Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management

Abstract

Neurogenic orthostatic hypotension is a distinctive and treatable sign of cardiovascular autonomic dysfunction. It is caused by failure of noradrenergic neurotransmission that is associated with a range of primary or secondary autonomic disorders, including pure autonomic failure, Parkinson’s disease with autonomic failure, multiple system atrophy as well as diabetic and nondiabetic autonomic neuropathies. Neurogenic orthostatic hypotension is commonly accompanied by autonomic dysregulation involving other organ systems such as the bowel and the bladder. In the present review, we provide an overview of the clinical presentation, pathophysiology, epidemiology, evaluation and management of neurogenic orthostatic hypotension focusing on neurodegenerative disorders.

Cardiovagal Baroreflex Sensitivity in Parkinson's Disease and Multiple-System Atrophy

“…Among the various symptoms of autonomic dysfunction, orthostatic hypotension (OH) is a common presentation in both of these disorders. [1][2][3] It has been suggested that despite their autonomic symptoms being similar, the underlying pathophysiological mechanisms are different. 4,5 Several studies have examined the baroreflex sensitivity (BRS) as a measure of autonomic function in PD and multiple-system atrophy (MSA).…”

Impaired peripheral vasoconstrictor response to orthostatic stress in patients with multiple system atrophy

“…In healthy participants, peripheral resistance increases, thereby maintaining BP during orthostatic stress. Patients with neurogenic OH exhibited impaired ability to increase total peripheral resistance, which was most likely caused by disturbed neural reflex vasoconstriction [15]. However, few studies have evaluated the peripheral vasoconstrictor response during head-up tilt in patients with MSA.…”

Effect of orthostatic hypotension on sustained attention in patients with autonomic failure

“…During HUT, the psychological stress caused by performing SART did result in a rise in blood pressure, although the rise was less pronounced than in controls. The blood pressure reactivity to psychological stress suggests that some part of the peripheral sympathetic system was still functional under the influence of central stress stimuli, which work through different pathways than the baroreflex does 25. Moreover, circulating factors like epinephrine and cortisol could explain the blood pressure response to psychological stress 26.…”