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

doi:10.3877/cma.j.issn.2095-8757.2017.02.003

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References 86

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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？

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？

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

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

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

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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）

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）

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