Ann Clin Neurophysiol.  2023 Oct;25(2):66-77. 10.14253/acn.2023.25.2.66.

Diagnosis and management of neurogenic orthostatic hypotension

• Ju W
• Sinn DI

• KMID: 2547398
• DOI: http://doi.org/10.14253/acn.2023.25.2.66

Abstract

Orthostatic hypotension is a sustained and pathological drop in blood pressure upon standing. Orthostatic hypotension can be due to non-neurogenic conditions or autonomic disorders. Impaired baroreflex-mediated vasoconstriction and insufficient release of norepinephrine play key roles in the pathophysiology of neurogenic orthostatic hypotension. Its common symptoms mainly related to inadequate cerebral blood flow include dizziness, lightheadedness, and syncope. It is crucial to differentiate neurogenic orthostatic hypotension from non-neurogenic orthostatic hypotension. For the management of neurogenic orthostatic hypotension, physicians should implement non-pharmacological methods and, if possible, reverse combined non-neurological conditions. Depending on severity of symptoms, pharmacological intervention may be tried af ter or with non-pharmacological methods. Its management should be individualized based on intensity of symptoms, comorbid conditions, drug side effects, and etiology. In this review, we discuss the definition, pathophysiology, clinical approach, and management of neurogenic orthostatic hypotension.

Figure

• 

  Fig. 1. Different changes in blood pressure (BP) and heart rate (HR) during tilt-table tests (A-C) or during active standing tests (D, E). Green lines indicate HR. Upper red lines indicate systolic BP (SBP) and lower lines reflect diastolic BP (DBP). In (D) and (E), only SBP is shown. Orthostatic hypotension (OH) is defined as a sustained drop in SBP by at least 20 mmHg or in DBP by at least 10 mmHg (A, B). An absolute HR increase of less than 15 beats per minute or a ratio of HR to SBP (ΔOH/ΔSBP) less than 0.5 can differentiate neurogenic OH (A) from non-neurogenic OH (B). Delayed OH is a sustained decline in BP occurring after 3 minutes of standing. When supine SBP is greater than 150 mmHg, 30/15 criteria may be more appropriate for OH or delayed OH instead of 20/10 (C). Initial OH is a ‘transient’ drop in SBP by at least 40 mmHg or in DBP by at least 20 mmHg during active standing (D). Delayed BP recovery is a transient decline in BP by 20/10 during active standing, but BP recovers 30 seconds or longer after standing up and within 3 minutes (E).

• 

  Fig. 2. Norepinephrine (NE) changes after standing up. In a supine/resting state, there is a baseline release of NE from the post-ganglionic adrenergic fibers. After standing up, signal traffic in the autonomic ganglia increases due to the enhanced release of acetylcholine from the pre-ganglionic sympathetic fibers. It activates the post-ganglionic fibers resulting in a surge in plasma NE level and vasoconstriction (A). In post-ganglionic degeneration in pure autonomic failure, the baseline NE level is decreased. Standing up does not bring up the NE level significantly (B). In pre-ganglionic degeneration in multiple system atrophy, the baseline level is normal or slightly lower than normal. But standing up does not increase the level like normal subjects (C).

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