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Alsayed Hassan DA, Chivese T, Syed MA, Alhussaini NWZ. Prevalence and factors associated with falls in older adults in a Middle Eastern population: a retrospective cross-sectional study. Public Health 2024; 233:54-59. [PMID: 38848620 DOI: 10.1016/j.puhe.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/24/2024] [Accepted: 04/05/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVE The main objective was to determine the prevalence of falls and associated factors in older adults living in Qatar. STUDY DESIGN Cross-sectional study. METHODS This is a cross-sectional study of older adults aged ≥60 years with at least one encounter with primary health care corporation (PHCC) in Qatar during the period 2017-2022. Data on documented falls, demographic variables, and medical comorbidities were extracted from all PHCCs in Qatar. Descriptive and inferential statistics were used to address the aim of the study. RESULTS A total of 68,194 older adults had at least one encounter with PHCC. The median age was 65.0 years, 58.9% were males, and 32.6% were Qatari nationality. A higher percentage of falls was found in individuals with hypertension (80%), diabetes (74.2%), and dyslipidemia (48.9%), which were also the most prevalent comorbidities. The prevalence of falls was 6.7% (95% CI 6.6-6.9). Compared to individuals aged 60-69 years, individuals aged 70-79, 80-89, and 90-99 had increased odds of falls by 1.6 (95% CI 1.5, 1.8), 2.5 (95% CI 2.2, 2.8), and 2.6 (95% CI 2.0, 3.3), respectively. Females and individuals of Qatari nationality had increased odds of fall by 1.5 (95% CI 1.4, 1.6) and 1.2 (95% CI 1.1, 1.3), respectively. Orthostatic hypotension, syncope, Parkinson's disease, and hip arthritis showed the strongest associations with falls. CONCLUSIONS Given the growing population of older adults in the Middle East and North African region, falls is a public health concern. The risk factors identified in this study suggest the need for proactive healthcare strategies tailored to the unique needs of older adult populations.
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Affiliation(s)
| | - T Chivese
- College of Medicine, Qatar University, QU Health, Doha, Qatar
| | - M A Syed
- Primary Health Care Corporation, Doha, Qatar
| | - N W Z Alhussaini
- College of Health Sciences, Qatar University, QU Health, Doha, Qatar
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Whitaker AA, Waghmare S, Montgomery RN, Aaron SE, Eickmeyer SM, Vidoni ED, Billinger SA. Lower middle cerebral artery blood velocity during low-volume high-intensity interval exercise in chronic stroke. J Cereb Blood Flow Metab 2024; 44:627-640. [PMID: 37708242 PMCID: PMC11197145 DOI: 10.1177/0271678x231201472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/16/2023]
Abstract
High-intensity interval training (HIIE) may present unique challenges to the cerebrovascular system in individuals post-stroke. We hypothesized lower middle cerebral artery blood velocity (MCAv) in individuals post-stroke: 1) during 10 minutes of HIIE, 2) immediately following HIIE, and 3) 30 minutes after HIIE, compared to age- and sex-matched controls (CON). We used a recumbent stepper submaximal exercise test to determine workloads for high-intensity and active recovery. Our low volume HIIE protocol consisted of 1-minute intervals for 10 minutes. During HIIE, we measured MCAv, mean arterial pressure (MAP), heart rate (HR), and end tidal carbon dioxide (PETCO2). We assessed carotid-femoral pulse wave velocity as a measure of arterial stiffness. Fifty participants completed the study (25 post-stroke, 76% ischemic, 32% moderate disability). Individuals post-stroke had lower MCAv during HIIE compared to CON (p = 0.03), which remained 30 minutes after HIIE. Individuals post-stroke had greater arterial stiffness (p = 0.01) which was moderately associated with a smaller MCAv responsiveness during HIIE (r = -0.44). No differences were found for MAP, HR, and PETCO2. This study suggests individuals post-stroke had a lower MCAv during HIIE compared to their peers, which remained during recovery up to 30 minutes. Arterial stiffness may contribute to the lower cerebrovascular responsiveness post-stroke.
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Affiliation(s)
- Alicen A Whitaker
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saniya Waghmare
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert N Montgomery
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Stacey E Aaron
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sarah M Eickmeyer
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, KS, USA
| | - Eric D Vidoni
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
- University of Kansas Alzheimer’s Disease Research Center, Fairway, KS, USA
| | - Sandra A Billinger
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, KS, USA
- University of Kansas Alzheimer’s Disease Research Center, Fairway, KS, USA
- Department of Cell Biology and Physiology, University of Kansas Medical Center, Kansas City, KS, USA
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Staples JA, Erdelyi S, Merchant K, Yip C, Khan M, Maclure KM, Redelmeier DA, Chan H, Brubacher JR. Syncope and Traffic Crash: A Population-Based Case-Crossover Analysis. Can J Cardiol 2024; 40:554-561. [PMID: 37290537 DOI: 10.1016/j.cjca.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/05/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Among individuals with recent syncope, recurrence of syncope while driving might incapacitate a driver and cause a motor vehicle crash. Current driving restrictions assume that some forms of syncope transiently increase crash risk. We evaluated whether syncope is associated with a transient increase in crash risk. METHODS We performed a case-crossover analysis of linked administrative health and driving data from British Columbia, Canada (2010 to 2015). We included licensed drivers who visited an emergency department with "syncope and collapse" and who were involved as a driver in an eligible motor vehicle crash, both within the study interval. Using conditional logistic regression, we compared the rate of emergency visits for syncope in the 28 days before crash (the "pre-crash interval") with the rate of emergency visits for syncope in 3 self-matched 28-day control intervals (ending 6, 12, and 18 months before the crash). RESULTS Among eligible crash-involved drivers, 47 of 3026 pre-crash intervals and 112 of 9078 control intervals had emergency visits for syncope, indicating syncope was not significantly associated with subsequent crash (1.6% vs 1.2%; adjusted odds ratio [OR], 1.27; 95% confidence interval [CI], 0.90-1.79; P = 0.18). There was no significant association between syncope and crash in subgroups at higher risk for adverse outcomes after syncope (eg, age > 65 years, cardiovascular disease, cardiac syncope). CONCLUSIONS In the context of prevailing modifications of driving behaviour after syncope, an emergency department visit for syncope did not transiently increase the risk of subsequent traffic collision. Overall crash risks after syncope appear to be adequately addressed by current driving restrictions.
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Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada.
| | - Shannon Erdelyi
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ketki Merchant
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Candace Yip
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayesha Khan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - K Malcolm Maclure
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald A Redelmeier
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Herbert Chan
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey R Brubacher
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e16-e30. [PMID: 38205630 PMCID: PMC11067441 DOI: 10.1161/hyp.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.
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Liu Z, Lin S, Zhou J, Wang X, Wang Z, Yang Y, Ma H, Chen Z, Ren K, Wu L, Zhuang H, Ling Y, Feng T. Machine-learning model for the prediction of acute orthostatic hypotension after levodopa administration. CNS Neurosci Ther 2024; 30:e14575. [PMID: 38467597 PMCID: PMC10927600 DOI: 10.1111/cns.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/11/2023] [Accepted: 12/06/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Levodopa could induce orthostatic hypotension (OH) in Parkinson's disease (PD) patients. Accurate prediction of acute OH post levodopa (AOHPL) is important for rational drug use in PD patients. Here, we develop and validate a prediction model of AOHPL to facilitate physicians in identifying patients at higher probability of developing AOHPL. METHODS The study involved 497 PD inpatients who underwent a levodopa challenge test (LCT) and the supine-to-standing test (STS) four times during LCT. Patients were divided into two groups based on whether OH occurred during levodopa effectiveness (AOHPL) or not (non-AOHPL). The dataset was randomly split into training (80%) and independent test data (20%). Several models were trained and compared for discrimination between AOHPL and non-AOHPL. Final model was evaluated on independent test data. Shapley additive explanations (SHAP) values were employed to reveal how variables explain specific predictions for given observations in the independent test data. RESULTS We included 180 PD patients without AOHPL and 194 PD patients with AOHPL to develop and validate predictive models. Random Forest was selected as our final model as its leave-one-out cross validation performance [AUC_ROC 0.776, accuracy 73.6%, sensitivity 71.6%, specificity 75.7%] outperformed other models. The most crucial features in this predictive model were the maximal SBP drop and DBP drop of STS before medication (ΔSBP/ΔDBP). We achieved a prediction accuracy of 72% on independent test data. ΔSBP, ΔDBP, and standing mean artery pressure were the top three variables that contributed most to the predictions across all individual observations in the independent test data. CONCLUSIONS The validated classifier could serve as a valuable tool for clinicians, offering the probability of a patient developing AOHPL at an early stage. This supports clinical decision-making, potentially enhancing the quality of life for PD patients.
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Affiliation(s)
- Zhu Liu
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Shinuan Lin
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeRoslindaleMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Xuemei Wang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zhan Wang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Yaqin Yang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Huizi Ma
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zhonglue Chen
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Kang Ren
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Lingyu Wu
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Haimei Zhuang
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Yun Ling
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Tao Feng
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
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Ögren J, Mooe T, Irewall AL. Orthostatic hypotension in stroke/TIA patients: Association with new events and the effect of the NAILED intervention. PLoS One 2024; 19:e0298435. [PMID: 38394187 PMCID: PMC10889642 DOI: 10.1371/journal.pone.0298435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Fear of orthostatic hypotension (OH) and a reported association with an increased risk of cardiovascular (CV) events may limit antihypertensive treatment after stroke/TIA. In the NAILED trial, systematic titration of antihypertensive treatment resulted in lower blood pressure (BP) and reduced the incidence of stroke. Our aim was to assess the association between OH and CV events or death in a stroke/TIA population and the association between group allocation in the NAILED trial and risk of OH during follow-up. METHODS AND FINDINGS This post-hoc analysis included all patients with complete BP measurement at baseline in the NAILED trial (n = 814). OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mmHg 1 minute after standing from a seated position. The association between OH and a composite of stroke, myocardial infarction, or death was assessed using an adjusted Cox regression model with OH as a time-varying variable. The association between group allocation (intervention vs. control) and OH was assessed using logistic regression. During a mean follow-up of 4.8 years, 35.3% of patients had OH at some point. OH was not significantly associated with the composite outcome (HR: 1.11, 95% CI: 0.80-1.54). Allocation to the intervention group in the NAILED trial was not associated with OH during follow-up (OR: 0.84, 95% CI: 0.62-1.13). CONCLUSIONS OH was not associated with an increased risk of CV events or death in this stroke/TIA population. Systematic titration of antihypertensive treatment did not increase the prevalence of OH compared to usual care. Thus, OH did not reduce the gains of antihypertensive treatment.
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Affiliation(s)
- Joachim Ögren
- Department of Public Health and Clinical Medicine, Umeå University, Östersund, Sweden
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine, Umeå University, Östersund, Sweden
| | - Anna-Lotta Irewall
- Department of Public Health and Clinical Medicine, Umeå University, Östersund, Sweden
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O'Halloran AM, Cremers J, Vrangbæk K, Roe L, Bourke R, Mortensen LH, Westendorp RGJ, Kenny RA. Cardiovascular disease and the risk of incident falls and mortality among adults aged ≥ 65 years presenting to the emergency department: a cohort study from national registry data in Denmark. BMC Geriatr 2024; 24:93. [PMID: 38267873 PMCID: PMC10809657 DOI: 10.1186/s12877-023-04618-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Falls cause 58% of injury-related Emergency Department (ED) attendances. Previous research has highlighted the potential role of cardiovascular risk factors for falls. This study investigated the impact of cardiovascular disease (CVD) risk on three-year incident falls, with presentation to the ED, and mortality. METHODS A matched cohort study design was employed using national registry data from 82,292 adults (33% male) aged ≥ 65 years living in Denmark who attended the ED in 2013. We compared age and gender matched ED attendees presenting with a fall versus another reason. The cohort was followed for three-year incident falls, with presentation to the ED, and mortality. The impact of falls-related CVDs was also examined. RESULTS Three-year incident falls was twofold higher among age and gender matched ED attendees aged ≥ 65 years presenting with a fall versus another reason at baseline. A presentation of falls with hip fracture had the highest percentage of incident falls in the 65-74 age group (22%) and the highest percentage mortality in all age groups (27-62%). CVD was not a significant factor in presenting with a fall at the ED, nor did it contribute significantly to the prediction of three-year incident falls. CVD was strongly associated with mortality risk among the ED fall group (RR = 1.81, 95% CI: 1.67-1.97) and showed interactions with both age and fall history. CONCLUSION In this large study of adults aged ≥ 65 years attending the ED utilising data from national administrative registers in Denmark, we confirm that older adults attending the ED with a fall, including those with hip fracture, were at greatest risk for future falls. While CVD did not predict incident falls, it increased the risk of mortality in the three-year follow up with advancing age. This may be informative for the provision of care pathways for older adults attending the ED due to a fall.
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Affiliation(s)
- Aisling M O'Halloran
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland.
| | - Jolien Cremers
- Data Science Lab, Statistics Denmark, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Karsten Vrangbæk
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
- Centre for Health Economics and Policy, University of Copenhagen, Copenhagen, Denmark
- Department of Political Science, University of Copenhagen, Copenhagen, Denmark
| | - Lorna Roe
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland
- Global Brain Health Institute (GBHI), Trinity College Dublin, Dublin, Ireland
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Robert Bourke
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
| | - Laust H Mortensen
- Data Science Lab, Statistics Denmark, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Rudi G J Westendorp
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Rose Anne Kenny
- Medical Gerontology, School of Medicine, Trinity College Dublin, Trinity Central, 152-160 Pearse Street, Dublin, Ireland
- Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin, Ireland
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Ma Y, Zhang Y, Coresh J, Viswanathan A, Sullivan KJ, Walker KA, Liu C, Lipsitz LA, Selvin E, Sharrett AR, Gottesman RF, Blacker D, Hofman A, Windham BG, Juraschek SP. Orthostatic Blood Pressure Change, Dizziness, and Risk of Dementia in the ARIC Study. Hypertension 2024; 81:96-106. [PMID: 37869909 PMCID: PMC10843561 DOI: 10.1161/hypertensionaha.123.21438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/14/2023] [Indexed: 10/24/2023]
Abstract
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.
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Affiliation(s)
- Yuan Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Yiwen Zhang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Josef Coresh
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, USA
| | - Kevin J. Sullivan
- Memory Impairment and Neurogenerative Dementia Center, University of Mississippi Medical Center, Jackson, MS USA
| | - Keenan A. Walker
- Intramural Research Program of the National Institute on Aging, NIH, Baltimore, Maryland, USA
| | - Chelsea Liu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Lewis A. Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, and Hebrew Senior Life Hinda and Arthur Marcus Institute for Aging Research, Boston, USA
| | - Elizabeth Selvin
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A. Richey Sharrett
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca F. Gottesman
- National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland, USA
| | - Deborah Blacker
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Albert Hofman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - B. Gwen Windham
- Memory Impairment and Neurogenerative Dementia Center, University of Mississippi Medical Center, Jackson, MS USA
| | - Stephen P Juraschek
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Strumia M, Vidal JS, Cestac P, Sallerin B, Hanon O, Rouch L. Orthostatic hypotension and orthostatic hypertension are both associated with lower cognitive function: The S.AGES cohort. J Am Geriatr Soc 2023; 71:3721-3730. [PMID: 37655948 DOI: 10.1111/jgs.18571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/22/2023] [Accepted: 07/02/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Blood pressure (BP) postural changes, both orthostatic hypotension (OHYPO) and orthostatic hypertension (OHYPER) are common in older adults. Few studies have investigated their association with cognition, particularly for OHYPER, an emerging cardiovascular risk factor. We aimed to assess the association between OHYPO, OHYPER and cognition in non-institutionalized older subjects. METHODS The S.AGES (Sujets ÂGES, Aged Subjects) cohort followed every 6 months for 3 years non-institutionalized subjects aged ≥65 years without dementia at inclusion, in France. OHYPO and OHYPER were respectively defined as a fall or an increase of ≥20 mmHg in systolic BP and/or ≥10 mmHg in diastolic BP after standing from a sitting position. Cognition was assessed using the Mini-Mental State Examination (MMSE). Linear mixed models were used for the analyses. RESULTS Among the 3170 subjects included (mean age 78 years, 56% women), 209 (6.5%) had OHYPO and 226 (7.1%) had OHYPER at baseline. After adjustment for demographics, cardiovascular risk factors and disease, seated SBP/DBP and BP lowering treatment, mean MMSE was 0.52 point lower in participants with OHYPER compared to those with normal BP postural changes (β adjusted [95% CI] = -0.52 [-0.96; -0.09], p = 0.02) and 0.50 point lower in participants with OHYPO compared to those with normal BP postural changes (β adjusted [95% CI] = -0.50 [-0.95; -0.06], p = 0.03). Sensitivity analyses showed a dose-response relationship between OHYPO and cognition. CONCLUSION Although the absolute differences in MMSE were small, both OHYPO and OHYPER were associated with lower cognition. Orthostatic BP measurements could help identify patients with risk of cognitive impairment. Further studies are needed to assess whether controlling orthostatic BP could be a promising interventional target in preserving cognition among older adults.
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Affiliation(s)
- M Strumia
- Maintain Aging Research Team, CERPOP, Université de Toulouse, Inserm, Université Paul Sabatier, Toulouse, France
- Département de pharmacie Clinique, pôle gériatrie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - J S Vidal
- EA 4468, Université de Paris, Paris, France
- Service de gériatrie, Hôpital Broca, AP-HP, Hôpitaux Universitaires Paris Centre, Paris, France
| | - P Cestac
- Maintain Aging Research Team, CERPOP, Université de Toulouse, Inserm, Université Paul Sabatier, Toulouse, France
- Département de pharmacie Clinique, pôle gériatrie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - B Sallerin
- Département de pharmacie Clinique, pôle gériatrie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- RESTORE UMR 1301, Inserm 5070, CNRS EFS, équipe FLAMES, Université Paul Sabatier, Toulouse, France
| | - O Hanon
- EA 4468, Université de Paris, Paris, France
- Service de gériatrie, Hôpital Broca, AP-HP, Hôpitaux Universitaires Paris Centre, Paris, France
| | - L Rouch
- Maintain Aging Research Team, CERPOP, Université de Toulouse, Inserm, Université Paul Sabatier, Toulouse, France
- Département de pharmacie Clinique, pôle gériatrie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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Petriceks AH, Appel LJ, Miller ER, Mitchell CM, Schrack JA, Mukamal KJ, Lipsitz LA, Wanigatunga AA, Plante TB, Michos ED, Juraschek SP. Timing of orthostatic hypotension and its relationship with falls in older adults. J Am Geriatr Soc 2023; 71:3711-3720. [PMID: 37668347 PMCID: PMC10842425 DOI: 10.1111/jgs.18573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND There is inconsistent evidence on the optimal time after standing to assess for orthostatic hypotension. We determined the prevalence of orthostatic hypotension at different time points after standing in a population of older adults, as well as fall risk and symptoms associated with orthostatic hypotension. METHODS We performed a secondary analysis of the Study to Understand Fall Reduction and Vitamin D in You (STURDY), a randomized clinical trial funded by the National Institute on Aging, testing the effect of differing vitamin D3 doses on fall risk in older adults. STURDY occurred between July 2015 and May 2019. Secondary analysis occurred in 2022. Participants were community-dwelling adults, 70 years or older. In the orthostatic hypotension assessment, participants stood upright from supine position and underwent six standing blood pressure measurements (M1-M6) in two clusters of three measurements (immediately and 3 min after standing). Cox proportional hazard models were used to examine the relationship between orthostatic hypotension at each measurement and subsequent falls. Participants were followed until the earlier of their 24-month visit or study completion. RESULTS Orthostatic hypotension occurred in 32% of assessments at M1, and only 16% at M5 and M6. Orthostatic hypotension from average immediate (M1-3) and average delayed (M4-6) measurements, respectively, predicted higher fall risk (M1-3 = 1.65 [1.08, 2.52]; M4-6 = 1.73 [1.03, 2.91]) (hazard ratio [95% confidence interval]). However, among individual measurements, only orthostatic hypotension at M5 (1.84 [1.16, 2.93]) and M6 (1.85 [1.17, 2.91]) predicted higher fall risk. Participants with orthostatic hypotension at M1 (3.07 [1.48, 6.38]) and M2 (3.72 [1.72, 8.03]) were more likely to have reported orthostatic symptoms. CONCLUSIONS Orthostatic hypotension was most prevalent and symptomatic immediately within 1-2 min after standing, but more informative for fall risk after 4.5 min. Clinicians may consider both intervals when assessing for orthostatic hypotension.
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Affiliation(s)
- Aldis H. Petriceks
- Harvard Medical School, Boston, Massachusetts, USA
- Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lawrence J. Appel
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Edgar R. Miller
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine M. Mitchell
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer A. Schrack
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kenneth J. Mukamal
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lewis A. Lipsitz
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Amal A. Wanigatunga
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Timothy B. Plante
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
- Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Erin D. Michos
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen P. Juraschek
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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11
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Earle WB, Kondo JK, Kendrick KN, Turkson-Ocran RA, Ngo L, Cluett JL, Mukamal KJ, Daya Malek N, Selvin E, Lutsey PL, Coresh J, Juraschek SP. Association of Supine Hypertension Versus Standing Hypotension With Adverse Events Among Middle-Aged Adults. Hypertension 2023; 80:2437-2446. [PMID: 37646155 PMCID: PMC10640713 DOI: 10.1161/hypertensionaha.123.21215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023]
Abstract
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 (P-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.
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Affiliation(s)
- William B Earle
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Jordan K Kondo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Karla N Kendrick
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Ruth-Alma Turkson-Ocran
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Jennifer L Cluett
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Natalie Daya Malek
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (P.L.L.)
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
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12
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Kondo JK, Earle WB, Turkson-Ocran RAN, Ngo LH, Cluett JL, Lipsitz LA, Daya NR, Selvin E, Lutsey PL, Coresh J, Windham BG, Kendrick KN, Juraschek SP. Standing Blood Pressure and Risk of Falls, Syncope, Coronary Heart Disease, and Mortality. Am J Hypertens 2023; 36:593-601. [PMID: 37458702 PMCID: PMC11003466 DOI: 10.1093/ajh/hpad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/05/2023] [Accepted: 07/13/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND ACC/AHA guidelines caution against the use of antihypertensive therapy in the setting of low standing systolic BP (SBP) < 110 mm Hg due to unclear benefits. METHODS The Atherosclerosis Risk in Communities (ARIC) Study measured supine and standing SBP in adults aged 45-64 years between 1987 and 1989. We used Cox regression to evaluate the associations of low standing SBP (<110 mm Hg) with risk of falls, syncope, coronary heart disease (CHD), and mortality through December 31, 2019. Falls and syncope were ascertained by hospitalization and outpatient claims; CHD events were adjudicated. Associations were examined overall and in strata of hypertension stage, 10-year atherosclerotic cardiovascular disease (ASCVD) risk, age, and sex. RESULTS Among 12,467 adults followed a median of 24 years (mean age at enrollment 54.1 ± 5.8 years, 55% women, 26% Black adults), 3,000 (24%) had a standing SBP < 110 mm Hg. A standing SBP < 110 mm Hg compared to standing SBP ≥ 110 mm Hg was not significantly associated with falls or syncope, and was associated with a lower risk of CHD events and mortality with HRs of 1.02 (95% CI 0.94, 1.11), 1.02 (0.93, 1.11), 0.88 (0.80, 0.97), and 0.91 (0.86, 0.97), respectively. There were no clinically meaningful differences when stratified by hypertension stage, 10-year ASCVD risk, age, and sex. CONCLUSIONS In this community-based population, low standing SBP was common and not significantly associated with falls or syncope, but was associated with a lower risk of CHD and mortality. These findings do not support screening for low standing BP as a risk factor for adverse events.
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Affiliation(s)
| | - William B Earle
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ruth-Alma N Turkson-Ocran
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Long H Ngo
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jennifer L Cluett
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Lewis A Lipsitz
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Natalie R Daya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Beverly Gwen Windham
- Department of Medicine, Division of Geriatric Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Karla N Kendrick
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Winchester Hospital, Beth Israel Lahey Health, Woburn, MA, USA
| | - Stephen P Juraschek
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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13
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Liu Z, Su D, Zhou J, Wang X, Wang Z, Yang Y, Ma H, Feng T. Acute effect of levodopa on orthostatic hypotension and its association with motor responsiveness in Parkinson's disease: Results of acute levodopa challenge test. Parkinsonism Relat Disord 2023; 115:105860. [PMID: 37742502 DOI: 10.1016/j.parkreldis.2023.105860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Levodopa administration can induce or worsen orthostatic hypotension (OH) in patients with Parkinson's disease (PD). Understanding of acute OH post levodopa (AOHPL) is important for rational drug use in PD patients. Primary objective of this study was to investigate the incidence of AOHPL in PD patients. The secondary objectives were a) hemodynamic character of AOHPL; b) risk factors of AOHPL; c) relationship between motor responsiveness and blood pressure (BP) change. METHODS 490 PD inpatients underwent acute levodopa challenge test (LCT). Supine-to-standing test (STS) was done 4 times during LCT, including before levodopa and every hour post levodopa intake within 3 h. Patients were classified into two groups, AOHPL and non-AOHPL. A comprehensive set of clinical features scales was assessed, including both motor (e.g., motor response, wearing-off) and nonmotor symptoms (e.g., autonomic dysfunction, neuropsychology). RESULTS 33.1% PD patients had OH before drug, 50.8% the same subjects had AOHPL during levodopa effectiveness. PD patients who had better response to levodopa likely to have lower standing mean artery pressure (MAP) and severer systolic BP drop after levodopa intake. BP increased when the motor performance worsened and vice versa. Beneficial response was a risk factors of AOHPL (OR = 1.624, P = 0.017). CONCLUSIONS AOHPL was very common in PD patients. We suggested that PD patients with risk factors should monitor hemodynamic change during LCT to avoid AOHPL following the introduction or increase of oral levodopa. The fluctuations of BP were complicated and multifactorial, likely caused by the process of PD and levodopa both.
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Affiliation(s)
- Zhu Liu
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dongning Su
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Xuemei Wang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhan Wang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yaqin Yang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huizi Ma
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Tao Feng
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
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14
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Fernando CV, Osborn S, Horne M. At-Home Blood Pressure Measurements Provide Better Assessments of Orthostatic Hypotension in Parkinson's Disease. J Pers Med 2023; 13:1324. [PMID: 37763091 PMCID: PMC10532916 DOI: 10.3390/jpm13091324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/29/2023] Open
Abstract
Orthostatic hypotension (OH) is common in Parkinson's Disease (PD). It is intermittent, exacerbated by stressors including meals, medications, and dehydration, and frequently is unrecognized. Although intermittent, assessment is usually by a single "in clinic" BP measurement. This study examines whether 10 home measurements are more sensitive in detecting OH than a single "in clinic" measurement. Participants (44 people with PD and 16 controls) were instructed to measure lying and standing BP at home. BP was measured on five consecutive days upon waking and before bedtime. Symptoms were also assessed using the Movement Disorder Society United Parkinson's Disease Rating Scale and the Non-Motor Questionnaire. While a postural drop in systolic BP (≥20 mmHg) was recorded "in clinic" in thirteen of the forty-four PD participants, a postural drop was found in at least one of the ten home measurements in twenty-eight of the forty-four participants. Morning hypertension and variability in lying systolic BP was more common in these subjects than in those without a postural drop or the controls. A greater number of measurements of lying and standing BP are more likely to reveal orthostatic hypotension, variation in systolic BP, and hypertension than a single office measurement in people with PD.
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Affiliation(s)
| | - Sarah Osborn
- The Bionics Institute, East Melbourne, VIC 3002, Australia;
| | - Malcolm Horne
- The Bionics Institute, East Melbourne, VIC 3002, Australia;
- Department of Medicine, University of Melbourne, St Vincent’s Hospital, Fitzroy, VIC 3065, Australia
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15
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Yu Y, Wang Y, Hou X, Tian F. Recent advances in the identification of related factors and preventive strategies of hip fracture. Front Public Health 2023; 11:1006527. [PMID: 36992874 PMCID: PMC10040558 DOI: 10.3389/fpubh.2023.1006527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
Hip fracture is the most devastating type of osteoporosis-related fracture, and is a major worldwide public health problem with a high socioeconomic burden, morbidity rate, and mortality rate. Thus, it is crucial to uncover the risk factors and protective factors to create a hip fracture prevention strategy. In addition to a briefly review of some well accepted risk and protective factors of hip fracture, this review mainly summarized the recent advances in the identification of emerging risk or protective factors for hip fracture, in terms of regional differences in medical services, diseases, drugs, mechanical load, neuromuscular mass, genes, blood types, cultural differences. This review provides a comprehensive review of the associated factors and effective prevention measures for hip fracture, and discusses issues that need further investigation. These issues include the determination of the influencing mechanism of risk factors triggering hip fracture and their interlinked correlation with other factors, as well as the confirmation or correction of emerging factors associated with hip fracture, particularly those that are still controversial. These recent findings will aid in optimizing the strategy for preventing hip fracture.
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16
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Raber I, Belanger MJ, Farahmand R, Aggarwal R, Chiu N, Al Rifai M, Jacobsen AP, Lipsitz LA, Juraschek SP. Orthostatic Hypotension in Hypertensive Adults: Harry Goldblatt Award for Early Career Investigators 2021. Hypertension 2022; 79:2388-2396. [PMID: 35924561 PMCID: PMC9669124 DOI: 10.1161/hypertensionaha.122.18557] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Inbar Raber
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Matthew J Belanger
- Northeast Medical Group, Yale New Haven Hospital, New Haven, Connecticut
| | - Rosemary Farahmand
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Rahul Aggarwal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nicholas Chiu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Alan P. Jacobsen
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Lewis A. Lipsitz
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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17
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WHEN AND HOW TO USE ORTHOSTATIC VITAL SIGNS. J Emerg Med 2022; 63:460-466. [DOI: 10.1016/j.jemermed.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/11/2022] [Accepted: 09/05/2022] [Indexed: 11/12/2022]
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18
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Schell K, Lyons DL. Staff knowledge of orthostatic vital signs measurement. Nursing 2022; 52:55-61. [PMID: 35866863 DOI: 10.1097/01.nurse.0000839824.99290.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE To determine the nursing staff's knowledge of the proper procedure for measuring orthostatic vital signs. METHODS The Knowledge of Orthostatic Vital Signs Survey was sent via email to direct staff on 31 patient-care units in a large hospital system. RESULTS Eighty percent of the participants were RNs and 12% were unlicensed assistants. Survey results showed that many respondents did not know how to properly size the cuff and were uncertain about the timing of measurements with position changes. Fifty-seven percent of respondents did not correctly identify abnormal findings with regard to the systolic BP, but 80% were aware of the diastolic BP drop in orthostatic hypotension. CONCLUSION This survey identified gaps in the staff's knowledge about the proper procedure for measuring orthostatic vital signs.
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Affiliation(s)
- Kathleen Schell
- Kathleen Schell is an associate professor at the University of Delaware's School of Nursing. Denise Lyons is a gerontology and adult clinical nurse specialist and a WISH/NICHE program manager at ChristianaCare
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19
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Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol 2022; 21:735-746. [PMID: 35841911 PMCID: PMC10024337 DOI: 10.1016/s1474-4422(22)00169-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/24/2023]
Abstract
Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.
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Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; UCL Queen Square Institute of Neurology, University College London, London, UK; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
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Van den Eynde V, Abdelmoemin WR, Abraham MM, Amsterdam JD, Anderson IM, Andrade C, Baker GB, Beekman ATF, Berk M, Birkenhäger TK, Blackwell BB, Blier P, Blom MBJ, Bodkin AJ, Cattaneo CI, Dantz B, Davidson J, Dunlop BW, Estévez RF, Feinberg SS, Finberg JPM, Fochtmann LJ, Gotlib D, Holt A, Insel TR, Larsen JK, Mago R, Menkes DB, Meyer JM, Nutt DJ, Parker G, Rego MD, Richelson E, Ruhé HG, Sáiz-Ruiz J, Stahl SM, Steele T, Thase ME, Ulrich S, van Balkom AJLM, Vieta E, Whyte I, Young AH, Gillman PK. The prescriber's guide to classic MAO inhibitors (phenelzine, tranylcypromine, isocarboxazid) for treatment-resistant depression. CNS Spectr 2022; 28:1-14. [PMID: 35837681 DOI: 10.1017/s1092852922000906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This article is a clinical guide which discusses the "state-of-the-art" usage of the classic monoamine oxidase inhibitor (MAOI) antidepressants (phenelzine, tranylcypromine, and isocarboxazid) in modern psychiatric practice. The guide is for all clinicians, including those who may not be experienced MAOI prescribers. It discusses indications, drug-drug interactions, side-effect management, and the safety of various augmentation strategies. There is a clear and broad consensus (more than 70 international expert endorsers), based on 6 decades of experience, for the recommendations herein exposited. They are based on empirical evidence and expert opinion-this guide is presented as a new specialist-consensus standard. The guide provides practical clinical advice, and is the basis for the rational use of these drugs, particularly because it improves and updates knowledge, and corrects the various misconceptions that have hitherto been prominent in the literature, partly due to insufficient knowledge of pharmacology. The guide suggests that MAOIs should always be considered in cases of treatment-resistant depression (including those melancholic in nature), and prior to electroconvulsive therapy-while taking into account of patient preference. In selected cases, they may be considered earlier in the treatment algorithm than has previously been customary, and should not be regarded as drugs of last resort; they may prove decisively effective when many other treatments have failed. The guide clarifies key points on the concomitant use of incorrectly proscribed drugs such as methylphenidate and some tricyclic antidepressants. It also illustrates the straightforward "bridging" methods that may be used to transition simply and safely from other antidepressants to MAOIs.
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Affiliation(s)
| | | | | | - Jay D Amsterdam
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian M Anderson
- Department of Psychiatry, University of Manchester, Manchester, UK
| | - Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Glen B Baker
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Aartjan T F Beekman
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Michael Berk
- Institute for Mental and Physical Health and Clinical Translation, Deakin University, Geelong, VIC, Australia
| | - Tom K Birkenhäger
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Barry B Blackwell
- Department of Psychiatry, University of Wisconsin, Milwaukee, WI, USA
| | - Pierre Blier
- Departments of Psychiatry and Cellular & Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | | | - Bezalel Dantz
- Department of Psychiatry and Behavioral Sciences, Rush Medical College, Chicago, IL, USA
| | - Jonathan Davidson
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Ryan F Estévez
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Shalom S Feinberg
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York, NY, USA
| | - John P M Finberg
- Department of Molecular Pharmacology, Technion-Israel Institute of Technology, Haifa, Israel
| | - Laura J Fochtmann
- Department of Psychiatry, Department of Pharmacological Sciences, and Biomedical Informatics, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | | | - Andrew Holt
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Thomas R Insel
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jens K Larsen
- Department of Affective Disorders, Aarhus University Hospital, Aarhus, Denmark
| | - Rajnish Mago
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David B Menkes
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jonathan M Meyer
- Department of Psychiatry, UC San Diego School of Medicine, San Diego, CA, USA
| | - David J Nutt
- Department of Brain Sciences, Imperial College, London, UK
| | - Gordon Parker
- Discipline of Psychiatry and Mental Health, University of New South Wales, Sydney, NSW, Australia
| | - Mark D Rego
- Yale Institute for Global Health, Yale School of Medicine, New Haven, CT, USA
| | - Elliott Richelson
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA
| | - Henricus G Ruhé
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Stephen M Stahl
- Department of Psychiatry and Neuroscience, University of California, Riverside, Riverside, CA, USA
| | - Thomas Steele
- Department of Psychiatry and Behavioral Sciences, University of South Carolina, Columbia, SC, USA
| | - Michael E Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anton J L M van Balkom
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Eduard Vieta
- Department of Psychiatry and Psychology, University of Barcelona Hospital Clinic, Barcelona, Spain
| | - Ian Whyte
- Department of Clinical Toxicology and Pharmacology, University of Newcastle, Callaghan, NSW, Australia
| | - Allan H Young
- Department of Psychological Medicine, King's College London, London, UK
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21
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Adverse Effects of Angiotensin-Converting Enzyme Inhibitors in Humans: A Systematic Review and Meta-Analysis of 378 Randomized Controlled Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148373. [PMID: 35886227 PMCID: PMC9324875 DOI: 10.3390/ijerph19148373] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 11/29/2022]
Abstract
Background: Although angiotensin-converting enzyme (ACE) inhibitors are among the most-prescribed medications in the world, the extent to which they increase the risk of adverse effects remains uncertain. This study aimed to systematically determine the adverse effects of ACE inhibitors versus placebo across a wide range of therapeutic settings. Methods: Systematic searches were conducted on PubMed, Web of Science, and Cochrane Library databases. Randomized controlled trials (RCTs) comparing an ACE inhibitor to a placebo were retrieved. The relative risk (RR) and its 95% confidence interval (95% CI) were utilized as a summary effect measure. A random-effects model was used to calculate pooled-effect estimates. Results: A total of 378 RCTs fulfilled the eligibility criteria, with 257 RCTs included in the meta-analysis. Compared with a placebo, ACE inhibitors were associated with an significantly increased risk of dry cough (RR = 2.66, 95% CI = 2.20 to 3.20, p < 0.001), hypotension (RR = 1.98, 95% CI = 1.66 to 2.35, p < 0.001), dizziness (RR = 1.46, 95% CI = 1.26 to 1.70, p < 0.001), and hyperkalemia (RR = 1.24, 95% CI = 1.01 to 1.52, p = 0.037). The risk difference was quantified to be 0.037, 0.030, 0.017, and 0.009, respectively. Conclusions: We quantified the relative risk of numerous adverse events associated with the use of ACE inhibitors in a variety of demographics. This information can help healthcare providers be fully informed about any potential adverse consequences and make appropriate suggestions for their patients requiring ACE inhibitor therapy.
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22
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Juraschek SP, Appel LJ, M Mitchell C, Mukamal KJ, Lipsitz LA, Blackford AL, Cai Y, Guralnik JM, Kalyani RR, Michos ED, Schrack JA, Wanigatunga AA, Miller ER. Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms. J Am Geriatr Soc 2022; 70:2310-2319. [PMID: 35451096 PMCID: PMC9378443 DOI: 10.1111/jgs.17804] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/07/2022] [Accepted: 03/16/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) based on a change from seated-to-standing blood pressure (BP) is often used interchangeably with supine-to-standing BP. METHODS The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial of vitamin D3 supplementation and fall in adults aged ≥70 years at high risk of falls. OH was defined as a drop in systolic or diastolic BP of at least 20 or 10 mmHg, measured at pre-randomization, 3-, 12-, and 24-month visits with each of 2 protocols: seated-to-standing and supine-to-standing. Participants were asked about orthostatic symptoms, and falls were ascertained via daily fall calendar, ad hoc reporting, and scheduled interviews. RESULTS Among 534 participants with 993 paired supine and seated assessments (mean age 76 ± 5 years, 42% women, 18% Black), mean baseline BP was 130 ± 19/68 ± 11 mmHg; 62% had a history of high BP or hypertension. Mean BP increased 3.5 (SE, 0.4)/2.6 (SE, 0.2) mmHg from sitting to standing, but decreased with supine to standing (mean change: -3.7 [SE, 0.5]/-0.8 [SE, 0.3] mmHg; P-value < 0.001). OH was detected in 2.1% (SE, 0.5) of seated versus 15.0% (SE, 1.4) of supine assessments (P < 0.001). While supine and seated OH were not associated with falls (HR: 1.55 [0.95, 2.52] vs 0.69 [0.30, 1.58]), supine systolic OH was associated with higher fall risk (HR: 1.77 [1.02, 3.05]). Supine OH was associated with self-reported fainting, blacking out, seeing spots and room spinning in the prior month (P-values < 0.03), while sitting OH was not associated with any symptoms (P-values ≥ 0.40). CONCLUSION Supine OH was more frequent, associated with orthostatic symptoms, and potentially more predictive of falls than seated OH.
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence J Appel
- Divison of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,The Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine M Mitchell
- Divison of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,The Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Amanda L Blackford
- Divison of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,The Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Yurun Cai
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rita R Kalyani
- The Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland, USA.,Division of Endocrinology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erin D Michos
- The Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer A Schrack
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,The Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Amal A Wanigatunga
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edgar R Miller
- Divison of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,The Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland, USA
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23
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Contreras-Merino AM, Davydov DM, Galvez-Sánchez CM, Reyes del Paso GA. Blunted short-term autonomic cardiovascular reactivity to orthostatic and clinostatic challenges in fibromyalgia as an indicator of the severity of chronic pain. Int J Psychophysiol 2022; 175:61-70. [DOI: 10.1016/j.ijpsycho.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
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24
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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25
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Ong CEC, Yong H, Qiu H, Velu K, Choa PH. Preparing for the silver boom: A falls prevention tool for older adults in the emergency department. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:109-112. [PMID: 35224607 DOI: 10.47102/annals-acadmedsg.2021173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Geriatric falls presenting to the emergency department (ED) are rising due to our rapidly ageing population. As part of a group of geriatric-focused emergency medicine practitioners, we describe a multidisciplinary falls prevention tool using the acronym.
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26
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Haider MN, Cunningham A, Darling S, Suffoletto HN, Freitas MS, Jain RK, Willer B, Leddy JJ. Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms. Br J Sports Med 2021; 55:1427-1433. [PMID: 34510003 DOI: 10.1136/bjsports-2020-103690] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The Buffalo Concussion Physical Examination (BCPE) is a brief, but pertinent physical examination designed for the subacute, outpatient assessment of concussion. The purpose of this study was to perform the BCPE on a larger sample and derive a scoring system to identify children at risk for Persistent Post-Concussive Symptoms (PPCS, recovery ≥30 days). METHODS This prospective, observational cohort study from September 2016 to March 2019 was performed at three university-affiliated concussion clinics. Male and female children (n=270, 14.92±1.86 years, range 8-18, 38% female) were diagnosed with a concussion within 14 days of injury and followed-up until recovery. Logistic regression was used with history and physical examination variables to predict PPCS and a weighted scoring metric was derived. RESULTS Out of 15 predictor variables, the main effects of 1 preinjury variable (≥3 previous concussions), 2 injury characteristic variables (days-since-injury and type-of-injury), 3 physical examination variables (orthostatic intolerance (OI), vestibulo-ocular reflex (VOR) and tandem gait) and 2 interaction terms (OI/VOR and tandem gait/type-of-injury) produced a score that was 85% accurate for identifying children with low-risk, medium-risk and high-risk for PPCS on cross-validation. CONCLUSION The Risk for Delayed Recovery (RDR)-Score allows physicians in an outpatient setting to more accurately predict which children are at greater risk for PPCS early after their injury, and who would benefit most from targeted therapies. The RDR-Score is intended to be used as part of a comprehensive assessment that should include validated symptom checklists, mental health history and adjunct testing (eg, cognitive or physical exertion) where clinically indicated.
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Affiliation(s)
- Mohammad Nadir Haider
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Adam Cunningham
- Biostatistics, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Scott Darling
- Family Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Invision Health, Amherst, New York, USA
| | - Heidi N Suffoletto
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Emergency Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Michael S Freitas
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Family Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Rajiv K Jain
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Barry Willer
- Psychiatry, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - John J Leddy
- Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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27
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Christopoulos EM, Reijnierse EM, Lange PW, Meskers CGM, Maier AB. Orthostatic Hypotension and Orthostatic Intolerance Symptoms in Geriatric Rehabilitation Inpatients, RESORT. J Am Med Dir Assoc 2021; 22:2468-2477.e2. [PMID: 34478695 DOI: 10.1016/j.jamda.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/09/2021] [Accepted: 08/14/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Orthostatic hypotension (OH) and orthostatic intolerance symptoms are common in older community-dwelling adults and are associated with reduced quality of life and detrimental health outcomes. This study aimed to determine the prevalence, co-occurrence and determinants of OH and orthostatic intolerance symptoms in geriatric rehabilitation inpatients. DESIGN Observational, longitudinal cohort, "REStORing the health of acutely unwell adulTs" (RESORT). SETTING AND PARTICIPANTS Geriatric rehabilitation inpatients (n = 1505) of a tertiary teaching hospital in Melbourne, Australia. METHODS OH was defined as a drop in systolic blood pressure by ≥20 mm Hg and/or diastolic blood pressure by ≥10 mm Hg within three 3 of moving from supine to a standing or sitting position. Symptoms were recorded following the 3 minutes. Determinants included sociodemographics, reason for admission, cognitive health, nutritional status, physical performance, frailty, morbidity, medication use, length of stay (LOS), and number of geriatric conditions. Independent t-tests, Mann-Whitney U tests or χ2 tests were used to analyze differences between inpatients with and without OH and symptoms. Logistic regression analyses were used to ascertain the determinants. RESULTS OH and orthostatic intolerance symptoms were prevalent in 19.8% (standing: 21.4%, sitting: 18.2%) and 22.6% (standing: 25.0%, sitting: 20.2%) of inpatients, respectively. Symptoms were reported by 32.8% of inpatients with OH and 20.1% without OH. Higher number of comorbidities and geriatric conditions, low functional independence, and longer LOS were determinants of OH. Female gender, higher number of morbidities and geriatric conditions, low functional independence, depression risk, poor physical performance, musculoskeletal and "other" reasons for admission, and long LOS during geriatric rehabilitation were determinants of symptoms. CONCLUSIONS AND IMPLICATIONS OH and orthostatic intolerance symptoms occur in one-fifth of geriatric rehabilitation inpatients, however, the co-occurrence is low and determinants differ. Poorer health in patients with orthostatic intolerance symptoms highlights the need to assess symptoms in clinical practice, independent of an OH diagnosis.
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Affiliation(s)
- Elena M Christopoulos
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Esmee M Reijnierse
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia; Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Peter W Lange
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands; Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore.
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Mancusi C, de Simone G, Asteggiano R, Richter D, Williams B, Ferrini M. Survey on arterial hypertension management: a report from the ESC Council for Cardiology Practice and the ESC Council on Hypertension. EUROPEAN HEART JOURNAL OPEN 2021; 1:oeab013. [PMID: 35919263 PMCID: PMC9241483 DOI: 10.1093/ehjopen/oeab013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/19/2021] [Accepted: 08/05/2021] [Indexed: 01/14/2023]
Abstract
Aims To explore the management of hypertensive patients by general cardiologists a few months after the European Society of Cardiology (ESC)-European Society of Hypertension (ESH) Guidelines publication. Methods and results A survey based on a 26-point questionnaire was sent to ∼69 000 worldwide ESC members, a few months after the ESC-ESH Guidelines publication. A total of 1458 responses were collected via a web-based form. Among them, 68% were men, 48% were below 45 years old, and 60% were from Europe. Current guidelines have been read, at least partially, by 92.8%. Measurement of blood pressure (BP) is mostly done using the auscultatory method (58.8%) while unattended BP is rarely performed. Different bladder cuffs are not available for different arm circumferences for 27% of responders. Routine workup in hypertensive patients includes more often 12 leads ECG (97.7%) and echocardiography (79.6%). Only 30.9% of responders systematically assess the cardiovascular risk by the SCORE system and orthostatic hypotension is systematically researched by only 39.1%. Respondents consider that BP target of 140/90 mmHg is achievable in 60-80% of patients and 130/80 mmHg in 40-60%. Guidelines are considered too tight to be achievable by 15.6%, while 77.4% consider they are exactly right. Low patient's compliance, awareness of hypertension (HT) risk, and, at a lower degree, physician inertia, represent the main treatment challenges in reaching BP goals to most respondents, while treatment effectiveness is not in question. The present survey demonstrates specific gaps in HT management that need attention in clinical practice.
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Affiliation(s)
- Costantino Mancusi
- Hypertension Research Center, Federico II University Hospital, Naples, Italy
| | - Giovanni de Simone
- Hypertension Research Center, Federico II University Hospital, Naples, Italy
| | - Riccardo Asteggiano
- School of Medicine, University of Insubria, ASST-Settelaghi, Varese, Italy
- LARC (Laboratorio Analisi e Ricerca Clinica), Turin, Italy
| | | | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London, London, UK
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Marc Ferrini
- CH Saint Joseph et Saint Luc, 55 rue Vendome, Lyon 69006, France
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Hohtari-Kivimäki U, Salminen M, Vahlberg T, Kivelä SL. Orthostatic Hypotension is a Risk Factor for Falls Among Older Adults: 3-Year Follow-Up. J Am Med Dir Assoc 2021; 22:2325-2330. [PMID: 34384767 DOI: 10.1016/j.jamda.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/05/2021] [Accepted: 07/10/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To assess the prevalence of orthostatic hypotension (OH) and the association of OH with the risk of falls among community-dwelling older adults with a previous fall. DESIGN Longitudinal study. SETTING AND PARTICIPANTS The subjects (n = 561) were participants in fall prevention conducted in western Finland. METHODS Blood pressure (BP) was measured in supine position and at 30 seconds and 3 minutes after standing. The participants were divided according to the consensus definition to an OH group (OHG) and a non-OH group (non-OHG). Falls were recorded by fall diaries during 12 months. Falls requiring treatment were gathered from health center and hospital registers during 12 and 36 months. RESULTS The prevalence of OH was 23.4% (30 seconds) and 7.3% (3 minutes). The 30-second measurement showed that the incidence of falls and that of falls requiring treatment were significantly higher in OHG compared with non-OHG during 12 months. After adjustments, the incidence of falls remained higher in all 5 adjusted models whereas that of falls requiring treatment remained higher only after adjustment for functional balance. The 3-minute measurement showed that the incidence of falls was higher in OHG compared with non-OHG during 12 months and remained higher after adjustments for functional balance and for age and functional balance. During the 36-month follow-up, OH measured at 30 seconds or 3 minutes after standing was not associated with the occurrence of falls leading to treatment. CONCLUSIONS AND IMPLICATIONS OH at 30 seconds or 3 minutes after standing is associated with a greater risk for falling within 12 months in older adults. The 30-second blood pressure measurement is more reliable to detect the risk than the 3-minute measurement. The results support the usability of 30-second measurement in determining OH and the risk for falling among older persons.
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Affiliation(s)
| | - Marika Salminen
- Faculty of Medicine, Unit of Family Medicine, University of Turku, Turku, Finland; City of Turku, Welfare Division/Turku City Hospital, Turku, Finland
| | - Tero Vahlberg
- Faculty of Medicine, Biostatistics, University of Turku, Turku, Finland
| | - Sirkka-Liisa Kivelä
- Faculty of Medicine, Unit of Family Medicine, University of Turku, Turku, Finland; Faculty of Pharmacy, University of Helsinki, Turku, Finland
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Increased pulse wave velocity in patients with an orthostatic blood pressure rise independent of other cardiovascular risk factors. J Hypertens 2021; 39:1352-1360. [PMID: 33470734 DOI: 10.1097/hjh.0000000000002787] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Positional changes in blood pressure (BP) have been shown to have effects on long-term outcomes. Although a BP drop with upright posture is frequently observed, an orthostatic rise in BP can also occur. Here, we aimed to investigate whether the phenotype of orthostatic hypertension is associated with more pronounced vascular hypertension-mediated organ damage (HMOD) and whether this is associated with other cardiovascular risk factors. METHODS In a cohort of 200 patients referred to our tertiary hypertension clinic, we prospectively assessed unattended seated automated office BP and the response to 1 min of upright posture. The difference in BP after standing up was calculated and pulse wave velocity (PWV) was assessed as a marker of vascular HMOD. Routine clinical cardiovascular risk markers were also assessed. Regression models were used to assess the association between orthostatic BP changes and pulse wave velocity. RESULTS Baseline characteristics and clinic cardiovascular risk factors were similar between orthostatic BP response groups. A U-shaped association was evident between PWV and orthostatic BP changes with elevated PWV in patients with either a fall or a rise in BP in response to upright posture. The regression models remained significant after adjusting for other cardiovascular risk factors, including 24 h ambulatory BP. CONCLUSION Both an orthostatic BP drop and rise were associated with elevated PWV. Although standing BP is commonly measured in elderly hypertensive patients to exclude significant orthostatic hypotension, this simple measurement may provide an additional independent risk factor for vascular HMOD at any age.
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Spectrum of Hemodynamic Responses in the First 60 Seconds after Active Standing Up: Importance of Time Course of Blood Pressure Changes and Definitions. J Am Med Dir Assoc 2021; 22:2401-2403. [PMID: 34126059 DOI: 10.1016/j.jamda.2021.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 12/21/2022]
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Ghazi L, Drawz PE, Pajewski NM, Juraschek SP. The Association of Orthostatic Hypotension With Ambulatory Blood Pressure Phenotypes in SPRINT. Am J Hypertens 2021; 34:511-520. [PMID: 33186448 PMCID: PMC8140655 DOI: 10.1093/ajh/hpaa184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clinic blood pressure (BP) when measured in the seated position, can miss meaningful BP phenotypes, including low ambulatory BP (white coat effects [WCE]) or high supine BP (nocturnal non-dipping). Orthostatic hypotension (OH) measured using both seated (or supine) and standing BP, could identify phenotypes poorly captured by seated clinic BP alone. METHODS We examined the association of OH with WCE and night-to-daytime systolic BP (SBP) in a subpopulation of SPRINT, a randomized trial testing the effects of intensive or standard (<120 vs. <140 mm Hg) SBP treatment strategies in adults at increased risk of cardiovascular disease. OH was assessed during follow-up (6, 12, and 24 months) and defined as a decrease in mean seated SBP ≥20 or diastolic BP ≥10 mm Hg after 1 min of standing. WCE, based on 24-hour ambulatory BP monitoring performed at 27 months, was defined as the difference between 27-month seated clinic and daytime ambulatory BP ≥20/≥10 mm Hg. Reverse dipping was defined as a ratio of night-to-daytime SBP >1. RESULTS Of 897 adults (mean age 71.5±9.5 years, 29% female, 28% black), 128 had OH at least once. Among those with OH, 15% had WCE (vs. 7% without OH). Moreover, 25% of those with OH demonstrated a non-dipping pattern (vs. 14% without OH). OH was positively associated with both WCE (OR=2.24; 95%CI: 1.28, 4.27) and reverse dipping (OR=2.29; 95% CI: 1.31, 3.99). CONCLUSIONS The identification of OH in clinic was associated with two BP phenotypes often missed with traditional seated BP assessments. Further studies on mechanisms of these relationships are needed. CLINICAL TRIALS REGISTRATION Trial Number NCT03569020.
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Affiliation(s)
- Lama Ghazi
- Yale University, School of Medicine, Clinical and Translational Research Accelerator, New Haven, Connecticut, USA
| | - Paul E Drawz
- University of Minnesota Medical School, Department of Medicine, Division of Nephrology and Hypertension, Minneapolis, Minnesota, USA
| | - Nicholas M Pajewski
- Wake Forest School of Medicine, Department of Biostatistics and Data Science, Winston-Salem, North Carolina, USA
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Medicine, Division of General Medicine, Boston, Massachusetts, USA
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Fitzgibbon-Collins LK, Heckman GA, Bains I, Noguchi M, McIlroy WE, Hughson RL. Older Adults' Drop in Cerebral Oxygenation on Standing Correlates With Postural Instability and May Improve With Sitting Prior to Standing. J Gerontol A Biol Sci Med Sci 2021; 76:1124-1133. [PMID: 32766776 DOI: 10.1093/gerona/glaa194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Impaired blood pressure (BP) recovery with orthostatic hypotension on standing occurs in 20% of older adults. Low BP is associated with low cerebral blood flow but mechanistic links to postural instability and falls are not established. We investigated whether posture-related reductions in cerebral tissue oxygenation (tSO2) in older adults impaired stability upon standing, if a brief sit before standing improved tSO2 and stability, and if Low-tSO2 predicted future falls. METHOD Seventy-seven older adults (87 ± 7 years) completed (i) supine-stand, (ii) supine-sit-stand, and (iii) sit-stand transitions with continuous measurements of tSO2 (near-infrared spectroscopy). Total path length (TPL) of the center of pressure sway quantified stability. K-cluster analysis grouped participants into High-tSO2 (n = 62) and Low-tSO2 (n = 15). Fall history was followed up for 6 months. RESULTS Change in tSO2 during supine-stand was associated with increased TPL (R = -.356, p = .001). When separated into groups and across all transitions, the Low-tSO2 group had significantly lower tSO2 (all p < .01) and poorer postural stability (p < .04) through 3 minutes of standing compared to the High-tSO2 group. There were no effects of transition type on tSO2 or TPL for the High-tSO2 group, but a 10-second sitting pause improved tSO2 and enhanced postural stability in the Low-tSO2 group (all p < .05). During 6-month follow-up, the Low-tSO2 group had a trend (p < .1) for increased fall risk. CONCLUSIONS This is the first study to show an association between posture-related cerebral hypoperfusion and quantitatively assessed instability. Importantly, we found differences among older adults suggesting those with lower tSO2 and greater instability might be at increased risk of a future fall.
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Affiliation(s)
- Laura K Fitzgibbon-Collins
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
- Department of Kinesiology, University of Waterloo, Ontario, Canada
| | - George A Heckman
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
| | - Ikdip Bains
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
| | - Mamiko Noguchi
- Department of Kinesiology, University of Waterloo, Ontario, Canada
| | | | - Richard L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
- Department of Kinesiology, University of Waterloo, Ontario, Canada
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Mol A, Blom MEC, van den Bosch DJ, Van Wezel RJA, Meskers CGM, Maier AB. Orthostatic Blood Pressure Recovery Measured Using a Sphygmomanometer Is Not Associated with Physical Performance or Number of Falls in Geriatric Outpatients. Gerontology 2021; 68:75-79. [PMID: 33902032 DOI: 10.1159/000515658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) and impaired OH recovery derived from beat-to-beat blood pressure (BP) measurements are associated with detrimental clinical outcome, but the clinical relevance of OH recovery assessed using the widely available sphygmomanometer is still unclear. METHOD 635 geriatric outpatients underwent comprehensive geriatric assessment, including orthostatic BP measurements using a sphygmomanometer, during supine rest and 1 and 3 min after standing up and assessment of physical performance (i.e., the timed up and go test and the Short Physical Performance Battery) and the number of falls in the past year. The association between BP recovery, defined as BP at 3 min minus BP at 1 min after standing up, with physical performance and falls was assessed using regression analyses, adjusting for age and sex, both in the entire cohort and after stratifying for the presence of OH at 1 min after standing up. RESULTS BP recovery was not associated with physical performance or number of falls, neither in the entire cohort, nor in subpopulations with or without OH. CONCLUSION The clinical relevance of BP recovery between 1 and 3 min after standing up could not be demonstrated. The results suggest that sphygmomanometer measurements have an inadequate time resolution to record the clinically relevant dynamics of orthostatic BP recovery.
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Affiliation(s)
- Arjen Mol
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Marieke Esmé Charlotte Blom
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Danique Johanna van den Bosch
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Richard Jack Anton Van Wezel
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands.,Biomedical Signals and Systems, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam University Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore, Singapore
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35
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Christopoulos EM, Tran J, Hillebrand SL, Lange PW, Iseli RK, Meskers CGM, Maier AB. Initial orthostatic hypotension and orthostatic intolerance symptom prevalence in older adults: A systematic review. Int J Cardiol Hypertens 2021; 8:100071. [PMID: 33884364 PMCID: PMC7803043 DOI: 10.1016/j.ijchy.2020.100071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/13/2020] [Accepted: 12/04/2020] [Indexed: 11/25/2022] Open
Abstract
Background Initial orthostatic hypotension is a clinically relevant syndrome in older adults which has been associated with symptoms of orthostatic intolerance. The aim of this systematic review was to determine the prevalence of orthostatic intolerance symptoms in older adults with initial orthostatic hypotension. Methods MEDLINE (from 1946), EMBASE (from 1974) and Cochrane were searched to December 6th, 2019 using the terms "initial orthostatic hypotension", "postural hypotension" and "older adults". Study selection involved the following criteria: published in English; mean or median age ≥ 65 years and diagnosis of initial orthostatic hypotension encompassed a decrease in systolic blood pressure by ≥ 40 mmHg and/or diastolic blood pressure by ≥ 20 mmHg within a maximum of 1 min following a postural change. Results Of 8311 articles, 12 articles reporting initial orthostatic hypotension prevalence in 3446 participants with a mean age of 75 (6 SD) years (56.5% female) were included. Five initial orthostatic hypotension definition variations were utilised and symptoms were reported in six articles (968 participants, mean age 73.4 (6.1 SD) years, 56% female). The prevalence of symptoms in older adults with initial orthostatic hypotension ranged from 24 to 100% and was dependent on variations in timing or the inclusion of symptoms in the initial orthostatic hypotension definition. Conclusions Where orthostatic intolerance symptoms were reported, a large proportion of older adults with a diagnosis of initial orthostatic hypotension were symptomatic. However, the literature on initial orthostatic hypotension and orthostatic intolerance symptoms is scarce and a variety of definitions of initial orthostatic hypotension are utilised.
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Affiliation(s)
- Elena M Christopoulos
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Jennifer Tran
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Sarah L Hillebrand
- Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Peter W Lange
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Rebecca K Iseli
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.,Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, VU University Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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Abstract
Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and post-prandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy and quality of life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence, Italy -
| | - Artur Fedorowski
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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37
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Harms MPM, Finucane C, Pérez-Denia L, Juraschek SP, van Wijnen VK, Lipsitz LA, van Lieshout JJ, Wieling W. Systemic and cerebral circulatory adjustment within the first 60 s after active standing: An integrative physiological view. Auton Neurosci 2021; 231:102756. [PMID: 33385733 PMCID: PMC8103784 DOI: 10.1016/j.autneu.2020.102756] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/30/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023]
Abstract
Transient cardiovascular and cerebrovascular responses within the first minute of active standing provide the means to assess autonomic, cardiovascular and cerebrovascular regulation using a real-world everyday stimulus. Traditionally, these responses have been used to detect autonomic dysfunction, and to identify the hemodynamic correlates of patient symptoms and attributable causes of (pre)syncope and falls. This review addresses the physiology of systemic and cerebrovascular adjustment within the first 60 s after active standing. Mechanical factors induced by standing up cause a temporal mismatch between cardiac output and vascular conductance which leads to an initial blood pressure drops with a nadir around 10 s. The arterial baroreflex counteracts these initial blood pressure drops, but needs 2-3 s to be initiated with a maximal effect occurring at 10 s after standing while, in parallel, cerebral autoregulation buffers these changes within 10 s to maintain adequate cerebral perfusion. Interestingly, both the magnitude of the initial drop and these compensatory mechanisms are thought to be quite well-preserved in healthy aging. It is hoped that the present review serves as a reference for future pathophysiological investigations and epidemiological studies. Further experimental research is needed to unravel the causal mechanisms underlying the emergence of symptoms and relationship with aging and adverse outcomes in variants of orthostatic hypotension.
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Affiliation(s)
- Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ciáran Finucane
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Laura Pérez-Denia
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Johannes J van Lieshout
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; School of Life Sciences, The Medical School, MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, Nottingham, United Kingdom
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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38
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Haider MN, Patel KS, Willer BS, Videira V, Wilber CG, Mayer AR, Master CL, Mariotti BL, Wertz C, Storey EP, Arbogast KB, Park G, Oglesbee SJ, Bezherano I, Aguirre K, Fodero JG, Johnson BD, Mannix R, Miecznikowski JC, Leddy JJ. Symptoms upon postural change and orthostatic hypotension in adolescents with concussion. Brain Inj 2021; 35:226-232. [PMID: 33459038 DOI: 10.1080/02699052.2021.1871951] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective: 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.Participants: 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).Methods: 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).Results: Initial visit; Concussion Group reported feeling lightheaded/dizzy on postural change more often than the Control Group (37% vs 4%, p < .001) but did not differ in meeting standard OH criteria (3% vs 5%, p = .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%, p = .65).Conclusion: Adolescents commonly experience orthostatic intolerance after concussion without meeting the standard criteria for OH.
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Affiliation(s)
- M Nadir Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Kush S Patel
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | | | - Charles G Wilber
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Andrew R Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, Unites States.,Departments of Neurology and Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Christina L Master
- Sports Medicine and Performance Center, Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brandon L Mariotti
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Christopher Wertz
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, Unites States
| | - Eileen P Storey
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Grace Park
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Scott J Oglesbee
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Itai Bezherano
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Kenneth Aguirre
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Jesse G Fodero
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Blair D Johnson
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - Rebekah Mannix
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey C Miecznikowski
- Department of Biostatistics, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
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Gilani A, Ramsay SE, Welsh P, Papacosta O, Lennon LT, Whincup PH, Wannamethee SG. Vitamin D deficiency is associated with orthostatic hypotension in older men: a cross-sectional analysis from the British Regional Heart Study. Age Ageing 2021; 50:198-204. [PMID: 32902636 PMCID: PMC7793603 DOI: 10.1093/ageing/afaa146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Indexed: 01/27/2023] Open
Abstract
Background orthostatic hypotension (OH) that occurs within, or at, 1 minute of standing is associated with higher risk of falls, myocardial infarction, syncope and mortality, compared to OH that occurs after 1 minute of standing. Whether vitamin D deficiency increases the risk of OH is controversial. Methods this was a cross-sectional analysis of 3,620 older, community-dwelling men. Multinomial, multiple logistic regression models were used to calculate the risk of OH across categories of vitamin D status (deficient [<25 nmol/l], insufficient [≥25–<50 nmol/l] and sufficient [≥50 nmol/l]) and parathyroid hormone quintile. Results men with vitamin D deficiency were more likely to have OH that occurred within 1 minute of standing in univariate logistic regression (OR 1.88, 95% CI 1.40–2.53) and multinomial, multiple logistic regression (OR 1.51, 95% CI 1.06–2.15), compared to men with sufficient levels of vitamin D. Vitamin D insufficiency was not associated with the risk of OH. Elevated parathyroid hormone was not associated with risk of OH. Conclusion the absence of an association between vitamin D insufficiency and risk of OH and the presence of an association between vitamin D deficiency and risk of OH suggest that there may be a threshold effect; it is only below a particular level of vitamin D that risk of OH is increased. In this cohort, the threshold was <25 nmol/l. Future work should investigate whether treating vitamin D deficiency can improve postural blood pressure or if preventing vitamin D deficiency reduces the incidence of OH.
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Affiliation(s)
- Artaza Gilani
- Research Department of Primary Care and Population Health, University College London, Royal Free Campus, London NW3 2PF, UK
- Address correspondence to: Dr Artaza Gilani. Tel: 02080168021.
| | - Sheena E Ramsay
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE2 4AX, UK
| | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow G12 8TA, UK
| | - Olia Papacosta
- Research Department of Primary Care and Population Health, University College London, Royal Free Campus, London NW3 2PF, UK
| | - Lucy T Lennon
- Research Department of Primary Care and Population Health, University College London, Royal Free Campus, London NW3 2PF, UK
| | - Peter H Whincup
- Population Health Research Institute, St George's, University of London, London SW17 0RE, UK
| | - S Goya Wannamethee
- Research Department of Primary Care and Population Health, University College London, Royal Free Campus, London NW3 2PF, UK
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40
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Juraschek SP, Hu JR, Cluett JL, Ishak A, Mita C, Lipsitz LA, Appel LJ, Beckett NS, Coleman RL, Cushman WC, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor AA, Thijs L, Wright JT, Mukamal KJ. Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension : A Systematic Review and Individual Participant-based Meta-analysis. Ann Intern Med 2021; 174:58-68. [PMID: 32909814 PMCID: PMC7855528 DOI: 10.7326/m20-4298] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH). PURPOSE To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults. DATA SOURCES MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions. STUDY SELECTION Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing. DATA EXTRACTION 2 investigators independently abstracted articles and rated risk of bias. DATA SYNTHESIS 5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged. LIMITATIONS Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available. CONCLUSION Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Jiun-Ruey Hu
- Vanderbilt University Medical Center, Nashville, Tennessee (J.H.)
| | - Jennifer L Cluett
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Anthony Ishak
- Healthcare Associates, Beth Israel-Lahey Health System, Boston, Massachusetts (A.I.)
| | - Carol Mita
- Countway Library, Harvard University, Boston, Massachusetts (C.M.)
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center, Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Harvard Medical School, Boston, Massachusetts (L.A.L.)
| | | | - Nigel S Beckett
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (N.S.B.)
| | - Ruth L Coleman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - William C Cushman
- University of Tennessee Health Science Center, Memphis, Tennessee (W.C.C.)
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas (B.R.D.)
| | - Greg Grandits
- School of Public Health, University of Minnesota, Minneapolis, Minnesota (G.G.)
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - Edgar R Miller
- Johns Hopkins University, Baltimore, Maryland (L.J.A., E.R.M.)
| | - Ruth Peters
- University of New South Wales, Sydney, and Neuroscience Research Australia, Randwick, New South Wales, Australia (R.P.)
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, and NPA Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (J.A.S.)
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas (A.A.T.)
| | - Lutgarde Thijs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, Belgium (L.T.)
| | - Jackson T Wright
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio (J.T.W.)
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
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Sumi Y, Nakayama C, Kadotani H, Matsuo M, Ozeki Y, Kinoshita T, Goto Y, Kano M, Yamakawa T, Hasegawa-Ohira M, Ogawa K, Fujiwara K. Resting Heart Rate Variability Is Associated With Subsequent Orthostatic Hypotension: Comparison Between Healthy Older People and Patients With Rapid Eye Movement Sleep Behavior Disorder. Front Neurol 2020; 11:567984. [PMID: 33329309 PMCID: PMC7719719 DOI: 10.3389/fneur.2020.567984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/12/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Orthostatic hypotension (OH) caused by autonomic dysfunction is a common symptom in older people and patients with idiopathic rapid eye movement sleep behavior disorder (iRBD). The orthostatic challenge test is a standard autonomic function test that measures a decrease of blood pressure during a postural change from supine to standing positions. Although previous studies have reported that changes in heart rate variability (HRV) are associated with autonomic dysfunction, no study has investigated the relationship between HRV before standing and the occurrence of OH in an orthostatic challenge test. This study aims to examine the connection between HRV in the supine position and the occurrence of OH in an orthostatic challenge test. Methods: We measured the electrocardiograms of patients with iRBD and healthy older people during an orthostatic challenge test, in which the supine and standing positions were held for 15 min, respectively. The subjects were divided into three groups: healthy controls (HC), OH-negative iRBD [OH (-) iRBD], and OH-positive iRBD [OH (+) iRBD]. HRV measured in the supine position during the test were calculated by time-domain analysis and Poincaré plots to evaluate the autonomic dysfunction. Results: Forty-two HC, 12 OH (-) iRBD, and nine OH (+) iRBD subjects were included. HRV indices in the OH (-) and the OH (+) iRBD groups were significantly smaller than those in the HC group. The multivariate logistic regression analysis for OH identification for the iRBD groups showed the model whose inputs were the HRV indices, i.e., standard deviation 2 (SD2) and the percentage of adjacent intervals that varied by more than 50 ms (pNN50), had a receiver operating characteristic curve with area under the curve of 0.840, the sensitivity to OH (+) of 1.000, and the specificity to OH (-) of 0.583 (p = 0.023). Conclusions: This study showed the possibility that short-term HRV indices in the supine position would predict subsequent OH in iRBD patients. Our results are of clinical importance in terms of showing the possibility that OH can be predicted using only HRV in the supine position without an orthostatic challenge test, which would improve the efficiency and safety of testing.
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Affiliation(s)
- Yukiyoshi Sumi
- Department of Psychiatry, Shiga University of Medical Science, Otsu, Japan
| | - Chikao Nakayama
- Department of Systems Science, Kyoto University, Kyoto, Japan
| | - Hiroshi Kadotani
- Department of Sleep and Behavioral Sciences, Shiga University of Medical Science, Otsu, Japan
| | - Masahiro Matsuo
- Department of Psychiatry, Shiga University of Medical Science, Otsu, Japan
| | - Yuji Ozeki
- Department of Psychiatry, Shiga University of Medical Science, Otsu, Japan
| | | | - Yuki Goto
- Department of Systems Science, Kyoto University, Kyoto, Japan
| | - Manabu Kano
- Department of Systems Science, Kyoto University, Kyoto, Japan
| | - Toshitaka Yamakawa
- Department of Priority Organization for Innovation and Excellence, Kumamoto University, Kumamoto, Japan
| | | | - Keiko Ogawa
- Graduate School of Humanities and Social Sciences, Hiroshima University, Higashihiroshima, Japan
| | - Koichi Fujiwara
- Department of Systems Science, Kyoto University, Kyoto, Japan.,Department of Materials Process Engineering, Nagoya University, Nagoya, Japan
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Abstract
Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.
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Affiliation(s)
- Jake Ryan Gibbon
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - James Frith
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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Lin HJ, Wang TD, Yu-Chih Chen M, Hsu CY, Wang KL, Huang CC, Hsieh MJ, Chiu YW, Chiang LT, Chuang WP, Hsu PF, Wu CH, Hung CS, Chen KC, Wu CC, Wang YC, Chou PC, Yap HY, Cheng HM. 2020 Consensus Statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on Home Blood Pressure Monitoring for the Management of Arterial Hypertension. ACTA CARDIOLOGICA SINICA 2020; 36:537-561. [PMID: 33235411 PMCID: PMC7677637 DOI: 10.6515/acs.202011_36(6).20201106a] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 11/06/2020] [Indexed: 12/30/2022]
Abstract
To facilitate the applications of home blood pressure (HBP) monitoring in clinical settings, the Taiwan Hypertension Society and the Taiwan Society of Cardiology jointly put forward the Consensus Statement on HBP monitoring according to up-to-date scientific evidence by convening a series of expert meetings and compiling opinions from the members of these two societies. In this Consensus Statement as well as recent international guidelines for management of arterial hypertension, HBP monitoring has been implemented in diagnostic confirmation of hypertension, identification of hypertension phenotypes, guidance of anti-hypertensive treatment, and detection of hypotensive events. HBP should be obtained by repetitive measurements based on the " 722 " principle, which is referred to duplicate blood pressure readings taken per occasion, twice daily, over seven consecutive days. The " 722" principle of HBP monitoring should be applied in clinical settings, including confirmation of hypertension diagnosis, 2 weeks after adjustment of antihypertensive medications, and at least every 3 months in well-controlled hypertensive patients. A good reproducibility of HBP monitoring could be achieved by individuals carefully following the instructions before and during HBP measurement, by using validated BP devices with an upper arm cuff. Corresponding to office BP thresholds of 140/90 and 130/80 mmHg, the thresholds (or targets) of HBP are 135/85 and 130/80 mmHg, respectively. HBP-based hypertension management strategies including bedtime dosing (for uncontrolled morning hypertension), shifting to drugs with longer-acting antihypertensive effect (for uncontrolled evening hypertension), and adding another antihypertensive drug (for uncontrolled morning and evening hypertension) should be considered. Only with the support from medical caregivers, paramedical team, or tele- monitoring, HBP monitoring could reliably improve the control of hypertension.
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Affiliation(s)
- Hung-Ju Lin
- Cardiovascular Center and Divisions of Cardiology, Department of Internal Medicine, National Taiwan University Hospital
| | - Tzung-Dau Wang
- Cardiovascular Center and Divisions of Cardiology and Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Michael Yu-Chih Chen
- Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien
| | - Chien-Yi Hsu
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine
- Taipei Heart Institute, Taipei Medical University
| | | | - Chin-Chou Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Cardiovascular Research Center
- Institute of Pharmacology, National Yang-Ming University, Taipei
| | - Ming-Jer Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine
| | - Yu-Wei Chiu
- Department of Computer Science and Engineering, Yuan Ze University, Taoyuan
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital
| | - Liang-Ting Chiang
- Division of Cardiology, Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City
- Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Wen-Po Chuang
- Division of Cardiology, Far Eastern Memorial Hospital, New Taipei City
| | - Pai-Feng Hsu
- Healthcare and Management Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Chun-Hsien Wu
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Chi-Sheng Hung
- Cardiovascular Center and Divisions of Cardiology, Department of Internal Medicine, National Taiwan University Hospital
| | - Kuan-Chun Chen
- Heart Center, Cheng Hsin General Hospital
- National Defense Medical Center
- Institute of Emergency and Critical Care Medicine, National Yang Ming University, Taipei
| | - Chih-Cheng Wu
- Cardiovascular Center, National Taiwan University Hospital Hsin-Chu Branch
- Institute of Biomedical Engineering, National Tsing-Hwa University, Hsinchu
- Institute of Cellular and System Medicine, National Health Research Institute, Miaoli, Taiwan
| | - Yu-Chen Wang
- Division of Cardiology, Department of Internal Medicine, Asia University Hospital
- Department of Biotechnology, Asia University
- Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital, Taichung
| | - Po-Ching Chou
- Cardiovascular Center of Cathay General Hospital, Taipei
| | - Hui-Yi Yap
- Department of cardiology, Chi Mei Medical Center, Liouying
| | - Hao-Min Cheng
- Faculty of Medicine, National Yang-Ming University School of Medicine
- Center for Evidence-based Medicine, Department of Medical Education, Taipei Veterans General Hospital
- Institute of Public Health and Community Medicine Research Center
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
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Nakada T, Shirai S, Oya Y, Takahashi Y, Sakakura N, Ohtsuka T, Kuroda H. Four Hours Postoperative Mobilization is Feasible After Thoracoscopic Anatomical Pulmonary Resection. World J Surg 2020; 45:631-637. [PMID: 33098011 DOI: 10.1007/s00268-020-05836-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND We aimed to analyze the feasibility and risk factors associated with early mobilization (EM) within 4 h after thoracoscopic lobectomy and segmentectomy. METHODS This study retrospectively evaluated 214 consecutive patients who underwent thoracoscopic anatomical pulmonary resection using our EM protocol between October 2017 and February 2019. We compared the correlations of the patients' characteristics including the total number of drugs and perioperative parameters such as air leak, and orthostatic hypotension (OH) between the EM (E group) and failed EM (F group) groups. Second, we evaluated risk factors for OH, which often causes critical complications. RESULTS A total of 198 patients (92.5%: E group) completed the EM protocol, whereas 16 patients did not (7.5%: F group). The primary causes of failure were severe pain, air leak, postoperative nausea and vomiting, and OH (n = 1, 3, 8, and 4). Upon univariate analysis, air leakage, OH, and non-hypertension were identified as risk factors for failed EM (all p <0.05). EM was associated with a shortened chest tube drainage period (p <0.01). Thirty patients (14%) experienced OH, and 20% of them failed EM. A total number of drugs ≥5 (p = 0.015) was an independent risk factor for OH. Operative and anesthetic variables were not associated with EM or OH. CONCLUSIONS The EM protocol was safe and useful for tubeless management. Surgeons should be advised to actively prevent air leak. Our EM protocol achieved a low frequency of OH in mobilization. Due to its versatility, our mobilization protocol may be promising, especially in patients without severe comorbidities. Clinical registration number: The study protocol was approved by the Review Board of Aichi Cancer Center (approval number: 2020-1-067).
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Affiliation(s)
- Takeo Nakada
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan.
| | - Suguru Shirai
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yuko Oya
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Yusuke Takahashi
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Noriaki Sakakura
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
| | - Takashi Ohtsuka
- Division of Thoracic Surgery, Department of Surgery, The Jikei University School of Medicine, Nishishinbashi 3-19-18, Minatoku, Tokyo, 105-8471, Japan
| | - Hiroaki Kuroda
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, 464-8681, Japan
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Soysal P, Kocyigit SE, Dokuzlar O, Ates Bulut E, Smith L, Isik AT. Relationship between sarcopenia and orthostatic hypotension. Age Ageing 2020; 49:959-965. [PMID: 32614946 DOI: 10.1093/ageing/afaa077] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The relationship between sarcopenia and orthostatic hypotension (OH) is unclear. OBJECTIVES The aim of the present study was to investigate associations between sarcopenia/sarcopenia severity and OH. DESIGN A total of 511 patients attending a geriatric outpatient clinic were included. OH was defined as a decrease in systolic and/or diastolic blood pressure of ≥ 20 mmHg and/or ≥ 10 mmHg, respectively, when one transitions from the supine to an upright position. OH was measured by the Head-up Tilt Table test at 1, 3 and 5 min (OH1, OH3 and OH5, respectively). Sarcopenia and its severity were defined according to the revised European consensus on definition and diagnosis. RESULTS The mean age of the sample was 75.40 ± 7.35 years, and 69.9% were female. The prevalence of probable sarcopenia, sarcopenia and severe sarcopenia was 42.2%, 6.06% and 11.1%, respectively. After adjustment for all covariates, systolic OH1, OH1 and systolic OH5 were statistically significantly different between severe sarcopenia and the robust group (odds ratio [OR]: 3.26, confidence interval [CI] 0.98-10.84; P = 0.05 for systolic OH1; OR 4.31, CI 1.31-14.15; P = 0.016 for OH1; OR 4.09, CI 1.01-16.55; P = 0.048 for systolic OH5). Only systolic OH1 was statistically different between the sarcopenia and severe sarcopenia groups (OR 2.64, CI 1.87-8.73; P = 0.012). OH1 and OH5 were statistically significant different between severe sarcopenia and probable sarcopenia groups (P < 0.05); there was no relationship between the robust group and probable sarcopenia (P > 0.05). CONCLUSIONS There is a close relationship between sarcopenia and severe sarcopenia and OH in older adults. Therefore, when a healthcare practitioner is evaluating an older patient with sarcopenia, OH should also be evaluated, and vice versa.
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Affiliation(s)
- Pinar Soysal
- Department of Geriatric Medicine, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey
| | - Suleyman Emre Kocyigit
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Ozge Dokuzlar
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Esra Ates Bulut
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Lee Smith
- The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | - Ahmet Turan Isik
- Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Gannon J, Claffey P, Laird E, Newman L, Kenny RA, Briggs R. The cross-sectional association between diabetes and orthostatic hypotension in community-dwelling older people. Diabet Med 2020; 37:1299-1307. [PMID: 31770459 DOI: 10.1111/dme.14187] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2019] [Indexed: 01/28/2023]
Abstract
AIMS Orthostatic hypotension is a recognized complication of diabetes, but studies examining prevalence in diabetes are limited. The aim of this study was to ascertain the prevalence of orthostatic hypotension and the pattern of orthostatic BP response in a cohort of people with diabetes aged ≥ 50 years, embedded within the Irish Longitudinal Study of Ageing. METHODS Orthostatic hypotension was defined as a drop in systolic blood pressure (SBP) ≥ 20 mmHg or drop in diastolic blood pressure (DBP) ≥ 10 mmHg at 30 s after standing. Diabetes was defined by self-report but cross-checked against HbA1c and medication records. Multilevel mixed effects linear regression models were used to compare orthostatic BP in people with and without diabetes. RESULTS Some 3222 people were included, 7% (213 of 3222) of whom had diabetes. Prevalence of orthostatic hypotension in the group with diabetes was 22% (46 of 213) vs. 13% in those without diabetes; χ2 = 12.43; P < 0.001. Multilevel models demonstrated prolonged recovery of DBP in people with diabetes, with only 41% (87 of 213) returning to baseline by 60 s. Logistic regression models demonstrated that diabetes was associated with a significantly increased likelihood of orthostatic hypotension (odds ratio 1.84, 95% confidence interval 1.30-2.59; P = 0.001) and this remained robust after controlling for covariates. CONCLUSION Over one-fifth of older people with diabetes had orthostatic hypotension. Recovery of DBP is related to dynamic changes in total peripheral resistance and impairment of this baroreflex-mediated response may explain the higher prevalence in diabetes. Given the prognostic implications when co-existing with diabetes, orthostatic hypotension may represent a potentially modifiable risk factor for adverse outcomes in late-life diabetes.
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Affiliation(s)
- J Gannon
- Mercers Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - P Claffey
- Mercers Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - E Laird
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - L Newman
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - R A Kenny
- Mercers Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - R Briggs
- Mercers Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
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Juraschek SP, Longstreth WT, Lopez OL, Gottdiener JS, Lipsitz LA, Kuller LH, Mukamal KJ. Orthostatic hypotension, dizziness, neurology outcomes, and death in older adults. Neurology 2020; 95:e1941-e1950. [PMID: 32732296 DOI: 10.1212/wnl.0000000000010456] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/16/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Stephen P Juraschek
- From the Department of Medicine (S.P.J., L.A.L., K.J.M.), Beth Israel Deaconess Medical Center, Boston, MA; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurology (O.L.L.) and Department of Epidemiology, Graduate School of Public Health (L.H.K.), University of Pittsburgh, PA; Department of Medicine (J.S.G.), University of Maryland, Baltimore; and Hinda and Arthur Marcus Institute for Aging Research (L.A.L.), Hebrew SeniorLife, Roslindale, MA.
| | - W T Longstreth
- From the Department of Medicine (S.P.J., L.A.L., K.J.M.), Beth Israel Deaconess Medical Center, Boston, MA; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurology (O.L.L.) and Department of Epidemiology, Graduate School of Public Health (L.H.K.), University of Pittsburgh, PA; Department of Medicine (J.S.G.), University of Maryland, Baltimore; and Hinda and Arthur Marcus Institute for Aging Research (L.A.L.), Hebrew SeniorLife, Roslindale, MA
| | - Oscar L Lopez
- From the Department of Medicine (S.P.J., L.A.L., K.J.M.), Beth Israel Deaconess Medical Center, Boston, MA; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurology (O.L.L.) and Department of Epidemiology, Graduate School of Public Health (L.H.K.), University of Pittsburgh, PA; Department of Medicine (J.S.G.), University of Maryland, Baltimore; and Hinda and Arthur Marcus Institute for Aging Research (L.A.L.), Hebrew SeniorLife, Roslindale, MA
| | - John S Gottdiener
- From the Department of Medicine (S.P.J., L.A.L., K.J.M.), Beth Israel Deaconess Medical Center, Boston, MA; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurology (O.L.L.) and Department of Epidemiology, Graduate School of Public Health (L.H.K.), University of Pittsburgh, PA; Department of Medicine (J.S.G.), University of Maryland, Baltimore; and Hinda and Arthur Marcus Institute for Aging Research (L.A.L.), Hebrew SeniorLife, Roslindale, MA
| | - Lewis A Lipsitz
- From the Department of Medicine (S.P.J., L.A.L., K.J.M.), Beth Israel Deaconess Medical Center, Boston, MA; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurology (O.L.L.) and Department of Epidemiology, Graduate School of Public Health (L.H.K.), University of Pittsburgh, PA; Department of Medicine (J.S.G.), University of Maryland, Baltimore; and Hinda and Arthur Marcus Institute for Aging Research (L.A.L.), Hebrew SeniorLife, Roslindale, MA
| | - Lewis H Kuller
- From the Department of Medicine (S.P.J., L.A.L., K.J.M.), Beth Israel Deaconess Medical Center, Boston, MA; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurology (O.L.L.) and Department of Epidemiology, Graduate School of Public Health (L.H.K.), University of Pittsburgh, PA; Department of Medicine (J.S.G.), University of Maryland, Baltimore; and Hinda and Arthur Marcus Institute for Aging Research (L.A.L.), Hebrew SeniorLife, Roslindale, MA
| | - Kenneth J Mukamal
- From the Department of Medicine (S.P.J., L.A.L., K.J.M.), Beth Israel Deaconess Medical Center, Boston, MA; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurology (O.L.L.) and Department of Epidemiology, Graduate School of Public Health (L.H.K.), University of Pittsburgh, PA; Department of Medicine (J.S.G.), University of Maryland, Baltimore; and Hinda and Arthur Marcus Institute for Aging Research (L.A.L.), Hebrew SeniorLife, Roslindale, MA
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LeWitt PA, Kymes S, Hauser RA. Parkinson Disease and Orthostatic Hypotension in the Elderly: Recognition and Management of Risk Factors for Falls. Aging Dis 2020; 11:679-691. [PMID: 32489712 PMCID: PMC7220277 DOI: 10.14336/ad.2019.0805] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022] Open
Abstract
Parkinson disease (PD) is often associated with postural instability and gait dysfunction that can increase the risk for falls and associated consequences, including injuries, increased burden on healthcare resources, and reduced quality of life. Patients with PD have nearly twice the risk for falls and associated bone fractures compared with their general population counterparts of similar age. Although the cause of falls in patients with PD may be multifactorial, an often under-recognized factor is neurogenic orthostatic hypotension (nOH). nOH is a sustained decrease in blood pressure upon standing whose symptomology can include dizziness/lightheadedness, weakness, fatigue, and syncope. nOH is due to dysfunction of the autonomic nervous system compensatory response to standing and is a consequence of the neurodegenerative processes of PD. The symptoms associated with orthostatic hypotension (OH)/nOH can increase the risk of falls, and healthcare professionals may not be aware of the real-world clinical effect of nOH, the need for routine screening, or the value of early diagnosis of nOH when treating elderly patients with PD. nOH is easily missed and, importantly, healthcare providers may not realize that there are effective treatments for nOH symptoms that could help lessen the fall risk resulting from the condition. This review discusses the burden of, and key risk factors for, falls among patients with PD, with a focus on practical approaches for the recognition, assessment, and successful management of OH/nOH. In addition, insights are provided as to how fall patterns can suggest fall etiology, thereby influencing the choice of intervention.
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Affiliation(s)
- Peter A LeWitt
- 1Henry Ford Hospital and Wayne State University School of Medicine, West Bloomfield, MI 48322, USA
| | | | - Robert A Hauser
- 3University of South Florida Parkinson's Disease and Movement Disorders Center, Parkinson Foundation Center of Excellence, Tampa, FL 33613, USA
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Yi YY, Xu HW, Zhang SB, Hu T, Wang SJ, Wu DS. Does the C3/4 disc play a role in cervical spondylosis with dizziness? A retrospective study. INTERNATIONAL ORTHOPAEDICS 2020; 44:1159-1168. [PMID: 32193610 DOI: 10.1007/s00264-020-04531-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/04/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE To investigate the effect of C3/4 disc degeneration on cervical spondylosis with dizziness (CSD) and to assess the curative effect of anterior cervical decompression and fusion (ACDF) in patients with CSD. METHOD Four hundred nineteen patients who underwent ACDF for treatment of myelopathy or radiculopathy were divided into dizziness and non-dizziness group. The visual analog scale (VAS) score and Japanese Orthopaedic Association (JOA) score were used to determine the intensity of dizziness and neurological symptoms, respectively. Cervical disc degeneration was evaluated using Miyazaki's classification system. Some parameters were measured using cervical radiographs. The surgical effects on CSD were compared between surgery with and without C3/4 level. Multivariate logistic regression analysis was used to determine the risk factors for CSD. RESULTS The pre-operative incidence of CSD was 33.9%. Women were more likely to develop dizziness than men (p < 0.05), CSD was significantly associated with C3/4 disc degeneration (69.7%, p < 0.001), and smokers were more subject to dizziness (p < 0.05). Regression analysis showed that female (OR = 1.611, p = 0.031), smoking (OR = 1.719, p = 0.032), Miyazaki grade of C3/4 ≥ IV (OR = 2.648, p < 0.001), and instability on C3/4 (OR = 1.672, p = 0.024) were risk factors for CSD. Treatment of CSD by ACDF involving C3/4 was more effective than not involving C3/4 (efficacy rate, 73.2% vs 51.7%, p < 0.05). CONCLUSION The CSD is a common clinical manifestation in elderly patients, especially patients with cervical spondylosis at the C3/4 level. Female, smoking, instability on C3/4, and C3/4 Miyazaki grade ≥ IV could be considered significant risk factors for CSD. CSD is more likely to be alleviated by ACDF involving C3/4.
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Affiliation(s)
- Yu-Yang Yi
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hao-Wei Xu
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shu-Bao Zhang
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tao Hu
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shan-Jin Wang
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.
| | - De-Sheng Wu
- Department of Spinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Mol A, Maier AB, van Wezel RJA, Meskers CGM. Multimodal Monitoring of Cardiovascular Responses to Postural Changes. Front Physiol 2020; 11:168. [PMID: 32194438 PMCID: PMC7063121 DOI: 10.3389/fphys.2020.00168] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background In the poorly understood relationship between orthostatic hypotension and falls, next to blood pressure (BP), baroreflex sensitivity (BRS) and cerebral autoregulation (CAR) may be key measures. The posture- and movement dependency of orthostatic hypotension requires continuous and unobtrusive monitoring. This may be possible using simultaneous photoplethysmography (PPG), electrocardiography (ECG), and near-infrared spectroscopy (NIRS) signal recordings, from which pulse wave velocity (PWV; potentially useful for BP estimation), BRS and CAR can be derived. The PPG, NIRS and PWV signal correlation with BP and BRS/CAR reliability and validity need to be addressed. Methods In 34 healthy adults (mean age 25 years, inter quartile range 22–45; 10 female), wrist and finger PPG, ECG, bifrontal NIRS (oxygenated and deoxygenated hemoglobin) and continuous BP were recorded during sit to stand and supine to stand movements. Sixteen participants performed slow and rapid supine to stand movements; eighteen other participants performed a 1-min squat movement. Pulse wave velocity (PWV) was defined as the inverse of the ECG R-peak to PPG pulse delay; PPG, NIRS and PWV signal correlation with BP as their Pearson correlations with mean arterial pressure (MAP) within 30 s after the postural changes; BRS as inter beat interval drop divided by systolic BP (SBP) drop during the postural changes; CAR as oxygenated hemoglobin drop divided by MAP drop. BRS and CAR were separately computed using measured and estimated (linear regression) BP. BRS/CAR reliability was defined by the intra class correlation between repeats of the same postural change; validity as the Pearson correlation between BRS/CAR values based on measured and estimated BP. Results The highest correlation with MAP was found for finger PPG and oxygenated hemoglobin, ranging from 0.75–0.79 (sit to stand), 0.66–0.88 (supine to stand), and 0.82–0.94 (1-min squat). BRS and CAR reliability was highest during the different supine to stand movements, ranging from 0.17 – 0.49 (BRS) and 0.42-0.75 (CAR); validity was highest during rapid supine to stand movements, 0.54 and 0.79 respectively. Conclusion PPG-ECG-NIRS recordings showed high correlation with BP and enabled computation of reliable and valid BRS and CAR estimates, suggesting their potential for continuous unobtrusive monitoring of orthostatic hypotension key measures.
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Affiliation(s)
- Arjen Mol
- Department of Human Movement Sciences @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Medicine and Aged Care @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Richard J A van Wezel
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.,Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - Carel G M Meskers
- Department of Human Movement Sciences @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Rehabilitation Medicine, Amsterdam UMC, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, Netherlands
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