PATIENTS WITH nOH MAY EXPERIENCE SUPINE HYPERTENSION

Up to 70% of patients with neurogenic orthostatic hypotension (nOH) have associated supine hypertension.1 This 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.2,3 Patients with autonomic failure lack the normal blood pressure buffering mechanisms that offset both hypo- and hypertension.4-6

Supine hypertension is arbitrarily defined as systolic blood pressure ≥150 mm Hg or diastolic blood pressure ≥90 mm Hg while in the supine position.7-9 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.9

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Patients with supine hypertension experience elevated systolic blood pressure while recumbent

SUPINE AND STANDING ORTHOSTATIC MEASUREMENTS MAY REVEAL SUPINE HYPERTENSION

In-clinic orthostatic measurements help identify patients with supine hypertension. 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.4 Supine hypertension may persist undetected if orthostatic measurements are conducted only in the seated position.If the patient's blood pressure drops after standing for at least 3 minutes, he or she may also have nOH.8,10

THE CLINICAL DILEMMA OF nOH AND ASSOCIATED SUPINE HYPERTENSION

Many patients with nOH will also experience supine hypertension, which may complicate management approaches; management of one may worsen the other.7,10 Adjustments that may help reduce the effects of supine hypertension include7,11:

  • 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 drugs that can worsen supine hypertension, including NSAIDs and nasal decongestants
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SOME ANTIHYPERTENSIVE DRUGS MAY WORSEN SYMPTOMS OF nOH

The agents found most likely to worsen nOH in patients include peripheral vasodilators such as α-receptor antagonists and nondihydropyridine calcium channel antagonists. Agents that are less likely to exacerbate symptoms of nOH include ACE inhibitors, angiotensin-receptor antagonists, and β-adrenoceptor antagonists with intrinsic sympathomimetic activity.4

REFERENCES
  1. 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.
  2. Freeman R. Neurogenic orthostatic hypotension. N Engl J Med. 2008;358(6):615-624.
  3. 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.
  4. 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. 
  5. Low PA, Singer W. Management of neurogenic orthostatic hypotension: an update. Lancet Neurol. 2008;7(5):451-458.
  6. 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. 
  7. 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.
  8. Low PA. Neurogenic orthostatic hypotension: pathophysiology and diagnosis. Am J Manag Care. 2015;21(suppl 13):s248-s257.
  9. Carretero OA, Oparil S. Essential hypertension. Part I: definition and etiology. Circulation. 2000;101(3):329-335.
  10. 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.
  11. Palma JA. Kaufmann H. Epidemiology, diagnosis, and management of neurogenic orthostatic hypotension. Mov Disord Clin Pract. 2017:4(3):298-308.