The Hypertension of Autonomic Failure and Its Treatment

Author:

Shannon John1,Jordan Jens1,Costa Fernando1,Robertson Rose Marie1,Biaggioni Italo1

Affiliation:

1. From the Divisions of Clinical Pharmacology and Cardiology, the Clinical Research Center, and the Autonomic Dysfunction Center, Departments of Medicine and Pharmacology, Vanderbilt University, Nashville, Tenn.

Abstract

Abstract We studied the incidence and severity of supine hypertension in 117 patients with severe primary autonomic failure presenting to a referral center over a 9-year period. Patients were uniformly characterized by disabling orthostatic hypotension, lack of compensatory heart rate increase, abnormal autonomic function tests, and unresponsive plasma norepinephrine. Fifty-four patients had isolated autonomic impairment (pure autonomic failure). Sixty-three patients had central nervous system involvement in addition to autonomic impairment (multiple-system atrophy). Patients were studied off medications, in a metabolic ward, and on a controlled diet containing 150 mEq of sodium. Fifty-six percent of patients had supine diastolic blood pressure ≥90 mm Hg. The prevalence of hypertension was slightly greater in females (63%) than in males (52%). Potential mechanisms responsible for this hypertension were investigated. No correlation was found between blood volume and blood pressure. Similarly, plasma norepinephrine (92±15 pg/mL) and plasma renin activity (0.3±0.05 ng/mL per hour) were very low in the subset of patients with pure autonomic failure and supine hypertension (mean systolic/diastolic pressure, 177±6/108±2 mm Hg, range 167/97 to 219/121). Supine hypertension represents a challenge in the treatment of orthostatic hypotension. We found these patients to be particularly responsive to the hypotensive effects of transdermal nitroglycerin. Doses ranging from 0.025 to 0.1 mg/h decreased systolic blood pressure by 36±7 mm Hg and may effectively treat supine hypertension overnight, but the dose should be individualized and used with caution.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Internal Medicine

Reference27 articles.

1. Robertson D Biaggioni I. Disorders of the Autonomic Nervous System. London UK: Harwood; 1995.

2. Dopamine- -hydroxylase deficiency in humans

3. Patterns of plasma levels of catechols in neurogenic orthostatic hypotension

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