切换至 "中华医学电子期刊资源库"
高级检索
中华老年病研究电子杂志

中华老年病研究电子杂志 ›› 2017, Vol. 04 ›› Issue (02) : 16 -27. doi: 10.3877/cma.j.issn.2095-8757.2017.02.003

所属专题： 文献； 指南共识；

指南快译

神经源性直立性低血压与相关仰卧位高血压的筛查、诊断和治疗专家共识
  1. 1. 310013　杭州，浙江医院神经内科
    2. 310013　杭州，浙江医院神经内科；310013　杭州，浙江医院老年医学科
  • 收稿日期:2017-05-08 出版日期:2017-05-28
  • 基金资助:
    浙江省中医药管理局一般项目(2013ZA009)

The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension

  • Received:2017-05-08 Published:2017-05-28
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

. 神经源性直立性低血压与相关仰卧位高血压的筛查、诊断和治疗专家共识[J]. 中华老年病研究电子杂志, 2017, 04(02): 16-27.

表1 疑似OH/nOH的筛查问题
序号 筛查问题
1 你最近晕倒/黑朦过吗？
2 你站立时感到头晕目眩吗？
3 你站立时有视力障碍吗？
4 你站立时有呼吸困难吗？
5 你站立时有腿弯或腿软吗？
6 你站立时有过颈痛吗？
7 你坐下或躺下时上述症状有改善或消失吗？
8 这些症状在早晨或饭后是否会加重？
9 你最近有跌倒过吗？
10 在起立或站立3～5 min时，你一般会不会出现其他一些症状，而坐下或躺下时症状会改善？
图1 nOH逐步诊断方案
表2 评估呈现OH/nOH个体的推荐初始检查
检查 在OH/nOH鉴别诊断中的作用
心电图 评估心脏电活动
全血细胞计数 评估可能导致非神经源性OH的贫血或感染
基础代谢（钠、钾、氯、碳酸氢钠、血尿素氮、肌酐和空腹血糖） 检查低钠/高钠血症、低钠/高钾血症、酸碱失衡、血容量不足[ BUN:Cr比（20 mg/dL:1mg/dL）]，肾功能不全或糖尿病
促甲状腺激素 评估甲状腺功能障碍
B12水平、甲基丙二酸 寻找B12缺乏证据
辅助实验室检查（考虑用于选定患者） ?
? 白蛋白 识别营养不良或慢性疾病
? 肝酶检测、白蛋白 评估体重减轻和全身性症状患者的肝功能障碍
? 神经抗体研究（副肿瘤综合征组） 识别自身抗体；指征极少，仅适用于存在其他神经或全身性症状的情况下，提示自身免疫性或副肿瘤综合征的nOH亚急性发作患者。应对单纯性自主神经衰竭综合征进行抗神经节乙酰胆碱受体抗体检测
? 血清和尿蛋白电泳 识别单克隆丙种球蛋白病；仅适用于有周围神经病变特征的患者
表3 可能导致OH或加重nOH症状的常见药物
药物类别 常见药物
多巴胺能药 左旋多巴、多巴胺激动剂
抗抑郁药（特别是三环类制剂）a 阿米替林、去甲替林、丙咪嗪、地昔帕明
抗胆碱能药物 阿托品、格隆溴铵、莨菪碱
抗高血压药 ?
? 降低前负荷药物 ?
? ? 利尿药a 呋塞米、托拉塞米、乙酰唑胺、氢氯噻嗪、螺内酯
? ? 硝酸盐类a 硝普钠、硝酸异山梨酯、硝酸甘油
? ? 磷酸二酯酶E5抑制剂 西地那非、伐地那非、他达拉非
? 血管扩张剂 ?
? ? α-1肾上腺素能拮抗剂a 阿夫唑嗪、多沙唑嗪、哌唑嗪、特拉唑嗪、坦索罗辛（主要用于良性前列腺增生）
? ? 二氢吡啶钙通道阻滞剂 氨氯地平、硝苯地平、尼卡地平
? ? 其他直接血管扩张剂 肼苯哒嗪、米诺地尔
? 负性肌力/变时性剂 ?
? ? β-肾上腺素能阻滞剂 普萘洛尔、美托洛尔、阿替洛尔、比索洛尔、奈比洛尔（也是血管扩张剂）、卡维地洛（也是α-1拮抗剂）、拉贝洛尔（也是α-1拮抗剂）
? ? 非二氢吡啶钙通道阻滞剂 维拉帕米、地尔硫卓
? 中枢抗交感神经药 ?
? ? 中枢α-2激动剂 可乐定
? ? 假神经递质 α-甲基多巴
? 肾素-血管紧张素系统拮抗剂 ?
? ? 血管紧张素转换酶抑制剂 卡托普利、依那普利、培哚普利
? ? Ⅱ型血管紧张素受体阻滞剂 氯沙坦、替米沙坦、坎地沙坦
表4 nOH分级量表
级别 属性
1级 症状偶发/站立时间无限制和轻度OH（仰卧位检查时SBP下降20～30 mmHg）
2级 站立时间≥5 min（但非无限制）和（SBP下降>30 mmHg或中度影响ADL）
3级 站立时间<5 min和（SBP下降>30 mmHg或严重影响ADL）
4级 站立时间< 1分钟和（SBP下降> 30 mmHg或无行为能力）
图2 治疗nOH的4个步骤
表5 nOH相关仰卧位高血压的治疗建议
治疗方案* 作用机制 常用剂量
卡托普利 血管紧张素转换酶抑制剂 25 mg/h
可乐定a 中枢α-2激动剂 0.2 mg与晚餐同服
肼苯哒嗪 外周平滑肌松弛剂 每晚临睡前10～25 mg
氯沙坦 血管紧张素Ⅱ受体拮抗剂 每晚临睡前50 mg
硝酸甘油贴剂 血管扩张剂 每晚临睡前0.1 mg/h贴（早晨移除贴剂）
[1]
Low PA. Prevalence of orthostatic hypotension[J]. Clin Auton Res, 2008, 18(Suppl 1): 8-13.
[2]
Metzler M, Duerr S, Granata R, et al.Wen-ning GK (2013) Neurogenic orthostatic hypotension: patho-physiology, evaluation, and management[J]. J Neurol, 260(9): 2212-2219.
[3]
Maule S, Milazzo V, Maule MM, et al. Mortality and prognosis in patients with neurogenic orthostatic hypotension[J]. Funct Neurol, 2012, 27(2): 101-106.
[4]
Gibbons CH, Freeman R. Clinical implications of delayed orthostatic hypotension: a 10-year follow-up study[J]. Neurology, 2015, 85(16): 1362-1367.
[5]
Xin W, Lin Z, Mi S. Orthostatic hypotension and mortality risk: a meta-analysis of cohort studies[J]. Heart, 2014, 100(5): 406-413.
[6]
Freeman R. Clinical practice. Neurogenic orthostatic hypotension[J]. N Engl J Med, 2008, 358(6): 615-624.
[7]
Low PA, Singer W. Management of neurogenic orthostatic hypotension: an update[J]. Lancet Neurol, 2008, 7(5): 451-458.
[8]
Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the pos-tural tachycardia syndrome[J]. Auton Neurosci, 2011, 161(1-2): 46-48.
[9]
Loavenbruck A, Sandroni P. Neurogenic orthostatic hypotension: roles of norepinephrine deficiency in its causes, its treatment, and future research directions[J]. Curr Med Res Opin, 2015, 31(11): 2095-2104.
[10]
Goldstein DS, Pechnik S, Holmes C, et al. Association between supine hypertension and orthostatic hypotension in autonomic failure[J]. Hypertension, 2003, 42(2): 136-142 .
[11]
Jankovic J, Gilden JL, Hiner BC, et al. Fouad-Tarazi FM Neurogenic orthostatic hypotension: a double-blind, placebo- controlled study with midodrine[J]. Am J Med, 1993, 95(1): 38-48 .
[12]
Low PA, Gilden JL, Freeman R, et al. Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double blind multicenter study[J]. JAMA, 1997, 277(13): 1046-1051.
[13]
Wright RA, Kaufmann HC, Perera R, et al. A double-blind, dose-response study of midodrine in neurogenic orthostatic hypotension[J]. Neurology, 1998, 51(1): 120-124.
[14]
Singer W, Sandroni P, Opfer-Gehrking TL, et al. Pyri-dostigmine treatment trial in neurogenic orthostatic hypotension[J]. Arch Neurol, 2006, 63(4): 513-518.
[15]
Kaufmann H, Freeman R, Biaggioni I, et al. Droxidopa for neurogenic orthostatic hypotension: a randomized, placebo-controlled, phase 3 trial[J]. Neurology, 2014, 83(4): 328-335.
[16]
Biaggioni I, Freeman R, Mathias CJ, et al. Randomized withdrawal study of patients with symptomatic neurogenic orthostatic hypotension responsive to droxidopa[J]. Hypertension, 2015, 65(1): 101-107.
[17]
Hauser RA, Isaacson S, Lisk JP, et al. Droxidopa for the short-term treatment of symptomatic neuro-genic orthostatic hypotension in Parkinson's disease (nOH306B)[J]. Mov Disord, 2015, 30(5): 646-654.
[18]
Singer W, Opfer-Gehrking TL, McPhee BR, et al. Acetylcholinesterase inhibition: a novel approach in the treatment of neurogenic orthostatic hypotension[J]. J Neurol Surg Psychiatry, 2003, 74(9): 1294-1298.
[19]
Senard JM. Pyridostigmine in the treatment of orthostatic hypotension[J]. Clin Auton Res, 2005, 15(6): 421-422.
[20]
Singer W, Opfer-Gehrking TL, Nickander KK, et al. Acetylcholinesterase inhibition in patients with orthostatic intolerance[J]. J Clin Neurophysiol, 2006, 23(5): 476-481.
[21]
Provitera V, Nolano M, Pagano A. Acetylcholinesterase inhibition and orthostatic hypotension[J]. J Clin Auton Res Soc, 2006, 16(2): 136.
[22]
Lahrmann H, Cortelli P, Hilz M, et al. EFNS guidelines on the diagnosis and management of orthostatic hypotension[J]. Eur J Neurol, 2006, 13(9): 930-936.
[23]
Bleasdale-Barr KM, Mathias CJ. Neck and other muscle pains in autonomic failure: their association with orthostatic hypotension[J]. J R Soc Med, 1998, 91(7): 355-359.
[24]
Gibbons CH, Freeman R. Orthostatic dyspnea: a neglected symptom of orthostatic hypotension[J]. Clin Auton Res, 2005, 15(1): 40-44.
[25]
Robertson D, Kincaid DW, Haile V, et al. The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache[J]. Clin Auton Res, 1994, 4(3): 99-103.
[26]
Guaraldi P, Poda R, Calandra-Buonaura G, et al. Cognitive function in peripheral autonomic disorders[J]. PLoS One, 2014, 9(1): e85020.
[27]
Centi J, Freeman R, Gibbons CH, et al. Effects of orthostatic hypotension on cognition in Parkinson disease[J]. Neurology, 2017, 88(1): 17-24.
[28]
Shibao C, Grijalva CG, Raj SR, et al. Orthostatic hypotension-related hospitalizations in the United States[J]. Am J Med, 2007, 120(11): 975-980.
[29]
Low PA. Neurogenic orthostatic hypotension: pathophys-iology and diagnosis[J]. Am J Manag Care, 2015, 21(13 Suppl): s248-s257.
[30]
Davidson C, Smith D, Morgan DB. Diurnal pattern of water and electrolyte excretion and body weight in idiopathic orthostatic hypotension. The effect of three treatments[J]. Am J Med, 1976, 61(5): 709-715.
[31]
Ikeda T, Matsubara T, Sato Y, et al. Circadian blood pressure variation in diabetic patients with autonomic neuropathy[J]. J Hypertens, 1993, 11(5): 581-587.
[32]
Mann S, Bellamy GR, Hunyor SN, et al. Supine hypertension, blood pressure variability and cir-cadian rhythm in autonomic failure: the role of ambulatory intra-arterial monitoring[J]. Clin Exp Pharmacol Physiol, 1984, 11(4): 347-350.
[33]
Shibao C, Lipsitz LA, Biaggioni I. American Society of Hyper-tension Writing Group Evaluation and treatment of orthostatic hypotension[J]. J Am Soc Hypertens, 2013, 7(4): 317-324.
[34]
Gibbons CH, Freeman R. Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance[J]. Neurology, 2006, 67(1):28-32.
[35]
Biaggioni I. Treatment: special conditions: orthostatic hypotension[J]. J Am Soc Hypertens, 2015, 9(1): 67-69.
[36]
White NJ. Heart-rate changes on standing in elderly patients with orthostatic hypotension[J]. Clin Sci, 1980, 58(5): 411-413.
[37]
Poon IO, Braun U. High prevalence of orthostatic hypotension and its correlation with potentially causative medi-cations among elderly veterans[J]. J Clin Pharm Ther, 2005, 30(2): 173-178.
[38]
Gibbons CH, Freeman R. Clinical implications of delayed orthostatic hypotension: a 10-year follow-up study[J]. Neurology, 2015, 85(16): 1362-1367.
[39]
Low PA, Tomalia VA, Park KJ. Autonomic function tests: some clinical applications[J]. J Clin Neurol, 2013, 9(1): 1-8.
[40]
Baschieri F, Calandra-Buonaura G, Doria A, et al. Cardiovascular autonomic testing performed with a new integrated instrumental approach is useful in differentiating MSA-P from PD at an early stage[J]. Parkinsonism Relat Disord, 2015, 21(5): 477-482.
[41]
Goldstein DS, Holmes C, Sharabi Y, et al. Plasma levels of catechols and metanephrines in neuro-genic orthostatic hypotension[J]. Neurology, 2003, 60(8): 1327-1332.
[42]
Robertson D. The pathophysiology and diagnosis of orthostatic hypotension[J]. Clin Auton Res, 2008, 18(Suppl 1): 2-7.
[43]
Freeman R. Treatment of orthostatic hypotension[J]. Semin Neurol, 2003, 23(4): 435-442.
[44]
Weinberg AD, Minaker KL. Dehydration: evaluation and management in older adults[J]. J Am Med Assoc, 1995, 274(19):1552-1556.
[45]
Jordan J, Shannon JR, Black BK, et al. The pressor response to water drinking in humans: a sympathetic reflex[J]? Circulation, 2000, 101(5): 504-509
[46]
Shannon JR, Diedrich A, Biaggioni I, et al. Water drinking as a treatment for orthostatic syndromes[J]. Am J Med, 2002, 112(5): 355-360.
[47]
May M, Jordan J. The osmopressor response to water drinking[J].Am J Physiol Regul Integr Comp Physiol, 2011, 300(1):R40-R46.
[48]
Lipp A, Tank J, Franke G, et al. Osmosensitive mechanisms contribute to the water drinking-in-duced pressor response in humans[J].Neurology, 2005, 65(6): 905-907.
[49]
Raj SR, Biaggioni I, Black BK, et al. Sodium paradoxically reduces the gas-tropressor response in patients with orthostatic hypotension[J]. Hypertension, 2006, 48(2): 329-334.
[50]
Schroeder C, Bush VE, Norcliffe LJ, et al. Water drinking acutely improves orthostatic tolerance in healthy subjects[J]. Circulation, 2002, 106(22): 2806-2811.
[51]
Jordan J, Shannon JR, Diedrich A, et al. Water potentiates the pressor effect of ephedra alkaloids[J]. Circulation, 2004, 109(15): 1823-1825.
[52]
Mathias CJ, Young TM. Water drinking in the manage-ment of orthostatic intolerance due to orthostatic hypotension, vasovagal syncope and the postural tachycardia syndrome[J]. Eur J Neurol, 2004, 11(9): 613-619.
[53]
Claydon VE, Schroeder C, Norcliffe LJ, et al. Water drinking improves orthostatic tolerance in patients with posturally related syncope[J]. Clin Sci, 2006, 110(3): 343-352.
[54]
Kerstens MN, Kobold AC, Volmer M, et al. Reference values for aldosterone-renin ratios in normotensive individuals and effect of changes in dietary sodium consumption[J]. Clin Chem, 2011, 57(11): 1607-1611.
[55]
Mtinangi BL, Hainsworth R. Early effects of oral salt on plasma volume, orthostatic tolerance, and baroreceptor sensitivity in patients with syncope[J]. Clin Auton Res, 1998, 8(4): 231-235.
[56]
Baas SJ, Endert E, Fliers E, et al. Establishment of reference values for endocrine tests III: primary aldosteronism[J]. The Netherlands J Med, 2003, 61(2): 37-43.
[57]
Kranzler HR, Cardoni A. Sodium chloride treatment of antidepressant-induced orthostatic hypotension[J]. J Clin Psychiatry, 1988, 49: 366-368 .
[58]
Smith GD, Mathias CJ. Postural hypotension enhanced by exercise in patients with chronic autonomic failure[J]. QJM, 1995, 88(4): 251-256.
[59]
Zion AS, De Meersman R, Diamond BE, et al. A home-based resistance-training program using elastic bands for elderly patients with orthostatic hypotension[J]. Clin Auton Res, 2003, 13(4): 286-292.
[60]
Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: as easy as A, B, C[J]. Cleve Clin J Med, 2010, 77(5): 298-306.
[61]
Pierangeli G, Provini F, Maltoni P, et al. Nocturnal body core temperature falls in Parkinson's disease but not in Multiple-System Atrophy[J]. Mov Disord, 2001, 16(2): 226-232.
[62]
Wieling W, van Lieshout JJ, van Leeuwen AM. Physical manoeuvres that reduce postural hypotension in autonomic fail-ure[J].Clin Auton Res, 1993, 3(1): 57-65.
[63]
Harkel AD, van Lieshout JJ, Wieling W. Treatment of orthostatic hypotension with sleeping in the head-up tilt position, alone and in combination with fludrocortisone[J]. J Intern Med, 1992, 232(2): 139-145.
[64]
Henry R, Rowe J, O'Mahony D, Haemodynamic analysis of efficacy of compression hosiery in elderly fallers with ortho-static hypotension [letter] [J]. Lancet, 1999, 354(9172): 45-46.
[65]
Denq JC, Opfer-Gehrking TL, Giuliani M, et al. Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension[J].Clin Auton Res, 1997, 7(6): 321-326.
[66]
Smit AA, Wieling W, Fujimura J, et al. Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction[J]. Clin Auton Res, 2004, 14(3): 167-175.
[67]
Okamoto LE, Diedrich A, Baudenbacher FJ, et al. Efficacy of servo-controlled splanchnic venous compression in the treatment of orthostatic hypoten-sion: a randomized comparison with midodrine[J]. Hypertension, 2016, 68(2): 418-426.
[68]
Jansen RW, Lipsitz LA. Postprandial hypotension: epi-demiology, pathophysiology, and clinical management[J]. Ann Intern Med, 1995, 122(4): 286-295.
[69]
Puisieux F, Boumbar Y, Bulckaen H, et al. Intraindividual variability in orthostatic blood pressure changes among older adults: the influence of meals[J]. J Am Geriatr Soc, 1999, 47(11): 1332-1336.
[70]
Puvi-Rajasingham S, Mathias CJ. Effect of meal size on post-prandial blood pressure and on postural hypotension in pri-mary autonomic failure[J]. Clin Auton Res, 1996, 6(2): 111-114.
[71]
Berry MK, Russo A, Wishart JM, et al. Effect of solid meal on gastric emptying of, and glycemic and cardiovascular responses to, liquid glucose in older subjects[J]. Am J Physiol Gastrointest Liv Physiol, 2003, 284(4): G655- G662.
[72]
Jansen RW, Peeters TL, van Lier HJ, et al. The effect of oral glucose, protein, fat and water loading on blood pressure and the gastrointestinal peptides VIP and somatostatin in hypertensive elderly subjects[J].Eur J Clin Invest, 1990, 20(2): 192-198.
[73]
Onrot J, Goldberg MR, Biaggioni I, et al. Hemodynamic and humoral effects of caf-feine in autonomic failure. Therapeutic implications for post-prandial hypotension[J]. N Engl J Med, 1985, 313(9): 549-554.
[74]
Shibao C, Gamboa A, Diedrich A, et al. Acarbose, an alpha-glucosidase inhibitor, attenuates postprandial hypotension in autonomic failure[J]. Hypertension, 2007, 50(1): 54-61.
[75]
Ando Y, Asahara K, Obayashi K, et al. Autonomic dysfunction and anemia in neurologic disorders[J]. J Auton Nerv Syst, 1996, 61(2): 145-148.
[76]
Beitzke M, Pfister P, Fortin J, et al. Autonomic dysfunction and hemodynamics in vitamin B12 deficiency[J]. Auton Neurosci, 2002, 97(1): 45-54.
[77]
Skrabal F. Syncope, falls and cobalamin deficiency in the old population[J]. Clin Auton Res, 2004, 14(2): 60-66.
[78]
Parsaik AK, Singh B, Altayar O, et al. Midodrine for orthostatic hypotension: a systematic review and meta-analysis of clinical trials[J]. J Gen Intern Med, 2013, 28(11): 1496-1503.
[79]
McClellan KJ, Wiseman LR, Wilde MI. A review of its therapeutic use in the management of orthostatic hypotension[J]. Drugs Aging, 1998, 12(1): 76-86.
[80]
Kaufmann H, Saadia D, Voustianiouk A, et al. Norepinephrine pre-cursor therapy in neurogenic orthostatic hypotension[J]. Circulation, 2003, 108(6): 724-728.
[81]
Campbell IW, Ewing DJ, Clarke BF. 9-Alpha-fluorohy-drocortisone in the treatment of postural hypotension in diabetic autonomic neuropathy[J]. Diabetes, 1975, 24: 381-384.
[82]
Decaux G. Fludrocortisone in orthostatic hypotension [letter] [J]. N Engl J Med, 1979, 301: 1121-1122.
[83]
Watt SJ, Tooke JE, Perkins CM, et al. The treatment of idiopathic orthostatic hypotension: a combined fludrocortisone and flurbiprofen regime[J]. Q J Med, 1981, 50: 205-212.
[84]
van Lieshout JJ, ten Harkel AD, Wieling W. Fludrocorti-sone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure[J]. Clin Auton Res, 2000, 10(1): 35-42.
[85]
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee(JNC 8)[J]. JAMA, 2014, 311(5): 507-520.
[86]
Jordan J, Biaggioni I. Diagnosis and treatment of supine hypertension in autonomic failure patients with orthostatic hypotension[J].J Clin Hypertens, 2002, 4(2): 139-145.
No related articles found!
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号