-
American Journal of Hypertension May 2018Multiple definitions are used to characterize orthostatic hypotension (OH), but the degree to which these definitions correspond with orthostatic symptoms is unknown. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Multiple definitions are used to characterize orthostatic hypotension (OH), but the degree to which these definitions correspond with orthostatic symptoms is unknown.
METHODS
We analyzed data from African American Study of Kidney Disease and Hypertension (AASK), a randomized trial of African Americans with hypertension and kidney disease, to characterize the relationship between OH definitions and self-reported syncope, dizziness, or light-headedness. Orthostatic changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), or heart rate (HR) were determined each visit after standing 2:45 minutes. OH was defined using the consensus definition (a drop in SBP ≥20 mm Hg or DBP ≥10 mm Hg) or an often used clinical substitute based on HR (an increase ≥20 bpm).
RESULTS
Among 1,094 participants (mean age 54.5 ± 10.7 years, 38.9% female), there were 52,636 visits (mean 48/person). Mean resting SBP, DBP, and HR at baseline were 147.7 ± 22.3 mm Hg, 92.2 ± 13.4 mm Hg, and 71.1 ± 11.7 bpm, respectively. While the OH consensus definition was associated with syncope (odds ratio 2.49; 95% confidence interval: 1.13, 5.51), dizziness (1.89; 1.53, 2.33), and light-headedness (1.84; 1.52, 2.23), the clinical HR definition was only associated with dizziness (1.28; 1.07, 1.52). None of the OH components (SBP, DBP, or HR) reflected a natural threshold in the prevalence of symptoms; definitions using each of the 3 components were highly specific (≥96%) with low sensitivity (1-5%).
CONCLUSIONS
While the consensus definition was more strongly associated with symptoms, OH definitions did not reflect natural thresholds in symptoms and were insensitive. This implies that the absence of OH using either consensus or clinical definitions does not exclude orthostatic symptoms, which has implications for evaluating clinical events like falls.
CLINICAL TRIALS REGISTRATION
Trial Number: NCT01206062 (clinicaltrials.gov).
Topics: Adult; Black or African American; Aged; Blood Pressure; Dizziness; Female; Heart Rate; Humans; Hypertension; Hypotension, Orthostatic; Kidney Diseases; Male; Middle Aged; Syncope
PubMed: 29370333
DOI: 10.1093/ajh/hpy010 -
Europace : European Pacing,... Mar 2024The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled...
The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled out. Reflex syncope and orthostatic hypotension are the most frequent aetiologies of non-cardiac syncope. As no specific therapy is effective for all types of non-cardiac syncope, identifying the underlying haemodynamic mechanism is the essential prerequisite for an effective personalized therapy and prevention of syncope recurrences. Indeed, choice of appropriate therapy and its efficacy are largely determined by the syncope mechanism rather than its aetiology and clinical presentation. The two main haemodynamic phenomena leading to non-cardiac syncope include either profound hypotension or extrinsic asystole/pronounced bradycardia, corresponding to two different haemodynamic syncope phenotypes, the hypotensive and bradycardic phenotypes. The choice of therapy-aimed at counteracting hypotension or bradycardia-depends on the given phenotype. Discontinuation of blood pressure-lowering drugs, elastic garments, and blood pressure-elevating agents such as fludrocortisone and midodrine are the most effective therapies in patients with hypotensive phenotype. Cardiac pacing, cardioneuroablation, and drugs preventing bradycardia such as theophylline are the most effective therapies in patients with bradycardic phenotype of extrinsic cause.
Topics: Humans; Bradycardia; Syncope; Syncope, Vasovagal; Hypotension; Hypotension, Orthostatic
PubMed: 38529800
DOI: 10.1093/europace/euae073 -
Texas Heart Institute Journal Mar 2022
Topics: Aged; Heart; Humans; Hypertension; Hypotension, Orthostatic
PubMed: 35353895
DOI: 10.14503/THIJ-21-7808 -
Clinical Autonomic Research : Official... Dec 2021In neurogenic orthostatic hypotension, blood pressure falls when upright owing to impaired release of norepinephrine, leading to dizziness. Ampreloxetine, a selective... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
In neurogenic orthostatic hypotension, blood pressure falls when upright owing to impaired release of norepinephrine, leading to dizziness. Ampreloxetine, a selective norepinephrine reuptake inhibitor, increases circulating norepinephrine levels. This study explored the safety of ampreloxetine and its effect on blood pressure and symptoms in patients with neurogenic orthostatic hypotension.
METHODS
A multicenter ascending-dose trial (range 1-20 mg, Part A) was followed by a 1 day, double-blind, randomized, placebo-controlled study (median dose 15 mg, Part B). Eligible patients then enrolled in a 20-week, open-label, steady-state extension phase (median dose 10 mg, Part C) followed by a 4-week withdrawal. Assessments included the Orthostatic Hypotension Symptom Assessment Scale (item 1), supine/seated/standing blood pressure, and safety.
RESULTS
Thirty-four patients (age 66 ± 8 years, 22 men) were enrolled. Part A: The proportion of participants with a positive response (i.e., increase from baseline in seated systolic blood pressure of ≥ 10 mmHg) was greater with the 5 and 10 mg ampreloxetine doses than with placebo or other active ampreloxetine doses. Part B: Seated blood pressure increased 15.7 mmHg 4 h after ampreloxetine and decreased 14.2 mmHg after placebo [least squares mean difference (95% CI) 29.9 mmHg (7.6-52.3); P = 0.0112]. Part C: Symptoms of dizziness/lightheadedness improved 3.1 ± 3.0 points from baseline and standing systolic blood pressure increased 11 ± 12 mmHg. After 4 weeks of withdrawal, symptoms returned to pretreatment levels. The effect of ampreloxetine on supine blood pressure was minimal throughout treatment duration.
CONCLUSION
Ampreloxetine was well tolerated and improved orthostatic symptoms and seated/standing blood pressure with little change in supine blood pressure.
TRIAL REGISTRATION
NCT02705755 (first posted March 10, 2016).
Topics: Aged; Blood Pressure; Dizziness; Double-Blind Method; Droxidopa; Humans; Hypotension, Orthostatic; Male; Middle Aged; Norepinephrine
PubMed: 34657222
DOI: 10.1007/s10286-021-00827-0 -
Journal of the American Heart... May 2018Although orthostatic hypotension (OH) is a well-recognized manifestation of neuropathy and hypovolemia, its contribution to cardiovascular disease (CVD) risk is... (Observational Study)
Observational Study
BACKGROUND
Although orthostatic hypotension (OH) is a well-recognized manifestation of neuropathy and hypovolemia, its contribution to cardiovascular disease (CVD) risk is controversial.
METHODS AND RESULTS
Participants with OH, defined as a decrease in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, were identified during the first visit of the ARIC (Atherosclerosis Risk in Communities) Study (1987-1989) within 2 minutes of standing. All participants were followed up for the development of myocardial infarction, heart failure, stroke, fatal coronary heart disease (CHD), any CHD (combination of silent, nonfatal, and fatal CHD or cardiac procedures), and all-cause mortality. Participants were assessed for carotid intimal thickness and plaque during the first visit. Detectable high-sensitivity troponin T (≥5 ng/L) and elevated NT-proBNP (N-terminal pro-B-type natriuretic peptide; ≥100 pg/mL) were determined in blood collected during the second visit (1990-1992). All associations were adjusted for known CVD risk factors. In 9139 participants (57% women; 23% black; mean age, 54±5.7 years), 3% had OH. During follow-up (median, 26 years), OH was associated with myocardial infarction (hazard ratio [HR], 1.88; 95% confidence interval [CI], 1.44-2.46), congestive heart failure (HR, 1.65; 95% CI, 1.34-2.04), stroke (HR, 1.83; 95% CI, 1.35-2.48), fatal CHD (HR, 2.77; 95% CI, 1.93-3.98), any CHD (HR, 2.00; 95% CI, 1.64-2.44), and all-cause mortality (HR, 1.68; 95% CI, 1.45-1.95). OH was also associated with carotid intimal thickness (β, 0.05 mm; 95% CI, 0.04-0.07 mm), carotid plaque (odds ratio, 1.51; 95% CI, 1.18-1.93), detectable high-sensitivity troponin T (odds ratio, 1.49; 95% CI, 1.16-1.93), and elevated NT-proBNP (odds ratio, 1.92; 95% CI, 1.48-2.49).
CONCLUSIONS
OH identified in community-dwelling middle-aged adults was associated with future CVD events and subclinical CVD. Further research is necessary to establish a causal role for OH in the pathogenesis of CVD.
Topics: Asymptomatic Diseases; Blood Pressure; Cardiovascular Diseases; Female; Humans; Hypotension, Orthostatic; Incidence; Male; Middle Aged; Posture; Prognosis; Prospective Studies; Risk Assessment; Risk Factors; Time Factors; United States
PubMed: 29735525
DOI: 10.1161/JAHA.118.008884 -
Neurologia I Neurochirurgia Polska 2021Dementia in advanced Parkinson's Disease (PD) is a fatal milestone resulting in reduced life expectancy and nursing home placement. Cognitive impairment and... (Review)
Review
Dementia in advanced Parkinson's Disease (PD) is a fatal milestone resulting in reduced life expectancy and nursing home placement. Cognitive impairment and cardiovascular dysautonomia are common and debilitating non-motor symptoms that frequently coexist in PD since the early stages and progress in subsequent years. In particular, blood pressure (BP) abnormalities, including orthostatic hypotension (OH), supine hypertension (SH) and the loss of nocturnal BP fall (non-dipping) in PD have been associated with cognitive deterioration. They usually have multifactorial aetiology, including neuronal (central and peripheral) mechanisms and concomitant intake of medications. BP abnormalities can influence cognition in many ways, including repeated cerebral hypoperfusion leading to cerebral ischaemic lesions, higher burden of white matter hyperintensities, and possible impact on neurodegenerative process in PD. They are often asymptomatic and remain unrecognised, hence 24-hour ambulatory BP monitoring is recommended in patients with clinical symptoms of dysautonomia. Management is challenging and should address the multifactorial nature of BP disturbances. The aim of this review was to present the state of current knowledge regarding the possible relationship between cardiovascular dysautonomia and cognition in PD, its diagnosis and treatment.
Topics: Blood Pressure; Blood Pressure Monitoring, Ambulatory; Cognition; Humans; Hypotension, Orthostatic; Parkinson Disease; Primary Dysautonomias
PubMed: 34037978
DOI: 10.5603/PJNNS.a2021.0040 -
Brain Injury Jan 2021: Concussion is associated with dysautonomia, altered blood pressure (BP) control, and may cause Orthostatic Hypotension (OH). We measured prevalence of OH using the...
: Concussion is associated with dysautonomia, altered blood pressure (BP) control, and may cause Orthostatic Hypotension (OH). We measured prevalence of OH using the 1-minute supine-to-standing OH Test in adolescents with concussion and controls.: Adolescents within 10 days of injury (Concussion Group, n = 297, 15.0 ± 1.7 years, 59% male) were compared with controls (Control Group, n = 214, 15.0 ± 1.5 years, 58% male).: BP, heart rate (HR), and complaints of lightheadedness/dizziness were measured after 2-minute supine and 1-minute standing. Control Group was assessed once. Concussion Group was assessed twice; (1) initial visit (mean 6.0 ± 3 days-since-injury) and (2) after clinical recovery (mean 46.3 ± 42 days-since-injury).: Initial visit; Concussion Group reported feeling lightheaded/dizzy on postural change more often than the Control Group (37% vs 4%, < .001) but did not differ in meeting standard OH criteria (3% vs 5%, = .32). Experiencing symptoms did not correlate with meeting OH criteria, but correlated with abnormal vestibulo-ocular reflex. After clinical recovery; Concussion Group did not differ in experiencing lightheaded/dizziness on postural change than controls (4%, = .65).: Adolescents commonly experience orthostatic intolerance after concussion without meeting the standard criteria for OH.
Topics: Adolescent; Blood Pressure; Brain Concussion; Dizziness; Female; Heart Rate; Humans; Hypotension, Orthostatic; Male
PubMed: 33459038
DOI: 10.1080/02699052.2021.1871951 -
European Heart Journal Jun 2022Unexplained syncope is an important clinical challenge. The influence of age at first syncope on the final syncope diagnosis is not well studied.
AIMS
Unexplained syncope is an important clinical challenge. The influence of age at first syncope on the final syncope diagnosis is not well studied.
METHODS AND RESULTS
Consecutive head-up tilt patients (n = 1928) evaluated for unexplained syncope were stratified into age groups <30, 30-59, and ≥60 years based on age at first syncope. Clinical characteristics and final syncope diagnosis were analysed in relation to age at first syncope and age at investigation. The age at first syncope had a bimodal distribution with peaks at 15 and 70 years. Prodromes (64 vs. 26%, P < 0.001) and vasovagal syncope (VVS, 59 vs. 19%, P < 0.001) were more common in early-onset (<30 years) compared with late-onset (≥60 years) syncope. Orthostatic hypotension (OH, 3 vs. 23%, P < 0.001), carotid sinus syndrome (CSS, 0.6 vs. 9%, P < 0.001), and complex syncope (>1 concurrent diagnosis; 14 vs. 26%, P < 0.001) were more common in late-onset syncope. In patients aged ≥60 years, 12% had early-onset and 70% had late-onset syncope; older age at first syncope was associated with higher odds of OH (+31% per 10-year increase, P < 0.001) and CSS (+26%, P = 0.004). Younger age at first syncope was associated with the presence of prodromes (+23%, P < 0.001) and the diagnoses of VVS (+22%, P < 0.001) and complex syncope (+9%, P = 0.018).
CONCLUSION
In patients with unexplained syncope, first-ever syncope incidence has a bimodal lifetime pattern with peaks at 15 and 70 years. The majority of older patients present only recent syncope; OH and CSS are more common in this group. In patients with early-onset syncope, prodromes, VVS, and complex syncope are more common.
Topics: Humans; Hypotension, Orthostatic; Incidence; Syncope; Syncope, Vasovagal; Tilt-Table Test
PubMed: 35139180
DOI: 10.1093/eurheartj/ehac017 -
Journal of Internal Medicine Jan 2015
Comparative Study Review
Topics: Blood Pressure; Cardiac Output; Exercise; Female; Hemodynamics; Humans; Hypotension, Orthostatic; Male; Muscle Contraction; Physical Fitness; Postural Balance; Risk Factors; Severity of Illness Index; Syncope, Vasovagal
PubMed: 24697914
DOI: 10.1111/joim.12249 -
Hypertension (Dallas, Tex. : 1979) Mar 2020Orthostatic hypotension (OH) is frequently observed with hypertension treatment, but its contribution to adverse outcomes is unknown. The SPRINT (Systolic Blood Pressure... (Comparative Study)
Comparative Study Randomized Controlled Trial
Orthostatic hypotension (OH) is frequently observed with hypertension treatment, but its contribution to adverse outcomes is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) was a randomized trial of adults, age ≥50 years at high risk for cardiovascular disease with a seated systolic blood pressure (BP) of 130 to 180 mm Hg and a standing systolic BP ≥110 mm Hg. Participants were randomized to a systolic BP treatment goal of either <120 or <140 mm Hg. OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mm Hg 1 minute after standing from a seated position. We used Cox models to examine the association of OH with cardiovascular disease or adverse study events by randomized BP goal. During the follow-up period (median 3years), there were 1170 (5.7%) instances of OH among those assigned a standard BP goal and 1057 (5.0%) among those assigned the intensive BP goal. OH was not associated with higher risk of cardiovascular disease events (primary outcome: hazard ratio 1.06 [95% CI, 0.78-1.44]). Moreover, OH was not associated with syncope, electrolyte abnormalities, injurious falls, or acute renal failure. OH was associated with hypotension-related hospitalizations or emergency department visits (hazard ratio, 1.77 [95% CI, 1.11-2.82]) and bradycardia (hazard ratio, 1.94 [95% CI, 1.19-3.15]), but these associations did not differ by BP treatment goal. OH was not associated with a higher risk of cardiovascular disease events, and BP treatment goal had no effect on OH's association with hypotension and bradycardia. Symptomless OH during hypertension treatment should not be viewed as a reason to down-titrate therapy even in the setting of a lower BP goal. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01206062.
Topics: Adult; Aged; Antihypertensive Agents; Asymptomatic Diseases; Blood Pressure; Bradycardia; Cardiovascular Diseases; Comorbidity; Female; Follow-Up Studies; Goals; Humans; Hypertension; Hypotension; Hypotension, Orthostatic; Male; Middle Aged; Proportional Hazards Models; Racial Groups; Renal Insufficiency, Chronic; Risk
PubMed: 31983312
DOI: 10.1161/HYPERTENSIONAHA.119.14309