. 2017 Jul 10;19(7):713–721. doi: 10.1111/jch.13023
Clinical and prognostic significance of a reverse dipping pattern on ambulatory monitoring: An updated review
Blood Pressure Patterns in Patients with Parkinson’s Disease: A Systematic Review
Yes, this pattern—lower daytime blood pressure (110/80) and higher nighttime blood pressure (140/100) after stopping hydrochlorothiazide—is a recognized phenomenon in some individuals, particularly those with Parkinson’s disease and autonomic dysfunction.
Key Considerations:
-
Parkinson’s and Autonomic Dysfunction:
- Parkinson’s disease can affect the autonomic nervous system, leading to blood pressure dysregulation.
- This often manifests as nocturnal hypertension (elevated BP at night) and daytime hypotension, especially if there is autonomic involvement.
-
Loss of Diurnal BP Variation:
- Normally, blood pressure dips at night ("dipping pattern").
- Some people with autonomic dysfunction or Parkinson’s develop a non-dipping or reverse-dipping pattern, meaning BP rises at night instead.
-
Effect of Stopping Hydrochlorothiazide:
- Hydrochlorothiazide is a mild diuretic, reducing blood volume slightly and lowering BP during the day.
- When you stopped taking it, your daytime BP (110/80) normalized, suggesting your previous dose may have been contributing to daytime hypotension.
- However, your nighttime BP remains high, likely due to autonomic dysregulation rather than volume status.
What to Consider Next?
- Ambulatory BP Monitoring (24-hour BP study): This can confirm if you are a reverse dipper, which has implications for stroke and cardiovascular risk.
- Medication Timing Adjustments:
- Some people take a low-dose antihypertensive at night to target nocturnal hypertension while avoiding daytime hypotension.
- Mild alpha-blockers (like doxazosin) or long-acting calcium channel blockers can sometimes be useful.
- Cardiovascular Risks of Nocturnal Hypertension:
- Chronically elevated nighttime BP is associated with higher stroke and heart disease risk, so it’s worth discussing with a specialist.
- Check for Supine Hypertension:
- Some Parkinson’s patients develop supine hypertension, meaning BP spikes when lying down.
- If you notice higher BP when lying down at night, it could suggest autonomic involvement.
Next Steps
- Monitor BP trends for another week.
- Consider a 24-hour BP study.
- Discuss medication timing with a physician to balance daytime and nighttime BP control.
- If symptoms like dizziness return, reconsider whether any postural BP drops are occurring.
This is a nuanced issue, but the pattern fits Parkinson’s-related autonomic changes rather than simple medication withdrawal.
###
Korean study Kim et al. 2023
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-023-00241-w
When adjusted covariates, less sleep duration and poor sleep quality were positively associated with nighttime systolic BP.
Additionally, sleep quality was the independent associated factor for dipper and reverse dipper phenotypes. The study also found that male sex, low estimated glomerular filtration rate, high ambulatory BP, low office BP, and poor sleep quality were associated with blunted nighttime SBP dipping.
What is Cardiovascular Dysantonomia?
Cardiovascular dysautonomia in Parkinson’s disease (PD) refers to the dysfunction of the autonomic nervous system (ANS) in regulating blood pressure (BP), heart rate, and vascular tone. The ANS normally adjusts BP to maintain stable circulation throughout the day and night, but in PD, these mechanisms become impaired due to neurodegeneration affecting autonomic control centers.
Key Features of Cardiovascular Dysautonomia in PD
-
Impaired Baroreflex Function
- The baroreflex helps regulate BP by adjusting heart rate and vascular tone in response to positional changes.
- In PD, baroreceptor sensitivity is reduced, leading to difficulty maintaining BP stability.
-
Orthostatic Hypotension (OH)
- A common manifestation where BP drops significantly upon standing.
- Caused by failure to constrict blood vessels appropriately, leading to dizziness, lightheadedness, or fainting.
-
Nocturnal Hypertension (Reverse Dipping)
- Instead of the normal nighttime BP dip (~10-20%), PD patients may have higher BP at night than during the day.
- This is due to autonomic failure, leading to loss of normal BP circadian rhythm.
-
Supine Hypertension
- BP rises when lying down, often occurring in combination with daytime orthostatic hypotension.
- This paradoxical pattern is due to impaired autonomic regulation of vascular tone.
-
Heart Rate Variability Reduction
- The normal fluctuations in heart rate (HRV) in response to activity, stress, or sleep are blunted.
- This reflects ANS dysfunction affecting both sympathetic and parasympathetic regulation.
Why Does Cardiovascular Dysautonomia Happen in PD?
-
Loss of Dopaminergic and Autonomic Neurons:
- PD is not just a motor disorder; it affects the autonomic nervous system due to degeneration of neurons in the brainstem (e.g., dorsal motor nucleus of the vagus, locus coeruleus) and peripheral autonomic ganglia.
-
Alpha-Synuclein Accumulation (Lewy Bodies):
- The spread of Lewy bodies into autonomic centers (like the hypothalamus and medulla) disrupts BP regulation.
-
Loss of Norepinephrine in Autonomic Nerves:
- Sympathetic nerve fibers supplying the heart and blood vessels show reduced norepinephrine, impairing BP control.
Clinical Implications
- Higher Risk of Stroke and Cardiovascular Events
- Nocturnal hypertension (reverse dipping) is a stronger predictor of cardiovascular disease and stroke than daytime BP.
- Falls and Syncope from Orthostatic Hypotension
- A dangerous consequence of autonomic dysfunction, increasing injury risk.
- Challenges in BP Management
- Medications for orthostatic hypotension (e.g., midodrine, fludrocortisone) may worsen supine hypertension.
- Timing and choice of antihypertensives (if treating nocturnal hypertension) must balance autonomic dysfunction risks.
Management Strategies
- Monitor BP Trends (Day vs. Night, Supine vs. Upright)
- Increase Salt and Fluids (if no heart failure) to Improve Orthostatic Tolerance
- Adjust Medication Timing to Avoid Worsening Orthostatic Hypotension or Supine Hypertension
- Consider Sleep Position (Mild Incline to Reduce Supine Hypertension)
Bottom Line
Cardiovascular dysautonomia in PD leads to abnormal BP regulation, including reverse dipping (nocturnal hypertension), orthostatic hypotension, and supine hypertension. These changes arise from autonomic nervous system failure due to neurodegeneration in PD, making BP management a delicate balance.
