellence Center, centre hospitalier Princesse Grace, 1, avenue Pasteur, 98000 Monaco, France
| | - J-P Azulay
- Service de neurologie et pathologie du mouvement, hôpital de la Timone, 13385 Marseille cedex 05, France
| | - A Pavy-Le Traon
- Service de neurologie, CHU de Toulouse, 31059 Toulouse cedex, France; UMR 1297, institut des maladies métaboliques et cardiovasculaires, Toulouse, France
| | - O Hanon
- Service de gériatrie, université Paris-Cité, EA4468, hôpital Broca, AP-HP, 75013 Paris, France
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Skylynn T, Abel T, Christopher L, Suliman G, Dominic R, Joel V, Yu Z, Pemminati S. Benefits and Risks of Medications Used in the Management of Hypotension: A Review. Cureus 2024; 16:e51608. [PMID: 38313995 PMCID: PMC10837047 DOI: 10.7759/cureus.51608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
This comprehensive literature review addresses the scarcity and limited study of hypotension treatments compared to abundant antihypertensive drugs. Hypotension, categorized as absolute, relative, or orthostatic, has diverse causes. This review explores various treatments, including drugs affecting the sympathetic nervous system, such as midodrine, dihydroergotamine, and ergotamine, which have shown efficacy in managing hypotension. Dopamine agonists/antagonists and other drugs such as ephedrine, norepinephrine, and fludrocortisone are also discussed, each with distinct mechanisms and applications. Additionally, adjunctive agents such as non-steroidal anti-inflammatory agents, caffeine, and monoamine oxidase inhibitors are reviewed for their effects on blood pressure. This review underscores the importance of understanding the efficacy and safety profiles of hypotension treatments to guide healthcare professionals in optimal drug selection and management, emphasizing the need for further research and comparative studies for evidence-based guidelines.
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Affiliation(s)
- Thangwaritorn Skylynn
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Thomas Abel
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Lee Christopher
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Ghafary Suliman
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Rivera Dominic
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Varughese Joel
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Zeyu Yu
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Sudhakar Pemminati
- Department of Pharmacology, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
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Sharma N, Sistla R, Andugulapati SB. Yohimbine ameliorates liver inflammation and fibrosis by regulating oxidative stress and Wnt/β-catenin pathway. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 123:155182. [PMID: 37952411 DOI: 10.1016/j.phymed.2023.155182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/17/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND AND PURPOSE Chronic liver injury, caused by various aetiologies, causes recurrent tissue damage, culminating in decreased liver regenerative ability and resulting in fibrosis followed by cirrhosis. In this study, the anti-fibrotic activity of Yohimbine hydrochloride (YHC) was investigated using various in vitro models and in vivo models. METHODS To assess the anti-inflammatory, antioxidant, and anti-fibrotic effects of YHC, lipopolysaccharide or TGF-β induced differentiation or lipid-induced oxidative-stress models were employed using HLECs, HSC-LX2, and HepG2 cells. Further, thioacetamide (TAA) induced hepatic inflammation/fibrosis models were utilized to validate the YHC's anti-fibrotic activity in rats. RESULTS Inflammation/differentiation experiments in HLECs and HSC-LX2 revealed that YHC treatment significantly (p < 0.001) mitigated the lipopolysaccharide or TGF-β induced upregulation of inflammatory and fibrotic markers expression respectively. In addition, YHC dose-dependently reduced the TGF-β induced migration and palmitic acid-induced oxidative stress in HepG2 cells. Further, TAA administration (5 weeks) in vivo rat model showed increased inflammatory marker levels/expression, oxidative stress, and pathological abnormalities. Additionally, TAA administration (9 weeks) elevated the fibrotic marker expression, collagen deposition in liver tissues, and shortened longevity in rats. Treatment with YHC dose-dependently mitigated the TAA-induced abnormalities in both inflammation and fibrosis models and improved the survival of the rats. Further mechanistic approaches revealed that TAA administration elevated the JNK, Wnt components and β-catenin expression in hepatic stellate cells and animal tissues. Further treatment with YHC significantly modulated the JNK/Wnt/β-catenin signaling. Moreover, the β-catenin nuclear translocation results showed that β-catenin levels were significantly elevated in the nuclear fraction of TAA control samples and reduced in YHC-treated samples. CONCLUSION Yohimbine treatment significantly improved inflammation and fibrosis by inhibiting differentiation, oxidative stress, and collagen deposition by partly modulating the JNK/Wnt/β-catenin pathway. These results might serve as a foundation for proposing yohimbine as a potential lead compound for liver fibrosis.
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Affiliation(s)
- Nidhi Sharma
- Department of Applied Biology, CSIR-Indian Institute of Chemical Technology, Hyderabad-500 007, Telangana, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh-201 002, India
| | - Ramakrishna Sistla
- Department of Applied Biology, CSIR-Indian Institute of Chemical Technology, Hyderabad-500 007, Telangana, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh-201 002, India
| | - Sai Balaji Andugulapati
- Department of Applied Biology, CSIR-Indian Institute of Chemical Technology, Hyderabad-500 007, Telangana, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh-201 002, India.
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Chen B, Yang W, Luo Y, Tan EK, Wang Q. Non-pharmacological and drug treatment of autonomic dysfunction in multiple system atrophy: current status and future directions. J Neurol 2023; 270:5251-5273. [PMID: 37477834 DOI: 10.1007/s00415-023-11876-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic, fatal, and rapidly progressive neurodegenerative disease of unknown etiology that is clinically characterized by autonomic failure, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. Early onset and extensive autonomic dysfunction, including cardiovascular dysfunction characterized by orthostatic hypotension (OH) and supine hypertension, urinary dysfunction characterized by overactive bladder and incomplete bladder emptying, sexual dysfunction characterized by sexual desire deficiency and erectile dysfunction, and gastrointestinal dysfunction characterized by delayed gastric emptying and constipation, are the main features of MSA. Autonomic dysfunction greatly reduces quality of life and increases mortality. Therefore, early diagnosis and intervention are urgently needed to benefit MSA patients. In this review, we aim to discuss the systematic treatment of autonomic dysfunction in MSA, and focus on the current methods, starting from non-pharmacological methods, such as patient education, psychotherapy, diet change, surgery, and neuromodulation, to various drug treatments targeting autonomic nerve and its projection fibers. In addition, we also draw attention to the interactions among various treatments, and introduce novel methods proposed in recent years, such as gene therapy, stem cell therapy, and neural prosthesis implantation. Furthermore, we elaborate on the specific targets and mechanisms of action of various drugs. We would like to call for large-scale research to determine the efficacy of these methods in the future. Finally, we point out that studies on the pathogenesis of MSA and pathophysiological mechanisms of various autonomic dysfunction would also contribute to the development of new promising treatments and concepts.
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Affiliation(s)
- BaoLing Chen
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Wanlin Yang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Yuqi Luo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Eng-King Tan
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China.
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Prajjwal P, Flores Sanga HS, Acharya K, Tango T, John J, Rodriguez RS, Dheyaa Marsool Marsool M, Sulaimanov M, Ahmed A, Hussin OA. Parkinson's disease updates: Addressing the pathophysiology, risk factors, genetics, diagnosis, along with the medical and surgical treatment. Ann Med Surg (Lond) 2023; 85:4887-4902. [PMID: 37811009 PMCID: PMC10553032 DOI: 10.1097/ms9.0000000000001142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/31/2023] [Indexed: 10/10/2023] Open
Abstract
After only Alzheimer's disease (AD), Parkinson's disease (PD) is the second most prevalent neurodegenerative disease. The incidence of this disease increases with age, especially for those above 70 years old. There are many risk factors that are well-established in the contribution to the development of PD, such as age, gender, ethnicity, rapid eye movement sleep disorder, high consumption of dairy products, traumatic brain injury, genetics, and pesticides/herbicides. Interestingly, smoking, consumption of caffeine, and physical activities are the protective factors of PD. A deficiency of dopamine in the substantia nigra of the brainstem is the main pathology. This, subsequently, alters the neurotransmitter, causing an imbalance between excitatory and inhibitory signals. In addition, genetics is also involved in the pathogenesis of the disease. As a result, patients exhibit characteristic motor symptoms such as tremors, stiffness, bradykinesia, and postural instability, along with non-motor symptoms, including dementia, urinary incontinence, sleeping disturbances, and orthostatic hypotension. PD may resemble other diseases; therefore, it is important to pay attention to the diagnosis criteria. Parkinson's disease dementia can share common features with AD; this can include behavioral as well as psychiatric symptoms, in addition to the pathology being protein aggregate accumulation in the brain. For PD management, the administration of pharmacological treatment depends on the motor symptoms experienced by the patients. Non-pharmacological treatment plays a role as adjuvant therapy, while surgical management is indicated in chronic cases. This paper aims to review the etiology, risk factors, protective factors, pathophysiology, signs and symptoms, associated conditions, and management of PD.
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Affiliation(s)
| | - Herson S Flores Sanga
- Department of Telemedicine, Hospital Nacional Carlos Alberto Seguin Escobedo, Arequipa, Peru
| | - Kirtish Acharya
- Maharaja Krishna Chandra Gajapati Medical College and Hospital, Brahmapur, Odisha
| | - Tamara Tango
- Faculty of Medicine Universitas, Jakarta, Indonesia
| | - Jobby John
- Dr. Somervell Memorial CSI Medical College and Hospital, Neyyāttinkara, Kerala, India
| | | | | | | | - Aneeqa Ahmed
- Shadan Hospital and Institute of Medical Sciences, Hyderabad, Telangana
| | - Omniat A. Hussin
- Department of Medicine, Sudan Academy of Sciences, Khartoum, Sudan
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10
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Stanford SC, Heal DJ. Adrenoceptors: A Focus on Psychiatric Disorders and Their Treatments. Handb Exp Pharmacol 2023. [PMID: 37495853 DOI: 10.1007/164_2023_675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Research into the involvement of adrenoceptor subtypes in the cause(s) of psychiatric disorders is particularly challenging. This is partly because of difficulties in developing animal models that recapitulate the human condition but also because no evidence for any causal links has emerged from studies of patients. These, and other obstacles, are outlined in this chapter. Nevertheless, many drugs that are used to treat psychiatric disorders bind to adrenoceptors to some extent. Direct or indirect modulation of the function of specific adrenoceptor subtypes mediates all or part of the therapeutic actions of drugs in various psychiatric disorders. On the other hand, interactions with central or peripheral adrenoceptors can also explain their side effects. This chapter discusses both aspects of the field, focusing on disorders that are prevalent: depression, schizophrenia, anxiety, attention-deficit hyperactivity disorder, binge-eating disorder, and substance use disorder. In so doing, we highlight some unanswered questions that need to be resolved before it will be feasible to explain how changes in the function of any adrenoceptor subtype affect mood and behavior in humans and other animals.
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Affiliation(s)
- S Clare Stanford
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK.
| | - David J Heal
- DevelRx Ltd, BioCity, Nottingham, UK
- Department of Life Sciences, University of Bath, Bath, UK
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11
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Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol 2022; 21:735-746. [PMID: 35841911 PMCID: PMC10024337 DOI: 10.1016/s1474-4422(22)00169-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/24/2023]
Abstract
Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.
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Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; UCL Queen Square Institute of Neurology, University College London, London, UK; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Advances in the Pathophysiology and Management of Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension. Curr Hypertens Rep 2022; 24:45-54. [PMID: 35230654 PMCID: PMC9553128 DOI: 10.1007/s11906-022-01168-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Patients with neurogenic orthostatic hypotension (OH) frequently have hypertension in the supine position (sHTN). We review the controversies surrounding the need and safety of treating sHTN in patients with OH. RECENT FINDINGS The presence of sHTN complicates the management of OH because treatment of one can worsen the other. New approaches have been developed to treat OH without worsening sHTN by preferentially improving standing blood pressure, such as medications that harness the patient's residual sympathetic tone like pyridostigmine and atomoxetine, and devices such as an automated abdominal binder that targets the inappropriate splanchnic venous pooling causing OH. There is a reluctance to treat sHTN for fear of increasing the risks of falls and syncope associated with OH, thought to be more immediate and dangerous than the late complications of organ damage associated with sHTN. This, however, does not take into account that nighttime sHTN induces natriuresis, volume loss, and begets daytime orthostatic hypotension. It is possible to treat sHTN in ways that reduce the risk of worsening OH. Furthermore, novel approaches, such as the use of local heat can control nighttime sHTN, reduce nocturia, and improve OH. Although continued progress is needed, recent findings offer hope that we can treat nocturnal sHTN and at the same time improve daytime OH, lessening the controversy whether to treat or not sHTN.
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Isaacson SH, Dashtipour K, Mehdirad AA, Peltier AC. Management Strategies for Comorbid Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension. Curr Neurol Neurosci Rep 2021; 21:18. [PMID: 33687577 PMCID: PMC7943503 DOI: 10.1007/s11910-021-01104-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In autonomic failure, neurogenic orthostatic hypotension (nOH) and neurogenic supine hypertension (nSH) are interrelated conditions characterized by postural blood pressure (BP) dysregulation. nOH results in a sustained BP drop upon standing, which can lead to symptoms that include lightheadedness, orthostatic dizziness, presyncope, and syncope. nSH is characterized by elevated BP when supine and, although often asymptomatic, may increase long-term cardiovascular and cerebrovascular risk. This article reviews the pathophysiology and clinical characteristics of nOH and nSH, and describes the management of patients with both nOH and nSH. RECENT FINDINGS Pressor medications required to treat the symptoms of nOH also increase the risk of nSH. Because nOH and nSH are hemodynamically opposed, therapies to treat one condition may exacerbate the other. The management of patients with nOH who also have nSH can be challenging and requires an individualized approach to balance the short- and long-term risks associated with these conditions. Approaches to manage neurogenic BP dysregulation include nonpharmacologic approaches and pharmacologic treatments. A stepwise treatment approach is presented to help guide neurologists in managing patients with both nOH and nSH.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, 951 NW 13th Street, Bldg. 5-E, Boca Raton, FL, USA.
| | - Khashayar Dashtipour
- Division of Movement Disorders, Department of Neurology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ali A Mehdirad
- Wright State University, Dayton VA Medical Center, Dayton, OH, USA
| | - Amanda C Peltier
- Department of Neurology and Medicine, Vanderbilt University, Nashville, TN, USA
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15
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Shibao CA, Biaggioni I. Management of Orthostatic Hypotension, Postprandial Hypotension, and Supine Hypertension. Semin Neurol 2020; 40:515-522. [PMID: 33058087 DOI: 10.1055/s-0040-1713886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This review provides recommendations for the treatment of neurogenic orthostatic hypotension (nOH), postprandial hypotension, and supine hypertension. It focuses on novel treatment strategies and new insights into the mechanism underlying these conditions. Our goal is to provide practical advice for clinicians on how to screen, diagnose, and treat these conditions with nonpharmacological and pharmacological approaches. For each disorder, we offered a stepwise recommendation on how to apply these new concepts to successfully ameliorate the symptoms associated with OH to prevent syncope and falls. The management of OH in patients who also have supine hypertension requires special considerations and pharmacotherapy. It is noteworthy that there are few therapeutic options for OH and only two Food and Drug Administration-approved drugs for the treatment of OH and nOH based on randomized clinical trials. We will use these studies to develop evidence-based guidelines for OH. The research is limited for postprandial hypotension and supine hypertension, and therefore the recommendations will be based on small studies, clinical expertise, and, above all, an understanding of the underlying pathophysiology.
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Affiliation(s)
- Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Park JW, Okamoto LE, Shibao CA, Biaggioni I. Pharmacologic treatment of orthostatic hypotension. Auton Neurosci 2020; 229:102721. [PMID: 32979782 DOI: 10.1016/j.autneu.2020.102721] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/18/2020] [Accepted: 08/23/2020] [Indexed: 12/20/2022]
Abstract
Neurogenic orthostatic hypotension (OH) is a disabling disorder caused by impairment of the normal autonomic compensatory mechanisms that maintain upright blood pressure. Nonpharmacologic treatment is always the first step in the management of this condition, but a considerable number of patients will require pharmacologic therapies. Denervation hypersensitivity and impairment of baroreflex buffering makes these patients sensitive to small doses of pressor agents. Understanding the underlying pathophysiology can help in selecting between treatment options. In general, patients with low "sympathetic reserve", i.e., those with peripheral noradrenergic degeneration (pure autonomic failure, Parkinson's disease) and low plasma norepinephrine, tend to respond better to "norepinephrine replacers" (midodrine and droxidopa). On the other hand, patients with relatively preserved "sympathetic reserve", i.e., those with impaired central autonomic pathways but spared peripheral noradrenergic fibers (multiple system atrophy) and normal or slightly reduced plasma norepinephrine, tend to respond better to "norepinephrine enhancers" (pyridostigmine, atomoxetine, and yohimbine). There is, however, a spectrum of responses within these extremes, and treatment should be individualized. Other nonspecific treatments include fludrocortisone and octreotide. The presence of associated clinical conditions, such as supine hypertension, heart failure, postprandial hypotension, PD, MSA, and diabetes need to be considered in the pharmacologic management of these patients.
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Affiliation(s)
- Jin-Woo Park
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Institute for Inflammation Control, Korea University, Seoul, Republic of Korea
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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17
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Soloveva A, Fedorova D, Villevalde S, Zvartau N, Mareev Y, Sitnikova M, Shlyakhto E, Fudim M. Addressing Orthostatic Hypotension in Heart Failure: Pathophysiology, Clinical Implications and Perspectives. J Cardiovasc Transl Res 2020; 13:549-569. [PMID: 32748206 DOI: 10.1007/s12265-020-10044-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022]
Abstract
Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities contributing to OH, as well as a high prevalence of medications with neurovascular and volume modulating properties. Early identification of OH in HF seems to be crucial as OH can have an impact on patient symptoms, activity level and independence, be a marker of specific pathophysiological changes or be an indicator of need for personalized treatment. OH might contribute significantly to bad enough prognosis in HF, as, besides a risk of falls and cognitive decline, it was found to be associated with cardiovascular morbidity and mortality. In this review, we aimed to incentivize the routine use of orthostatic testing in HF, as well as stimulate future research in this field, which could lead to significant advances in the treatment and outcomes.
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Affiliation(s)
- Anzhela Soloveva
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Darya Fedorova
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Svetlana Villevalde
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Nadezhda Zvartau
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Yury Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russian Federation
| | - Mariya Sitnikova
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Evgeny Shlyakhto
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
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18
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Dixon DD, Muldowney JAS. Management of neurogenic orthostatic hypotension in the heart failure patient. Auton Neurosci 2020; 227:102691. [PMID: 32559655 DOI: 10.1016/j.autneu.2020.102691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
Neurogenic orthostatic hypotension (nOH) is a common comorbidity in patients with neurodegenerative diseases. It is associated with an increased risk of falls, incident cardiovascular disease, and all-cause mortality. There are over 5 million individuals in the U.S. with heart failure (HF) with an associated 50% mortality rate at 5 years. The prevalence of nOH and HF increase with age and, as the population continues to age, will be increasingly common comorbid conditions. Thus, the effective management of these conditions has important implications for public health. The management of orthostatic hypotension in the context of congestive heart failure is challenging due to the fact that the fundamental principles of management of these disease states are in opposition to each other. In this review, we will discuss the principles of management of nOH and HF and outline strategies for the effective treatment of these comorbid conditions.
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Affiliation(s)
- Debra D Dixon
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - James A S Muldowney
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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19
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Olshansky B, Muldowney J. Cardiovascular Safety Considerations in the Treatment of Neurogenic Orthostatic Hypotension. Am J Cardiol 2020; 125:1582-1593. [PMID: 32204870 DOI: 10.1016/j.amjcard.2020.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 12/17/2022]
Abstract
Neurogenic orthostatic hypotension (nOH), a drop in blood pressure upon standing resulting from autonomic malfunction, may cause debilitating symptoms that can affect independence in daily activities and quality-of-life. nOH may also be associated with cardiovascular comorbidities (e.g., supine hypertension, heart failure, diabetes, and arrhythmias), making treatment decisions complicated and requiring management that should be based on a patient's cardiovascular profile. Additionally, drugs used to treat the cardiovascular disorders (e.g., vasodilators, β-blockers) can exacerbate nOH and concomitant symptoms. When orthostatic symptoms are severe and not effectively managed with nonpharmacologic strategies (e.g., water ingestion, abdominal compression), droxidopa or midodrine may be effective. Droxidopa may be less likely than midodrine to exacerbate supine hypertension, based on conclusions of a limited meta-analysis. In conclusion, treating nOH in patients with cardiovascular conditions requires a balance between symptom relief and minimizing adverse outcomes.
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20
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Quarracino C, Otero-Losada M, Capani F, Pérez-Lloret S. State-of-the-art pharmacotherapy for autonomic dysfunction in Parkinson’s disease. Expert Opin Pharmacother 2020; 21:445-457. [DOI: 10.1080/14656566.2020.1713097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Cecilia Quarracino
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Matilde Otero-Losada
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Francisco Capani
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Santiago Pérez-Lloret
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
- Department of Physiology, School of Medicine, University of Buenos Aires (UBA), Buenos Aires, Argentina
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21
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Affiliation(s)
- Horacio Kaufmann
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York
| | - Lucy Norcliffe-Kaufmann
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York
| | - Jose-Alberto Palma
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York
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22
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Okamoto LE, Shibao CA, Gamboa A, Diedrich A, Raj SR, Black BK, Robertson D, Biaggioni I. Synergistic Pressor Effect of Atomoxetine and Pyridostigmine in Patients With Neurogenic Orthostatic Hypotension. Hypertension 2019; 73:235-241. [PMID: 30571543 DOI: 10.1161/hypertensionaha.118.11790] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with autonomic failure are characterized by disabling orthostatic hypotension because of impaired sympathetic activity, but even severely affected patients have residual sympathetic tone which can be harnessed for their treatment. For example, norepinephrine transporter blockade with atomoxetine raises blood pressure (BP) in autonomic failure patients by increasing synaptic norepinephrine concentrations; acetylcholinesterase inhibition with pyridostigmine increases BP by facilitating ganglionic cholinergic neurotransmission to increase sympathetic outflow. We tested the hypothesis that pyridostigmine will potentiate the pressor effect of atomoxetine and improve orthostatic tolerance and symptoms in patients with severe autonomic failure. Twelve patients received a single oral dose of either placebo, pyridostigmine 60 mg, atomoxetine 18 mg or the combination on separate days in a single blind, crossover study. BP was assessed seated and standing before and 1-hour postdrug. In these severely affected patients, neither pyridostigmine nor atomoxetine improved BP or orthostatic tolerance compared with placebo. The combination, however, significantly increased seated BP in a synergistic manner (133±9/80±4 versus 107±6/66±4 mm Hg for placebo, 105±5/67±3 mm Hg for atomoxetine, and 99±6/64±4 mm Hg for pyridostigmine; P<0.001); the maximal increase in seated BP with the combination was 33±8/18±3 mm Hg at 60 minutes postdrug. Only the combination showed a significant improvement of orthostatic tolerance and symptoms. In conclusion, the combination pyridostigmine and atomoxetine had a synergistic effect on seated BP which was associated with improvement in orthostatic tolerance and symptoms. This pharmacological approach could be useful in patients with severe autonomic failure but further safety and long-term efficacy studies are needed.
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Affiliation(s)
- Luis E Okamoto
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Cyndya A Shibao
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Alfredo Gamboa
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - André Diedrich
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Biomedical Engineering (A.D.), Vanderbilt University School of Medicine, Nashville, TN
| | - Satish R Raj
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (S.R.R.)
| | - Bonnie K Black
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Robertson
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Neurology (D.R.), Vanderbilt University School of Medicine, Nashville, TN
| | - Italo Biaggioni
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
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Sarafis ZK, Monga AK, Phillips AA, Krassioukov AV. Is Technology for Orthostatic Hypotension Ready for Primetime? PM R 2019; 10:S249-S263. [PMID: 30269810 DOI: 10.1016/j.pmrj.2018.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/04/2018] [Accepted: 04/12/2018] [Indexed: 01/29/2023]
Abstract
Spinal cord injury (SCI) often results in the devastating loss of motor, sensory, and autonomic function. After SCI, the interruption of descending sympathoexcitatory pathways disrupts supraspinal control of blood pressure (BP). A common clinical consequence of cardiovascular dysfunction after SCI is orthostatic hypotension (OH), a debilitating condition characterized by rapid profound decreases in BP when assuming an upright posture. OH can result in a diverse array of insidious and pernicious health consequences. Acute effects of OH include decreased cardiac filling, cerebral hypoperfusion, and associated presyncopal symptoms such as lightheadedness and dizziness. Over the long term, repetitive exposure to OH is associated with a drastically increased prevalence of heart attack and stroke, which are leading causes of death in those with SCI. Current recommendations for managing BP after SCI primarily include pharmacologic interventions with prolonged time to effect. Because most episodes of OH occur in less than 3 minutes, this delay in action often renders most pharmacologic interventions ineffective. New innovative technologies such as epidural and transcutaneous spinal cord stimulation are being explored to solve this problem. It might be possible to electrically stimulate sympathetic circuitry caudal to the injury and elicit rapid modulation of BP to manage OH. This review describes autonomic control of the cardiovascular system before injury, resulting cardiovascular consequences after SCI such as OH, and the clinical assessment tools for evaluating autonomic dysfunction after SCI. In addition, current approaches for clinically managing OH are outlined, and new promising interventions are described for managing this condition.
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Affiliation(s)
- Zoe K Sarafis
- ICORD-BSCC, University of British Columbia, Vancouver, BC, Canada(∗)
| | - Aaron K Monga
- ICORD-BSCC, University of British Columbia, Vancouver, BC, Canada(†)
| | - Aaron A Phillips
- Departments of Physiology and Pharmacology, Clinical Neurosciences, Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada(‡)
| | - Andrei V Krassioukov
- ICORD-BSCC; Experimental Medicine Program; Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia; GF Strong Rehabilitation Center, Vancouver Coastal Health; 818 West 10th Avenue, Vancouver, BC, Canada, V5Z1M9(§).
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24
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Mucke HA. Drug Repurposing Patent Applications January–March 2019. Assay Drug Dev Technol 2019; 17:255-260. [DOI: 10.1089/adt.2019.938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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25
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The effect of pyridostigmine on small intestinal bacterial overgrowth (SIBO) and plasma inflammatory biomarkers in HIV-associated autonomic neuropathies. J Neurovirol 2019; 25:551-559. [PMID: 31098925 DOI: 10.1007/s13365-019-00756-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Indexed: 01/08/2023]
Abstract
Small intestinal bacterial overgrowth (SIBO) is common among patients with HIV-associated autonomic neuropathies (HIV-AN) and may be associated with increased bacterial translocation and elevated plasma inflammatory biomarkers. Pyridostigmine is an acetylcholinesterase inhibitor which has been used to augment autonomic signaling. We sought preliminary evidence as to whether pyridostigmine could improve proximal gastrointestinal motility, reduce SIBO, reduce plasma sCD14 (a marker of macrophage activation and indirect measure of translocation), and reduce the inflammatory cytokines IL-6 and TNFα in patients with HIV-AN. Fifteen participants with well-controlled HIV, HIV-AN, and SIBO were treated with 8 weeks of pyridostigmine (30 mg PO TID). Glucose breath testing for SIBO, gastric emptying studies (GES) to assess motility, plasma sCD14, IL-6, and TNFα, and gastrointestinal autonomic symptoms were compared before and after treatment. Thirteen participants (87%) experienced an improvement in SIBO following pyridostigmine treatment; with an average improvement of 50% (p = 0.016). There was no change in gastrointestinal motility; however, only two participants met GES criteria for gastroparesis at baseline. TNFα and sCD14 levels declined by 12% (p = 0.004) and 19% (p = 0.015), respectively; there was no significant change in IL-6 or gastrointestinal symptoms. Pyridostigmine may ameliorate SIBO and reduce levels of sCD14 and TNFα in patients with HIV-AN. Larger placebo-controlled studies are needed to definitively delineate how HIV-AN affects gastrointestinal motility, SIBO, and systemic inflammation in HIV, and whether treatment improves clinical outcomes.
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26
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Pérez-Lloret S, Quarracino C, Otero-Losada M, Rascol O. Droxidopa for the treatment of neurogenic orthostatic hypotension in neurodegenerative diseases. Expert Opin Pharmacother 2019; 20:635-645. [PMID: 30730771 DOI: 10.1080/14656566.2019.1574746] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION L-threo-3,4-dihydroxyphenylserine (droxidopa), a pro-drug metabolized to norepinephrine in nerve endings and other tissues, has been commercially available in Japan since 1989 for treating orthostatic hypotension symptoms in Parkinson's disease (PD) patients with a Hoehn & Yahr stage III rating, as well as patients with Multiple System Atrophy (MSA), familial amyloid polyneuropathy, and hemodialysis. Recently, the FDA has approved its use in symptomatic neurogenic orthostatic hypotension (NOH). Areas covered: The authors review the effects of droxidopa in NOH with a focus on the neurodegenerative diseases PD, MSA, and pure autonomic failure (PAF). Expert opinion: A few small and short placebo-controlled clinical trials in NOH showed significant reductions in the manometric drop in blood pressure (BP) after posture changes or meals. Larger Phase III studies showed conflicting results, with two out of four trials meeting their primary outcome and thus suggesting a positive yet short-lasting effect of the drug on OH Questionnaire composite score, light-headedness/dizziness score, and standing BP during the first two treatment-weeks. Results appear essentially similar in PD, MSA, and PAF. The FDA granted droxidopa approval in the frame of an 'accelerated approval program' provided further studies are conducted to assess its long-term effects on OH symptoms.
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Affiliation(s)
- Santiago Pérez-Lloret
- a Instituto de Investigaciones Cardiológicas , University of Buenos Aires, National Research Council (ININCA-UBA-CONICET) , Buenos Aires , Argentina.,b Department of Physiology , School of Medicine, University of Buenos Aires (UBA) , Buenos Aires , Argentina
| | - Cecilia Quarracino
- a Instituto de Investigaciones Cardiológicas , University of Buenos Aires, National Research Council (ININCA-UBA-CONICET) , Buenos Aires , Argentina
| | - Matilde Otero-Losada
- a Instituto de Investigaciones Cardiológicas , University of Buenos Aires, National Research Council (ININCA-UBA-CONICET) , Buenos Aires , Argentina
| | - Olivier Rascol
- c Services de Pharmacologie Clinique et Neurosciences, Centre d'Investigation Clinique CIC 1436, NS-Park/FCRIN Network, NeuroToul COEN Center , Université de Toulouse UPS, CHU de Toulouse, INSERM , Toulouse , France
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27
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Aljohar A, Muayqil T, Aldeeri A, Jammah A, Hersi A, Alhabib K. Pure Autonomic Failure with Asymptomatic Hypertensive Urgency: A Case Report and Literature Review. Case Rep Neurol 2018; 10:357-362. [PMID: 30687067 PMCID: PMC6341310 DOI: 10.1159/000495605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/19/2018] [Indexed: 11/19/2022] Open
Abstract
We report the case study of a 70-year-old gentleman who presented with isolated, slowly progressive dizziness after prolonged standing and was eventually diagnosed with pure autonomic failure. Initially, his symptoms improved with the use of midodrine and fludrocortisone, but gradually became refractory and disabling. Despite multiple therapeutic interventions, his symptoms persisted along with worsening supine hypertension. We discuss the challenges faced in the treatment of an uncommon condition and discuss the clinical utility of performing serial 24-h ambulatory monitoring to detect subclinical blood pressure fluctuations.
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Affiliation(s)
- Alwaleed Aljohar
- Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Taim Muayqil
- Division of Neurology, Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Aldeeri
- Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Anwar Jammah
- Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Hersi
- Department of Adult Cardiology, King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Alhabib
- Department of Adult Cardiology, King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
- *Prof. Khalid Alhabib, Department of Adult Cardiology, King Fahad Cardiac Center, King Saud University, PO Box 7805, Riyadh 11472 (Saudi Arabia), E-Mail
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Biaggioni I. Orthostatic Hypotension in the Hypertensive Patient. Am J Hypertens 2018; 31:1255-1259. [PMID: 29982276 DOI: 10.1093/ajh/hpy089] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/27/2018] [Indexed: 12/29/2022] Open
Abstract
Orthostatic hypotension (OH) is an important and common medical problem, particularly in the frail elderly with multiple comorbidities and polypharmacy. OH is an independent risk factor for falls and overall mortality. Hypertension is among the most common comorbidities associated with OH, and its presence complicates the management of these patients because treatment of one can worsen the other. However, there is evidence that uncontrolled hypertension worsens OH so that both should be managed. The limited data available suggest that angiotensin receptor blockers and calcium channel blockers are preferable antihypertensives for these patients. Patients with isolated supine hypertension can be treated with bedtime doses of short-acting antihypertensives. Treatment of OH in the hypertensive patients should focus foremost on the removal of drugs that can worsen OH, including ones that are easily overlooked, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol. OH and postprandial hypotension can be prevented with abdominal binders and acarbose, respectively, without the need to increase baseline blood pressure. Upright blood pressure can be improved by harnessing residual sympathetic tone with atomoxetine, which blocks norepinephrine reuptake in nerve terminals, and pyridostigmine, which facilitates cholinergic neurotransmission in autonomic ganglia. Oral water bolus acutely but transiently increases blood pressure in autonomic failure patients. If traditional pressor agents are needed, midodrine and droxidopa can be used, administered at the lowest dose and frequency that improves symptoms. Management of OH in the hypertensive patient is challenging, but a management strategy based on understanding the underlying pathophysiology can be effective in most patients.
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Affiliation(s)
- Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, and Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Tennessee, USA
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Cheshire WP. Chemical pharmacotherapy for the treatment of orthostatic hypotension. Expert Opin Pharmacother 2018; 20:187-199. [DOI: 10.1080/14656566.2018.1543404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Godbole GP, Aggarwal B. Review of management strategies for orthostatic hypotension in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gauri P. Godbole
- Gosford Hospital Pharmacy Department; Central Coast Local Health District; Gosford Australia
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31
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Chisholm P, Anpalahan M. Orthostatic hypotension: pathophysiology, assessment, treatment and the paradox of supine hypertension. Intern Med J 2017; 47:370-379. [PMID: 27389479 DOI: 10.1111/imj.13171] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/12/2016] [Accepted: 06/27/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Peter Chisholm
- Eastern Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mahesan Anpalahan
- Eastern Health, The University of Melbourne, Melbourne, Victoria, Australia.,North West Academic Centre, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Abstract
Cardiovascular autonomic dysfunctions, including neurogenic orthostatic hypotension, supine hypertension and post-prandial hypotension, are relatively common in patients with Parkinson disease. Recent evidence suggests that early autonomic impairment such as cardiac autonomic denervation and even neurogenic orthostatic hypotension occur prior to the appearance of the typical motor deficits associated with the disease. When neurogenic orthostatic hypotension develops, patients with Parkinson disease have an increased risk of mortality, falls, and trauma-related to falls. Neurogenic orthostatic hypotension reduces quality of life and contributes to cognitive decline and physical deconditioning. The co-existence of supine hypertension complicates the treatment of neurogenic orthostatic hypotension because it involves the use of drugs with opposing effects. Furthermore, treatment of neurogenic orthostatic hypotension is challenging because of few therapeutic options; in the past 20 years, the US Food and Drug Administration approved only two drugs for the treatment of this condition. Small, open-label or randomized studies using acute doses of different pharmacologic probes suggest benefit of other drugs as well, which could be used in individual patients under close monitoring. This review describes the pathophysiology of neurogenic orthostatic hypotension and supine hypertension in Parkinson disease. We discuss the mode of action and therapeutic efficacy of different pharmacologic agents used in the treatment of patients with cardiovascular autonomic failure.
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Affiliation(s)
- Cyndya A. Shibao
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, TN
| | - Horacio Kaufmann
- Department of Neurology, NYU Langone Medical Center, Dysautonomia Center, 530 1st Avenue, New York, NY, USA.
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Eschlböck S, Wenning G, Fanciulli A. Evidence-based treatment of neurogenic orthostatic hypotension and related symptoms. J Neural Transm (Vienna) 2017; 124:1567-1605. [PMID: 29058089 PMCID: PMC5686257 DOI: 10.1007/s00702-017-1791-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/18/2017] [Indexed: 02/06/2023]
Abstract
Neurogenic orthostatic hypotension, postprandial hypotension and exercise-induced hypotension are common features of cardiovascular autonomic failure. Despite the serious impact on patient’s quality of life, evidence-based guidelines for non-pharmacological and pharmacological management are lacking at present. Here, we provide a systematic review of the literature on therapeutic options for neurogenic orthostatic hypotension and related symptoms with evidence-based recommendations according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Patient’s education and non-pharmacological measures remain essential, with strong recommendation for use of abdominal binders. Based on quality of evidence and safety issues, midodrine and droxidopa reach a strong recommendation level for pharmacological treatment of neurogenic orthostatic hypotension. In selected cases, a range of alternative agents can be considered (fludrocortisone, pyridostigmine, yohimbine, atomoxetine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, octreotide, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin), though recommendation strength is weak and quality of evidence is low (atomoxetine, octreotide) or very low (fludrocortisone, pyridostigmine, yohimbine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin). In case of severe postprandial hypotension, acarbose and octreotide are recommended (strong recommendation, moderate level of evidence). Alternatively, voglibose or caffeine, for which a weak recommendation is available, may be useful.
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Affiliation(s)
- Sabine Eschlböck
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Byun JI, Moon J, Kim DY, Shin H, Sunwoo JS, Lim JA, Kim TJ, Lee WJ, Lee HS, Jun JS, Park KI, Lee ST, Jung KH, Jung KY, Lee SK, Chu K. Efficacy of single or combined midodrine and pyridostigmine in orthostatic hypotension. Neurology 2017; 89:1078-1086. [PMID: 28794253 DOI: 10.1212/wnl.0000000000004340] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/08/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the long-term (for up to 3 months) efficacy and safety of single or combined therapy with midodrine and pyridostigmine for neurogenic orthostatic hypotension (OH). METHODS This was a randomized, open-label clinical trial. In total, 87 patients with symptomatic neurogenic OH were enrolled and randomized to receive 1 of 3 treatments: midodrine only, pyridostigmine only, or midodrine + pyridostigmine. The patients were followed up at 1 and 3 months after treatment. The primary outcome measures were improvement in orthostatic blood pressure (BP) drop at 3 months. Secondary endpoints were improvement of the orthostatic BP drop at 1 month and amelioration of the questionnaire score evaluating OH-associated symptoms. RESULTS Orthostatic systolic and diastolic BP drops improved significantly at 3 months after treatment in all treatment groups. Orthostatic symptoms were significantly ameliorated during the 3-month treatment, and the symptom severity was as follows: midodrine only < midodrine + pyridostigmine < pyridostigmine only group. Mild to moderate adverse events were reported by 11.5% of the patients. CONCLUSIONS Single or combination treatment with midodrine and pyridostigmine was effective and safe in patients with OH for up to 3 months. Midodrine was better than pyridostigmine at improving OH-related symptoms. CLINICALTRIALSGOV IDENTIFIER NCT02308124. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with neurogenic OH, long-term treatment with midodrine alone, pyridostigmine alone, or both midodrine and pyridostigmine is safe and has similar effects in improving orthostatic BP drop up to 3 months.
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Affiliation(s)
- Jung-Ick Byun
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Jangsup Moon
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Do-Yong Kim
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Hyerim Shin
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Jun-Sang Sunwoo
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Jung-Ah Lim
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Tae-Joon Kim
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Woo-Jin Lee
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Han Sang Lee
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Jin-Sun Jun
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Kyung-Il Park
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Soon-Tae Lee
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea.
| | - Keun-Hwa Jung
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Ki-Young Jung
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
| | - Sang Kun Lee
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea.
| | - Kon Chu
- From the Department of Neurology (J.-I.B., J.M., D.-Y.K., H.S., J.-S.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J. S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Laboratory for Neurotherapeutics, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital; Department of Neurology (J.-I.B.), Kyung Hee University Hospital at Gangdong; Program in Neuroscience (J.-I.B., J.M., H.S., J.-A.L., T.-J.K., W.-J.L., H.S.L., J.-S.J., S.-T.L., K.-H.J., K.-Y.J., S.K.L., K.C.), Seoul National University College of Medicine; Department of Neurology (J.-S.S.), Soonchunhyang University Seoul Hospital; Department of Neurology (J.-A.L.), National Center for Mental Health, an affiliate of the Ministry for Health & Welfare; and Department of Neurology (K.-I.P.), Seoul National University Hospital Healthcare System Gangnam Center, Republic of Korea
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e60-e122. [DOI: 10.1161/cir.0000000000000499] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G. Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I. Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E. Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D. Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P. Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H. Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D. Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R. Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C. Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W. Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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Abstract
Neurogenic orthostatic hypotension (NOH) can be present in a number of disorders, including synucleinopathies, autoimmune disorders, and various genetic disorders. All are characterized by defective norepinephrine release from sympathetic terminals upon standing, resulting in impaired vasoconstriction. NOH is defined as a drop in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg, or both, within 3 minutes of standing or head up-tilt at a minimum of 60°. However, approximately 50% of patients have associated supine hypertension, which greatly complicates treatment. Supine hypertension not only is a common side effect of many anti-hypotensive agents but is also present in untreated patients, suggesting it is, in part, innate to the pathophysiology of autonomic dysfunction. Pathological mechanisms differ depending on the underlying autonomic disorder. In central neurodegenerative disorders, residual post-ganglionic sympathetic activity is likely the primary mechanism, whereas plasma angiotensin, aldosterone, and inappropriate mineralocorticoid receptor activity may contribute in peripheral autonomic lesions. Baroreflex failure/loss of baroreflex buffering is common to both. More work is required. Clinically, there is much dispute regarding the treatment of supine hypertension when there is a risk of exacerbating orthostatic hypotension. However, given the similar levels of end-organ damage (i.e., heart attack and stroke) seen with transient hypertension, it seems clear that treatment is important. Current therapies for both NOH and supine hypertension include a combination of pharmacological and conservative measures. However, in addition to the current standard of care, protocols may consider 24-h blood pressure monitoring and potential future examination of the peripheral post-ganglionic sympathetic nerves in order to apply individualized adjunct therapies. Finally, no anti-hypertensive agents are currently approved for use in this patient population, and development of novel therapies should focus on short-acting agents, selective to the supine position, that act primarily at night when hypertension is most severe/prolonged.
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Affiliation(s)
- Jacquie Baker
- School of Kinesiology, Western University, London, ON, Canada.,Department of Clinical Neurological Sciences, Rm. C7-131, University Hospital, London Health Sciences Centre, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Kurt Kimpinski
- School of Kinesiology, Western University, London, ON, Canada. .,Department of Clinical Neurological Sciences, Rm. C7-131, University Hospital, London Health Sciences Centre, 339 Windermere Road, London, ON, N6A 5A5, Canada. .,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
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2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: Executive summary. Heart Rhythm 2017; 14:e218-e254. [DOI: 10.1016/j.hrthm.2017.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 01/05/2023]
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40
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14:e155-e217. [PMID: 28286247 DOI: 10.1016/j.hrthm.2017.03.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/26/2022]
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41
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2017; 70:620-663. [PMID: 28286222 DOI: 10.1016/j.jacc.2017.03.002] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, Grubb BP, Hamdan MH, Krahn AD, Link MS, Olshansky B, Raj SR, Sandhu RK, Sorajja D, Sun BC, Yancy CW. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2017; 136:e25-e59. [PMID: 28280232 DOI: 10.1161/cir.0000000000000498] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Win-Kuang Shen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | | | - David G Benditt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mitchell I Cohen
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Daniel E Forman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Zachary D Goldberger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Blair P Grubb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mohamed H Hamdan
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Andrew D Krahn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Mark S Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Brian Olshansky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Satish R Raj
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Roopinder Kaur Sandhu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Dan Sorajja
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Benjamin C Sun
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
| | - Clyde W Yancy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison.,Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. HRS Representative. ACEP and SAEM Joint Representative. ACC/AHA Task Force on Performance Measures Liaison
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McDonell KE, Shibao CA, Claassen DO. Clinical Relevance of Orthostatic Hypotension in Neurodegenerative Disease. Curr Neurol Neurosci Rep 2016; 15:78. [PMID: 26486792 DOI: 10.1007/s11910-015-0599-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The autonomic nervous system appears to be uniquely susceptible to degeneration in disorders of α-synuclein pathology. Clinically, autonomic dysfunction in these disorders manifests as neurogenic orthostatic hypotension (nOH), a condition that results in substantial morbidity and mortality. nOH results from pathology affecting either the central autonomic pathways or peripheral autonomic nerve fibers. Determining the localization and pathophysiology of nOH is critical in effectively managing this disorder and selecting appropriate treatment options. In this review, we discuss the pathophysiology of nOH with respect to the various α-synuclein-related neurodegenerative conditions. We highlight the associated clinical features, including gait instability, rapid eye movement behavior disorder, and hyposmia. We also review the current pharmacologic treatment options for nOH. Overall, the goals of therapy are to improve symptoms and prevent syncope and falls. Non-pharmacologic interventions should be introduced first, followed by carefully selected pharmacologic therapies. Treatment decisions should be directed by an understanding of the underlying pathophysiology, as well as the comorbidities and potential contributing factors present in each individual patient.
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Affiliation(s)
- Katherine E McDonell
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South A-0118, Nashville, TN, 37232-2551, USA.
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Daniel O Claassen
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South A-0118, Nashville, TN, 37232-2551, USA
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Interventional trials in atypical parkinsonism. Parkinsonism Relat Disord 2016; 22 Suppl 1:S82-92. [DOI: 10.1016/j.parkreldis.2015.09.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 09/18/2015] [Indexed: 11/21/2022]
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Loavenbruck A, Sandroni P. Neurogenic orthostatic hypotension: roles of norepinephrine deficiency in its causes, its treatment, and future research directions. Curr Med Res Opin 2015; 31:2095-104. [PMID: 26373628 DOI: 10.1185/03007995.2015.1087988] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although a diversity of neurotransmitters and hormones participate in controlling blood pressure, norepinephrine released from postganglionic sympathetic nerve terminals is an important mediator of the rapid regulation of cardiovascular function required for homeostasis of cerebral perfusion. Hence, neurogenic orthostatic hypotension (NOH) often represents a deficiency of noradrenergic responsiveness to postural change. RESEARCH DESIGN AND METHODS PubMed searches with 'orthostatic hypotension' and 'norepinephrine' as conjoint search terms and no restriction on language or date, so as to survey the pathophysiologic and clinical relevance of norepinephrine deficiency for current NOH interventions and for future directions in treatment and research. RESULTS Norepinephrine deficiency in NOH can arise peripherally, due to cardiovascular sympathetic denervation (as in pure autonomic failure, Parkinson's disease, and a variety of neuropathies), or centrally, due to a failure of viscerosensory signals to generate adequate sympathetic traffic to intact sympathetic nerve endings (as in multiple system atrophy). Nonpharmacologic countermeasures such as pre-emptive water intake may yield blood-pressure increases exceeding those achieved pharmacologically. For patients with symptomatic NOH unresponsive to such strategies, a variety of pharmacologic interventions have been administered off-label on the basis of drug mechanisms expected to increase blood pressure via blood-volume expansion or vasoconstriction. Two pressor agents have received FDA approval: the sympathomimetic midodrine and more recently the norepinephrine prodrug droxidopa. CONCLUSIONS Pressor agents are important for treating symptomatic NOH in patients unresponsive to lifestyle changes alone. However, the dysautonomia underlying NOH often permits blood-pressure excursions toward both hypotension and hypertension. Future research should aim to shed light on the resulting management issues, and should also explore the possibility of pharmacotherapy selectively targeting orthostatic blood-pressure decreases.
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Affiliation(s)
- Adam Loavenbruck
- a a Department of Neurology , University of Minnesota , Minneapolis , MN , USA
| | - Paola Sandroni
- b b Department of Neurology , Mayo Clinic , Rochester , MN , USA
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46
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Abstract
Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.
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Affiliation(s)
- Pearl K Jones
- a 1 Department of Neurology, University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Brett H Shaw
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.,c 3 Department of Medicine, Division of Clinical Pharmacology, Autonomic Dysfunction Center, Vanderbilt University, Nashville, Tennessee, USA
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47
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Abstract
Orthostatic hypotension (OH) is defined as a sustained reduction of ≥ 20 mmHg systolic blood pressure or ≥ 10 mmHg diastolic blood pressure upon standing for ≤ 3 min. Orthostatic hypotension is commonly associated with hypertension, and its prevalence is highest in those with uncontrolled hypertension compared to those with controlled hypertension or normotensive community elderly subjects. Orthostatic hypotension can cause significant disability, with patients experiencing dizziness, lightheadedness or syncope, and other problems that potentially have a profound negative impact on activities of daily living that require standing or walking. Furthermore, OH increases the risk of falls and, importantly, is an independent risk factor of mortality. Despite its importance, there is a paucity of treatment options for this condition. Most of the advances in treatment options have relied on small studies of repurposed drugs done in patients with severe OH due to rare neurodegenerative conditions. Midodrine, an oral prodrug converted to the selective α1-adrenoceptor agonist desglymidodrine, was approved by the FDA for the treatment of OH in 1996. For almost two decades, no other pharmacotherapy was developed specifically for the treatment of OH until 2014, when droxidopa was approved by the FDA for the treatment of neurogenic OH associated with primary autonomic neuropathies including Parkinson disease, multiple system atrophy, and pure autonomic failure. These are neurodegenerative diseases ultimately characterized by failure of the autonomic nervous system to generate norepinephrine responses appropriate to postural challenge. Droxidopa is a synthetic amino acid that is converted to norepinephrine by dopa-decarboxylase, the same enzyme that converts levodopa into dopamine in the treatment of Parkinson disease. We will review this and other advances in the treatment of OH in an attempt to provide a practical guide to its management.
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Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, and the Autonomic Dysfunction Center, 560 RRB, Vanderbilt University, Nashville, TN, 37232, USA,
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Kuritzky L, Espay AJ, Gelblum J, Payne R, Dietrich E. Diagnosing and treating neurogenic orthostatic hypotension in primary care. Postgrad Med 2015; 127:702-15. [PMID: 26012731 DOI: 10.1080/00325481.2015.1050340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In response to a change in posture from supine or sitting to standing, autonomic reflexes normally maintain blood pressure (BP) by selective increases in arteriovenous resistance and by increased cardiac output, ensuring continued perfusion of the central nervous system. In neurogenic orthostatic hypotension (NOH), inadequate vasoconstriction and cardiac output cause BP to drop excessively, resulting in inadequate perfusion, with predictable symptoms such as dizziness, lightheadedness and falls. The condition may represent a central failure of baroreceptor signals to modulate cardiovascular function, a peripheral failure of norepinephrine release from cardiovascular sympathetic nerve endings, or both. Symptomatic patients may benefit from both non-pharmacologic and pharmacologic interventions. Among the latter, two pressor agents have been approved by the US Food and Drug Administration: the sympathomimetic prodrug midodrine, approved in 1996 for symptomatic orthostatic hypotension, and the norepinephrine prodrug droxidopa, approved in 2014, which is indicated for the treatment of symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure (Parkinson's disease, multiple system atrophy and pure autonomic failure). A wide variety of off-label options also have been described (e.g. the synthetic mineralocorticoid fludrocortisone). Because pressor agents may promote supine hypertension, NOH management requires monitoring of supine BP and also lifestyle measures to minimize supine BP increases (e.g. head-of-bed elevation). However, NOH has been associated with cognitive impairment and increases a patient's risk of syncope and falls, with the potential for serious consequences. Hence, concerns about supine hypertension - for which the long-term prognosis in patients with NOH is yet to be established - must sometimes be balanced by the need to address a patient's immediate risks.
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Affiliation(s)
- Louis Kuritzky
- a 1 Department of Community Health and Family Medicine, University of Florida , Gainesville, FL, USA
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Alagiakrishnan K. Current Pharmacological Management of Hypotensive Syndromes in the Elderly. Drugs Aging 2015; 32:337-48. [DOI: 10.1007/s40266-015-0263-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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50
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Multiple system atrophy: using clinical pharmacology to reveal pathophysiology. Clin Auton Res 2015; 25:53-9. [PMID: 25757803 DOI: 10.1007/s10286-015-0271-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/24/2015] [Indexed: 10/23/2022]
Abstract
Despite similarities in their clinical presentation, patients with multiple system atrophy (MSA) have residual sympathetic tone and intact post-ganglionic noradrenergic fibers, whereas patients with pure autonomic failure (PAF) and Parkinson disease have efferent post-ganglionic autonomic denervation. These differences are apparent biochemically, as well as in neurophysiological testing, with near normal plasma norephrine in MSA but very low levels in PAF. These differences are also reflected in the response patients have to drugs that interact with the autonomic nervous system. For example, the ganglionic blocker trimethaphan reduces residual sympathetic tone and lowers blood pressure in MSA, but less so in PAF. Conversely, the α2-antagonist yohimbine produces a greater increase in blood pressure in MSA compared to PAF, although significant overlap exists. In normal subjects, the norepinephrine reuptake (NET) inhibitor atomoxetine has little effect on blood pressure because the peripheral effects of NET inhibition that result in noradrenergic vasoconstriction are counteracted by the increase in brain norepinephrine, which reduces sympathetic outflow (a clonidine-like effect). In patients with autonomic failure and intact peripheral noradrenergic fibers, only the peripheral vasoconstriction is apparent. This translates to a significant pressor effect of atomoxetine in MSA, but not in PAF patients. Thus, pharmacological probes can be used to understand the pathophysiology of the different forms of autonomic failure, assist in the diagnosis, and aid in the management of orthostatic hypotension.
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