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Mayo Clinic Proceedings Feb 1981This article reviews the physiology and pathology of orthostatic blood pressure regulation. It describes the diverse clinical disorders of postural blood pressure... (Review)
Review
This article reviews the physiology and pathology of orthostatic blood pressure regulation. It describes the diverse clinical disorders of postural blood pressure adjustment, focusing attention on idiopathic orthostatic hypotension and the Shy-Drager syndrome, with emphasis on clinical aspects, pharmacology, and pathologic anatomy. Proposals are made for the diagnostic evaluation of patients with orthostatic hypotension and for steps to be taken in therapeutic management.
Topics: Adult; Aged; Animals; Extracellular Space; Female; Humans; Hypotension, Orthostatic; Male; Middle Aged; Plasma Substitutes; Posture; Shy-Drager Syndrome; Vasoconstrictor Agents
PubMed: 7007749
DOI: No ID Found -
Journal of Cardiovascular Translational... Aug 2020Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities... (Review)
Review
Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities contributing to OH, as well as a high prevalence of medications with neurovascular and volume modulating properties. Early identification of OH in HF seems to be crucial as OH can have an impact on patient symptoms, activity level and independence, be a marker of specific pathophysiological changes or be an indicator of need for personalized treatment. OH might contribute significantly to bad enough prognosis in HF, as, besides a risk of falls and cognitive decline, it was found to be associated with cardiovascular morbidity and mortality. In this review, we aimed to incentivize the routine use of orthostatic testing in HF, as well as stimulate future research in this field, which could lead to significant advances in the treatment and outcomes.
Topics: Adult; Aged; Aged, 80 and over; Blood Pressure; Comorbidity; Female; Heart Failure; Humans; Hypotension, Orthostatic; Male; Middle Aged; Posture; Prevalence; Prognosis; Young Adult
PubMed: 32748206
DOI: 10.1007/s12265-020-10044-1 -
The American Journal of Managed Care Oct 2015Although orthostatic hypotension in elderly patients is common, neurogenic orthostatic hypotension (NOH) is a condition with substantial morbidity and a variable... (Review)
Review
Although orthostatic hypotension in elderly patients is common, neurogenic orthostatic hypotension (NOH) is a condition with substantial morbidity and a variable prognosis. Patients with severe NOH have difficulty standing for any period of time and must scrupulously avoid orthostatic stressors that exacerbate their condition. In about half of patients, supine hypertension complicates management. The diagnosis is based on measurements of supine and standing blood pressures or head-up tilt testing and is confirmed by autonomic testing. Two self-report questionnaires, the Orthostatic Hypotension Questionnaire and the Orthostatic Grading Scale, can help evaluate a patient's level of impairment, document progression, and assess the response to pharmacotherapy in clinical practice. There are many gaps in our knowledge of this rare disorder; this review summarizes what is currently known about the pathophysiology, epidemiology, prognosis, signs and symptoms, and the diagnosis of NOH.
Topics: Comorbidity; Humans; Hypertension; Hypotension, Orthostatic; Neurodegenerative Diseases; Prognosis; Quality of Life; Supine Position; Surveys and Questionnaires
PubMed: 26790109
DOI: No ID Found -
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 -
Giornale Italiano Di Cardiologia (2006) Jan 2021Orthostatic hypotension is a medical condition potentially debilitating and associated with a negative prognosis. It is paramount for cardiologists to recognize it,... (Review)
Review
Orthostatic hypotension is a medical condition potentially debilitating and associated with a negative prognosis. It is paramount for cardiologists to recognize it, mostly for the following reasons: it is a predictive factor for cardiovascular events, it may cause syncope, and it is frequently associated with supine hypertension. Orthostatic hypotension may be secondary to neurogenic etiology (baroreflex dysfunction) or non-neurogenic etiology (dehydration or medication-related). Although laboratory tests exploring the autonomic nervous system are required for a detailed etiologic diagnosis, medical history and a sphygmomanometer can be sufficient for diagnosis. Therapeutic management of orthostatic hypotension is challenging, mostly because of the association in half of the cases with supine hypertension. Treatment should be a compromise between anti-hypotensive and anti-hypertensive measures with one overcoming the other based on the hour of the day. Non-pharmacological therapies, regarded as avoidance of precipitating factors and physical and dietary interventions, as well as chronic treatment revision, have a pivotal role.In this review we will discuss, in a pragmatic manner, about epidemiology, etiology, clinical aspects and diagnosis of orthostatic hypotension. Moreover, we will discuss about prognosis and management of orthostatic hypotension and supine hypertension.
Topics: Antihypertensive Agents; Humans; Hypertension; Hypotension, Orthostatic; Prognosis; Supine Position
PubMed: 33470242
DOI: 10.1714/3502.34882 -
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 -
Age and Ageing Mar 2017orthostatic hypotension (OH) is a common disabling condition associated with increased morbidity and mortality. Much of the evidence available is derived from younger... (Review)
Review
BACKGROUND
orthostatic hypotension (OH) is a common disabling condition associated with increased morbidity and mortality. Much of the evidence available is derived from younger populations with chronic neurological disease leading to uncertainty for the diagnosis and management of older people.
OBJECTIVE
to provide an overview of recent and emerging evidence for the diagnosis, management and prognosis of OH in older persons.
METHODS
a narrative review of recent studies, emerging therapies and relevant regulatory updates.
FINDINGS
revisions to the diagnostic criteria for OH include the duration of the blood pressure drop, specific criteria for initial and delayed OH and OH with hypertension. Non-drug therapies remain the first-line treatment option and Comprehensive Geriatric Assessment appears to result in lower rates of OH. Recent evidence concerning withdrawal of causative medication is inconsistent. Midodrine has recently become the only licenced medication for OH in the UK. Other emerging treatments include atomoxetine and droxidopa but these require further evaluation. Many other agents may be used but are not supported by high-quality evidence. The increase in mortality associated with OH is less apparent in older people.
SUMMARY
OH remains common in older people, the new diagnostic criteria address some of the previous uncertainty but evidence concerning withdrawal of antihypertensives is conflicting. Midodrine is now the only licenced medication for OH in the UK, but non-drug therapies remain first line and fludrocortisone may be considered before midodrine. We may see other agents such as droxidopa becoming increasingly used over the coming years.
Topics: Age Factors; Aged; Aged, 80 and over; Antihypertensive Agents; Blood Pressure; Fludrocortisone; Geriatric Assessment; Humans; Hypotension, Orthostatic; Midodrine; Predictive Value of Tests; Risk Factors; Treatment Outcome; Vasoconstrictor Agents
PubMed: 27864240
DOI: 10.1093/ageing/afw211 -
Journal of the American Association of... Sep 2013To enhance awareness of orthostatic hypotension (OH) in older populations, and guide primary care nurse practitioners (NPs) in the assessment and management of patients... (Review)
Review
PURPOSE
To enhance awareness of orthostatic hypotension (OH) in older populations, and guide primary care nurse practitioners (NPs) in the assessment and management of patients with OH.
DATA SOURCES
Electronic data collection was conducted on studies and reviews that were published between 2005 and 2012 in English, and contained information related to the purpose of this article from following databases: PubMed, Scopus, and MEDLINE.
CONCLUSIONS
OH is a syndrome that is accompanied by unfavorable symptoms such as dizziness, and headaches and can impede the individual's daily activities and quality of life. The prevalence of OH is higher in older people because of comorbidities, polypharmacy, and physiological changes that occur with aging. OH is diagnosed with serial blood pressure measurements and the primary goal of management is to relieve unfavorable symptoms and enhance patient safety. Pharmacological management is considered when nonpharmacological interventions fail.
IMPLICATIONS FOR PRACTICE
OH is not a problem to be taken lightly as it is highly related to the risk of falling and cardiovascular problems, as well as increasing morbidity and mortality rates. NPs can contribute to improving the quality of life for older adults and reducing adverse consequences by understanding OH and adequately managing it.
Topics: Age Factors; Aged; Humans; Hypotension, Orthostatic
PubMed: 24170648
DOI: 10.1002/2327-6924.12026 -
The New England Journal of Medicine Apr 2022Orthostatic hypotension is a cardinal feature of multiple-system atrophy. The upright posture provokes syncopal episodes that prevent patients from standing and walking...
Orthostatic hypotension is a cardinal feature of multiple-system atrophy. The upright posture provokes syncopal episodes that prevent patients from standing and walking for more than brief periods. We implanted a system to restore regulation of blood pressure and enable a patient with multiple-system atrophy to stand and walk after having lost these abilities because of orthostatic hypotension. This system involved epidural electrical stimulation delivered over the thoracic spinal cord with accelerometers that detected changes in body position. (Funded by the Defitech Foundation.).
Topics: Accelerometry; Atrophy; Blood Pressure; Electric Stimulation Therapy; Electrodes, Implanted; Epidural Space; Humans; Hypotension, Orthostatic; Multiple System Atrophy; Posture; Thoracic Vertebrae
PubMed: 35388667
DOI: 10.1056/NEJMoa2112809 -
Journal of the American Medical... Apr 2014The burden of orthostatic hypotension (OH) on public health is a universally recognized enigmatic clinical condition that is associated with significant increases on... (Review)
Review
The burden of orthostatic hypotension (OH) on public health is a universally recognized enigmatic clinical condition that is associated with significant increases on morbidity and mortality rates, and can take a major toll on one's quality of life. Orthostatic hypotension is predictive of vascular deaths from acute myocardial infarction, strokes in the middle aged population, and increases mortality rates when associated with diabetes, hypertension, Parkinson's disease, and patients receiving renal dialysis. The consensus definition for OH is a fall in systolic blood pressure of at least 20 mm Hg and/or diastolic blood pressure of at least 10 mm Hg within 3 minutes of quiet standing. Because neurogenic OH is often accompanied by supine hypertension, the treatment program should aim toward minimizing OH and the potential fall injuries related to cerebral hypoperfusion without exacerbating nocturnal hypertension that may lead to excessive cardiovascular complications.
Topics: Adult; Female; Hot Temperature; Humans; Hypotension, Orthostatic; Male; Vasoconstrictor Agents
PubMed: 24388946
DOI: 10.1016/j.jamda.2013.10.014