Management approaches to hypertension in autonomic failure.
OBJECTIVE
Supine hypertension is a common finding in autonomic failure that can worsen orthostatic hypotension and predispose to end-organ damage. This review focuses on nonpharmacologic and pharmacologic approaches to manage hypertension in these patients in the face of disabling orthostatic hypotension.


RESULTS
The hypertension of autonomic failure can be driven by sympathetic-dependent or independent mechanisms, contingent on the site of autonomic lesions. Management of supine hypertension should include simple nonpharmacologic approaches including avoiding the supine position during the daytime and sleeping in a head-up tilt position at night. Most patients, however, require pharmacologic treatment. Several antihypertensive therapies lower nighttime pressure in autonomic failure, but none improve nocturnal volume depletion or morning orthostatic tolerance. Regardless, treatment may still be beneficial in some patients but must be decided on an individual basis. Blood pressure monitoring is helpful in this regard, as well as titration of doses, as these patients are hypersensitive to depressor agents due to loss of baroreceptor reflexes.


CONCLUSIONS
Autonomic failure provides a unique opportunity to study blood pressure regulation independent of autonomic influences. Understanding mechanisms driving supine hypertension will have important implications for the treatment of autonomic failure and will improve our knowledge of cardiovascular regulation in other populations, including essential hypertension and elderly hypertensive individuals with comorbid orthostatic hypotension.
Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-6602, USA.
Amy C
AC
Arnold
Italo
I
Biaggioni
D001342:Autonomic Nervous System Diseases / Q000150:complications / Q000628:therapy*; D001794:Blood Pressure / Q000187:drug effects; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000628:therapy*; D016683:Supine Position / Q000502:physiology; D014665:Vasodilator Agents / Q000627:therapeutic use
D014665:Vasodilator Agents