Asymptomatic orthostatic hypotension in synucleinopathies: to treat or not to treat?

Orthostatic hypotension (OH) is a debilitating non-motor manifestation of synucleinopathies such as Parkinson’s disease (PD), multiple system atrophy (MSA), dementia with Lewy bodies (DLB), and pure autonomic failure (PAF) [1]. Classical OH is defined as a sustained drop in systolic blood pressure (SBP) > 20 mm Hg and/or diastolic blood pressure (DBP) > 10 mm Hg within 3 min of upright posture [1]. The prevalence of OH varies among the synucleinopathies, with up to half of PD and DLB patients and approximately 80% of patients with MSA presenting with this condition, and is a defining feature of PAF [2]. In general, the prevalence of OH in synucleinopathies increases with age and disease duration [2]. ‘Typical’ symptoms associated with OH may be reported as postural lightheadedness, dizziness, vision changes (tunnel or blurred), syncope, or near-syncope. Some patients report ‘atypical’ postural symptoms upon prompting, such as fatigue or cognitive dysfunction, pain in the shoulders and neck (also known as “coat hanger” pain), or even dyspnea [1]. In PD, OH is associated with more rapid disease progression, shorter survival time, dementia, falls, hospitalization, and institutionalization [3, 4]. …