Amela Kabaklić

Rationale: Coexistence of neurogenic orthostatic hypotension with supine or nocturnal hypertension creates a therapeutic challenge because treatment of either component may aggravate the other. This case illustrates a clinical management framework based on characterization of the full hemodynamic phenotype, repeated reassessment, and treatment adaptation according to posture and time of day, integrating postural blood pressure (BP) responses, 24-hour BP monitoring, symptoms, functional status, comorbidities, and safety findings. Patient concerns: A 63-year-old man with hypertension and insulin-treated type 2 diabetes presented with orthostatic dizziness and presyncope. Antihypertensive therapy was intensified for elevated seated BP. After intensification, upright tolerance worsened, with recurrent syncope, a rib fracture, and loss of functional independence. Symptoms remained disabling despite antihypertensive withdrawal and nonpharmacological measures. Diagnoses: Supine-to-seated-to-standing assessment showed a BP fall from 197/99 mm Hg supine to 122/81 mm Hg seated and 79/56 mm Hg standing, with presyncope and heart rate increasing from 72 to 86 beats/min. Supine measurements and 24-hour BP monitoring documented severe supine and nocturnal hypertension, reverse dipping, and mean asleep BP 203/107 mm Hg. Autonomic testing demonstrated combined cardiovagal and adrenergic dysfunction, supporting neurogenic orthostatic hypotension due to diabetic autonomic neuropathy. Interventions: Management was tailored to upright and recumbent periods. A removable transdermal nitroglycerin patch was used overnight. Nonpharmacological measures included repeated encouragement to increase fluid intake, but daily intake generally remained below 2 L. Clinical assessment suggested relative volume depletion. Low-dose morning fludrocortisone was introduced cautiously despite severe supine/nocturnal hypertension. After upright tolerance improved, morning lercanidipine was added. Subsequent 24-hour BP monitoring showed a more balanced profile. Outcomes: Orthostatic symptoms and upright tolerance improved. No further syncope or falls occurred, and functional independence improved. Later 24-hour BP monitoring showed reduced nocturnal predominance, with mean awake/asleep BP 164/86 and 165/89 mm Hg, respectively. Mild peripheral edema was managed with intermittent torasemide. Lessons: This case illustrates how integrating postural BP responses with 24-hour BP patterns can identify competing hemodynamic phenotypes that may require different management during upright and recumbent periods. Repeated reassessment and individualized treatment adaptation according to the documented BP pattern and clinical context may help balance competing risks of upright hypoperfusion and supine/nocturnal hypertension.

Orthostatic intolerance represents a broad clinical continuum encompassing orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS). Although both entities share overlapping manifestations, such as dizziness, presyncope, and palpitations, their underlying autonomic mechanisms differ substantially. Distinguishing between these disorders is crucial yet often diagnostically challenging, particularly in older adults and those with multimorbidity. We report the case of a 78-year-old woman with recurrent episodes of dizziness and presyncope, initially suspected to have orthostatic hypotension and possible arrhythmic etiology. During active standing, her heart rate increased by more than 30 bpm without a significant fall in blood pressure, fulfilling diagnostic criteria for POTS. Continuous 24-hour Holter electrocardiography revealed a tachycardic response to orthostasis without arrhythmogenic events. Comprehensive cardiovascular, neurological and endocrine evaluations were unremarkable, excluding secondary causes of orthostatic intolerance such as anemia, hypovolemia, endocrine disorders, or structural heart disease. The patient’s symptoms improved markedly with non-pharmacological measures, gradual mobilization and low-dose beta-blocker therapy. This case underscores the diagnostic complexity within the orthostatic intolerance spectrum and highlights the need for meticulous assessment of autonomic responses. OH and POTS may appear clinically similar but differ fundamentally in pathophysiology. OH is characterized by impaired vasoconstriction and an inadequate, often blunted heart rate response due to autonomic dysfunction, whereas POTS involves excessive sympathetic activation with a pronounced tachycardic response. Recognition of POTS in the older adults is critical, as misclassification can delay management. Comprehensive autonomic testing and individualized therapy remain key to optimizing outcomes.

Background and Objectives: Hypertension, atrial fibrillation (AF), and orthostatic hypotension (OH) are common in older adults and may coexist. Their coexistence challenges blood pressure (BP) assessment and treatment decisions because AF reduces measurement reproducibility, OH introduces posture-dependent BP changes, and therapies for hypertension or AF may affect orthostatic tolerance. This review examines evidence relevant to BP assessment and treatment decisions in this setting. Materials and Methods: A focused narrative review was conducted using targeted PubMed searches, supplemented by contemporary cardiovascular guidelines, scientific statements, consensus documents, systematic reviews, meta-analyses, and original studies. Results: Hypertension frequently coexists with OH in older adults, while AF adds marked beat-to-beat BP variability and reduces the reproducibility of BP readings. Orthostatic assessment identifies clinically relevant BP falls not captured by seated BP alone. Across hypertension trials, baseline OH did not appear to diminish the cardiovascular benefit of BP lowering, although frail older adults and patients with symptomatic, severe, or neurogenic OH were underrepresented. Effects on orthostatic tolerance differ by drug class and mechanism. β-blockers may blunt compensatory heart-rate responses but may still be required for AF rate control. Frailty and falls influence treatment tolerance and bleeding risk, while the fall risk alone does not generally justify withholding indicated anticoagulation. Conclusions: In older adults with hypertension, AF, and OH, treatment decisions should be guided by BP assessment that captures rhythm-related measurement variability and postural BP change. OH should prompt reassessment of the BP profile, symptoms, and contributing medications rather than automatic antihypertensive deintensification. Medication review should distinguish reversible contributors to orthostatic intolerance from therapies with compelling cardiovascular indications, while frailty, falls, and anticoagulation should inform risk–benefit assessment. Prospective studies are needed to establish how BP and hypertension can be reliably assessed in older adults with coexisting AF and OH and how such assessment should guide treatment.

Orthostatic blood pressure disorders are common in older adults and represent an important cardiovascular and hemodynamic challenge associated with falls, cognitive impairment, and loss of independence. This Perspective highlights the clinical spectrum of orthostatic blood pressure disorders in older adults, emphasizing the interplay between age-related cardiovascular and autonomic changes, diagnostic challenges, and their implications for cerebral perfusion, cognition, and functional status. Orthostatic hypotension, supine hypertension, orthostatic hypertension, and postprandial hypotension frequently coexist and fluctuate over time, reflecting impaired physiological reserve rather than isolated hemodynamic abnormalities. Because even modest posture-related blood pressure changes may have important clinical consequences, careful orthostatic assessment, including standardized supine-to-standing measurements and interpretation of heart rate responses, is essential for recognizing overlapping phenotypes and guiding individualized management. Recognition of these disorders as markers of impaired cardiovascular–cerebral reserve may improve clinical decisions, reduce falls and cognitive complications, and help preserve function and independence in older adults.

Introduction and aim. Arterial stiffness reflects vascular properties that can influence blood pressure (BP) and heart rate (HR) responses to exercise, but its association with post-exercise autonomic recovery in healthy young adults remains unclear. This exploratory pilot study investigated the relationship between baseline aortic stiffness and post-exercise hemodynamic and autonomic recovery following graded submaximal aerobic exercise. Material and methods. Thirty healthy young adults (17 women, 13 males; mean age 22.7±2.5 years) underwent baseline evaluation of carotid–femoral pulse wave velocity (cf-PWV), central BP, and pulse wave analysis. Participants completed a graded submaximal cycling protocol from 20 to 80% of the maximum oxygen uptake in 3-minute stages, followed by 5 minutes of seated recovery. HR was continuously recorded and BP measured at 1, 3, and 5 minutes of recovery. Autonomic recovery was assessed using heart rate recovery (HRR) and heart rate variability (HRV) indices. Associations were analyzed using correlation and multivariate linear regression adjusted for age, sex, and body mass index. Results. Higher baseline cf-PWV was associated with higher peak HR and systolic BP during exercise (p<0.01), and slower HRR at 1 min (r=-0.517, p=0.002). Cf-PWV independently predicted early HRR after adjustment. Conclusion. In this pilot sample of healthy young adults, greater aortic stiffness was associated with higher BP responses during exercise and slower early autonomic recovery. These findings suggest an association between vascular properties and early postexercise recovery, which should be confirmed in larger studies.