Coexistence of Orthostatic Hypotension and Refractory Hypertension in Diabetic Cardiovascular Autonomic Neuropathy: A Therapeutic Dilemma.

Diabetic cardiovascular autonomic neuropathy (DCAN) is a common, but underdiagnosed, complication of diabetes. The condition arises due to damage to the autonomic nerve fibres innervating the heart and vasculature. This can manifest clinically in a variety of ways, including coexisting orthostatic hypotension and supine hypertension. We present a case of DCAN in a middle-aged patient, which highlights how debilitating this condition can be and the therapeutic challenge posed to clinicians by its management. This female patient had severe orthostatic hypotension, causing recurrent collapses and limited mobility, alongside refractory hypertension, which progressed to cause target organ damage. Her management required a multidisciplinary approach including medical (cardiology, renal, neurology, endocrinology), physiotherapy, and occupational therapy teams. Her medication regimen was frequently titrated and modified to try to find a balance in blood pressure that maintained safety and functional status. Ultimately, she required a combination of five antihypertensive medications, and the orthostatic hypotension could only be managed supportively. This did not provide a satisfactory functional outcome for the patient, whose mobility and independence were severely restricted by haemodynamic fluctuations. This calls attention to the need for further research into management strategies for this condition.