Vagal Nerve Damage from Radiation
Hi folks - it's been a long time. My husband had tonsil cancer over a decade ago and got the full chemo and rad treatment. I was active here for a while, but after a few years, I saw that others could provide any info I could, and it was hard to relive the bad days.
Now, I'm learning about something that might be new to folks who had radiation to their necks - odd symptoms from vagal nerve damage. Our first indication was severe acid reflux, which started immediately and was expected, as a side-effect of chemo. It got better, and then started getting worse. Then, a year or so ago, he started having dizzy spells that seemed to be from his blood pressure dropping. Then, he developed sleep apnea, but not the obstructive type. He just stops breathing and actually says he feels fine, even when the oxygen monitor says he's below 80%. Then, he had a few episodes with angina - bloodwork showed no heart damage and he's very fit. Then, his blood pressure got wonky - sometimes high and sometimes low.
All of this could be attributed to damage to his vagal nerve from the radiation. Anyone else encountering these issues 5-10 years after remission?
Comments
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DrMary welcome and glad to have you.
You may want to have a look at the posting I just made after seeing it on another forum it sounds very similar to what is going on with your husband in some of the effects he is having.
"Baroreflex" Failure" A Rare Late Effect Of Radiation Treatment
Below is the link to the article I just posted on CSN and if you or anyone wants the other forum link contact me for it I may be able to PM it to you but the system does not let me post it here.
Take Care, God Bless-Russ
"Baroreflex" Failure" A Rare Late Effect Of Radiation Treatment
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Wow - thank you! I have been looking for that exact type of info. My husband's doctors are open minded (they don't treat me like a nut, but my PhD in chemistry might have something to do with that) but they still want to go with standard treatments for old, out of shape folks, even though he has a "good" BMI, eats mostly healthy foods, has no "bad" genes, has literally played hockey against Stanley Cup winners in the last few years, plays "elder hockey" a few times a week, and joins me in my HIIT fitness class that I lead once a week without any problems.
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Keep ice water on hand, it'll push him up 10mmhg pretty fast.
I cant remember the specialists thing I saw, but endocrine comes to mind?
Baroreflex syndrome actually does suck. Avoid the heat, avoid standing too fast, avoid raising hands/arms above your head.
I drink some water, then turn it on its side in the freezer, so its always cold. otherwise, there are meds, I have Midodrine, I take when I "feel" it, pretty much covered with the above comments - long term is ritalin (now maybe that would help my chemo brain!)
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so good to find this, my hsb had treatment in 2007 and has this year suffered all these debilitating symptoms and waiting to see specialists has been a nightmare because of course, once you are discharged from oncology, not so easy to get back to people who know what's going on...thank you so much for posting and to other links as well. feel rather let down by cardiologist dismissing his labile BP and not making sure carotid artery evaluation done. now feel empowered to ask and get proper scans, threat of stroke? oh well, somethin's gonna get ya and i remind myself how he was able to see his son married, grandchildren come along and the travelling we have done post CA...thanks to this network, warm thoughts to all who might be perusing...
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Hi Dr. Mary
I had tonsillar cancer in 2007.
Your post nailed my symptoms. While it is not great news that my autonomous system is failing it is a relief to know what is going on. Thank you very much for your post.
My blood pressure swings wildly and the Cardiologist was not much help as a 24 hour blood pressure monitor shows good average blood pressure. He says that this is the only thing they look at which made no sense to me when my pressure can go as low as 75/41 and as high as 215/125.
Other symptoms related to the vagal nerve for me are swallowing difficulties. Numbness on the left side of my face and neuropathy irritation behind my left ear and left chest which causes me to scratch for relief. Also very unpleasant has been occasional regurgitation through the nose with no warning. I believe this is also connected to the vagal nerve.
I take a proton blocker for my stomach acid which seems to work well.
Has your research led to any additional discoveries that might be helpful?
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Tate is your problem Vagal Nerve or the other problem mentioned here? "Baroreflex Failure" They may or may not be similar. If you read her second posting I believe she is leaning more toward the "Baroreflex Failure" as her husband's problem.
Take Care, God Bless-Russ
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And here's another odd symptom - his heart rate, normally about 60-70 bpm, will randomly spike, often over 150 bpm, but only for a minute at at time. I've only recorded it at night (he wears an O2 ring, which vibrates when his oxygen gets low, to remind him to breathe) and once while he was lying down, after his second angina episode. I had put it on him as soon as he reported the angina to me, and his heart rate was spiking between 120 bpm to above 150 bpm, dropping back down to about 90 bpm, every few minutes. It did this for an hour and then eased off, as did the angina (after 3 doses of nitro - if it hadn't, we would have headed for the ER). His BP was slightly low (it got very low during the episode, but that might have been due to pain). Since they had found nothing in the ER during the first episode, I couldn't convince him to go to the ER then - primary care doctor on Monday (episode was Saturday) wasn't worried ("those monitors are unreliable"). He'd just seen the cardiologist, and they find no problems. During the episode, he said he didn't feel like his pulse was racing. We're waiting on an appointment with the cardiologist again, but it seems like this must relate to vagus nerve damage. . .
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Well, Mary, that has to be terribly unnerving to deal with and I am so glad after the 3 doses of nitro it finally settled out. I am hoping when you see the cardiologist again he doesn't find any problems. This may be something that is going to crop up now and then and it seems to me you are prepared to deal with it. Your husband has one of the more profound aftereffects of radiation to deal with. So you are apparently leaning toward the vagus nerve as the culprit rather than a baroreflex failure is that correct? Hang in there.
Wishing You the Best
Take care, God Bless-Russ
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I'm not a doctor (well, PhD in chemistry, but not a "real" doctor) so I might be mixing up terms. In reading the baroreflux failure info, I see that the vagus nerve is a big part of the signaling system that fails, and I know that nerve got a butt-ton of radiation (unfortunately, we were on the trailing edge of conventional treatment for HPV-caused tonsil cancer, which, it turns out, can be treated with less/no chemo and much less radiation). I'm looking at the Vanderbilt University Medical Center as one option, as they seem to treat a lot of R-ABF (radiation-induced afferent baroreflux failure) there.
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The nitro was responsible for the sudden drop in blood pressure. I've seen it many times. Increase in rate is due to pain.
The baroreceptor dysfunction is not new, they just realized it was happening, and did some studies to prove it.
I know this will sound.. Strange, but are you sure it was his heart? Could it be the horrible GERD that seems to be popping up?
I ask because with negative heart tests, 3 nitro was a LOT. Does he have pain down his arm and up to his jaw? Or is it more the pain mid chest? To be honest the first few times I got the pain I thought 'heart' but I had a great heart check up not long ago.
Now I'm going through all the GERD stuff. Fun! Pantoprazole at night, nexium in the morning, and something else 3x a day. But at least the pain is being kept at bay!
Hope this might give some insight, cancer, the gift that keeps on giving.
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My goodness, Suz, you are surely going through your time of it too. Many on here are dealing with more than we know. Seems like it's always something. Hope you get the GERD under control, glad the medications are keeping the pain at bay.
Take care, God Bless-Russ
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Thanks DrMary.
I had radiation therapy 10 years ago and have experienced many of the symptoms you described. I have had many tests. My heart doc wants to put me on an expensive to quickly raise my BP but I'm not convinced my fainting is due to hypotension as opposed to HR drop. Not sure where to go from here.
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We narrowed the possibilities by having him take his blood pressure every time he had a dizzy spell (as well as other times in the day to establish baseline) - our machine also records pulse. His pulse was always fine, or a little elevated, but BP often was tanked. After the angina scares, I bought a Kardia (6-lead portable ECG) and he tests with that as well. Cardiologist thinks it can all be solved if we get rid of the apnea, but pulmonologist is treating it as obstructive apnea, which has done nothing for his oxygen and keeps him from sleeping. I'm looking at the vagal nerve stimulators (OTC - not implanted) right now. . .
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as we go into warmer (eventually) weather, it'll be worse.
Ice water on hand ALL the time. talk to endocrinology about midodrine
If he's home when it happens, lie down.
Check BP, standing, sitting, and lying, for orthostatic changes (those are more than 10mm mg changes)
Stand, measure, sit, measure, lie, measure, going the other way, you need to wait 10 mins or so between each
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I have a BP cuff that I'm going to keep with me when I anticipate standing. I used to get dizzy but now I just feel like I'm going to black out. Usually I catch myself and bend over a bit until stable. However, the last time it caught me by surprise. I felt a bit nauseated and the next thing I knew I was on the floor and broke my leg. I have also considered the stimulator. Let us know if it helps.
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In fall of 2022 I had a shortened course of radiation (30 days) and cisplatin (2 doses) in a trial treatment for squamous cell carcinoma in my right tonsil and a few lymph nodes in my neck. I've been in remission since, but now in the past few months, I've developed an intermittent racing heart rate of 100-120 BPM and occasional Premature Ventricular Contractions (PVC). My EKGs have been normal, other than the PVCs. However, for several months now I'm also having bouts of a strange spasm-like sensation in my upper chest that feels like either my esophageal muscles or bronchial tubes suddenly squeezing for just a second. It's not painful, but it's alarming every time it happens and it typically happens at least several times a day. I notice mostly after or while I eat food and when I'm laying down. I've been wondering if these symptoms are a result of vagus nerve damage from the radiation. I know my throat hasn't been the same since treatment. It's tighter and stickier in there, with bits of food often getting hung up in the sticky saliva in my throat (sorry, gross, I know). But that doesn't seem like it would affect my heart rate or cause bizarre spasms I described. Has anyone else here had symptoms like these? If so, what if anything have you been able to do about it?
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Hello, garrettnm, and welcome to the CSN H&N discussion forum.
I am going to post something below out of my archives, see if it relates to what you are experiencing.
Also, Our Motto Here Is NEGU (Never Ever Give Up)
I would also recommend you check out the Superthread at the top of the head and neck home page there is loads of information in there with links and you will find it helpful.
Check out the posting below…..
"Baroreflex" Failure" A Rare Late Effect Of RadiationTreatment
I came across this article written by a Gentleman on another forum about late-term post-radiation effects which can give you a condition where your blood pressure swings wildly from high to low or low to high without notice. There is no cure but some control can be realized with meds. I just wanted to let the group know about this and make people aware. In fact, there may be someone on here that has this problem but I have never seen it brought up that I can remember. Below I will post his description and then some information below it. Radiation for head and neck cancers can cause debilitation problems years after treatment is completed.
Take Care, God Bless-Russ
The fellow that made the original posting goes by the name of Criswell and here is his post and then information on this post-radiation situation follows.
Mar 7, 2020 • 11:45 AM
I had radiation and chemo for tongue cancer in 2013-2014. While I am now cancer-free in 2020 I am suffering from BaroreflexFailure, a rare late effect of radiation treatment. Basically, it means that all control of my blood pressure is now gone forever. My systolic readings can range from 65 to 235 for no reason, all within an hour. There is no treatment, but some management can be achieved through medication. I can't find anyone else who has been through what I am experiencing. I am now a ticking time bomb, in fear of my life even while being cancer-free. I would love to hear from someone in my situation.
Information on this condition--
BARORECEPTOR DYSFUNCTION
Radiation for head and neck cancers can cause debilitation problems years after treatment is completed. When radiated areas include the neck or base of the skull, as is the case with tonsil and base of tongue primaries, the long-term damage may not surface for several years. Much of the damage is caused by radiation-induced fibrosis as the body continually attempts to heal the tissue damaged during treatment. We have pairs of nerves that extend from the brain through the neck and they are responsible for most functions of the body, as well as significant pain as fibrosis sets in. These nerves are called Cranial Nerves and the Lower Cranial Nerves are the nerves that are most affected from radiation-induced fibrosis. The particular Lower Cranial Nerves related to heart rate and blood pressure that are affected are the Glossopharyngeal Nerve (Cranial Nerve IX) and the Vagus Nerve (Cranial Nerve X). The Glossopharyngeal Nerve contains motor fibers, for activating muscles, and sensory nerve fibers to transmit information to the brain, via afferent nerve fibers, and receive instructions from the brain, via efferent . To regulate blood pressure, the glossopharyngeal nerver receives information from visceral fibers that sense oxygen levels inthe trunk and the carotid bodies for measuring blood pressure. This information is sent to the brain to allow the autonomic nervous system (automatic body functions in simple terms) to control oxygen adjustment and blood pressure, for example. The Vagus Nerve is perhaps the most important nerve in the body and is also called the meandering or wandering nerve. To regulate blood pressure and heart rate, sensory nerve fibers of the vagus nerve receive information, via afferent nerve fibers from the carotid and aortic bodies. Thevagus nerve, via efferent nerve fibers then innervates the heart andlungs. Baroreceptor Function, or baroreflex is a term that describes fluctuations in heart rate and blood pressure to maintain blood pressure as constant as possible. Baroreflex, the reflex mechanism by which baroreceptors regulate blood pressure, includes the transmission of nerve impulses from the baroreceptors to a specific portion of the brain called the Medulla Oblongata or Command Center of the body, specifically the medulla nucleus tractus solitaries(NTS) in response to a change in blood pressure that produces vasodilation (opening up of blood vessels) and a decrease in heart rate when blood pressure increases and vasoconstriction (closing of blood vessels) and an increase in heart rate when blood pressure decreases. Baroreflex can affect the heart and the brain by insufficient or excessive blood pressure, or changes in oxygen levels in the blood supplying the brain. Baroreceptor Failure is a condition that means the process is out of control while BaroreceptorDysfunction more accurately describes what many people that have had radiation treatment and/or surgery to the neck as treatment for head and neck cancer can develop because baroreflex is sporadic and in control some of the time. Baroreceptor Dysfunction is a chronic disorder, occurring about 6 years after the completion of treatment in some cases. (1,2)
Baroreceptors are mechano-sensitive terminals of the glossopharyngeal (Cranial Nerve IX) and the vagus (Cranial Nerve X)nerves that project to the nucleus tractus solitarius (NTS) in the caudal medulla located in the medulla oblongata. The sinus nerve branches off of the glossopharyngeal nerve to the interior carotid artery to dilate or constrict the carotid artery flow to the brain. In response to postural changes, efferent projections from the NTS to sympathetic and parasympathetic preganglionic neurons in the brain and spinal cord govern acute fluctuations in heart rate and blood pressure. Baroreceptors are found in the blood vessels of all vertebrate animals, residing in the heart, vena cavae, arteries,carotid sinuses, and the aortic arch. The process is continuous and necessary to ensure blood pressure is maintained. The most sensitive baroreceptors are located in the carotid sinuses, usually in the field of radiation, and the aortic arch, the second major anatomical region of the aorta that sends blood from the left ventricle of the heart to the rest of the body. Impaired afferent signaling of this arterial baroreceptor reflex arc in humans causes a sustained increase in mean
BARORECEPTOR DYSFUNCTION
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arterial pressure lability (constant change), often leading to both paroxysms (sudden change) of hypercatecholaminergic tone(excitement of neurotransmitters) that resemble pheochromocytoma(attacks of raised blood pressure, heart palpitations, and headache)and contrasting episodes of profound orthostatic hypotension(decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position). What causes fluctuations in blood pressure? Cardiovascular adaptations are regulated by the autonomic nervous system. Standing activates afferent autonomic neural pathways to induce baroreceptor unloading, causing increases in efferent sympathetic outflow and vasoconstriction, to increase venous return and maintain resting blood pressure. When we change from sitting to standing, information is sent via baroreceptors to the brain because there is an automatic increase in systolic blood pressure. Orthostatic venous pooling(excess blood and fluid pooling from poor blood return to the heart)occurs in the legs when we stand and our body needs to modulate the blood pressure. Baroreflex failure occurs when afferent baroreceptor nerves or their central connections are impaired, causing a loss of buffering, and wide fluctuations of blood pressure and heart rate. Impairment of the baroreflex may present under a wide spectrum of symptoms with hypertensive crisis as the most common. Over a period of time, volatile hypertension (high blood pressure) with periods of hypotension (low blood pressure) occurs and may continue for months and years, usually with some attenuation of press or surges and greater prominence of depressor valleys. Other scenarios include orthostatic tachycardia (rapid heartbeat) or orthostatic intolerance may appear, or vagotonia (excessive excitability of the vagus nerve resulting typically in vasomotor instability, constipation, and sweating) with severe bradycardia (low heartbeat) and hypotension and episodes of sinus arrest (loss of electrical signal to the heart that allows the heart to contract). In particular, after neck irradiation, long-term injury occurs commonly in the carotid arteries. Atherosclerotic (thickening or hardening of the walls of arteries)and thrombotic complications (blood clots or dislodged plaque in arteries that can result in heart attack or stroke) have drawn the most attention. Among 910 patients who survived at least 5 years after irradiation of head and neck tumors, stroke occurred in 6% and clinically significant carotid stenosis in 17%. Chronic inflammation and fibrosis of carotid arterial walls might lead to “splinting” of carotid sinus baroreceptors. Because these are stretch or distortion receptors, stiffening of the carotid sinus would be expected to lead to a decreased gain of the arterial baroreflex. Nevertheless, few reports have noted baroreflex failure after neck or brain stem surgery or irradiation. (4) At the American Neurological Association 133rd Annual Meeting, investigators presented are trospective review highlighting the clinical features and typical findings on autonomic testing in patients with radiation-induced baroreflex failure. "The important thing is to recognize that patients who've had head and neck radiation may have late complications that may not manifest for years after treatment," second author Sara Schrader, MD, from the Mayo Clinic in Scottsdale, Arizona, told Medscape Neurology & Neurosurgery. "Radiation can cause multiple cranial neuropathy, which can manifest in many ways," Dr. Schrader noted. (5)
Neck Radiation Associated With Cranial Neuropathy
BARORECEPTOR DYSFUNCTION
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The researchers were led by Brent Goodman, MD, also from the Mayo Clinic. They identified 34 patients who had a history of neck radiation, labile hypertension, orthostatic hypotension, or syncope. The malignancy type was squamous-cell carcinoma in all but 2patients. The mean age of participants at the time of diagnosis was 63 years. The average time from radiation exposure to the development of symptoms was 6.4 years. Radiation doses ranged from 55 Gy to 70 Gy. Formal autonomic testing was performed in 22 patients. Cardiovascular adrenergic function was the most frequent abnormality, showing impairment in late phase 2 and 4 during the Valsalvamaneuver.
Neurological Complications Following Neck Radiation
Signs Symptoms Patients (%) Autonomic Postural lightheadedness 97Labile hypertension 78 Syncope 73 Cardiac dysrhythmia 9 BulbarDysphagia 78 Dysarthria 33 Cerebrovascular Stroke 12 Carotid artery stenosis/occlusion 57 Vertebral artery stenosis 7
"This is a retrospective study, and some of the patients we've seen clinically, but the vast majority, we have not," Dr.Schrader pointed out during an interview. "The data we have for patients were not uniform, and testing may have differed," she noted. Shapiro and colleagues discovered lightheadedness and fluctuations in cardiovascular reflexes attributable to baroreceptor damage caused by radiation was elusive on routine cardiovascular testing. In a broader sense, cardiovascular dysautonomia has been linked to carotid sinus dysfunction occurring from radiation damage but also included bilateral carotid artery stenosis as a potential etiology. Further, response to traditional management when autonomic failure is caused by centrally mediated dysfunction is not effective,leading to severely diminished quality of life with greater risk for cardiovascular morbidity and mortality. (6) Table 1 presents an excerpt of head and neck cancer patients that received radiation or patients that had carotid stenosis.
BARORECEPTOR DYSFUNCTION
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Table 1. Excerpts of Characteristics of Head and Neck Radiation and Carotid Stenosis Patient Cases With Orthostatic Hypotension andSupine Hypertension Related to Baroreceptor Dysfunction
Case
Age, y Sex
FollowUp, mo
Cause of Baroreceptor Dysfunction
Pharmacologic Interventions
Nonpharmacologic ic Interventions
αAgonists
Fludrocortis one
Mean Home BPs/HR at Baseline (Supine/Standin g)
Mean Home BPs/HR at Last Visit (Supine/Standin g)
1. Abbreviations: BID, twice a day; BP, blood pressure; F, female;HR, heart rate; M, male.
2. Nonpharmacological interventions include: moderate sodium intake (2500-5000 mg/d), predominantly before noon on a given day, use of support stocking to thighs (25-30 mmHg), and when needed sleeping with head/neck elevated to 15-20 degree angle.
Case 1 84 M 1
Neck radiation therapy for laryngeal cancer and advanced bilateral carotid stenosis
Atenolol 25 mg BID and isradipine 5 mg at bedtime + – −
167/67/65 145/65/60
94/62/61 117/55/58
Case 3 63 M 14
Neck radiation therapy for tongue cancer
Atenolol 25 mg BID and isradipine 5 mg at bedtime + – −
146/91//57 136/86/58
97/63/60 104/84/62
Case 4 74 F 12
Advanced bilateral carotid stenosis
Atenolol 100 mg at night and nicardipine 40 mg at bedtime and 20mg in the am + – −
162/90/77 155/85/70
110/76/75 147/70/70
Case 5 84 M 1
Advanced bilateral carotid stenosis
Atenolol 100 mg at night and nicardipine 40 mg at bedtime − –−
180/80/75 160/92/68
80/50/80 120/70/67
Case 6 82 M 12
Neck radiation therapy for head and neck cancer None +
Midodrine 5 mg in am as needed −
130/68/62 122/66/60
86/58/64 104/60/61
Case 7 63 M 12
Neck radiation therapy for tongue cancer
Atenolol 50 mg at bedtime + – +
185/105/62 152/82/58
155/76/68 146/80/60
Case 10 65 M 36
Neck radiation therapy for head and neck cancer
Atenolol 50 mg at bedtime and guanfacine 2 mg at bedtime + – −
156/80/84 145/77/56
128/60/82 123/67/60
Case 11 50 M 1
Neck radiation therapy for head and neck cancer
Nebivolol 10 mg qam and 5 mg qpm with ramipril 5 mg BID + – +
136/86/85 128/80/80
110/75/95 118/75/87
BARORECEPTOR DYSFUNCTION
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Autonomic dysfunction leads to impairment of compensatory mechanisms and clinically results in orthostatic hypotension, defined as a reduction in SBP ≥20 mm Hg or diastolic BP ≥10 mm Hg within 3 minutes of standing or head-up tilt to an angle of at least 60°.In hypertensive patients, a reduction of SBP >30 mm Hg is more appropriate. In addition to unpleasant and disabling symptoms,orthostatic hypotension is associated with an increased risk off alls, cognitive dysfunction, (7) coronary arterial disease, (8)chronic kidney disease, (9) stroke, (10) and cardiovascular and all-cause mortality. (11,12) The mechanisms behind them are unclear,and whether orthostatic hypotension is a cause or consequence of comorbidities is still uncertain. Orthostatic hypotension is associated with non dipping or reverse-dipping pattern of diurnal BP,while the cardiovascular risk remained even after adjustment for such diurnal BP patterns. (13) Once orthostatic hypotension is diagnosed,clinicians should take the patient's medical history and physical examination carefully. Certain medications such as anti hypertensive drugs (eg, α-blockers, diuretics, and vasodilators) and antidepressants, and changes of daily life (eg, dehydration, weight loss, diet, infection, stress, sleep problems) are common causes o forthostatic hypotension. Assessments of other manifestations of autonomic neuropathy or neurodegenerative diseases can be helpful in the diagnosis of neurogenic orthostatic hypotension. Laboratory tests such as anemia, glucose, electrolyte, renal function, hormones (eg,thyroid and adrenal), and proteinuria might be helpful.Non pharmacologic measures are important components of therapy oforthostatic hypotension. These include removal of offending medications, patient education to avoid precipitating factors, physical and dietary interventions, and patient education. Recognition and removal of drugs, which can cause orthostatichy potension, is crucial. The most common offending medications are diuretics, α-adrenergic antagonists, and antidepressants.
Patients should also be instructed to 1. maintain throughout the day by drinking at least 1.5 L/d to 2 L/d of water during meals and before exercise and also rapid intake of water in the morning before getting out of bed; 2. arise slowly, in stages, from supine to sitting to standing, particularly in the morning when orthostatic hypotension is more pronounced; 3. avoid activities that reduce venous return such as walking in hot weather, or straining; 4. elevate the head of the bed 10° to 20° to decrease nocturnal diuresis and maintain intravascular volume; 5. prevent episodes of postprandial hypotension by avoiding large meals, minimizing alcohol intake, and avoiding standing immediately after eating; and 6. perform leg-crossing maneuvers while actively standing to increase cardiac output and systemic BP. (14) The use of compression stockings that produce at least 20- to 25-mm Hg pressure or tight abdominal binders permits the application of graded pressure to the lower extremities and lower abdomen, thereby minimizing
BARORECEPTO DYSFUNCTION
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peripheral blood pooling in lower extremity and splanchnic circulation. It is essential that such stockings extend above the knees to the waist since most peripheral pooling occurs in the splanchnic circulation. Many patients, particularly those with peripheral neuropathies or those living in hot climates, poorly tolerate compression stockings. The efficacy of compression stockings and abdominal binders was validated in a small crossover study that showed reduced orthostatic BP decrease and symptoms compared with controls. (15) Increased salt and water intake are essential parts of treatment. Rapid ingestion of 500 cc of water in <5 minutes can serve as a therapeutic measure in symptomatic patients. The BP effectis observed in the first 5 to 10 minutes and peaks around 30 minutes after ingestion and is mediated by a sympathetic reflex rather than a volume effect. (16) Patients should be instructed to consume high-sodium–containing foods. Salt tablets may also be prescribed.While the optimal dose will vary among patients, a target dose of 6g/d to 10 g/d of sodium taken with breakfast and lunch, or a target urinary sodium level of 150 mEq to 200 mEq should be maintained. Night dosing of salt intake should be minimized to avoid worsening of supine hypertension. (17)
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Been chasing these symptoms for 5 - 7 years, seen every kind of referral, specialist, witch doctor, been grasping at straws hoping for an answer. Thank you so much for the timely information. had all but given up, but now I have a direction and will be back in the fight.
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