Time- and posture-specific management of severe supine hypertension and neurogenic orthostatic hypotension in diabetic autonomic neuropathy: A case report.
Petra Šinigoj Porčnik, Amela Kabaklić
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Case in brief
A 63-year-old man with insulin-treated type 2 diabetes and hypertension developed worsening orthostatic dizziness and recurrent syncope after antihypertensive intensification, including a rib fracture and loss of independence. Blood pressure fell from 197/99 mm Hg supine to 79/56 mm Hg standing, while monitoring showed severe supine and nocturnal hypertension, with mean asleep BP 203/107 mm Hg. Autonomic testing supported neurogenic orthostatic hypotension from diabetic autonomic neuropathy. Posture- and time-specific management, including overnight transdermal nitroglycerin and cautiously introduced morning fludrocortisone and lercanidipine, improved upright tolerance and symptoms; no further syncope or falls occurred.
What made this case unusual
The case combined profound neurogenic orthostatic hypotension with severe supine and nocturnal hypertension, creating opposing hemodynamic problems that required treatment tailored to posture and time of day.
Diagnostic / clinical pearl
Assess blood pressure across supine, seated, and standing positions and use 24-hour monitoring when orthostatic symptoms coexist with hypertension; seated readings alone may obscure the competing hemodynamic pattern.
Why it matters
Repeated reassessment helped balance upright symptoms against recumbent hypertension in this patient, while monitoring treatment response and safety.