Author + information
- Received July 16, 2019
- Revision received October 18, 2019
- Accepted October 21, 2019
- Published online December 2, 2019.
- Italo Biaggioni, MDa,b,c,d,∗ (, )@autonomiccenter,
- Cyndya A. Shibao, MDa,b,d,
- André Diedrich, MD, PhDa,b,d,
- James A.S. Muldowney 3rd, MDb,d,e,
- Cheryl L. Laffer, MD, PhDa,b and
- Jens Jordan, MDf,g
- aDivision of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
- bDepartment of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- cDepartment of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
- dVanderbilt Autonomic Dysfunction Center, Nashville, Tennessee
- eDivision of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- fInstitute of Aerospace Medicine, German Aerospace Center, Cologne, Germany
- gAerospace Medicine, University of Cologne, Cologne, Germany
- ↵∗Address for correspondence:
Dr. Italo Biaggioni, Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, 560A RRB, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, Tennessee 37232.
• Afferent baroreflex failure can cause severe supine hypertension, episodes of profound hypotension, and orthostatic hypotension, making it one of the most challenging forms of hypertension to manage.
• Long-acting central sympatholytic drugs are the mainstay of treatment; short-acting agents should be avoided because of rebound hypertension.
• More research is needed to validate treatment recommendations and develop preventive measures.
Afferent baroreflex failure is most often due to damage of the carotid sinus nerve because of neck surgery or radiation. The clinical picture is characterized by extreme blood pressure lability with severe hypertensive crises, hypotensive episodes, and orthostatic hypotension, making it the most difficult form of hypertension to manage. There is little evidence-based data to guide treatment. Recommendations rely on understanding the underlying pathophysiology, relevant clinical pharmacology, and anecdotal experience. The goal of treatment should be improving quality of life rather than normalization of blood pressure, which is rarely achievable. Long-acting central sympatholytic drugs are the mainstay of treatment, used at the lowest doses that prevent the largest hypertensive surges. Short-acting clonidine should be avoided because of rebound hypertension, but can be added to control residual hypertensive episodes, often triggered by mental stress or exertion. Hypotensive episodes can be managed with countermeasures and short-acting pressor agents if necessary.
This study was supported by National Institutes of Health R01 HL122847, HL149386, DK111175-01, FD04778-04, and Vanderbilt CTSA grant 1UL1 RR000445. Drs. Biaggioni and Shibao have received grant support from Office of Orphan Products Development and Food and Drug Administration grant #FD-R-04778-01-A3. Dr. Biaggioni has received consulting honoraria from Lundbeck and Theravance Biopharma. Dr. Shibao has received a research grant from the Doris Duke Foundation; has received speaker honorarium from Lundbeck Pharmaceuticals; has received consulting honoraria from Lundbeck and Theravance Biopharma; and is a member of the Board for the American Autonomic Society. Dr. Muldowney 3rd has received consulting honoraria from Lundbeck; and has served as a co-investigator for Novartis, Sanofi, and Amgen. Dr. Jordan has received consulting honoraria from Theravance Biopharma; and is cofounder of Eternygen GmbH. None of these disclosures are directly related to the current paper. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 16, 2019.
- Revision received October 18, 2019.
- Accepted October 21, 2019.
- 2019 American College of Cardiology Foundation
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