Management of Patients With Hypertension and Orthostatic Hypotension. Parallel Progress

Orthostatic hypotension (OH) is a common comorbidity among patients with hypertension, affecting about 10% of patients referred to hypertension clinics.Conversely, hypertension is present in 70% of patients with severe OH.The treatment of patients that have both conditions remains a management challenge because treatment of one could worsen the other.It is reassuring that large phase 3 hypertension trials have shown that hypertension can be effectively treated in most patients without worsening OH, but these trials typically exclude patients with the most severe forms of OH.Conversely, novel treatments for OH have been approved based on clinical trials that excluded patients with the most common causes of OH.The purpose of this editorial is to alert physicians that treatment recommendations derived from these studies may not apply to individual patients. ORTHOSTATIC HYPOTENSION. SPECTRUM OF DISEASEOH is defined a fall in systolic blood pressure 20 mm Hg (or in diastolic blood pressure of 10 mm Hg) within 3 minutes of standing.Humans are able to stand because of autonomic and other compensatory mechanisms that prevent OH.If these mechanisms are impaired, as occurs in patients with primary neurodegenerative autonomic disorders, severe OH ensues.Most cases of OH lie in the middle of this spectrum and occur in patients who suffer from some degree of autonomic impairment caused by aging, diabetes, or other neuropathies, and in combination with aggravating factors, often the use of medications that impair compensatory mechanisms that maintain orthostatic tolerance (Figure).