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CLINICAL STUDY: AUTONOMIC DYSFUNCTION

Ambulatory norepinephrine treatment of severe autonomic orthostatic hypotension

Olaf Oldenburg, MD^*, Anna Mitchell, MD, Jens Nürnberger, MD, Susanne Koeppen, MD, Raimund Erbel, MD, FACC, FESC^*, Thomas Philipp, MD and Andreas Kribben, MD

^* Division of Internal Medicine, Department of Cardiology, University Hospital, Essen, Germany
Division of Internal Medicine, Department of Nephrology and Hypertension, University Hospital, Essen, Germany
Clinic of Neurology, University Hospital, Essen, Germany

Manuscript received May 3, 2000; revised manuscript received August 1, 2000, accepted September 14, 2000.

Reprint requests and correspondence: Dr. Olaf Oldenburg, Division of Internal Medicine, Department of Cardiology, University Hospital Essen, Hufelandstrasse #55, D-45122 Essen, Germany
olaf.oldenburg{at}uni-essen.de

OBJECTIVES

This study was designed to establish a patient-controlled, ambulatory norepinephrine treatment of refractory orthostatic hypotension due to primary autonomic failure.

BACKGROUND

Autonomic dysfunction leads to disabling postural hypotension. Particularly in primary autonomic dysfunction, repeated syncope and immobilization can be the result. Medical treatment of orthostatic hypotension often fails in advanced cases.

METHODS

Ambulatory, patient-controlled norepinephrine therapy was initiated in six patients with orthostatic hypotension due to primary autonomic failure that had been refractory to conventional treatment. Before this therapy, three patients were bedridden; one was immobilized in a wheelchair. All had recurrent syncope and tolerated upright tilt-table testing for less than 15 min despite extensive medical treatment. For ambulatory treatment, a port-a-cath system was implanted and, using a CADD ambulatory infusion pump, norepinephrine was infused in individually adjusted dosages.

RESULTS

Norepinephrine infusion therapy enabled all patients to sit, stay and walk around for more than 45 min. One patient died after a five-year treatment period, another after nine months because of nonhemorrhagic brain stem infarctions, both in the absence of norepinephrine treatment. The remaining four patients are still mobile after a period of 19, 10, 9 and 7 months, respectively. None of them has suffered complications due to arterial hypo- or hypertension, and there has been no infection of the infusion system.

CONCLUSIONS

In these selected patients with refractory orthostatic hypotension due to primary autonomic dysfunction, ambulatory norepinephrine infusion therapy has proved to be a promising new therapeutic option. Further long-term studies including more patients are necessary to assess additional indications, reliability and safety of this new method.

Abbreviations and Acronyms   BP = blood pressure   HUT = hea-up tilt table test   MAP = mean arterial blood pressure

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