What is your approach to managing patients with labile blood pressures secondary to baroreflex failure?

Managing BP in the setting of baroreflex failure or dysautonomia is challenging. It is sometimes helpful to educate patients on realistic expectations. Medications will not be able to replace the baroreflex function. Conservative measures like compression socks during the day, bathroom modifications with fall precautions, and slow transitions in position are often the most helpful. I have patients take a detailed home BP log and then choose medications targeting their BP patterns.

For example, if the patient is having frequent lows with symptoms, I avoid long-acting BP meds and use prn doses of guanfacine or labetalol for BP spikes. If BP spikes occur at certain times of day, then the timing of medications can be shifted. I still avoid enco...