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(Circulation. 2009;119:139-146.)
© 2009 American Heart Association, Inc.

Contemporary Reviews in Cardiovascular Medicine

Neurogenic Orthostatic Hypotension

A Pathophysiological Approach

David S. Goldstein, MD, PhD; Yehonatan Sharabi, MD

From the Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md (D.S.G., Y.S.); and Hypertension Unit, Sheba Medical Center, Tel-HaShomer, and Sackler Faculty of Medicine, Tel Aviv, Israel (Y.S.).

Correspondence to Dr David S. Goldstein, Bldg 10, Room 6N252, 10 Center Dr, MSC-1620, Bethesda, Md 20892-1620. E-mail goldsteind@ninds.nih.gov

Key Words: hypotension • nervous system, sympathetic • norepinephrine • orthostatic hypotension • tomography

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Orthostatic hypotension (OH) is defined as a persistent, consistent, orthostatic fall in systolic blood pressure of 20 mm Hg or diastolic pressure of 10 mm Hg by 3 minutes of standing up.¹ Acute, unexpected, episodic falls in blood pressure while standing, as in neurocardiogenic syncope, do not satisfy criteria for OH.

Medical records for 0.4% of all hospitalizations in the United States include OH as a diagnosis, and of these 17% have OH as the primary diagnosis.² OH is associated with increased mortality in middle-aged adults³ and occurs especially commonly in the elderly, with a prevalence in the United States of 12%.⁴ The rate of hospitalization for nonacute OH increases exponentially with age.² Therefore, as the US population ages, the prevalence of OH and the incidence of OH-related morbidity are likely to increase.

OH can be an asymptomatic sign or manifest as symptoms that range from lightheadedness to loss of consciousness. In our experience, patients with OH do not typically present with recurrent syncope because they come to recognize and respond to premonitory symptoms such as generalized weakness, dizziness, fading vision, or lightheadedness that are relieved by lying down. Instead, OH patients often present with orthostatic intolerance and recurrent falls, an important risk factor for hip fracture and head trauma.

Moreover, OH often occurs concurrently with supine hypertension, which can be severe.⁵ The combination of OH and supine hypertension poses a challenging clinical dilemma because the clinician must balance the risk of chronic high blood pressure versus the immediate risk . . . [Full Text of this Article]