How to treat cardiovascular autonomic failure in Parkinson’s disease

Cardiovascular autonomic failure is a frequent non-motor feature of Parkinson's disease (PD) that affects up to one third of individuals from the premotor to the advanced stages of the disease, with major diagnostic, therapeutic and prognostic implications. It may manifest with orthostatic, post-prandial or exercise-induced hypotension, as well as hypertensive episodes in the supine position during wakefulness or nocturnal sleep. Hypotensive episodes may remain asymptomatic or manifest with symptoms of end-organ hypoperfusion in the upright position, after meals or during exertion that may include lightheadedness, blurred vision, cognitive slowness, shuffling gait, back pain, fatigue or, in severe cases, syncope. Supine and nocturnal hypertension are likewise often asymptomatic, yet may cause nocturnal polyuria, and disrupt sleep through frequent nocturnal toilet visits. Bedside screening for cardiovascular autonomic failure relies on targeted history taking, eventually supported by validated questionnaires, and supine to standing heart rate and blood pressure measurements. A more detailed assessment is obtained with cardiovascular autonomic function tests under continuous, non-invasive, hemodynamic monitoring, complemented by 24-hours ambulatory blood pressure monitoring and home blood pressure diaries. Hypotensive episodes are managed by addressing potential triggers, such as infections, anemia, dehydration and polypharmacy, followed by a stepwise implementation of behavioral, non-pharmacological and pharmacological strategies. Individuals with orthostatic hypotension should be constantly monitored for concomitant supine and nocturnal hypertension, especially if treatment with pressor agents has been recently started. Hypertensive episodes are likewise treated in a stepwise fashion with preventive, non-pharmacological and pharmacological measures, prioritizing hypotension control during daytime and mitigating hypertension overnight.