Neurogenic orthostatic hypotension in synucleinopathies: review and simplified diagnostic algorithm

Neurogenic orthostatic hypotension (nOH) is a hallmark of synucleinopathies, such as Parkinson's disease (PD), multiple system atrophy, and dementia with Lewy bodies, often presenting as pure autonomic failure before motor or cognitive symptoms.In Latin América, limited diagnostic resources necessitate standardized, accessible tools for nOH assessment.This narrative review synthesizes current knowledge on nOH in synucleinopathies, focusing on clinical evaluation, diagnostic tools, and phenoconversion.We conducted a literature search (PubMed, Google Scholar, Scopus; 1980-2025), analyzing 50 key studies on nOH pathophysiology, diagnostics, and management.Baroreflex dysfunction, characterized by a Δ Delta heart rate/delta systolic blood pressure ratio, distinguishes nOH from non-neurogenic causes.We propose a simplified algorithm for Latin América clinics: (1) confirm nOH via orthostatic blood pressure, (2) screen olfaction with University of Pennsylvania smell identification test (UPSIT) test, (3) assess cognition with Montreal Cognitive Assessment, (4) monitor movement with video-recorded movement disorder society-unified PD rating scale/The Unified Multiple System Atrophy Rating Scale (UMSARS), and (5) evaluate urinary function with bladder scan.This pipeline uses widely available tools, reducing costs, that is, in the tilt table testing.nOH exacerbates falls and cardiovascular risks, underscoring early diagnosis.Limitations include algorithm validation needs and UPSIT variability.This approach enhances diagnostic accuracy and supports early intervention in Latin America resource-limited settings.