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Degenerative Diseases of the Nervous System
Published in Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw, Hankey's Clinical Neurology, 2020
James A. Mastrianni, Elizabeth A. Harris
Dysautonomia: similar to PD, as features of dysautonomia are otherwise indistinguishable between the two diseases. Briefly:30Neurogenic bladder: antimuscarinics for overactive bladder, botulinum toxin injections in detrusor muscle, desmopressin for nocturia, intermittent self-catheterization for urinary retention, pharmacologic therapies for urinary retention (cholinergics, alpha-1 antagonists).Sildenafil for erectile dysfunction in men, though this may worsen hypotension.Orthostatic hypotension: increase water and salt intake, raising head of bed during sleep, compression stockings/abdominal binders. Medications include midodrine, droxidopa, fludrocortisone. Exacerbation of supine hypertension is a frequent side effect.
Pharmacological Treatment of Orthostatic Hypotension
Published in David Robertson, Italo Biaggioni, Disorders of the Autonomic Nervous System, 2019
Yohimbine is an aβ-receptor antagonist. Central «2 stimulation inhibits the activity of the sympathetic nervous system, and yohimbine, by interfering with this, enhances the sympathetic outflow (Goldberg and Robertson, 1983; Goldberg, Hollister and Robertson, 1983). In patients with autonomic failure, 2.5-5 mg yohimbine induced a small but significant rise in plasma noradrenaline and sustained elevations in seated blood pressure (Onrot et al., 1987a; Biaggioni, Robertson and Robertson, 1993). Side effects were related to sympathetic stimulation, including anxiety, diarrhoea and tremulousness, and may limit therapy in some patients. Supine hypertension was encountered. Patients who can tolerate chronic therapy may have long-term improvements in standing times and symptoms (Onrot et al., 1987a). Yohimbine has also been used with some success in orthostatic hypotension induced by tricyclic antidepressants (LeCrubier, Puech and Des Lauriers, 1981; Seibyl et al., 1989) and in Parkinsonian patients on levodopa (Montastruc et al., 1981). Yohimbine can be used to treat impotence (Morales et al., 1983) and this added indication can theoretically be exploited in males with milder forms of autonomic failure.
Evaluation and management of syncope and related disorders in the elderly
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Andrea Ungar, Martina Rafanelli, Michele Brignole
If nonpharmacological measures do not attenuate symptoms sufficiently, pharmacological interventions may become necessary. Nevertheless, supine hypertension has to be considered in pharmacological treatment. Volume expansion may be achieved with fludrocortisone, a synthetic mineralocorticoid that increases plasma volume by renal sodium retention. Unless peripheral vascular resistance (PVR) declines sufficiently, fludrocortisone treatment may result in dose-dependent supine hypertension.
Postural orthostatic tachycardia syndrome: pathophysiology, management, and experimental therapies
Published in Expert Opinion on Investigational Drugs, 2022
Bharat Narasimhan, Devika Aggarwal, Priyanka Satish, Bharat Kantharia, Wilbert S. Aronow
In patients with symptomatic hyperadrenergic POTS, a short acting non selective beta-blocker like propranolol, given one hour prior to exercise, could be beneficial in reducing tachycardia and associated symptoms [32]. Caution is necessary as beta blockade may exacerbate symptoms in patients with low plasma renin levels, however it is well tolerated in the majority of patients [54,55]. Ivabradine, an I-funny current (If) blocker, though not FDA approved for this indication – has been shown to reduce heart rate, and improve QOL in patients with hyperadrenergic POTS. It may be preferable to beta blockers because of a more favorable side effect profile [56–58]. Pyridostigmine, which is an acetylcholinesterase inhibitor, is occasionally used at a 30–60 mg dose three times a day and may be useful for patients with post viral, paraneoplastic and or autoimmune etiologies [59,60]. It has a lower risk of causing supine hypertension but the gastrointestinal side effects are often the limiting factor.
Identification and Management of Cardiometabolic Risk after Spinal Cord Injury
Published in The Journal of Spinal Cord Medicine, 2019
Mark S. Nash, Suzanne L. Groah, David R. Gater, Trevor A. Dyson-Hudson, Jesse A. Lieberman, Jonathan Myers, Sunil Sabharwal, Allen J. Taylor
The AHA Scientific Statement on Recommendations for Blood Pressure Measurement in Humans86 is the most current AHA authority on BP measurement procedures, selection of devices, and device calibration. The BP goals are consistent with AHA/NHLBI Guidelines on the diagnosis of CMD.10,11 Posture may affect blood pressure in people with SCI, especially those with tetraplegia. A study of veterans with SCI reported differential orthostatic effects on systolic hypertension based on the level of injury. Prevalence of systolic blood pressure (SBP) ≥140 mmHg was lower in the supine compared to the seated position in subjects with low paraplegia, whereas the incidence of a supine SBP ≥ 140 mmHg was increased by 53% compared to seated in subjects with tetraplegia.47 The presence of supine hypertension may be missed in individuals with tetraplegia if only seated blood pressure is measured. Supine hypertension may be associated with lack of a nocturnal dip in blood pressure, which has been associated with cardiovascular risk in the general population.
A “hot crossed buns” sign, orthostatic syncope & gait ataxia point to probable multiple systems atrophy with dysarthria and slowed fluency suspicious for associated cognitive impairment
Published in Cogent Medicine, 2018
Anthony C. Torres, Garet J. Zaugg, Nasir Tufail, Paul H. Janda
On physical exam, an unsteady, ataxic gait was seen. The patient’s speech demonstrated dysarthria, and slowed fluency. There was no appreciable deficit in extremity motor strength, though encouragement was required to elicit full effort. There was no tremor, rigidity, fasciculation or myoclonus. Sensation was intact to light touch. The patient remained afebrile. Supine hypertension was noted; orthostatic vital signs were significant for severe orthostatic hypotension on repeated assessment. The typical sitting blood pressure was 120s/70s mmHg; the standing blood pressure was 80s/50s mmHg. Although the patient was often hypertensive in the supine position, orthostatic vital signs repeatedly elicited evidence of orthostasis, with declines in systolic blood pressure consistently greater than 40 mmHg.