Neurogenic Orthostatic Hypotension. Lessons From Synucleinopathies

Area of Science:

• Neuroscience
• Cardiovascular Medicine
• Autonomic Dysfunction

Background:

• Upright blood pressure regulation relies on the autonomic nervous system; its failure causes neurogenic orthostatic hypotension (NOH).
• Severe NOH is linked to α-synucleinopathies like multiple system atrophy (MSA), Parkinson's disease, Lewy body dementia, and pure autonomic failure (PAF).
• Understanding NOH pathophysiology is crucial for developing effective treatment strategies.

Purpose of the Study:

• To review the pathophysiology of NOH in neurodegenerative disorders.
• To outline current and emerging treatment options for NOH.
• To emphasize a patient-centered approach to NOH management.

Main Methods:

• Literature review of NOH pathophysiology and treatment strategies.
• Analysis of treatment efficacy based on disease severity and specific neurodegenerative conditions.
• Discussion of conservative and pharmacologic interventions.

Main Results:

• Treatment goals for NOH are symptom reduction, improved quality of life, and fall prevention, not necessarily blood pressure normalization.
• Conservative measures (diet, compression) and patient education are foundational.
• Pharmacologic treatments vary in efficacy depending on the underlying pathology and patient characteristics.

Conclusions:

• NOH management requires a tailored approach considering the specific neurodegenerative disease and associated conditions like supine hypertension.
• Pyridostigmine and atomoxetine are beneficial for enhancing sympathetic tone in milder cases or specific MSA subtypes.
• Midodrine and droxidopa are effective for norepinephrine replacement in conditions with peripheral noradrenergic fiber degeneration, such as PAF.