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Clinical Autonomic Research : Official... Aug 2023
Topics: Humans; Hypotension, Orthostatic; Droxidopa; Hypertension
PubMed: 37468794
DOI: 10.1007/s10286-023-00966-6 -
Minerva Medica Apr 2022Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced... (Review)
Review
Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and postprandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy, and Quality of Life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.
Topics: Blood Pressure; Humans; Hypertension; Hypotension; Hypotension, Orthostatic; Quality of Life; Syncope
PubMed: 33881284
DOI: 10.23736/S0026-4806.21.07562-5 -
Kardiologia Polska Nov 2019Orthostatic hypotension (OH) is a cardinal sign of cardiovascular (CV) autonomic dysfunction as a result of autonomic nervous system failure to control the postural... (Review)
Review
Orthostatic hypotension (OH) is a cardinal sign of cardiovascular (CV) autonomic dysfunction as a result of autonomic nervous system failure to control the postural hemodynamic homeostasis. The proportion of individuals with OH increases with aging and chronic conditions, such as neurodegenerative diseases, hypertension, heart failure, diabetes, renal dysfunction, autoimmune diseases, and cancer. In individuals over 70 years of age, more than 20% can be affected. It is now increasingly recognized that there is a direct relationship between OH and each step of the CV disease continuum, eventually leading to end‑stage heart disease and CV death. In particular, prevalent OH is associated with cardiac functional and structural remodeling, left ventricular hypertrophy, elevated levels of circulating markers of inflammation, increased intima‑media thickness, subclinical atherosclerosis, and thrombosis. Beyond subclinical changes, the presence of OH independently predicts coronary events, stroke, atrial fibrillation, heart failure, and CV mortality. Furthermore, OH is associated with syncope, falls, and fragility fractures, presenting hurdles to be overcome in the delivery of the best management of CV risk factors. Taken together, OH heralds disruption of global circulatory homeostasis and flags overt autonomic dysfunction. The presence of OH is also an independent risk factor for mortality and CV disease; however, until now, the importance of this highly prevalent disorder has been given insufficient attention by clinicians and other healthcare providers. Consequently, more studies are needed to find effective treatment for this troublesome condition and to identify preventive measures that could reduce the burden of CV risk in OH and autonomic dysfunction.
Topics: Autonomic Nervous System; Cardiovascular Diseases; Humans; Hypotension, Orthostatic
PubMed: 31713533
DOI: 10.33963/KP.15055 -
Autonomic Neuroscience : Basic &... Dec 2020This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as... (Review)
Review
This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as neurogenic OH (nOH); these two conditions have distinct pathophysiologies and affect different patient populations. The prevalence of OH in the elderly varies depending on the study population. In community dwellers, OH prevalence is estimated at 16%, whereas in institutionalized patients, it may be as high as 60%. The prevalence of OH increases exponentially with age, particularly in those 75 years and older. Multiple epidemiological studies have identified OH as a risk factor for all-cause mortality and cardiovascular disease including heart failure and stroke. Real-world data from administrative databases found polypharmacy, multiple co-morbid conditions, and high health-care utilization as common characteristics in OH patients. A comprehensive evaluation of medications associated with OH is discussed with particular emphasis on the use of anti-hypertensive therapy from two large clinical trials on high-intensive versus standard blood pressure management. Finally, we also review the epidemiology of nOH based on the underlying neurodegenerative disorder (either Parkinson's disease or multiple system atrophy), and the presence of co-morbid conditions such as hypertension and cognitive impairment.
Topics: Aged; Aged, 80 and over; Cognitive Dysfunction; Comorbidity; Humans; Hypertension; Hypotension, Orthostatic; Multiple System Atrophy; Parkinson Disease
PubMed: 32896712
DOI: 10.1016/j.autneu.2020.102717 -
Journal of the American Geriatrics... Dec 2023There is inconsistent evidence on the optimal time after standing to assess for orthostatic hypotension. We determined the prevalence of orthostatic hypotension at... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
There is inconsistent evidence on the optimal time after standing to assess for orthostatic hypotension. We determined the prevalence of orthostatic hypotension at different time points after standing in a population of older adults, as well as fall risk and symptoms associated with orthostatic hypotension.
METHODS
We performed a secondary analysis of the Study to Understand Fall Reduction and Vitamin D in You (STURDY), a randomized clinical trial funded by the National Institute on Aging, testing the effect of differing vitamin D3 doses on fall risk in older adults. STURDY occurred between July 2015 and May 2019. Secondary analysis occurred in 2022. Participants were community-dwelling adults, 70 years or older. In the orthostatic hypotension assessment, participants stood upright from supine position and underwent six standing blood pressure measurements (M1-M6) in two clusters of three measurements (immediately and 3 min after standing). Cox proportional hazard models were used to examine the relationship between orthostatic hypotension at each measurement and subsequent falls. Participants were followed until the earlier of their 24-month visit or study completion.
RESULTS
Orthostatic hypotension occurred in 32% of assessments at M1, and only 16% at M5 and M6. Orthostatic hypotension from average immediate (M1-3) and average delayed (M4-6) measurements, respectively, predicted higher fall risk (M1-3 = 1.65 [1.08, 2.52]; M4-6 = 1.73 [1.03, 2.91]) (hazard ratio [95% confidence interval]). However, among individual measurements, only orthostatic hypotension at M5 (1.84 [1.16, 2.93]) and M6 (1.85 [1.17, 2.91]) predicted higher fall risk. Participants with orthostatic hypotension at M1 (3.07 [1.48, 6.38]) and M2 (3.72 [1.72, 8.03]) were more likely to have reported orthostatic symptoms.
CONCLUSIONS
Orthostatic hypotension was most prevalent and symptomatic immediately within 1-2 min after standing, but more informative for fall risk after 4.5 min. Clinicians may consider both intervals when assessing for orthostatic hypotension.
Topics: Humans; Aged; Hypotension, Orthostatic; Accidental Falls; Vitamin D; Blood Pressure
PubMed: 37668347
DOI: 10.1111/jgs.18573 -
Heart Failure Reviews Sep 2016Orthostatic hypotension (OH) is traditionally defined as a fall of ≥20 mmHg in systolic and/or ≥10 mmHg in diastolic blood pressure within 3 min of active... (Review)
Review
Orthostatic hypotension (OH) is traditionally defined as a fall of ≥20 mmHg in systolic and/or ≥10 mmHg in diastolic blood pressure within 3 min of active standing. OH is a common comorbidity among patients with heart failure (HF). A comprehensive review regarding the relationship between OH and HF has not been published in the English literature. Here we provide current information about concomitant HF and OH, including: pathophysiology, methods of evaluation, prevalence, risk factors, prognosis and management of OH in HF patients, as well as the incidence of HF among patients with OH. The prevalence of OH in HF ranges from 8 % among community-living individuals to 83 % in elderly hospitalized patients. Dizziness and palpitations are the most frequent OH symptoms. Main predisposing factors for OH are HF severity, non-ischemic HF etiology, prolonged bed rest, hypertension and polypharmacy. OH in HF is generally managed according to recommendations for treatment of OH in the non-HF population. However, since acceptable pharmacotherapy with fludrocortisone and midodrine is problematic in HF due to adverse effects, the management of OH is based mainly on non-pharmacologic interventions. Several prospective epidemiological studies reported that OH is independently associated with an increased risk of developing HF. Since OH is a common and frequently symptomatic condition in HF patients, its clinical implications should be emphasized. Longitudinal studies should be conducted to investigate the prognostic significance and optimal management of OH in the HF population.
Topics: Aged; Blood Pressure; Comorbidity; Disease Management; Heart Failure; Humans; Hypotension, Orthostatic; Prognosis; Risk Factors
PubMed: 26880254
DOI: 10.1007/s10741-016-9541-z -
Nephrologie & Therapeutique Apr 2017Orthostatic hypotension, defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within... (Review)
Review
Orthostatic hypotension, defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3minutes of standing up, is a frequent finding, particularly in elderly patients. It is associated with a significant increase in morbidity and mortality. Although it is often multifactorial, the first favoring factor is medications. Other etiologies are divided in neurogenic orthostatic hypotension, characterized by autonomic failure due to central or peripheral nervous system disorders, and non-neurogenic orthostatic hypotension, mainly favoured by hypovolemia. Treatment always requires education of the patient regarding triggering situations and physiological countermanoeuvers. Pharmacological treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine. There is no predefined blood pressure target, the goal of therapy being the relief of symptoms and fall prevention.
Topics: Aging; Anti-Inflammatory Agents; Drug Therapy, Combination; Fludrocortisone; Humans; Hypotension, Orthostatic; Hypovolemia; Midodrine; Nervous System Diseases; Sympathomimetics
PubMed: 28577744
DOI: 10.1016/j.nephro.2017.01.003 -
Revue Neurologique 2024Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20mmHg or a drop in diastolic blood pressure of at least 10mmHg within 3minutes of... (Review)
Review
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20mmHg or a drop in diastolic blood pressure of at least 10mmHg within 3minutes of standing. It is a common disorder, especially in high-risk populations such as elderly subjects and patients with neurological diseases, and is associated with markedly increased morbidity and mortality. Its management can be challenging, particularly in cases where supine hypertension is associated with severe orthostatic hypotension. Education of the patient, non-pharmacological measures, and drug adaptation are the cornerstones of treatment. Pharmacological treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions. First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases.
Topics: Humans; Aged; Hypotension, Orthostatic; Midodrine; Hypertension; Blood Pressure; Nervous System Diseases
PubMed: 38123372
DOI: 10.1016/j.neurol.2023.11.001 -
Current Opinion in Cardiology Jan 2018Orthostatic hypotension is a phenomenon commonly encountered in a cardiologist's clinical practice that has significant diagnostic and prognostic value for a... (Review)
Review
PURPOSE OF REVIEW
Orthostatic hypotension is a phenomenon commonly encountered in a cardiologist's clinical practice that has significant diagnostic and prognostic value for a cardiologist. Given the mounting evidence associating cardiovascular morbidity and mortality with orthostatic hypotension, cardiologists will play an increasing role in treating and managing patients with orthostatic hypotension.
RECENT FINDINGS
The American College of Cardiology, American Heart Association, and Heart Rhythm Society recently published consensus guidelines on the diagnosis, treatment, and management of syncope and their instigators, including orthostatic hypotension. Additionally, consensus guidelines have also been recently updated, reinforcing the universal definition orthostatic hypotension and its closely associated pathologies. Finally, the United States Food and Drug Administration (FDA) recently approved droxidopa, a synthetic oral norepinephrine prodrug, in 2014 for the treatment of neurogenic orthostatic hypotension (nOH), and it represents a well tolerated, effective, and easy to use intervention for nOH. This represents only the second drug approved by the FDA for orthostatic hypotension, the first being midodrine in 1986. A handful of smaller head-to-head studies have pitted not only pharmacologic agents to one another but also nonpharmacologic interventions to pharmacologic agents. Additionally, recent studies have also reported on more convenient screening tools for orthostatic hypotension.
SUMMARY
Though there have been many advances in the management of orthostatic hypotension, nOH remains a chronic, debilitating, and often progressively fatal condition. Cardiologists can play a very important role in optimizing hemodynamics in this patient population to improve quality of life and minimize cardiovascular risk.
Topics: Antiparkinson Agents; Cardiologists; Droxidopa; Humans; Hypotension, Orthostatic; Midodrine; Posture; Sympathomimetics; Tilt-Table Test
PubMed: 28984649
DOI: 10.1097/HCO.0000000000000467 -
Autonomic Neuroscience : Basic &... Nov 2020Orthostatic hypotension (OH) is a common clinical manifestation characterized by a significant fall in blood pressure with postural change and is frequently accompanied... (Review)
Review
Orthostatic hypotension (OH) is a common clinical manifestation characterized by a significant fall in blood pressure with postural change and is frequently accompanied by debilitating symptoms of orthostatic intolerance. The reported prevalence of OH ranges between 5 and 10% in middle-aged adults with a burden that increases concomitantly with age; in those over 60 years of age, the prevalence is estimated to be over 20%. Unfortunately, the clinical course of OH is not necessarily benign. OH patients are at an increased risk of adverse clinical outcomes including death, falls, cardiovascular and cerebrovascular events, syncope, and impaired quality of life. The differential diagnosis of OH is broad and includes acute precipitants as well as chronic underlying medical conditions, especially of neurological origin. Appropriate diagnosis relies on a systematic history and physical examination with particular attention to orthostatic vital signs, keeping in mind that ambient conditions during diagnostic testing may affect OH detection due to factors such as diurnal variation.
Topics: Autonomic Nervous System Diseases; Diagnosis, Differential; Humans; Hypotension, Orthostatic; Postural Orthostatic Tachycardia Syndrome; Syncope, Vasovagal
PubMed: 32805514
DOI: 10.1016/j.autneu.2020.102713