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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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Elkholey K, Wahba A, Paranjape SY, Saleem M, Kirabo A, Joos KM, Diedrich A, Shibao CA, Biaggioni I. Post-COVID-19 Afferent Baroreflex Failure. Hypertension 2023; 80:895-900. [PMID: 36802914 PMCID: PMC10112935 DOI: 10.1161/hypertensionaha.123.20316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- Khaled Elkholey
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- Autonomic Dysfunction Center (K.E., A.W., S.Y.P., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Amr Wahba
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- Autonomic Dysfunction Center (K.E., A.W., S.Y.P., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Sachin Y. Paranjape
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- Autonomic Dysfunction Center (K.E., A.W., S.Y.P., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Mohammad Saleem
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Annet Kirabo
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- Autonomic Dysfunction Center (K.E., A.W., S.Y.P., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- and Vanderbilt Eye Institute (K.M.J.), Vanderbilt University Medical Center, Nashville, TN
| | - Karen M. Joos
- and Vanderbilt Eye Institute (K.M.J.), Vanderbilt University Medical Center, Nashville, TN
| | - André Diedrich
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- Autonomic Dysfunction Center (K.E., A.W., S.Y.P., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Cyndya A. Shibao
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- Autonomic Dysfunction Center (K.E., A.W., S.Y.P., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Italo Biaggioni
- Divisions of Clinical Pharmacology, Department of Medicine (K.E., A.W., S.P., M.S., S.K., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
- Autonomic Dysfunction Center (K.E., A.W., S.Y.P., A.D., C.A.S., I.B.), Vanderbilt University Medical Center, Nashville, TN
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Mahmoud A, Kania B, Geris S, Akroush W, Manickam R, Azzam MHK. The unpredictability of labile blood pressure: Afferent baroreflex failure in a critical patient with multiple thyroid surgeries and COVID-19 infection. Radiol Case Rep 2023; 18:715-718. [PMCID: PMC9742062 DOI: 10.1016/j.radcr.2022.11.030] [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] [Received: 10/29/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 12/14/2022] Open
Abstract
The carotid sinus-arterial baroreflex is essential in maintaining blood pressure (BP) regulation. Afferent baroreflex failure (ABF) can present with labile changes in BP within seconds and can be secondary to neck surgery or radiation. We present here the first case, to our knowledge, of ABF precipitated by thyroidectomy, in a patient with active COVID-19 pneumonia, causing difficult control of severely labile BP in a critical care unit. Contributing factors included her critical illness state with upregulation of IL-6 leading to pituitary-adrenal axis alteration, her thyroidectomy further exacerbating autonomic dysfunction, as well as downregulation of ACE2 via COVID-19 infection. Management was achieved with a combination of midodrine and clonidine catered to specific BP thresholds. Additional research with a multidisciplinary approach is warranted to fully optimize the treatment of ABF in patients with neck surgery and or inflammatory conditions such as COVID-19.
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Affiliation(s)
- Anas Mahmoud
- Department of Medicine, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
| | - Brooke Kania
- Department of Medicine, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA,Corresponding author
| | - Shady Geris
- Department of Medicine, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
| | - Wadah Akroush
- Department of Medicine, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
| | - Rajapriya Manickam
- Department of Critical Care, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
| | - Moh'd Hazem K Azzam
- Department of Critical Care, St. Joseph's University Medical Center, 703 Main St, Paterson, NJ 07503, USA
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