MANY PATIENTS WITH nOH MAY ALSO EXPERIENCE ASSOCIATED SUPINE HYPERTENSION

Up to 70% of patients with neurogenic orthostatic hypotension (nOH) also have associated supine hypertension.1,2 This association may be due to a patient’s pre-existing neurodegenerative disorder and autonomic dysfunction, including Parkinson’s disease, multiple system atrophy, and pure autonomic failure.2-4 Patients with autonomic failure lack the normal blood pressure buffering mechanisms that offset both hypo- and hypertension.1,5-7

Supine hypertension is arbitrarily defined as systolic blood pressure ≥150 mm Hg or diastolic blood pressure ≥90 mm Hg while in the supine position.3,8,9 Supine hypertension is not to be confused with essential or primary hypertension, which accounts for 95% of all hypertension cases. Patients with essential hypertension have, on average, higher blood pressures, in both seated and standing positions. Essential hypertension is a heterogeneous disorder, with causes varying across patients.10

 

SUPINE AND STANDING ORTHOSTATIC MEASUREMENTS MAY REVEAL SUPINE HYPERTENSION

In-clinic orthostatic measurements may be able to help identify supine hypertension in patients. Measurements taken after 5 to 10 minutes in the supine position and then repeated once a patient stands for 3 to 5 minutes may indicate that the patient has supine hypertension. Supine hypertension may persist undetected if orthostatic measurements are conducted only in the seated position.6 If the patient’s blood pressure drops after standing for at least 3 minutes, he or she may also have nOH.1,11

 

THE CLINICAL DILEMMA OF nOH AND ASSOCIATED SUPINE HYPERTENSION

Many patients with nOH will also experience supine hypertension, which may confound management approaches as management of one may worsen the other.1-4 There are some adjustments a patient can make that may prove helpful in reducing the effects of supine hypertension, including1,3:

  • Avoiding lying completely flat; patients should elevate the head of their bed so that their heart is higher than their feet
  • Abstaining from drinking water an hour before bed
  • Refraining from taking any over-the-counter drugs that can worsen supine hypertension, including NSAIDs and nasal decongestants

SOME MEDICATIONS MAY WORSEN SYMPTOMS OF nOH

Some antihypertensive drugs may worsen nOH in patients. The agents found most likely to worsen nOH in patients include peripheral vasodilators such as α-receptor antagonists and nondihydropyridine calcium channel antagonists. Some agents may be less likely to exacerbate existing nOH. These include ACE inhibitors, angiotensin-receptor antagonists, and β-adrenoceptor antagonists with intrinsic sympathomimetic activity.6

References: 1. Kaufmann H, Norcliffe-Kaufmann L, Palma JA. Droxidopa in neurogenic orthostatic hypotension. Expert Rev Cardiovasc Ther. 2015;13(8):875-891. 2. Berganzo K, Diez-Arrola B, Tijero B, et al. Nocturnal hypertension and dysautonomia in patients with Parkinson’s disease: are they related? J Neurol. 2013;260(7):1752-1756. 3. Jordan J, Biaggioni I. Diagnosis and treatment of supine hypertension in autonomic failure patients with orthostatic hypotension. J Clin Hypertens. 2002;4(2):139-145. 4. Goldstein DS, Pechnik S, Holmes C, et al. Association between supine hypertension and orthostatic hypotension in autonomic failure. Hypertension. 2003;42(2):136-142. 5. Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017;264(8):1567-1582. 6. Naschitz JE, Slobodin G, Elias N, et al. The patient with supine hypertension and orthostatic hypotension: a clinical dilemma. Postgrad Med J. 2006;82(966):246-253. 7. Low PA, Singer W. Management of neurogenic orthostatic hypotension: an update. Lancet Neurol. 2008;7(5):451-458. 8. Stuebner E, Vichayanrat E, Low DA, et al. Twenty-four hour non-invasive ambulatory blood pressure and heart rate monitoring in Parkinson’s disease. Front Neurol. 2013;4:49. 9. Low PA. Neurogenic orthostatic hypotension: pathophysiology and diagnosis. Am J Manag Care. 2015;21(suppl 13):s248-s257. 10. Carretero OA, Oparil S. Essential hypertension. Part I: definition and etiology. Circulation. 2000;101(3):329-335. 11. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72.