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(Hypertension. 2001;37:e24.)
© 2001 American Heart Association, Inc.

Letter to the Editor

Normalization of Blood Pressure in a Patient With Severe Orthostatic Hypotension and Supine Hypertension Using Clonidine

Rajesh Brahmbhatt; Paul Baggaley; Bernard Hockings

Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Nedlands, Australia

	Introduction

 
To the Editor:

A 78-year-old woman presented to us with a 4-year history of recurrent dizzy spells, which had increased in frequency over past 12-months. Past medical history included hypertension and glaucoma. Current medications were oral perindopril (an ACE inhibitor), aspirin, and 3 eye drops—brimonidine (a ₂-adrenergic agonist), betaxolol (a topical ß₁-adrenergic blocking agent), and latanoprost (a selective prostanoid F₂-receptor agonist)—for glaucoma.

Cardiovascular examination revealed an aortic ejection systolic murmur; supine blood pressure was 180/100 mm Hg. There was no clinical evidence of autonomic dysfunction, parkinsonian features, or gross neurological abnormalities.

She had 4 presyncopal episodes over 5 days, with no arrhythmia on telemetry. She had mild aortic stenosis (peak and mean gradients of 19 and 11 mm Hg, respectively) and normal left ventricular function by echocardiography. Exercise stress test was negative. Tilt table test and routine blood pressure observations revealed significant postural hypotension (180/100 mm Hg supine to 120/90 mm Hg erect with no significant change in her heart rate).

Treatment with oral perindopril was stopped after 4 days because of worsening of postural drop and continuing symptoms. Brimonidine tartrate is a ₂-adrenergic agonist that is 1000 times more selective for ₂-adrenoceptor than the ₁-adrenergic receptor. Topical administration of brimonidine tartrate decreases intraocular pressure with minimal effects on cardiovascular parameters, although bradycardia and hypotension are known to occur in neonates. Caution is advised with concomitant use of sympathomimetic agents or agonists or antagonists of adrenergic receptor because brimonidine eye drops may reduce blood pressure.¹ Betaxolol hydrochloride is . . . [Full Text of this Article]