Highs and Lows: A Tale of Supine Hypertension and Orthostatic Hypotension Melissa Rae LeBlanc MD*‡ and Joseph Chiovaro MD*‡ *Oregon Health & Science University, Portland, Oregon , VA Portland Health care systems, Portland, Oregon

INTRODUCTION: CASE PRESENTATION: In we are often faced with clinical conundrums. An elderly man with prolonged history of orthostasis, difficult to manage Medical management of supine hypertension and orthostatic HTN, CAD, CKD and prior history of TIA presented with progressive hypotension is an example of such a conundrum, as treatment orthostasis symptoms, severe weakness, dizziness and recurrent of one often worsens the other. syncopal episodes. He was found to have NEUROGENIC ORTHOSTASIS evidenced by severe supine hypertension (systolic >200) and severe orthostatic hypotension and otherwise unremarkable BARORECEPTOR REFLEX ARC work up.

Treatment Trials: 1. Supportive care alone: ▪ Hydration ▪ Compression stockings ▪ list reviewed for concerning agents that may cause hypotension ▪ Head of bed elevation while supine ▪ Physical 2. Single agent strategies: ▪ Low dose beta blockade to slow heart rate increase ventricular filling time, did not improve his symptoms. ▪ Nitroglycerine cream at bedtime, worsened headache DIFFERENTIAL FOR NEUROGENIC ORTHOSTASIS Disorder Autonomic Symptoms Motor Symptoms Other Features 3. Short Acting Strategy Multiple- Severe autonomic Parkinsonism features Dysarthria ▪ Short acting antihypertensives while supine, Captopril and System dysfunction (80%) Stridor Atrophy Develops early (may be Cerebellar symptoms (20%) Dystonia Clonidine at bedtime the first symptoms) Corticospinal tract REM sleep behavior ▪ augmentation during the day with Midodrine dysfunction disorder Dementia Parkinson’s Occur late in the disease Parkinsonism REM sleep behavior Outcome: Disease process disorder May be worsened by Dementia late in the ▪ Experienced clinical improvement with combination of treatment of motor course supportive and short acting strategy symptoms Usually mild to moderate ▪ Discharged to Skilled Nursing facility then eventually back Lewy-Body Autonomic dysfunction Parkinsonism Progressive dementia home independently Dementia occurs early in clinical (often prior to motor course features) REFERENCES: Fluctuating cognitive DISCUSSION: 1. Vagaonescu, T.D. et al. dysfunction Hypertensive cardiovascular 2 damage in patients with primary Visual Hallucinations Supportive autonomic failure. The Lancet. 2000; 355: 725-726. REM sleep behavior 2. Lanier, J.B. et al. Evaluation and ▪ Ensuring adequate hydration Management of Orthostatic disorder Hypotension. AAFP. 2011; 84 (5): ▪ Compression Stockings or Abdominal Binders 527-536. Pure Gradual progressive None None 3. Shannon, J. et al. The Autonomic dysautonomia Hypertension of Autonomic Failure ▪ Removal of offending agents and its Treatment. Hypertension. Failure Prognosis better then the 1997; 30: 1062-1067. ▪ Elevation of head of bed during sleep 4. Chisholm, P. and Anpalahan, M. above disorders Orthostatic Hypotension: Reference: adapted from Freeman, R. Neurogenic Orthostatic Hypotension. NEJM. 2008; 358: 615-624. pathophysiology, assessment, ▪ and Occupational Therapy treatment, and the paradox of supine hypertension. Journal. 2017; 47 (4): 370- TAKE HOME POINTS: 379. 5. Ahmed, A. et al. Syndrome of Use short acting antihypertensives for supine periods Supine Hypertension with IT’S NOT ABOUT THE NUMBERS! What is your patients Orthostatic Hypotension. A 3 Nightmare for . The functional goal? What do they value? ▪ Nitroglycerine and Hydralazine Journal of Innovations in Cardiac 4,5,6 Rhythm Management. Mar 2016; 7: ▪ Short acting Ace Inhibitors and Clonidine 2285-2288. USE SHORT ACTING AGENTS! Allows different treatment 6. Lamarre-Cliché, M. Orthostatic Hypotension and Supine strategies at different points during the day. Use of Blood Pressure Augmentation Agents Hypertension in the Patient with 4,5,6 Autonomic Failure. Canadian ▪ Midodrine, Fludrocortisone, Pyridostigmine Journal of General Internal REQUIRES PATIENT BUY IN! Otherwise it’s likely to fail. Medicine. 2014; 9 (3): 91-95.