Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem

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.

Keywords: cardiovascular diseases; heart failure; hypertension; orthostatic hypotension; patient care.

Figure 1.

Cardiovascular disease cascade and autonomic dysfunction. Orthostatic hypotension has been associated with different mechanisms involved in cardiovascular disease progression, from a strong relationship with traditional cardiovascular risk factors and subclinical changes on functional level to increased risk of cardiovascular death.

Figure 2.

Cardiac and extracardiac disorders associated with cardiovascular autonomic dysfunction as represented by orthostatic hypotension.

Figure 3.

Global blood pressure control and mechanisms of orthostatic hypotension. The etiology of orthostatic hypotension (OH) is heterogenous and spans neurodegenerative diseases (e.g., Parkinson’s disease), diabetes, renal failure, inflammatory states, autoimmune diseases (e.g., Sjögren’s disease), and cardiovascular conditions (e.g., essential hypertension and heart failure). Disorders that directly affect central and periphery autonomic neural input are traditionally termed “neurogenic OH”. Two major types of cardiovascular autonomic dysfunction, i.e., cardiac and vascular dysfunction may overlap and interact.

Figure 4.

Proposed classification of orthostatic hypotension based on interaction between autonomic nervous system and cardiovascular system. Mixed etiology affects both the autonomic nervous system and cardiovascular organs, the heart and the vessel.

Figure 5.

Proposed orthostatic hypotension evaluation algorithm. Go to Supplemental Figure II for further details.

Figure 6.

Sites of action and mechanisms of therapeutic agents used for the treatment of neurogenic orthostatic hypotension. Modified from Palma et al. (Created with BioRender.com).