Orthostatic Hypotension Presenting as Chest Pain in a Woman with Parkinson’s Disease

coronary artery disease (CAD) and Parkinson’s Disease presented with episodic dizziness and left sided chest pressure that occurs when climbing one flight of stairs. Her symptoms resolve only after lying supine at the top of the stairs. Changes in vital signs taken at the bottom of and after climbing one flight of stairs were: systolic blood pressure (SBP): 132 to 82 mmHg; heart rate: 70 to 92 beats per minute (bpm). She did not develop symptoms when walking on a treadmill without an incline for 30 minutes. Her medications include metoprolol XL 50 mg daily and Carbidopa/levodopa 25/100 mg twice daily. On exam, moving from a supine to a standing position was associated with chest pain, orthostasis (a 36mmHg decrease in SBP) and development of a systolic ejection murmur heard loudest at the left sternal border. She was initially treated with midodrine, which was not associated with a significant change in her symptomatology. A tread mill sestamibi stress test was negative for ischemia. Echocardiography demonstrated a small left ventricular (LV) cavity with hypertrophy and hyperdynamic systolic function. Valsalva maneuver was associated with a 49 mmHg gradient across the left ventricular outflow tract (LVOT). Diagnostic cardiac catheterization revealed widely patent stents and no obstructive CAD. No significant LVOT gradient was noted at rest. A single dose of intravenous hydralazine was administered to treat hypertension during the catheterization procedure. This resulted in systemic hypotension, which was associated with the development of chest pain and an LV-aortic gradient of 60mmHg with a Brockenbrough sign (Figure 1). As a result of these findings, her Carbidopa/levodopa dose was decreased to treat her orthostatic hypotension. On subsequent follow-up, her orthostatic hypotension improved and she reported significant improvement in lightheadedness, chest pain, and ability to walk stairs without symptoms. Comments