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Hypertension (Dallas, Tex. : 1979) Jan 2024Abnormal orthostatic blood pressure (BP) regulation may result in cerebral hypoperfusion and brain ischemia and contribute to dementia. It may also manifest as early...
BACKGROUND
Abnormal orthostatic blood pressure (BP) regulation may result in cerebral hypoperfusion and brain ischemia and contribute to dementia. It may also manifest as early symptoms of the neurodegenerative process associated with dementia. The relationship between the magnitude and timing of orthostatic BP responses and dementia risk is not fully understood.
METHODS
We conducted a prospective cohort analysis of the associations of orthostatic BP changes and self-reported orthostatic dizziness with the risk of dementia in the Atherosclerosis Risk in Communities study (ARIC). We calculated changes in BP from the supine to the standing position at 5 measurements taken within 2 minutes after standing during the baseline visit (1987-1989). The primary outcome was adjudicated dementia ascertained through 2019.
RESULTS
Among 11 644 participants (mean [SD] age, 54.5 [5.7] years; 54.1% women; 25.9% Black), 2303 dementia cases were identified during a median follow-up of 25.9 years. Large decreases in systolic BP from the supine to standing position measured at the first 2 measurements ≈30 and 50 seconds after standing, but not afterward, were associated with orthostatic dizziness and a higher risk of dementia. Comparing a decrease in systolic BP of ≤-20 or >-20 to -10 mm Hg to stable systolic BP (>-10 to 10 mm Hg) at the first measurement, the adjusted hazard ratios were 1.22 (95% CI, 1.01-1.47) and 1.10 (95% CI, 0.97-1.25), respectively.
CONCLUSIONS
Abnormal orthostatic BP regulation, especially abrupt drops in BP within the first minute, might be early risk markers for the development of dementia. Transient early orthostatic hypotension warrants more attention in clinical settings.
Topics: Humans; Female; Middle Aged; Male; Dizziness; Blood Pressure; Standing Position; Prospective Studies; Hypotension, Orthostatic; Hypotension; Atherosclerosis; Dementia
PubMed: 37869909
DOI: 10.1161/HYPERTENSIONAHA.123.21438 -
The Canadian Journal of Cardiology Dec 2017The maintenance of blood pressure upon the assumption of upright posture depends on rapid cardiovascular adaptations driven primarily by the autonomic nervous system.... (Review)
Review
The maintenance of blood pressure upon the assumption of upright posture depends on rapid cardiovascular adaptations driven primarily by the autonomic nervous system. Failure of these compensatory mechanisms can result in orthostatic hypotension (OH), defined as sustained reduction in systolic blood pressure > 20 mm Hg or diastolic blood pressure > 10 mm Hg within 3 minutes of standing or > 60° head-up tilt. OH is a common finding, particularly in elderly populations, associated with cardiovascular and cerebrovascular morbidity and mortality. Therefore, it is important to identify OH in the clinical setting. The detection of OH requires blood pressure measurements in the supine and standing positions. A more practical approach in clinics might be measurement of seated and standing blood pressure, but this can produce smaller depressor responses because of reduced gravitational stress. Heart rate responses to standing should be concomitantly measured to assess integrity of baroreflex function. Patients with OH can present with symptoms of cerebral hypoperfusion on standing predisposing to syncope and falls; however, many patients are asymptomatic. When the diagnosis of OH is established, it is important to document potentially deleterious medications and comorbidities and to assess for neurogenic autonomic impairment to establish underlying causes. Treatment should be initiated in a structured and stepwise approach starting with nonpharmacological interventions (eg, lifestyle modifications and physical countermanoeuvres), and adding pharmacological interventions as needed in patients with severe OH (eg, midodrine, droxidopa, fludrocortisone). The treatment goal in OH should be to improve symptoms and functional status, and not to target arbitrary blood pressure values.
Topics: Autonomic Nervous System; Blood Pressure; Cardiovascular System; Disease Management; Humans; Hypotension, Orthostatic; Posture
PubMed: 28807522
DOI: 10.1016/j.cjca.2017.05.007 -
Clinical Autonomic Research : Official... Aug 2023
Topics: Humans; Hypertension; Autonomic Nervous System Diseases; Hypotension, Orthostatic; Blood Pressure
PubMed: 37389705
DOI: 10.1007/s10286-023-00961-x -
Hypertension (Dallas, Tex. : 1979) Nov 2022Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular... (Review)
Review
Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular disease, stroke, and death. Among adults with hypertension, orthostatic hypotension has also been shown to predict patterns of blood pressure dysregulation that may not be appreciated in the office setting, including nocturnal nondipping. Individuals with uncontrolled hypertension are at particular risk of orthostatic hypotension and may meet diagnostic criteria for the condition with a smaller relative reduction in blood pressure compared with normotensive individuals. Antihypertensive medications are commonly de-prescribed to address orthostatic hypotension; however, this approach may worsen supine or seated hypertension, which may be an important driver of adverse events in this population. There is significant variability between guidelines for the diagnosis of orthostatic hypotension with regards to timing and position of blood pressure measurements. Clinically relevant orthostatic hypotension may be missed when standing measurements are delayed or when taken after a seated rather than supine position. The treatment of orthostatic hypotension in patients with hypertension poses a significant management challenge for clinicians; however, recent evidence suggests that intensive blood pressure control may reduce the risk of orthostatic hypotension. A detailed characterization of blood pressure variability is essential to tailoring a treatment plan and can be accomplished using both in-office and out-of-office monitoring.
Topics: Humans; Hypotension, Orthostatic; Hypertension; Blood Pressure; Antihypertensive Agents; Awards and Prizes
PubMed: 35924561
DOI: 10.1161/HYPERTENSIONAHA.122.18557 -
Hypertension (Dallas, Tex. : 1979) Jul 2023Orthostatic hypotension (OH) has been associated with elevated risk of cardiovascular diseases (CVDs) and dementia risk. To better understand the OH-dementia...
BACKGROUND
Orthostatic hypotension (OH) has been associated with elevated risk of cardiovascular diseases (CVDs) and dementia risk. To better understand the OH-dementia association, we assessed the associations of OH with CVD and subsequent dementia in older adults and considered the temporality of CVD and dementia onset.
METHODS
This 15-year population-based cohort study included, at baseline, 2703 dementia-free participants (mean age, 73.7 years) who were divided into a CVD-free cohort (n=1986) and a CVD cohort (n=717). OH was defined as a systolic/diastolic blood pressure decline of ≥20/10 mm Hg after standing up from a supine position. CVDs and dementia were ascertained by physicians or identified from registers. Multistate Cox regressions were applied to assess the associations of OH with CVD and subsequent dementia in the CVD-free and dementia-free cohort. The OH-dementia association in the CVD cohort was examined with Cox regressions.
RESULTS
OH was present in 434 (21.9%) individuals in the CVD-free cohort and 180 (25.1%) individuals in the CVD cohort. OH was associated with a hazard ratio of 1.33 (95% CI, 1.12-1.59) for CVD. OH was not significantly associated with incident dementia in the absence of CVD occurring before dementia diagnosis (hazard ratio, 1.22 [95% CI, 0.83-1.81]). In the CVD cohort, individuals with OH had a higher dementia risk than those without OH (hazard ratio, 1.54 [95% CI, 1.06-2.23]).
CONCLUSIONS
The association between OH and dementia may partly be explained by the intermediate development of CVD. In addition, in people with CVD, those with OH may have a poorer cognitive prognosis.
Topics: Humans; Aged; Cardiovascular Diseases; Hypotension, Orthostatic; Cohort Studies; Blood Pressure; Risk Factors
PubMed: 37203439
DOI: 10.1161/HYPERTENSIONAHA.123.21210 -
Neurology Oct 2020To test the hypothesis that orthostatic hypotension (OH) might cause cerebral hypoperfusion and injury, we examined the longitudinal relationship between OH or...
OBJECTIVE
To test the hypothesis that orthostatic hypotension (OH) might cause cerebral hypoperfusion and injury, we examined the longitudinal relationship between OH or orthostatic symptoms and incident neurologic outcomes in a community population of older adults.
METHODS
Cardiovascular Health Study participants (≥65 years) without dementia or stroke had blood pressure (BP) measured after lying down for 20 minutes and after standing 3 for minutes. Participants reported dizziness immediately upon standing and any dizziness in the past 2 weeks. OH was defined as a drop in standing systolic/diastolic BP ≥20/≥10 mm Hg. We determined the association between OH or dizziness with (1) MRI brain findings (ventricular size, white matter hyperintensities, brain infarcts) using linear or logistic regression, (2) cognitive function (baseline and over time) using generalized estimating equations, and (3) prospective adjudicated events (dementia, stroke, death) using Cox models. Models were adjusted for demographic characteristics and OH risk factors. We used multiple imputation to account for missing OH or dizziness (n = 534).
RESULTS
Prior to imputation, there were 5,007 participants (mean age 72.7 ± 5.5 years, 57.6% women, 10.9% Black, 16% with OH). OH was modestly associated with death (hazard ratio [HR] 1.11; 95% confidence interval 1.02-1.20), but not MRI findings, cognition, dementia, or stroke. In contrast, dizziness upon standing was associated with lower baseline cognition (β = -1.20; -1.94 to -0.47), incident dementia (HR 1.32; 1.04-1.62), incident stroke (HR 1.22; 1.06-1.41), and death (HR 1.13; 1.06-1.21). Similarly, dizziness over the past 2 weeks was associated with higher white matter grade (β = 0.16; 0.03-0.30), brain infarcts (OR 1.31; 1.06-1.63), lower baseline cognition (β = -1.18; -2.01 to -0.34), and death (HR 1.13; 1.04-1.22).
CONCLUSIONS
Dizziness was more consistently associated with neurologic outcomes than OH 3 minutes after standing. Delayed OH assessments may miss pathologic information related to cerebral injury.
Topics: Aged; Brain; Cognition; Dementia; Dizziness; Female; Humans; Hypotension, Orthostatic; Male; Risk Factors; Stroke
PubMed: 32732296
DOI: 10.1212/WNL.0000000000010456 -
Syndrome of Supine Hypertension with Orthostatic Hypotension: Pathophysiology and Clinical Approach.Current Cardiology Reviews 2020This article is intended to provide guidance and clinical considerations for physicians managing patients suffering from supine hypertension with orthostatic... (Review)
Review
This article is intended to provide guidance and clinical considerations for physicians managing patients suffering from supine hypertension with orthostatic hypotension, referred to as "SH-OH". We review the normal physiologic response to orthostasis, focusing on the appropriate changes to autonomic output in this state. Autonomic failure is discussed with a generalized overview of the disease and examination of specific syndromes that help shed light on the pathophysiology of SH-OH. The goal of this review is to provide a better framework for clinical evaluation of these patients, review treatment options, and ultimately work toward achieving a better quality of life for patients afflicted with this disease.
Topics: Humans; Hypertension; Hypotension, Orthostatic; Supine Position; Syndrome
PubMed: 31215392
DOI: 10.2174/1573403X15666190617095032 -
Clinical Nursing Research Jun 2021The aim of this retrospective study was to determine the prevalence of orthostatic hypotension (OH) among a convenience sample of older adults on two Acute Care of the...
The aim of this retrospective study was to determine the prevalence of orthostatic hypotension (OH) among a convenience sample of older adults on two Acute Care of the Elderly (ACE) units of the ChristianaCare™ in Delaware. Another aim was to determine if subjects with documented OH experienced falls. Retrospective de-identified data was obtained from electronic medical records for the years 2015 to 2018. Among all patients who had valid first orthostatic vital sign (OVS) readings ( = 7,745), 39.2% had orthostatic hypotension on the first reading. Among the patients, 42.8% were found to be hypotensive during OVS. Thirty-one (0.9%) of those with OH fell at some point during their stay. The odds ratio for falls in the presence of OH was 1.34 with a 95% confidence interval (0.82, 2.21), but a chi-square test failed to find significance ( = .2494). The results could not determine if OVS should be mandatory in fall prevention protocols.
Topics: Aged; Blood Pressure; Humans; Hypotension, Orthostatic; Prevalence; Retrospective Studies
PubMed: 33426904
DOI: 10.1177/1054773820986682 -
Cleveland Clinic Journal of Medicine Dec 2014There are three major types of syncope: neurally mediated (the most common), orthostatic hypotensive, and cardiac (the most worrisome). Several studies have shown a... (Review)
Review
There are three major types of syncope: neurally mediated (the most common), orthostatic hypotensive, and cardiac (the most worrisome). Several studies have shown a normal long-term survival rate in patients with syncope who have no structural heart disease, which is the most important predictor of death and ventricular arrhythmia. The workup of unexplained syncope depends on the presence or absence of heart disease: electrophysiologic study if the patient has heart disease, tilt-table testing in those without heart disease, and prolonged rhythm monitoring in both cases if syncope remains unexplained.
Topics: Heart Diseases; Humans; Hypotension, Orthostatic; Syncope; Syncope, Vasovagal
PubMed: 25452354
DOI: 10.3949/ccjm.81a.13152 -
Journal of Inherited Metabolic Disease May 2021Dopamine beta hydroxylase (DBH) deficiency is an extremely rare autosomal recessive disorder with severe orthostatic hypotension, that can be treated with... (Review)
Review
Dopamine beta hydroxylase (DBH) deficiency is an extremely rare autosomal recessive disorder with severe orthostatic hypotension, that can be treated with L-threo-3,4-dihydroxyphenylserine (L-DOPS). We aimed to summarize clinical, biochemical, and genetic data of all world-wide reported patients with DBH-deficiency, and to present detailed new data on long-term follow-up of a relatively large Dutch cohort. We retrospectively describe 10 patients from a Dutch cohort and 15 additional patients from the literature. We identified 25 patients (15 females) from 20 families. Ten patients were diagnosed in the Netherlands. Duration of follow-up of Dutch patients ranged from 1 to 21 years (median 13 years). All patients had severe orthostatic hypotension. Severely decreased or absent (nor)epinephrine, and increased dopamine plasma concentrations were found in 24/25 patients. Impaired kidney function and anemia were present in all Dutch patients, hypomagnesaemia in 5 out of 10. Clinically, all patients responded very well to L-DOPS, with marked reduction of orthostatic complaints. However, orthostatic hypotension remained present, and kidney function, anemia, and hypomagnesaemia only partially improved. Plasma norepinephrine increased and became detectable, while epinephrine remained undetectable in most patients. We confirm the core clinical characteristics of DBH-deficiency and the pathognomonic profile of catecholamines in body fluids. Impaired renal function, anemia, and hypomagnesaemia can be part of the clinical presentation. The subjective response to L-DOPS treatment is excellent and sustained, although the neurotransmitter profile in plasma does not normalize completely. Furthermore, orthostatic hypotension as well as renal function, anemia, and hypomagnesaemia improve only partially.
Topics: Autonomic Nervous System Diseases; Blood Pressure; Dopamine; Dopamine beta-Hydroxylase; Droxidopa; Humans; Hypotension, Orthostatic; Norepinephrine
PubMed: 33034372
DOI: 10.1002/jimd.12321