Orthostatic Hypotension and Supine Hypertension in Primary Autonomic Failure

Abstract

To the Editor: We read with interest the article of Shibao et al dealing with the treatment options when neurogenic orthostatic hypotension is complicated by supine hypertension.1 When orthostatic hypotension is caused by central and peripheral nervous system disorders such as primary autonomic failure, the patients report several syncope episodes, and treatment of hypertension is a “dilemma.” In the “management of supine hypertension” section, the authors propose a stepwise approach to treat hypertension, including the use of antihypertensive agents in patients with pure autonomic failure (PAF) and multiple system atrophy. Because it is more important to avoid daytime hypotension than hypertension, we suggest caution in the use of antihypertensive agents. The physician in charge should remember that the decision of starting antihypertensive drugs should not be based on the blood pressure values measured while the patient is lying in bed in the hospital. In case of supine hypertension, laboratory investigation, resting electrocardiography, echocardiography, and ultrasound carotid examination should be performed according to recent guidelines for the management of arterial hypertension.2 Moreover, a 24-hour noninvasive ambulatory blood pressure measurement (ABPM) should be included in the clinical assessment because it correlates strictly with target organ damage,2–3⇓ and it can show the real blood pressure pattern during everyday life. The documentation of …