Maule Simona, Papotti Grazia, Naso Diego, Magnino Corrado, Testa Elisa, Veglio Franco
Autonomic and Hypertension Unit, Department of Medicine and Experimental Oncology, S. Giovanni Battista Hospital, University of Turin, Italy.
Cardiovasc Hematol Disord Drug Targets. 2007 Mar;7(1):63-70. doi: 10.2174/187152907780059029.
Orthostatic hypotension (OH) may be dependent upon various neurogenic and non-neurogenic disorders and conditions. Neurogenic causes include the main autonomic failure syndromes, primary (multiple system atrophy, pure autonomic failure, and autonomic failure associated with Parkinson's disease) and secondary (central nervous system diseases, peripheral neuropathies and systemic diseases). Non-neurogenic causes of OH include cardiac impairment, fluid and electrolyte loss, vasodilatation, and old age. A number of drugs may also cause OH, through their vasoactive action or by interfering with the autonomic nervous system. Symptoms of OH are debilitating, often confining patients to bed, and longitudinal studies have shown that OH increases the risk of stroke, myocardial ischemia and mortality. The therapeutic goal is to decrease the incidence and severity of postural symptoms, rather than restore normotension. In non-neurogenic OH, treatment of the underlying cause may be curative. In neurogenic OH a combination of non-pharmacological and pharmacological measures is often needed. Patient education and non-pharmacological measures represent the first step; among these interventions, fluid repletion and physical countermanoeuvres have been proven very effective. Pharmacological treatment comprises a number of agents acting on blood vessels, on blood volume or with other pressor mechanisms. The drugs most currently used are fludrocortisone and midodrine. Fludrocortisone expands the extravascular body fluid volume and improves alpha-adrenergic sensitivity. Midodrine is a peripheral, selective alpha1-adrenergic agonist that causes arterial and venous vasoconstriction. Despite the wide use of these drugs, multicentre, randomised and controlled studies for the treatment of OH are still scarce and limited to few agents and groups of patients. Pharmacological management of OH substantially improves the quality of life of patients, although it may be problematic. The development of supine hypertension and subsequent congestive heart failure should be avoided, especially in those patients with a pre-existing cardiovascular risk, such as in diabetes or ischemic heart disease.
直立性低血压（OH）可能取决于多种神经源性和非神经源性疾病及状况。神经源性病因包括主要的自主神经功能衰竭综合征，原发性（多系统萎缩、单纯自主神经功能衰竭以及与帕金森病相关的自主神经功能衰竭）和继发性（中枢神经系统疾病、周围神经病变和全身性疾病）。OH的非神经源性病因包括心脏功能损害、液体和电解质丢失、血管扩张以及老年。许多药物也可能通过其血管活性作用或干扰自主神经系统而导致OH。OH的症状使人虚弱，常常使患者卧床不起，纵向研究表明OH会增加中风、心肌缺血和死亡的风险。治疗目标是降低体位性症状的发生率和严重程度，而非恢复正常血压。在非神经源性OH中，治疗潜在病因可能会治愈疾病。在神经源性OH中，通常需要非药物和药物措施相结合。患者教育和非药物措施是第一步；在这些干预措施中，补充液体和物理对抗措施已被证明非常有效。药物治疗包括多种作用于血管、血容量或其他升压机制的药物。目前最常用的药物是氟氢可的松和米多君。氟氢可的松可扩大血管外体液容量并提高α-肾上腺素能敏感性。米多君是一种外周选择性α1-肾上腺素能激动剂，可引起动脉和静脉血管收缩。尽管这些药物被广泛使用，但用于治疗OH的多中心、随机对照研究仍然很少，且仅限于少数药物和患者群体。OH的药物管理虽然可能存在问题，但能显著改善患者的生活质量。应避免发生仰卧位高血压及随后的充血性心力衰竭，尤其是在那些已有心血管风险的患者中，如糖尿病或缺血性心脏病患者。
