Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, and Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Tennessee, USA.
Am J Hypertens. 2018 Nov 13;31(12):1255-1259. doi: 10.1093/ajh/hpy089.
Orthostatic hypotension (OH) is an important and common medical problem, particularly in the frail elderly with multiple comorbidities and polypharmacy. OH is an independent risk factor for falls and overall mortality. Hypertension is among the most common comorbidities associated with OH, and its presence complicates the management of these patients because treatment of one can worsen the other. However, there is evidence that uncontrolled hypertension worsens OH so that both should be managed. The limited data available suggest that angiotensin receptor blockers and calcium channel blockers are preferable antihypertensives for these patients. Patients with isolated supine hypertension can be treated with bedtime doses of short-acting antihypertensives. Treatment of OH in the hypertensive patients should focus foremost on the removal of drugs that can worsen OH, including ones that are easily overlooked, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol. OH and postprandial hypotension can be prevented with abdominal binders and acarbose, respectively, without the need to increase baseline blood pressure. Upright blood pressure can be improved by harnessing residual sympathetic tone with atomoxetine, which blocks norepinephrine reuptake in nerve terminals, and pyridostigmine, which facilitates cholinergic neurotransmission in autonomic ganglia. Oral water bolus acutely but transiently increases blood pressure in autonomic failure patients. If traditional pressor agents are needed, midodrine and droxidopa can be used, administered at the lowest dose and frequency that improves symptoms. Management of OH in the hypertensive patient is challenging, but a management strategy based on understanding the underlying pathophysiology can be effective in most patients.
直立性低血压（OH）是一个重要且常见的医学问题，尤其是在患有多种合并症和多种药物治疗的虚弱老年人中。OH 是跌倒和总体死亡率的独立危险因素。高血压是与 OH 最常见的合并症之一，其存在使这些患者的管理变得复杂，因为治疗一种疾病可能会使另一种疾病恶化。然而，有证据表明，未控制的高血压会使 OH 恶化，因此两者都需要治疗。有限的可用数据表明，血管紧张素受体阻滞剂和钙通道阻滞剂是这些患者的首选降压药。对于仅仰卧位高血压的患者，可以使用短效降压药的睡前剂量进行治疗。高血压患者 OH 的治疗应首先侧重于去除可能使 OH 恶化的药物，包括那些容易被忽视的药物，如坦索罗辛、替扎尼定、西地那非、曲唑酮和卡维地洛。通过使用腹部束带和阿卡波糖，可以分别预防 OH 和餐后低血压，而无需增加基础血压。通过利用阿托西汀来抑制神经末梢去甲肾上腺素的再摄取，以及使用吡啶斯的明来促进自主神经节中的胆碱能神经传递，可以改善直立血压。口服水冲击可在自主神经衰竭患者中急性但短暂地升高血压。如果需要传统的升压剂，可以使用米多君和屈昔多巴，以改善症状所需的最低剂量和频率给药。高血压患者 OH 的管理具有挑战性，但基于对潜在病理生理学的理解的管理策略可以在大多数患者中有效。
