Which specialist manages orthostatic hypotension?

Which Specialist Manages Orthostatic Hypotension

Orthostatic hypotension is primarily managed by cardiologists, with involvement from neurologists for neurogenic causes, and requires a multidisciplinary approach depending on the underlying etiology. 1

Primary Specialists Involved

Cardiology as the Lead Specialty

• The 2017 ACC/AHA/HRS Syncope Guidelines were developed by a writing committee composed of cardiologists and electrophysiologists with expertise in caring for patients with syncope and orthostatic hypotension, establishing cardiology as the primary specialty for evaluation and management 1
• Cardiologists manage the cardiovascular aspects of orthostatic hypotension, including assessment of cardiac causes, medication adjustments, and treatment of associated conditions like supine hypertension 1

Neurology for Neurogenic Causes

• Neurologists play a critical role when orthostatic hypotension is neurogenic in origin, caused by autonomic nervous system dysfunction from conditions like Parkinson's disease, multiple system atrophy, or diabetic autonomic neuropathy 2, 3
• The American Autonomic Society provides guidelines for neurogenic orthostatic hypotension, indicating neurology's central role in these cases 2
• Distinguishing neurogenic from non-neurogenic orthostatic hypotension has therapeutic implications, as patients with peripheral sympathetic denervation respond better to norepinephrine agonists/precursors like droxidopa, while those with central autonomic dysfunction respond better to norepinephrine reuptake inhibitors 3

Additional Specialists Based on Etiology

Endocrinology

• Endocrinologists manage orthostatic hypotension related to diabetes mellitus and diabetic autonomic neuropathy, which is a common cause of neurogenic orthostatic hypotension 2, 4
• The American Diabetes Association provides specific recommendations for assessment and management of cardiovascular autonomic neuropathy in diabetic patients with orthostatic hypotension 5

Geriatric Medicine

• Geriatricians frequently manage orthostatic hypotension in elderly patients, where prevalence reaches 30% in those over 65 years and up to 50% in institutionalized older adults 2, 6
• Age-related orthostatic hypotension often involves multiple contributing factors including polypharmacy, deconditioning, and age-related autonomic dysfunction 6, 4

Emergency Medicine

• Emergency physicians evaluate and provide initial management for patients presenting with syncope and orthostatic hypotension in acute settings 1
• The ACC/AHA/HRS guidelines include emergency physicians in the writing committee, reflecting their role in initial evaluation 1

Specialized Syncope Units

• The ACC/AHA/HRS guidelines recommend specialized syncope facilities for comprehensive evaluation and management of patients with orthostatic hypotension and syncope 1
• These units typically involve cardiologists, electrophysiologists, and autonomic specialists working collaboratively 1

Clinical Pearls for Referral

• Refer to cardiology for initial evaluation, risk stratification, medication management, and when cardiac causes are suspected (arrhythmias, structural heart disease, or medication-induced orthostatic hypotension) 1
• Refer to neurology when neurogenic orthostatic hypotension is suspected based on blunted heart rate response (<10 bpm increase with standing), presence of neurodegenerative disease, or autonomic symptoms 2, 3
• Refer to endocrinology for diabetic patients with autonomic neuropathy or when endocrine disorders contribute to orthostatic hypotension 2, 5
• Drug-induced autonomic failure is the most frequent cause of orthostatic hypotension, making initial management by the prescribing physician (often primary care or cardiology) essential before specialist referral 5