Falls in blood pressure are a common problem affecting the elderly. The challenge when evaluating a patient with low blood pressure in the upright position is to determine what causes the fall. This can either be due to a pathological lesion affecting the nerves or secondary to other exacerbating factors.
As we age our reflexes that control blood pressure become less efficient, which means they are less able to withstand gravity, so that dehydration, mild anemia or overuse of anti-hypertensive medications can cause a symptomatic drop in blood pressure. Secondary orthostatic hypotension usually resolves when the underlying exacerbating factors are corrected.
In a smaller number of patients, the approach to treatment is different because the nerves no longer work due to an underlying neurological process. So called neurogenic orthostatic hypotension may require pharmacological (drug) treatment.
The latest issue of Continuum features an article written by Dr. Kaufmann and Dr. Palma on the treatment of orthostatic hypotension, with particular focus on what to do when the cause is found to be neurogenic.
The article discusses the use of volume expansion and pressor agents, providing a hypothesis-driven approach. The management of neurogenic orthostatic hypotension, explained Dr. Kaufmann, should focus on improving quality of life rather than restoring blood pressure to normal values. There are several options when it comes to pharmacological strategies. First, we try to ensure the patient has a sufficient blood volume. Then, if necessary, you can replace the neurotransmitter, norepinephrine, with droxidopa, or directly stimulate the adrenergic receptors on the blood vessels, with midodrine. Both ways cause vasoconstriction, which increases blood pressure in all positions.
Still, there are unmet needs when it comes to treating patients with neurogenic orthostatic hypotension. Not all patients respond to therapies and in many cases, these drugs also raise blood pressure in the supine position, causing hypertension. This becomes quite a dilemma to manage. Strategies to mitigate supine hypertension include sleeping with the head of the bed raised and new guidelines are available.
Continuum is a widely read publication curated by the American Academy of Neurology. It selects experts in the field to write state-of-the-art reviews with the goal of educating neurologists throughout the world. The fact that Dr. Kaufmann and Dr. Palma were chosen as to write about treatment really shows how well recognized they are as leaders in the field.
Read the review here: https://www.ncbi.nlm.nih.gov/pubmed/31996627