Use of Multimodal Therapies to Treat Severe Orthostatic Hypotension From Autonomic Failure

Orthostatic hypotension is one of the most debilitating features of autonomic failure. Presentations tend to be diverse and non-specific, ranging from dizziness and lightheadedness to loss of consciousness. Early recognition of this illness may prove to be difficult, and control of symptoms typically requires a multidisciplinary approach with patient education, pharmacologic, and device therapies. This condition tends to be associated with significant patient morbidity and poor quality of life, and treatment regimens typically require frequent adjustments before optimal symptom control is achieved. However, with a multidisciplinary approach, utilization of multimodal therapies, and proper identification of underlying pathophysiologic mechanisms, symptom improvement may be achieved. An 81-year-old male was admitted to our hospital following a syncopal episode. While hospitalized, he experienced severe syncope and was treated with physical therapy, midodrine, fludrocortisone, octreotide, erythropoietin, and intravenous iron infusions. He displayed minimal improvement and then had a biventricular pacemaker placed and had a resolution of all postural symptoms.