Autonomic nervous system disorders

Transient orthostatic hypotension in Parkinson’s Disease

Transient orthostatic hypotension is as common as classic orthostatic hypotension in people with Parkinson’s disease. Short-lived falls in blood pressure when changing to the upright position may be overlooked with bedside BP measurements, but contribute to orthostatic intolerance and syncope in Parkinson’s disease.

Cardiovascular autonomic failure is a common non-motor feature of Parkinson’s Disease and typically manifests with classic orthostatic hypotension, i.e. a progressive fall in blood pressure within 3 minutes upon standing (1).

Besides classic orthostatic hypotension, transient falls in blood pressure within the first minute upon standing may occur (1, 2). Transient orthostatic hypotension manifests with short-lived, severe lightheadedness and blurred vision when changing to the upright position that recover within about a minute. In the elderly population, transient orthostatic hypotension may increase the risk of falls, orthostatic intolerance and frailty (2).

A recent study by Fanciulli, Campese et al. published in Neurology showed that transient orthostatic hypotension is as frequent as classic orthostatic hypotension in people with Parkinson’s disease. In this large retrospective cohort, 40% of people with Parkinson’s disease had a history of falls, in every third case due to syncope. Patients with history of orthostatic intolerance and syncope showed in fact more severe blood pressure falls upon standing, most pronounced in the first 30 to 60 seconds.

Bedside supine to standing blood pressure measurements with standard arm cuffs are an excellent screening for classic orthostatic hypotension, but do not capture short-lived blood pressure falls. When medical history is suggestive of transient orthostatic hypotension, performing a standing test under continuous blood pressure monitoring may help identifying a modifiable cause of syncope-related falls in people with Parkinson’s disease.

Key Points:

- Transient orthostatic hypotension is as common as classic orthostatic hypotension in people with Parkinson’s disease. 

- When suspected, screening for short-lived blood pressure falls upon standing up with continuous non-invasive blood pressure monitoring may help identify a treatable risk factor for syncope-related falls in Parkinson’s disease.

References:

1.        Brignole M, Moya A, de Lange FK et al., 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018 Jun 1;39(21):1883-1948. doi: 10.1093/eurheartj/ehy037

2.        Romero-Ortuno R, Cogan L, Foran T et al. Continuous noninvasive orthostatic blood pressure measurements and their relationship with orthostatic intolerance, falls, and frailty in older people. J Am Geriatr Soc 2011;59:655-665. doi: 10.1111/j.1532-5415.2011.03352.x.

3.        Fanciulli A, Campese N, Goebel G et al., Association of transient orthostatic hypotension with falls and syncope in patients with Parkinson's disease. Neurology. 2020 Sep 16:10.1212/WNL.0000000000010749. doi: 10.1212/WNL.0000000000010749