Advertisement

Differential diagnosis of orthostatic hypotension

  • Lucy Y. Lei
    Affiliations
    Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
    Search for articles by this author
  • Derek S. Chew
    Affiliations
    Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada

    Duke Clinical Research Institute, Duke University, Durham, NC, USA
    Search for articles by this author
  • Satish R. Raj
    Correspondence
    Corresponding author at: GAC70 HRIC Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada.
    Affiliations
    Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada

    Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
    Search for articles by this author

      Highlights

      • Orthostatic hypotension is associated with increased morbidity and mortality.
      • There are different forms of orthostatic hypotension, and mimics of orthostatic hypotension.
      • Understanding these can lead to more accurate diagnoses and better patient care.

      Abstract

      Orthostatic hypotension (OH) is a common clinical manifestation characterized by a significant fall in blood pressure with postural change and is frequently accompanied by debilitating symptoms of orthostatic intolerance. The reported prevalence of OH ranges between 5 and 10% in middle-aged adults with a burden that increases concomitantly with age; in those over 60 years of age, the prevalence is estimated to be over 20%. Unfortunately, the clinical course of OH is not necessarily benign. OH patients are at an increased risk of adverse clinical outcomes including death, falls, cardiovascular and cerebrovascular events, syncope, and impaired quality of life.
      The differential diagnosis of OH is broad and includes acute precipitants as well as chronic underlying medical conditions, especially of neurological origin. Appropriate diagnosis relies on a systematic history and physical examination with particular attention to orthostatic vital signs, keeping in mind that ambient conditions during diagnostic testing may affect OH detection due to factors such as diurnal variation.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Autonomic Neuroscience: Basic and Clinical
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Adalbert R.
        • Coleman M.P.
        Review: axon pathology in age-related neurodegenerative disorders.
        Neuropathol. Appl. Neurobiol. 2013; 39: 90-108
        • Aydin A.E.
        • Soysal P.
        • Isik A.T.
        Which is preferable for orthostatic hypotension diagnosis in older adults: active standing test or head-up tilt table test?.
        Clin. Interv. Aging. 2017; 12: 207-212
        • Bird S.T.
        • Delaney J.A.C.
        • Brophy J.M.
        • Etminan M.
        • Skeldon S.C.
        • Hartzema A.G.
        Tamsulosin treatment for benign prostatic hyperplasia and risk of severe hypotension in men aged 40–85 years in the United States: risk window analyses using between and within patient methdology.
        BMJ. 2013; 347: f6320
        • Buzelin J.M.
        • Fonteyne E.
        • Kontturi M.
        • Witjes W.P.
        • Khan A.
        Comparison of tamsulosin with alfuzosin in the treatment of patients with lower urinary tract symptoms suggestive of bladder outlet obstruction (symptomatic benign prostatic hyperplasia). The European Tamsulosin Study Group.
        Br. J. Urol. 1997; 80: 597-605
        • Chopra K.
        • Tiwari V.
        Alcoholic neuropathy: possible mechanisms and future treatment possibilities.
        Br. J. Clin. Pharmacol. 2012; 73: 348-362
        • Clarke D.A.
        • Medow M.S.
        • Taneja I.
        • Ocon A.J.
        • Stewart J.M.
        Initial orthostatic hypotension in the young is attenuated by static handgrip.
        J. Pediatr. 2010; 156: 1019-1022
        • Cooke J.
        • Carew S.
        • O’Connor M.
        • Costelloe A.
        • Sheehy T.
        • Lyons D.
        Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension.
        QJM. 2009; 102: 355-359
        • Damasceno A.
        • França M.C.
        • Cury H.
        • Nucci A.
        Autonomic dysfunction in non-paraneoplastic sensory neuronopathy: beyond sensory abnormalities.
        J. Neurol. 2011; 258: 231-237
        • Fedorowski A.
        • Melander O.
        Syndromes of orthostatic intolerance: a hidden danger.
        J. Intern. Med. 2013; 273: 322-335
        • Finucane C.
        • O’Connell M.D.L.
        • Donoghue O.
        • Richardson K.
        • Savva G.M.
        • Kenny R.A.
        Impaired orthostatic blood pressure recovery is associated with unexplained and injurious falls.
        J. Am. Geriatr. Soc. 2017; 65: 474-482
        • Freeman R.
        Autonomic peripheral neuropathy.
        Lancet. 2005; 365: 1259-1270
        • Freeman R.
        Neurogenic orthostatic hypotension.
        N. Engl. J. Med. 2008; 358: 615-624
        • Freeman R.
        • Wieling W.
        • Axelrod F.B.
        • Benditt D.G.
        • Benarroch E.
        • Biaggioni I.
        • et al.
        Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.
        Clin. Auton. Res. 2011; 21: 69-72
        • Freeman R.
        • Abuzinadah A.R.
        • Gibbons C.
        • Jones P.
        • Miglis M.G.
        • Sinn D.I.
        Orthostatic hypotension.
        J. Am. Coll. Cardiol. 2018; 72: 1294-1309
        • Gibbons C.H.
        • Freeman R.
        Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance.
        Neurology. 2006; 67: 28-32
        • Gibbons C.H.
        • Freeman R.
        Clinical implications of delayed orthostatic hypotension: a 10-year follow-up study.
        Neurology. 2015; 85: 1362-1367
        • Gorelik O.
        • Feldman L.
        • Cohen N.
        Heart failure and orthostatic hypotension.
        Heart Fail. Rev. 2016; 21: 529-538
        • Horowitz D.R.
        • Kaufmann H.
        Autoregulatory cerebral vasodilation occurs during orthostatic hypotension in patients with primary autonomic failure.
        Clin. Auton. Res. 2001; 11: 363-367
        • Hunt A.
        • Harrington D.
        • Robinson S.
        Vitamin B12 deficiency.
        BMJ. 2014; 349: g5226
        • Jansen R.W.
        Postprandial hypotension: simple treatment but difficulties with the diagnosis.
        J. Gerontol. A Biol. Sci. Med. Sci. 2005; 60: 1268-1270
        • Jordan J.
        • Biaggioni I.
        Diagnosis and treatment of supine hypertension in autonomic failure patients with orthostatic hypotension.
        J. Clin. Hypertens. 2002; 4: 139-145
        • Julian T.H.
        • Syeed R.
        • Glascow N.
        • Zis P.
        Alcohol-induced autonomic dysfunction: a systematic review.
        Clin. Auton. Res. 2020; 30: 29-41
        • Kaufmann H.
        • Goldstein D.S.
        Pure autonomic failure: a restricted lewy body synucleinopathy or early Parkinson disease?.
        Neurology. 2010; 74: 536-537
        • Kaufmann H.
        • Palma J.A.
        Neurogenic orthostatic hypotension: the very basics.
        Clin. Auton. Res. 2017; 27: 39-43
        • Low P.A.
        Prevalence of orthostatic hypotension.
        Clin. Auton. Res. 2008; 18: 8-13
        • Martí M.J.
        • Tolosa E.
        • Campdelacreu J.
        Clinical overview of the synucleinopathies.
        Mov. Disord. 2003; 18: S21-S27
        • McCann H.
        • Stevens C.H.
        • Cartwright H.
        • Halliday G.M.
        α-Synucleinopathy phenotypes.
        Parkinsonism Relat. Disord. 2014; 20: S62-S67
        • Mehrabian S.
        • Duron E.
        • Labouree F.
        • Rollot F.
        • Bune A.
        • Traykov L.
        • et al.
        Relationship between orthostatic hypotension and cognitive impairment in the elderly.
        J. Neurol. Sci. 2010; 299: 45-48
        • Narkiewicz K.
        • Cooley R.L.
        • Somers V.K.
        Alcohol potentiates orthostatic hypotension: implications for alcohol- related syncope.
        Circulation. 2000; 101: 398-402
        • Naslund M.J.
        • Miner M.
        A review of the clinical efficacy and safety of 5alpha-reductase inhibitors for the enlarged prostate.
        Clin. Ther. 2007; 29: 17-25
        • Norcliffe-Kaufmann L.
        • Kaufmann H.
        Is ambulatory blood pressure monitoring useful in patients with chronic autonomic failure?.
        Clin. Auton. Res. 2014; 24: 189-192
        • Norcliffe-Kaufmann L.
        • Kaufmann H.
        • Palma J.A.
        • Shibao C.A.
        • Biaggioni I.
        • Peltier A.C.
        • et al.
        Orthostatic heart rate changes in patients with autonomic failure caused by neurodegenerative synucleinopathies.
        Ann. Neurol. 2018; 83: 522-531
        • Nwazue V.C.
        • Raj S.R.
        Confounders of vasovagal syncope: orthostatic hypotension.
        Cardiol. Clin. 2013; 31: 89-100
        • Palma J.-A.
        • Kaufmann H.
        Epidemiology, diagnosis, and management of neurogenic orthostatic hypotension.
        Mov. Disord. Clin. Pract. 2017; 4: 298-308
        • Palma J.A.
        • Norcliffe-Kaufmann L.
        • Kaufmann H.
        An orthostatic hypotension mimic: the inebriation-like syndrome in Parkinson disease.
        Mov. Disord. 2016; 31: 598-600
        • Puvi-Rajasingham S.
        • Mathias C.J.
        Effect of meal size on post-prandial blood pressure and on postural hypotension in primary autonomic failure.
        Clin. Auton. Res. 1996; 6: 111-114
        • Raj S.R.
        • Guzman J.C.
        • Harvey P.
        • Richer L.
        • Schondorf R.
        • Seifer C.
        • et al.
        Canadian cardiovascular society position statement on postural orthostatic tachycardia syndrome (POTS) and related disorders of chronic orthostatic intolerance.
        Can. J. Cardiol. 2020; 36: 357-372
        • Ricci F.
        • De Caterina R.
        • Fedorowski A.
        Orthostatic hypotension: epidemiology, prognosis, and treatment.
        J. Am. Coll. Cardiol. 2015; 66: 848-860
        • Ricci F.
        • Fedorowski A.
        • Radico F.
        • Romanello M.
        • Tatasciore A.
        • Di Nicola M.
        • et al.
        Cardiovascular morbidity and mortality related to orthostatic hypotension: a meta-analysis of prospective observational studies.
        Eur. Heart J. 2015; 36: 1609-1617
        • Robertson D.
        • Diedrich A.
        • Chapleau M.
        Afferent baroreflex failure.
        Auton. Neurosci. 2012; 172: 1-3
        • Rose K.M.
        • Eigenbrodt M.L.
        • Biga R.L.
        • Couper D.J.
        • Light K.C.
        • Sharrett A.R.
        • et al.
        Orthostatic hypotension predicts mortality in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) study.
        Circulation. 2006; 114: 630-636
        • Saedon N.I.
        • Pin Tan M.
        • Frith J.
        The prevalence of orthostatic hypotension: a systematic review and meta-analysis.
        J. Gerontol. A Biol. Sci. Med. Sci. 2020; 75: 117-122
        • Sezgin M.
        • Bilgic B.
        • Tinaz S.
        • Emre M.
        Parkinson’s disease dementia and Lewy body disease.
        Semin. Neurol. 2019; 39: 274-282
        • Sheldon R.S.
        • Grubb B.P.
        • Olshansky B.
        • Shen W.-K.K.
        • Calkins H.
        • Brignole M.
        • et al.
        2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope.
        Heart Rhythm. 2015; 12: e41-e63
        • Shibao C.
        • Gamboa A.
        • Diedrich A.
        • Biaggioni I.
        Management of hypertension in the setting of autonomic failure: a pathophysiological approach.
        Hypertension. 2005; 45: 469-476
        • Shibao C.
        • Grijalva C.G.
        • Raj S.R.
        • Biaggioni I.
        • Griffin M.R.
        Orthostatic hypotension-related hospitalizations in the United States.
        Am. J. Med. 2007; 120: 975-980
        • Stewart J.M.
        Transient orthostatic hypotension is common in adolescents.
        J. Pediatr. 2002; 140: 418-424
        • Stewart J.M.
        • Clarke D.
        “He’s dizzy when he stands up.” An introduction to initial orthostatic hypotension.
        J. Pediatr. 2011; 158: 499-504
        • Streeten D.H.
        • Thomas D.
        • Bell D.S.
        The roles of orthostatic hypotension, orthostatic tachycardia, and subnormal erythrocyte volume in the pathogenesis of the chronic fatigue syndrome.
        Am J Med Sci. 2000; 320: 1-8
        • Tipre D.N.
        • Goldstein D.S.
        Cardiac and extracardiac sympathetic denervation in Parkinson’s disease with orthostatic hypotension and in pure autonomic failure.
        J. Nucl. Med. 2005; 46: 1775-1781
        • Trahair L.G.
        • Horowitz M.
        • Jones K.L.
        Postprandial hypotension: a systematic review.
        J. Am. Med. Dir. Assoc. 2014; 15: 394-409
        • van Twist D.J.L.
        • Dinh T.
        • Bouwmans E.M.E.
        • Kroon A.A.
        Initial orthostatic hypotension among patients with unexplained syncope: an overlooked diagnosis?.
        Int. J. Cardiol. 2018; 271: 269-273
        • Verwoert G.C.
        • Mattace-Raso F.U.S.
        • Hofman A.
        • Heeringa J.
        • Stricker B.H.C.
        • Breteler M.M.B.
        • et al.
        Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study.
        J. Am. Geriatr. Soc. 2008; 56: 1816-1820