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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 -
The American Journal of Medicine Jan 2022Orthostatic hypotension is a frequent cause of falls and syncope, impairing quality of life. It is an independent risk factor of mortality and a common cause of... (Review)
Review
Orthostatic hypotension is a frequent cause of falls and syncope, impairing quality of life. It is an independent risk factor of mortality and a common cause of hospitalizations, which exponentially increases in the geriatric population. We present a management plan based on a systematic literature review and understanding of the underlying pathophysiology and relevant clinical pharmacology. Initial treatment measures include removing offending medications and avoiding large meals. Clinical assessment of the patients' residual sympathetic tone can aid in the selection of initial therapy between norepinephrine "enhancers" or "replacers." Role of splanchnic venous pooling is overlooked, and applying abdominal binders to improve venous return may be effective. The treatment goal is not normalizing upright blood pressure but increasing it above the cerebral autoregulation threshold required to improve symptoms. Hypertension is the most common associated comorbidity, and confining patients to bed while using pressor agents only increases supine blood pressure, leading to worsening pressure diuresis and orthostatic hypotension. Avoiding bedrest deconditioning and using pressors as part of an orthostatic rehab program are crucial in reducing hospital stay.
Topics: Disease Management; Humans; Hypotension, Orthostatic; Inpatients
PubMed: 34416163
DOI: 10.1016/j.amjmed.2021.07.030 -
American Family Physician Sep 2011Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of... (Review)
Review
Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Less common symptoms include syncope, dyspnea, chest pain, and neck and shoulder pain. Causes include dehydration or blood loss; disorders of the neurologic, cardiovascular, or endocrine systems; and several classes of medications. Evaluation of suspected orthostatic hypotension begins by identifying reversible causes and underlying associated medical conditions. Head-up tilt-table testing can aid in confirming a diagnosis of suspected orthostatic hypotension when standard orthostatic vital signs are nondiagnostic; it also can aid in assessing treatment response in patients with an autonomic disorder. Goals of treatment involve improving hypotension without excessive supine hypertension, relieving orthostatic symptoms, and improving standing time. Treatment includes correcting reversible causes and discontinuing responsible medications, when possible. Nonpharmacologic treatment should be offered to all patients. For patients who do not respond adequately to nonpharmacologic treatment, fludrocortisone, midodrine, and pyridostigmine are pharmacologic therapies proven to be beneficial.
Topics: Autonomic Nervous System Diseases; Blood Pressure; Exercise Therapy; Humans; Hypotension, Orthostatic; Syncope; Vasoconstrictor Agents
PubMed: 21888303
DOI: No ID Found -
American Family Physician Sep 2011
Topics: Blood Pressure; Exercise Therapy; Humans; Hypotension, Orthostatic; Posture; Sodium, Dietary; Stockings, Compression
PubMed: 21888304
DOI: No ID Found -
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 -
Expert Review of Cardiovascular Therapy Nov 2015Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected... (Review)
Review
Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.
Topics: Humans; Hypertension; Hypotension, Orthostatic
PubMed: 26427904
DOI: 10.1586/14779072.2015.1095090 -
Lakartidningen Feb 2019Syncope is the chief complaint in 1-2 percent of emergency department visits. Syncope belongs to the broader category transient loss of consciousness (TLOC), defined as... (Review)
Review
Syncope is the chief complaint in 1-2 percent of emergency department visits. Syncope belongs to the broader category transient loss of consciousness (TLOC), defined as a short loss of consciousness with loss of awareness and responsiveness, and with subsequent amnesia for the event. Syncope is defined as TLOC due to cerebral hypoperfusion, with rapid onset and spontaneous complete recovery. The main categories of syncope are reflex syncope, orthostatic hypotension, and cardiac syncope. The 2018 guidelines by the European Society of Cardiology emphasizes the process of risk stratification in the initial management of suspected syncope. Risk stratification serves to separate the patients with likely orthostatic and reflex syncope with good prognosis from the patients with likely cardiac syncope and high short-term risk of an adverse outcome. It determines the appropriate next level of care. Further evaluation should be based on clinical suspicion and frequency of symptoms.
Topics: Cardiology; Critical Pathways; Diagnosis, Differential; Disease Management; Europe; Humans; Hypotension, Orthostatic; Practice Guidelines as Topic; Risk Assessment; Societies, Medical; Syncope; Syncope, Vasovagal
PubMed: 31192373
DOI: No ID Found -
Neurology Mar 2023Orthostatic hypotension (OH) increases dementia risk in patients with Parkinson disease (PD), although the underlying mechanisms and whether a similar association...
BACKGROUND AND OBJECTIVES
Orthostatic hypotension (OH) increases dementia risk in patients with Parkinson disease (PD), although the underlying mechanisms and whether a similar association between OH and cognitive impairment exists in other synucleinopathies remain unknown. The aim is to evaluate the association between OH and dementia risk in patients with PD, and cognitive impairment risk in patients with multiple system atrophy (MSA), and to explore relevant clinical and neuropathologic factors to understand underlying pathogenic mechanisms.
METHODS
This is a retrospective cohort study. Medical records throughout the entire disease course of consecutive patients with neuropathology-confirmed PD and MSA from the Queen Square Brain Bank were systematically reviewed. Time of onset and severity of OH-related symptoms were documented, and their association with other clinical and neuropathologic variables was evaluated. Dementia risk for patients with PD and cognitive impairment risk for patients with MSA were estimated using multivariable hazard regression.
RESULTS
One hundred thirty-two patients with PD and 137 with MSA were included. Patients with MSA developed OH more frequently, earlier in the disease course and with more severe symptoms. Cumulative dementia prevalence was higher in patients with PD. Multivariable adjusted regression models showed that early OH, but not its symptom severity, increased dementia risk in patients with PD by 14% per year (hazard ratio [HR] = 0.86; 95% CI, 0.80-0.93) and cognitive impairment risk in patients with MSA by 41% per year (HR = 0.59; 95% CI, 0.42-0.83). Early OH was not associated with increased α-synuclein, β-amyloid, tau, Alzheimer, or cerebrovascular pathologies. No significant associations were found between severity of OH symptoms and other clinical or neuropathologic variables.
DISCUSSION
Early OH, but not its symptom severity, increases the risk of cognitive impairment in patients with PD and MSA. OH is not associated with more extensive Lewy, β-amyloid, tau, Alzheimer, or cerebrovascular pathologies. It is likely that OH contributes to cognitive impairment in patients with PD and MSA by hypoxia-induced nonspecific neurodegeneration. Further research should evaluate whether improving brain perfusion by treating OH may modify the risk of dementia in these conditions.
Topics: Humans; Parkinson Disease; Multiple System Atrophy; Hypotension, Orthostatic; Alzheimer Disease; Retrospective Studies; Disease Progression
PubMed: 36526431
DOI: 10.1212/WNL.0000000000201659 -
Orphanet Journal of Rare Diseases Mar 2006Dopamine beta-hydroxylase (DbetaH) deficiency is a very rare form of primary autonomic failure characterized by a complete absence of noradrenaline and adrenaline in... (Review)
Review
Dopamine beta-hydroxylase (DbetaH) deficiency is a very rare form of primary autonomic failure characterized by a complete absence of noradrenaline and adrenaline in plasma together with increased dopamine plasma levels. The prevalence of DbetaH deficiency is unknown. Only a limited number of cases with this disease have been reported. DbetaH deficiency is mainly characterized by cardiovascular disorders and severe orthostatic hypotension. First symptoms often start during a complicated perinatal period with hypotension, muscle hypotonia, hypothermia and hypoglycemia. Children with DbetaH deficiency exhibit reduced ability to exercise because of blood pressure inadaptation with exertion and syncope. Symptoms usually worsen progressively during late adolescence and early adulthood with severe orthostatic hypotension, eyelid ptosis, nasal stuffiness and sexual disorders. Limitation in standing tolerance, limited ability to exercise and traumatic morbidity related to falls and syncope may represent later evolution. The syndrome is caused by heterogeneous molecular alterations of the DBH gene and is inherited in an autosomal recessive manner. Restoration of plasma noradrenaline to the normal range can be achieved by therapy with the synthetic precursor of noradrenaline, L-threo-dihydroxyphenylserine (DOPS). Oral administration of 100 to 500 mg DOPS, twice or three times daily, increases blood pressure and reverses the orthostatic intolerance.
Topics: Autonomic Nervous System; Deficiency Diseases; Diagnosis, Differential; Dopamine beta-Hydroxylase; Humans; Hypotension, Orthostatic; Mutation; Prognosis
PubMed: 16722595
DOI: 10.1186/1750-1172-1-7 -
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