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What do we really know about supine hypertension in patients with orthostatic hypotension

Jordan, Jensa,b,c; Tank, Jensa,c; Heusser, Karstena,c; Reuter, Hannesc,d,e; Biaggioni, Italof

Current Opinion in Cardiology: July 2019 - Volume 34 - Issue 4 - p 384–389
doi: 10.1097/HCO.0000000000000633
HYPERTENSION: Edited by Hector O. Ventura and Carl J. Lavie

Purpose of review Patients with severe orthostatic hypotension due to autonomic failure may be hypertensive in the supine position. Until recently, there were no internationally recognized diagnostic criteria for supine hypertension. This review covers diagnostic criteria, mechanisms, and management of supine hypertension in autonomic failure patients.

Recent findings Recently, an international consensus group defined supine hypertension in patients with neurogenic orthostatic hypotension as brachial SBP at least 140 mmHg and/or DBP at least 90 mmHg while supine. Using these criteria, a large proportion of patients with orthostatic hypotension is diagnosed with supine hypertension. Recent research supports the concept that the hypertension can be mediated through residual sympathetic nervous system function and independently from sympathetic activity, for example via mineralocorticoid receptor activation.

Summary The clear definition of supine hypertension is an important step that will hopefully foster clinical research in this area. Supine hypertension promotes renal sodium excretion, thus, worsening orthostatic hypotension the next morning. Supine hypertension may promote cardiovascular and renal disease. Yet, long-term benefits of treating supine hypertension be it through non pharmacological or pharmacological means have not been proven by sufficiently large clinical trials.

aInstitute of Aerospace Medicine, German Aerospace Center (DLR)

bChair of Aerospace Medicine

cUniversity Hypertension Center, University of Cologne

dDepartment of Internal Medicine and Cardiology, Ev. Klinikum Köln-Weyertal

eDepartment III of Internal Medicine, Heart Center of the University of Cologne, Cologne, Germany

fDivision of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA

Correspondence to Jens Jordan, MD, Institute for Aerospace Medicine, German Aerospace Center (DLR), Linder Hoehe, 51147 Cologne, Germany. Tel: +49 2203 601 3115; fax: +49 2203 69 5211; e-mail:

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