(Hypertension. 1997;30:1062-1067.)
© 1997 American Heart Association, Inc.
Articles |
The Hypertension of Autonomic Failure and Its Treatment
From the Divisions of Clinical Pharmacology and Cardiology, the Clinical Research Center, and the Autonomic Dysfunction Center, Departments of Medicine and Pharmacology, Vanderbilt University, Nashville, Tenn.
Correspondence to Italo Biaggioni, MD, Clinical Research Center, AA-3228 MCN, Vanderbilt University, Nashville, TN 37232.
Abstract We studied the incidence and severity of supine
hypertension in 117 patients with severe primary autonomic failure
presenting to a referral center over a 9-year period. Patients were
uniformly characterized by disabling orthostatic
hypotension, lack of compensatory heart rate increase, abnormal
autonomic function tests, and unresponsive plasma
norepinephrine. Fifty-four patients had isolated autonomic
impairment (pure autonomic failure). Sixty-three patients had central
nervous system involvement in addition to autonomic impairment
(multiple-system atrophy). Patients were studied off medications, in a
metabolic ward, and on a controlled diet containing 150 mEq
of sodium. Fifty-six percent of patients had supine
diastolic blood pressure 
90 mm Hg. The prevalence
of hypertension was slightly greater in females (63%) than in males
(52%). Potential mechanisms responsible for this hypertension were
investigated. No correlation was found between blood volume and blood
pressure. Similarly, plasma norepinephrine (92±15 pg/mL)
and plasma renin activity (0.3±0.05 ng/mL per hour) were very low in
the subset of patients with pure autonomic failure and supine
hypertension (mean systolic/diastolic
pressure, 177±6/108±2 mm Hg, range 167/97 to 219/121). Supine
hypertension represents a challenge in the treatment of
orthostatic hypotension. We found these patients to be
particularly responsive to the hypotensive effects of transdermal
nitroglycerin. Doses ranging from 0.025 to 0.1 mg/h
decreased systolic blood pressure by 36±7 mm Hg and may
effectively treat supine hypertension overnight, but the dose should be
individualized and used with caution.
Key Words: autonomic nervous system diseases • nitroglycerin • Shy-Drager syndrome • catecholamines
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