Neurogenic Orthostatic Hypotension: Screening & Diagnosis

NEUROGENIC ORTHOSTATIC HYPOTENSION: SCREENING & DIAGNOSIS
                                                           
 

SCREENING

If OH/nOH suspected, ask patient the following questions:

   1.  Recent fainting or blackouts?


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   2.  Dizzy or lightheaded upon standing?

   3.  Vision disturbances when standing?

   4.  Difficulty breathing when standing?

   5.  Leg buckling/weakness when standing?

   6.  Neck pain/aching when standing?

   7.  Symptoms improve or disappear when sitting or laying down?

   8.  Worse in the AM or after meals?

   9.  Any recent falls?

 10.  Other symptoms that occur when standing or within 3−5mins of standing and get better when sitting or laying down?

High-risk1
patient?

         
           
           
           
   

Routine screening recommended

 
   
   
           
           
           
           
           

Positive response to ≥1 screening question

       

Symptoms strongly suggest OH?

         
                     
                                       

Consider supine-to-stand BP test or head-up-tilt

 

DIAGNOSIS: STEP-WISE APPROACH

In-Clinic Monitoring
Monitor patient’s BP/HR after 5 minutes in supine (preferred) or seated position then repeat measurement after 1 and 3 minutes of standing

     

≥20/10mmHg decrease in BP with standing?

 

No

       
     

Yes

         
                           
                                                         
                                                 
 

At-Home Monitoring
Patient/caregiver measures BP/HR after 5 minutes in supine position or before arising in the AM; repeat measurement after 3 minutes of standing. If symptomatic, repeat testing while standing. Check vitals for 7 days before clinic visit; record in diary

                                   
                                     
           

Patient has OH

         
                     
                                         
                                 
                                                 
                                             
 

Medication Review2
Examine patient’s medication list to identify those that may cause or worsen OH/nOH; modify as needed

                               
         

HR increase of <15bpm upon standing3

       

HR increase of >15bpm upon standing3

       
                         
                         
                                                         
                                             
 

Evaluate Causes of OH/nOH
Obtain complete history (eg, cardiac) and perform physical exam, ECG, lab testing (eg, CBC, BMP, TSH) to rule out non-neurogenic causes of OH

                               
                                 
         

Diagnosis of nOH

       

Diagnosis of
non-neurogenic OH

       
                       
                                                         
                                                         
 

Specialty Testing
Considered in at-risk individuals with unexplained symptoms who do not meet the orthostatic BP criteria; includes: extended at-home BP monitoring, 24-hour ambulatory BP monitoring, and autonomic function tests

                                       
                                         
                                         
                                         
                                         
                                         
NOTES

Key: BMP = basic metabolic panel; CBC = complete blood count; nOH = neurogenic orthostatic hypotension; OH = orthostatic hypotension

1 Higher risk for OH/nOH: 1) neurodegenerative disease associated with autonomic dysfunction (eg, Parkinson’s Disease, Multiple System Atrophy, Pure Autonomic Failure, Dementia with Lewy Bodies); 2) unexplained fall or episode of syncope; 3) peripheral neuropathies associated with autonomic dysfunction (eg, diabetes, amyloidosis, HIV); 4) age ≥70yrs who are frail or on multiple medications; 5) postural dizziness or non-specific symptoms that occur only when standing.

2 Common medications that may cause OH or exacerbate nOH: Tricyclic antidepressants, diuretics, nitrates, alpha-1 blockers, dopaminergic agents, anticholinergics, PDE-5 inhibitors, beta-blockers, calcium channel blockers, ACEIs, ARBs, clonidine, hydralazine.

3 Without confounding medication effect (eg, beta blockers, alpha/beta blockers, diltiazem, verapamil) or intrinsic cardiac rhythm disturbances (eg, sick sinus syndrome, complete heart block, pacemaker).

REFERENCES

Gibbons CH, Schmidt P, Biaggiono 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 Jan 3. doi: 10.1007/s00415-016-8375-x.

(Created 10/2019)

This article originally appeared on MPR