Primary orthostatic hypotension

Primary orthostatic hypotension is a rare autonomic nervous system disorder characterized by a significant drop in blood pressure upon standing from a seated or lying position, occurring as a primary (idiopathic) condition rather than secondary to another disease. This condition results from a failure of the autonomic nervous system to appropriately regulate blood pressure during postural changes. The underlying defect involves impaired norepinephrine release from sympathetic nerve endings or deficient autonomic reflex pathways that normally constrict blood vessels and increase heart rate when a person assumes an upright posture. Key symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, and syncope (fainting) upon standing. Some patients may also experience neck and shoulder pain (coat-hanger pain), cognitive difficulties during upright posture, and exercise intolerance. In severe cases, recurrent falls and loss of consciousness can significantly impair quality of life and daily functioning. The condition primarily affects the cardiovascular and autonomic nervous systems. Treatment is largely supportive and symptomatic. Non-pharmacological measures include increased fluid and salt intake, wearing compression garments, sleeping with the head of the bed elevated, and avoiding prolonged standing or rapid postural changes. Pharmacological options may include fludrocortisone (a mineralocorticoid to expand blood volume), midodrine (an alpha-adrenergic agonist to increase vascular tone), and droxidopa (a norepinephrine precursor). Management is individualized based on symptom severity and patient response.

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