Neurogenic Orthostatic Hypotension in Parkinson Disease: A Primer

Abstract

Parkinson disease (PD) is associated with a variety of motor and non-motor clinical manifestations, including cardiovascular autonomic dysfunction. Neurogenic orthostatic hypotension (nOH) is a potentially serious manifestation of cardiovascular sympathetic failure that occurs in approximately 30% of patients with PD. Here we review the pathophysiology and effects of the condition as well as treatment considerations for patients with PD and nOH. Screening for nOH using orthostatic symptom questionnaires, orthostatic blood pressure measurements, and specialized autonomic testing is beneficial for the identification of symptomatic and asymptomatic cases because cardiac sympathetic denervation and nOH can occur even at early (premotor) stages of PD. Symptoms of nOH, such as orthostatic lightheadedness, in patients with PD, have been shown to adversely affect patient safety (with increased risk of falls) and quality of life and should prompt treatment with non-pharmacologic and, occasionally, pharmacologic measures. Patients with nOH are also at increased risk of supine hypertension, which requires balancing various management strategies. FUNDING: Lundbeck (Deerfield, IL).

Keywords: Non-motor symptoms of Parkinson disease; Orthostatic hypotension; Screening; Supine hypertension; Treatment.

Fig. 1

Orthostatic responses during head-up tilt and Valsalva maneuver in a healthy subject (a, b) and patient with Parkinson disease (PD) + neurogenic orthostatic hypotension (nOH) (c, d), showing sustained drop in blood pressure with minimal heart rate increase in the patient with PD + nOH

Fig. 2

Screening questions (a), diagnostic assessment (b), and treatment options (c) for orthostatic hypotension (OH) and neurogenic OH (nOH) [9, 10, 77, 108, 113, 114]. BP Blood pressure, FDA US Food and Drug Administration. Screening panel (a) was adapted from Gibbons et al. [9], under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)