Response to the letter by prof. Dal Moro: the Dark Side of the Swoon– antihypertensive treatment in the elderly

We would like to thank Prof. Dal Moro for his valuable contribution 1. Indeed, many patients, especially those who are older and who suffer from several concomitant diseases, are at risk of being ‘overtreated with good intentions’. The main problem is that the diagnosis of essential hypertension is at times assigned very liberally based on a single ambulatory measurement without taking into consideration the natural history and variation in systemic blood pressure 2. The orthostatic intolerance is often asymptomatic and thus not being looked for. Consequently, the antihypertensive treatment may additionally reduce blood pressure on standing and leads to unexpected syncopal attacks. Further, in the assessment of blood pressure in the elderly, we tend to forget about the Dark Lady in the white coat as well as about the Dark Night Riser (nondipper) 3. All of these can result in triggering of orthostatic syncope, if orthostatic hypotension is not detected prior to the initiation of antihypertensive treatment, or in the overtreatment of normotensive individuals (e.g. in white-coat syndrome). Moreover, nightly instead of daily dosage of antihypertensive agents (in nondippers) should be preferred 4 after 24-h-blood pressure monitoring had been performed and confirmed nondipping pattern. In Fig. 1, we present a head-up tilt record of an elderly patient with a pacemaker implanted due to sick sinus syndrome. He was diagnosed with hypertension and could not receive warfarin because of the pronounced fall risk. The ‘real’ resting BP was 90/55 mmHg, whereas on standing, the patient demonstrated a symptomatic orthostatic hypotension. We decided to stop all hypertensive treatment, and the patient has not had any syncopal episode yet. In Fig. 2, we present a ‘hypertensive’ man with syncopal attacks who was later diagnosed with orthostatic hypotension, white-coat syndrome and reversed dipping. Actually, as can be seen in the 24-h ambulatory BP measurement, he was, indeed, normotensive and, moreover, sporadically hypotensive during daily activities. After modifying and moving the antihypertensive drug dose to the night, he has not fainted anymore. So, beware the Dark Side of the Swoon, and treat your older patients with hypertension carefully. No conflict of interest to declare.