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      The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension


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          Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson’s disease, multiple system atrophy, pure autonomic failure, dementia with Lewy bodies, and peripheral neuropathies including amyloid or diabetic neuropathy. Due to the frequency of nOH in the aging population, clinicians need to be well informed about its diagnosis and management. To date, studies of nOH have used different outcome measures and various methods of diagnosis, thereby preventing the generation of evidence-based guidelines to direct clinicians towards ‘best practices’ when treating patients with nOH and associated supine hypertension. To address these issues, the American Autonomic Society and the National Parkinson Foundation initiated a project to develop a statement of recommendations beginning with a consensus panel meeting in Boston on November 7, 2015, with continued communications and contributions to the recommendations through October of 2016. This paper summarizes the panel members’ discussions held during the initial meeting along with continued deliberations among the panel members and provides essential recommendations based upon best available evidence as well as expert opinion for the (1) screening, (2) diagnosis, (3) treatment of nOH, and (4) diagnosis and treatment of associated supine hypertension.

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          Clinical practice. Neurogenic orthostatic hypotension.

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            Autonomic Function Tests: Some Clinical Applications

            Modern autonomic function tests can non-invasively evaluate the severity and distribution of autonomic failure. They have sufficient sensitivity to detect even subclinical dysautonomia. Standard laboratory testing evaluates cardiovagal, sudomotor and adrenergic autonomic functions. Cardiovagal function is typically evaluated by testing heart rate response to deep breathing at a defined rate and to the Valsalva maneuver. Sudomotor function can be evaluated with the quantitative sudomotor axon reflex test and the thermoregulatory sweat test. Adrenergic function is evaluated by the blood pressure and heart rate responses to the Valsalva maneuver and to head-up tilt. Tests are useful in defining the presence of autonomic failure, their natural history, and response to treatment. They can also define patterns of dysautonomia that are useful in helping the clinician diagnose certain autonomic conditions. For example, the tests are useful in the diagnosis of the autonomic neuropathies and distal small fiber neuropathy. The autonomic neuropathies (such as those due to diabetes or amyloidosis) are characterized by severe generalized autonomic failure. Distal small fiber neuropathy is characterized by an absence of autonomic failure except for distal sudomotor failure. Selective autonomic failure (which only one system is affected) can be diagnosed by autonomic testing. An example is chronic idiopathic anhidrosis, where only sudomotor function is affected. Among the synucleinopathies, autonomic function tests can distinguish Parkinson's disease (PD) from multiple system atrophy (MSA). There is a gradation of autonomic failure. PD is characterized by mild autonomic failure and a length-dependent pattern of sudomotor involvement. MSA and pure autonomic failure have severe generalized autonomic failure while DLB is intermediate.
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              Postprandial hypotension: epidemiology, pathophysiology, and clinical management.

              To show the clinical relevance of postprandial hypotension and to review its pathophysiology and management. Articles on postprandial hypotension were identified through MEDLINE and bibliographies of relevant articles. All articles and case reports describing meal-related hypotension in the elderly and in patients with autonomic failure. Postprandial hypotension, defined as a decrease in systolic blood pressure of 20 mm Hg or more, may result in syncope, falls, dizziness, weakness, angina pectoris, and stroke. Postprandial hypotension is distinct from and probably more common than orthostatic hypotension. Because meal-related hypotension is particularly common in older hypertensive patients, it has important implications for the evaluation and management of hypertension. The mechanism of postprandial hypotension is not fully understood. Possible contributors include inadequate sympathetic nervous system compensation for meal-induced splanchnic blood pooling; impairments in baroreflex function; inadequate postprandial increases in cardiac output; and impaired peripheral vasoconstriction, insulin-induced vasodilation, and release of vasodilatory gastrointestinal peptides. Although caffeine is often recommended as treatment for postprandial hypotension, available data do not support its use. Octreotide, a somatostatin analog, has been shown to be effective, but it is expensive and must be given parenterally. All physicians caring for elderly patients should be aware of the hypotensive effects of food intake and should consider postprandial hypotension in the evaluation of syncope, falls, dizziness, and other cerebral ischemic symptoms.

                Author and article information

                617-632-8454 , cgibbons@bidmc.harvard.edu
                J Neurol
                J. Neurol
                Journal of Neurology
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                3 January 2017
                3 January 2017
                : 264
                : 8
                : 1567-1582
                [1 ]ISNI 0000 0000 9011 8547, GRID grid.239395.7, , Harvard Medical School and Beth Israel Deaconess Medical Center, ; Boston, MA USA
                [2 ]ISNI 0000 0001 2236 2879, GRID grid.453428.c, , National Parkinson Foundation, ; Miami, FL USA
                [3 ]ISNI 0000 0004 1936 9916, GRID grid.412807.8, , Vanderbilt University Medical Center, ; Nashville, TN USA
                [4 ]ISNI 0000000100241216, GRID grid.189509.c, , Duke University Hospital and Central Carolina Hospital, ; Durham, NC USA
                [5 ]GRID grid.477790.a, , Parkinson’s Disease and Movement Disorders Center of Boca Raton, ; Boca Raton, FL USA
                [6 ]ISNI 0000 0004 0628 5895, GRID grid.411726.7, , University of Toledo Medical Center, ; Toledo, OH USA
                [7 ]ISNI 0000 0004 1936 8091, GRID grid.15276.37, , University of Florida College of Medicine, ; Gainesville, FL USA
                [8 ]ISNI 0000 0001 2156 6853, GRID grid.42505.36, , Keck/USC School of Medicine, ; Los Angeles, CA USA
                [9 ]ISNI 0000 0004 0459 167X, GRID grid.66875.3a, , Mayo Clinic, ; Rochester, MN USA
                [10 ]ISNI 0000 0004 0457 3148, GRID grid.412359.8, , Saint Louis University Hospital, ; St. Louis, MO USA
                [11 ]ISNI 0000 0004 1936 7697, GRID grid.22072.35, , University of Calgary, ; Calgary, BC Canada
                [12 ]ISNI 0000 0000 9482 7121, GRID grid.267313.2, , University of Texas Southwestern Medical Center, ; Dallas, TX USA
                [13 ]ISNI 0000 0001 2109 4251, GRID grid.240324.3, , New York University Langone Medical Center, ; New York, NY USA
                © The Author(s) 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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                © Springer-Verlag GmbH Germany 2017

                neurogenic orthostatic hypotension,supine hypertension,autonomic dysfunction,droxidopa,midodrine,fludrocortisone


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