-
Hypertension (Dallas, Tex. : 1979) Nov 2023Management of orthostatic hypotension (OH) prioritizes prevention of standing hypotension, sometimes at the expense of supine hypertension. It is unclear whether supine...
BACKGROUND
Management of orthostatic hypotension (OH) prioritizes prevention of standing hypotension, sometimes at the expense of supine hypertension. It is unclear whether supine hypertension is associated with adverse outcomes relative to standing hypotension.
OBJECTIVES
To compare the long-term clinical consequences of supine hypertension and standing hypotension among middle-aged adults with and without OH.
METHODS
The ARIC study (Atherosclerosis Risk in Communities) measured supine and standing blood pressure (BP) in adults aged 45 to 64 years, without neurogenic OH, between 1987 and 1989. We defined OH as a positional drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg, supine hypertension as supine BP≥140/≥90 mm Hg, and standing hypotension as standing BP≤105/≤65 mm Hg. Participants were followed for >30 years. We used Cox regression models to examine associations with cardiovascular disease events, all-cause mortality, falls, and syncope.
RESULTS
Of 12 489 participants (55% female, 26% Black, mean age 54 years, SD 6), 4.4% had OH. Among those without OH (N=11 943), 19% had supine hypertension and 21% had standing hypotension, while among those with OH (N=546), 58% had supine hypertension and 38% had standing hypotension. Associations with outcomes did not differ by OH status (-interactions >0.25). Supine hypertension was associated with heart failure (hazard ratio, 1.83 [95% CI, 1.68-1.99]), falls (hazard ratio, 1.12 [95% CI, 1.02-1.22]), and all-cause mortality (hazard ratio, 1.45 [95% CI, 1.37-1.54]), while standing hypotension was only significantly associated with mortality (hazard ratio, 1.06 [95% CI, 1.00-1.14]).
CONCLUSIONS
Supine hypertension was associated with higher risk of adverse events than standing hypotension, regardless of OH status. This challenges conventional OH management, which prioritizes standing hypotension over supine hypertension.
Topics: Middle Aged; Humans; Adult; Female; Male; Hypertension; Cardiovascular Diseases; Blood Pressure; Hypotension, Orthostatic; Blood Pressure Determination
PubMed: 37646155
DOI: 10.1161/HYPERTENSIONAHA.123.21215 -
Movement Disorders : Official Journal... Jan 2021Orthostatic hypotension is common in patients with Parkinson's disease (PD). However, it remains unknown whether orthostatic hypotension is a marker of prodromal PD or...
BACKGROUND
Orthostatic hypotension is common in patients with Parkinson's disease (PD). However, it remains unknown whether orthostatic hypotension is a marker of prodromal PD or more advanced disease. The objectives of this study were to assess whether orthostatic hypotension is a prodromal marker of PD in the general population.
METHODS
This study was embedded in the Rotterdam Study, a large prospective population-based cohort in the Netherlands. We measured orthostatic hypotension in 6910 participants. First, we determined the relation between prevalent PD and orthostatic hypotension using logistic regression. Second, we followed PD-free participants for the occurrence of PD until 2016 and studied the association between orthostatic hypotension and the risk of PD using Cox proportional hazards models. All models were adjusted for age and sex.
RESULTS
At baseline, the mean age ± standard deviation of the study population was 69.0 ± 8.8 years, and 59.1% were women. Orthostatic hypotension was present in 1245 participants (19.8%), and 62 participants (1.0%) had PD at the time of orthostatic hypotension measurement. Participants with PD were significantly more likely to have orthostatic hypotension (odds ratio, 1.88; 95% confidence interval, 1.09-3.24). During a median (interquartile range) follow-up of 16.1 years (8.5-22.7 years), 122 participants were diagnosed with incident PD. Orthostatic hypotension at baseline was not associated with an increased risk of PD (hazard ratio, 0.97; 95% confidence interval, 0.59-1.58).
CONCLUSIONS
Our study suggests that orthostatic hypotension is common in patients with PD, but that orthostatic hypotension is not associated with an increased risk of PD and thus is not a prodromal marker of PD in the general population. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
Topics: Cohort Studies; Female; Humans; Hypotension, Orthostatic; Male; Netherlands; Parkinson Disease; Prodromal Symptoms; Prospective Studies
PubMed: 32965064
DOI: 10.1002/mds.28303 -
Clinical Autonomic Research : Official... Feb 2021Neurogenic orthostatic hypotension (nOH) is the hallmark of neurodegenerative forms of autonomic failure, including pure autonomic failure, multiple system atrophy, and...
PURPOSE
Neurogenic orthostatic hypotension (nOH) is the hallmark of neurodegenerative forms of autonomic failure, including pure autonomic failure, multiple system atrophy, and Parkinson's disease. Studies have shown autonomic physiological differences in Africans Americans (AA) such as lower heart rate variability, enhanced blood pressure reactivity, and blunted sympathetic neural response compared to non-Hispanic whites. However, the clinical characteristics and neurohormonal profile of autonomic failure in AA is unknown.
METHODS
A total of 65 patients with nOH participated in this study (9 AA and 56 non-Hispanic whites). Both groups were of similar age and comorbidity status, and they underwent standardized autonomic testing and assessment of neurohormonal levels and renin activity and aldosterone in supine and upright positions.
RESULTS
There were no significant differences in baseline autonomic clinical characteristics between non-Hispanic whites and AA with nOH. Non-Hispanic whites demonstrated a significant increase in upright renin activity compared to AA (295 ± 88% vs. 13 ± 13%, respectively). AA showed a blunted increase in aldosterone compared to non-Hispanic whites (188 ± 27% vs. 59 ± 38%, respectively). These results indicated persistent suppression of the renin-angiotensin system in AA, particularly during upright posture.
CONCLUSION
Our findings demonstrate that AA with nOH have similar clinical characteristics and hemodynamic autonomic profiles, but lower upright renin activity and aldosterone levels, compared to non-Hispanic whites. Renin suppression persists in AA with severe autonomic failure and can potentially contribute to postural changes and supine hypertension.
Topics: Black or African American; Autonomic Nervous System Diseases; Blood Pressure; Humans; Hypertension; Hypotension, Orthostatic
PubMed: 33502643
DOI: 10.1007/s10286-020-00764-4 -
Journal of Parkinson's Disease 2023Multiple system atrophy (MSA) is a rare neurodegenerative disease characterized by Parkinsonism, ataxia, and autonomic nervous failure. Orthostatic hypotension (OH) is...
BACKGROUND
Multiple system atrophy (MSA) is a rare neurodegenerative disease characterized by Parkinsonism, ataxia, and autonomic nervous failure. Orthostatic hypotension (OH) is the main feature of central vascular autonomic failure in MSA.
OBJECTIVE
The study aimed elucidate the effects of OH on cognitive function, disease milestones, and survival.
METHODS
A total of 444 patients with clinically established MSA were enrolled. Mild and severe OH were defined as a decrease in systolic blood pressure (SBP)/diastolic blood pressure (DBP) >20/10 mmHg and SBP/DBP ≥30/15 mmHg, respectively.
RESULTS
In this study, 215 MSA patients presented without OH, 88 had mild OH, and 141 had severe OH. The proportion of MSA-C in the severe OH subgroup was significantly higher than that in the subgroup without OH (95/46 vs. 113/102, p = 0.021). The UMSARS I score and the frequency of supine hypertension (SH) in patients with OH were significantly higher than those in patients without OH (16.22 vs. 16.89 vs. 14.60, p < 0.001; 77/64 vs. 29/59 vs. 32/183, p < 0.001). Factors related to the severity of OH included sex (OR, 0.65; p = 0.031), onset age (OR, 0.98; p = 0.029), and SH (OR, 0.21; p < 0.001). The median survival time of patients with severe OH was significantly lower than that of patients without OH (6.79 vs. 8.13 years, p = 0.001). Consistently, Cox survival analysis found that compared with patients without OH, patients with severe OH had a significantly increased risk of death (OR, 2.22; p < 0.001).
CONCLUSION
Our large cohort study of MSA provides additional evidence for the negative impact of severe OH on survival.
Topics: Humans; Hypotension, Orthostatic; Multiple System Atrophy; Cohort Studies; Parkinson Disease; Hypertension; Prognosis
PubMed: 38143372
DOI: 10.3233/JPD-230095 -
Age and Ageing Sep 2021Initial orthostatic hypotension (OH) is a clinical syndrome of exaggerated transient orthostasis associated with higher risks of falls, frailty and syncope in older... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Initial orthostatic hypotension (OH) is a clinical syndrome of exaggerated transient orthostasis associated with higher risks of falls, frailty and syncope in older adults.
OBJECTIVE
To provide a prevalence estimate of initial OH in adults aged 65 years or older.
METHODS
Literature search of MEDLINE (from 1946), Embase (from 1947) and Cochrane Central Register of Controlled Trials was performed until 6 December 2019, using the terms 'initial orthostatic hypotension', 'postural hypotension' and 'older adults'. Articles were included if published in English and participants were 65 years or older. Random effects models were used for pooled analysis.
RESULTS
Of 5,136 articles screened, 13 articles (10 cross-sectional; 3 longitudinal) reporting data of 5,465 individuals (54.5% female) from the general (n = 4,157), geriatric outpatient (n = 1,136), institutionalised (n = 55) and mixed (n = 117) population were included. Blood pressure was measured continuously and intermittently in 11 and 2 studies, respectively. Pooled prevalence of continuously measured initial OH was 29.0% (95% CI: 22.1-36.9%, I2 = 94.6%); 27.8% in the general population (95% CI: 17.9-40.5%, I2 = 96.1%), 35.2% in geriatric outpatients (95% CI: 24.2-48.1%, I2 = 95.3%), 10.0% in institutionalised individuals (95% CI: 2.4-33.1%, I2 = 0%) and 21.4% in the mixed population (95% CI: 7.0-49.6, I2 = 0%). Pooled prevalence of intermittently measured initial OH was 5.6% (95% CI: 1.5-18.9%, I2 = 81.1%); 1.0% in the general population (95% CI: 0.0-23.9%, I2 = 0%) and 7.7% in geriatric outpatients (95% CI: 1.8-27.0%, I2 = 86.7%).
CONCLUSION
The prevalence of initial OH is high in older adults, especially in geriatric outpatients. Proper assessment of initial OH requires continuous blood pressure measurements.
Topics: Accidental Falls; Aged; Blood Pressure; Cross-Sectional Studies; Female; Frailty; Humans; Hypotension, Orthostatic; Male; Prevalence
PubMed: 34260686
DOI: 10.1093/ageing/afab090 -
Ugeskrift For Laeger Apr 2018Neurogenic autonomic dysfunction (NAD) is underdiagnosed, and it is likely in patients, who have orthostatic hypotension and symptoms from multiple organ systems as well... (Review)
Review
Neurogenic autonomic dysfunction (NAD) is underdiagnosed, and it is likely in patients, who have orthostatic hypotension and symptoms from multiple organ systems as well as abnormal results from a neurological examination. A clinical and neurophysiological examination of the autonomic nervous system combined with a standardised paraclinical evaluation should be performed. NAD may be present in neurodegenerative disorders, vitamin deficiency, toxicity, infection, and in paraneoplastic, metabolic, hereditary and immune-mediated conditions.
Topics: Adult; Algorithms; Autonomic Nervous System Diseases; Humans; Hypotension, Orthostatic; Parasympathetic Nervous System; Sympathetic Nervous System
PubMed: 29720343
DOI: No ID Found -
Hong Kong Medical Journal = Xianggang... Apr 2018Syncope is a prevalent health problem among elderly people. It may be neurally mediated or caused by conditions such as orthostatic hypotension, postprandial... (Review)
Review
Syncope is a prevalent health problem among elderly people. It may be neurally mediated or caused by conditions such as orthostatic hypotension, postprandial hypotension, and cardiac disorders. A combination of different aetiologies is not uncommon in the elderly people. Many pathophysiological processes, including age-related physiological changes, co-morbidities, concomitant medication use, and prolonged bedrest, coexist and predispose elderly people to syncope; advanced age and cardiac syncope are associated with increased mortality. Recurrent syncope and its co-morbidities, such as fall-related physical injury, negative psychological impact, and functional decline, may increase the dependency of elderly patients. Furthermore, the overlap between falls and syncope, and the interaction between syncope and frailty complicate management. Available clinical guidelines for the management of syncope that focus on diagnosis, investigation, and treatment are therefore insufficient to address syncope in elderly patients. A comprehensive geriatric approach that considers an individual's functional and cognitive capacities, as well as medical and psychosocial aspects, would be more appropriate.
Topics: Accidental Falls; Aged; Frailty; Humans; Hypotension, Orthostatic; Risk Factors; Syncope
PubMed: 29658484
DOI: 10.12809/hkmj176945 -
Hypertension (Dallas, Tex. : 1979) May 2020Orthostatic hypertension, which appears to be mediated through excess neurohumoral activation while standing, is a common blood pressure trait among patients with and... (Review)
Review
Orthostatic hypertension, which appears to be mediated through excess neurohumoral activation while standing, is a common blood pressure trait among patients with and without arterial hypertension. However, lack of consensus regarding the definition of orthostatic hypertension makes it difficult to assess the true prevalence of this condition. Orthostatic hypertension appears to predict the risk for progression to arterial hypertension in younger and risk of cardiovascular morbidity and mortality in older persons. Yet, the risk may differ between populations. Whether orthostatic hypertension indicates a generally increased risk of death, constitutes an intermediate variable in the causal pathway of cardiovascular risk factors, a simple measure of disease severity, or an independently acting mechanism is not known. Since both orthostatic hypotension and orthostatic hypertension herald increased risk of cardiovascular disease, it appears reasonable to screen the patients for abnormal orthostatic blood pressure responses using simple orthostatic testing. However, how presence of orthostatic hypertension may affect clinical management decisions such as the choice of antihypertensive drugs is currently difficult to ascertain. Clearly, this issue deserves more attention.
Topics: Adrenergic Neurons; Antihypertensive Agents; Autonomic Nervous System; Baroreflex; Disease Progression; Heart Conduction System; Humans; Hypertension; Hypotension, Orthostatic; Norepinephrine; Posture; Prevalence; Tilt-Table Test; Vascular Resistance; Vestibule, Labyrinth
PubMed: 32223382
DOI: 10.1161/HYPERTENSIONAHA.120.14340 -
Revista Da Associacao Medica Brasileira... Jan 2022The objective of this study was to analyze the association between orthostatic changes in blood pressure and mortality in elderly cardiopath patients.
OBJECTIVE
The objective of this study was to analyze the association between orthostatic changes in blood pressure and mortality in elderly cardiopath patients.
METHODS
A cohort of 455 elderly cardiopath patients, monitored at a referral outpatient cardiology clinic in Pernambuco, Brazil, from October 2015 to July 2018. The exposure groups were formed according to their orthostatic changes in blood pressure following the requirements of the Brazilian Guidelines for Hypertension.
RESULTS
Orthostatic hypotension was present in 46 patients (10.1%), 91 had orthostatic hypertension (20%), and 318 had no orthostatic alterations (69.9%). There were 52 deaths during follow-up. The results demonstrated that there was no statistically significant association between orthostatic hypotension and overall mortality (HR 1.30; 95%CI 0.53-3.14; p=0.567) nor between orthostatic hypertension and overall mortality (HR 0.95; 95%CI 0.65-1.39; p=0.34). Survival in relation to the exposure groups presented no statistically significant difference (p=0.504).
CONCLUSION
There was a low frequency of orthostatic hypotension and a mild high frequency of orthostatic hypertension when compared with previous studies, and no association was observed with overall mortality or with the survival time of elderly patients with heart disease.
Topics: Aged; Blood Pressure; Blood Pressure Determination; Heart Diseases; Humans; Hypertension; Hypotension, Orthostatic
PubMed: 35239932
DOI: 10.1590/1806-9282.20210199 -
Clinical Medicine (London, England) Apr 2015In this, the second of two articles, we continue our evaluation of drug therapies in older adults. Having previously described the pharmacokinetic and pharmacodynamic... (Review)
Review
In this, the second of two articles, we continue our evaluation of drug therapies in older adults. Having previously described the pharmacokinetic and pharmacodynamic consequences of physiological ageing, along with the challenge of appropriate prescribing, we proposed four key questions which should be considered when prescribing for this cohort of the population. Does this agent reflect the priorities of the patient? Are there alternatives - with greater efficacy, effectiveness or tolerability - that might be considered? Are the dose, frequency and formulation appropriate? How does this prescription relate to concurrent medication? We also highlighted the reliance on subgroup analysis to demonstrate the efficacy of drug therapies for older adults in osteoporosis and the underutilisation of appropriate treatments for patients with Alzheimer's disease as a result of flawed guidelines. Here we describe current drug therapies in systolic heart failure, noting the limited inclusion of older adults in key trials, while also reviewing the pharmacological treatment of orthostatic hypotension. In doing so, we advocate the intermittent use of midodrine as a first-line treatment for orthostasis in older adults, counter to the generic guidelines produced by various learned societies, but in keeping with the scant trial data available.
Topics: Age Factors; Cardiovascular Agents; Geriatrics; Heart Failure, Systolic; Humans; Hypotension, Orthostatic
PubMed: 25824068
DOI: 10.7861/clinmedicine.15-2-155