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Rojas-Solé C, Pinilla-González V, Lillo-Moya J, González-Fernández T, Saso L, Rodrigo R. Integrated approach to reducing polypharmacy in older people: exploring the role of oxidative stress and antioxidant potential therapy. Redox Rep 2024; 29:2289740. [PMID: 38108325 PMCID: PMC10732214 DOI: 10.1080/13510002.2023.2289740] [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] [Indexed: 12/19/2023] Open
Abstract
Increased life expectancy, attributed to improved access to healthcare and drug development, has led to an increase in multimorbidity, a key contributor to polypharmacy. Polypharmacy is characterised by its association with a variety of adverse events in the older persons. The mechanisms involved in the development of age-related chronic diseases are largely unknown; however, altered redox homeostasis due to ageing is one of the main theories. In this context, the present review explores the development and interaction between different age-related diseases, mainly linked by oxidative stress. In addition, drug interactions in the treatment of various diseases are described, emphasising that the holistic management of older people and their pathologies should prevail over the individual treatment of each condition.
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Affiliation(s)
- Catalina Rojas-Solé
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Víctor Pinilla-González
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
| | - José Lillo-Moya
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Tommy González-Fernández
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Luciano Saso
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Faculty of Pharmacy and Medicine, Sapienza University, Rome, Italy
| | - Ramón Rodrigo
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile
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Curcio F, Chiappetti R, De Furio M, Flocco V, Della Morte D, Testa G, Gargiulo G, Cacciatore F, Abete P, Galizia G. Chronic kidney disease and orthostatic hypotension in hospitalised older adults. Blood Press 2024; 33:2336243. [PMID: 38567958 DOI: 10.1080/08037051.2024.2336243] [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: 12/05/2023] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Orthostatic hypotension (OH) may predispose older adults to health complications leading to functional impairment. Despite the central role of the kidney in blood pressure control, the contribution of renal function in orthostatic hypotension is poorly investigated. To verify the association between Chronic Kidney Disease (CKD) and OH a population of hospitalised elderly patients with comorbidities was studied. MATERIALS AND METHODS 174 patients were consecutively admitted to Acute Geriatric Wards. On admission, patients underwent postural systolic (SBP) and diastolic (DBP) blood pressure evaluation by automatic oscillometric device after 10 min rest in lying position, and in standing position at time 0, 1, 3 and 5 min. CKD was assumed for estimated glomerular filtration rate (e-GFR) less than 60 mL/min/1.73 m2. RESULTS The mean age of the population enrolled was 74.4 ± 7.0. OH was found in 46.0% and CKD in 56.3% of patients, respectively. A lower e-GFR was observed in patients with (56.1 ± 16.7 mL/min/1.73 m2) than in those without OH (61.1 ± 15.9 mL/min/1.73 m2) (p < 0.05). A greater fall in SBP at 0-min (12.8 ± 6.3 vs. 7.7 ± 3.2 mmHg) and at 1-min (8.4 ± 4.5 vs. 5.7 ± 2.8 mmHg) was found in CKD patients in respect to patients without CKD during active standing test (p < 0.05). Similarly, a DBP reduction at 0-min and at 1-min was observed in CKD patients in respect to patients without CKD (p < 0.05). A multivariate logistic regression analysis showed that CKD was associated to OH (OR 2.426; 95%CI 1.192-4.937; p = 0.014). CONCLUSIONS CKD is associated to OH in hospitalised older adults.
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Affiliation(s)
- Francesco Curcio
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy
| | - Rosaria Chiappetti
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy
| | - Mattia De Furio
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy
| | - Veronica Flocco
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy
| | - David Della Morte
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Gianluca Testa
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Gaetano Gargiulo
- Division of Internal Medicine, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples "Federico II", Napoli, Italy
| | - Gianluigi Galizia
- IRCCS - ICS Maugeri, Scientific Institute of Gattico-Veruno, Novara, Italy
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Mastrandrea CJ, Hedge ET, Hughson RL. The Detrimental Effects of Bedrest: Premature Cardiovascular Aging and Dysfunction. Can J Cardiol 2024; 40:1468-1482. [PMID: 38759726 DOI: 10.1016/j.cjca.2024.05.009] [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: 01/25/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/19/2024] Open
Abstract
Bedrest as an experimental paradigm or as an in-patient stay for medical reasons has negative consequences for cardiovascular health. The effects of severe inactivity parallel many of the changes experienced with natural aging but over a much shorter duration. Cardiac function is reduced, arteries stiffen, neural reflex responses are impaired, and metabolic and oxidative stress responses impose burden on the heart and vascular systems. The effect of these changes is revealed in studies of integrative function. Aerobic fitness progressively deteriorates with bedrest and tolerance of upright posture is rapidly impaired. In this review we consider the similarities of aging and bedrest-induced cardiovascular deconditioning. We concur with many recent clinical recommendations that early and regular mobility with upright posture will reduce likelihood of hospital-associated disability related to bedrest.
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Affiliation(s)
- Carmelo J Mastrandrea
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada; Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Eric T Hedge
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada; Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Richard L Hughson
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada.
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Klop M, Maier AB, Meskers CGM, Steiner JM, Helsloot DO, van Wezel RJA, Claassen JAHR, de Heus RAA. The effect of a change in antihypertensive treatment on orthostatic hypotension in older adults: A systematic review and meta-analysis. Exp Gerontol 2024; 193:112461. [PMID: 38772447 DOI: 10.1016/j.exger.2024.112461] [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: 03/21/2024] [Revised: 05/07/2024] [Accepted: 05/15/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Orthostatic hypotension (OH) is common in older adults with hypertension. Antihypertensive treatment (AHT) prevents cardio- and cerebrovascular events. However, physicians are concerned to cause OH, making them hesitant to initiate or augment AHT in older adults with hypertension. METHODS We systematically researched electronic databases for trials with older participants (≥65 years) with hypertension and OH assessment after initiating, discontinuing, or augmenting AHT. Study quality was assessed using the ROBINS-I tool. Meta-analyses on OH prevalence and postural blood pressure (BP) drop were performed. RESULTS Twenty-five studies (26,695 participants) met inclusion criteria, of which fifteen could be included in the meta-analyses. OH prevalence decreased after AHT initiation or augmentation (risk ratio 0.39 (95 % CI = 0.21-0.72; I2 = 47 %; p < 0.01), n = 6 studies), but also after AHT discontinuation (risk ratio 0.39 (95 % CI = 0.28-0.55; I2 = 0 %; p < 0.01), n = 2 studies). Postural BP drop did not change after initiation or augmentation of AHT (mean difference 1.07 (95 % CI = -0.49-2.64; I2 = 92 %; p = 0.18), n = 11 studies). The main reason for ten studies not to be included in the meta-analyses was absence of baseline OH data. Most of these studies reported OH incidences between 0 and 2 %. Studies were heterogeneous in OH assessment methods (postural change, timing of BP measurements, and OH definition). Risk of bias was moderate to serious in twenty studies. CONCLUSION Results suggest that AHT initiation or augmentation decreases OH prevalence, implying that the risk of inducing OH may be overestimated in current AHT decision-making in older adults. However, the overall low level of evidence and the finding that AHT discontinuation reduces OH prevalence limit firm conclusions at present and highlight an important research gap. Future AHT trials in older adults should measure OH in a standardized protocol, adhering to consensus guidelines to overcome these limitations.
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Affiliation(s)
- Marjolein Klop
- Department of Neurobiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andrea B Maier
- 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; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Julika M Steiner
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - D Odette Helsloot
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Richard J A van Wezel
- Department of Neurobiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, the Netherlands; OnePlanet Research Center, Radboud University, Nijmegen, the Netherlands
| | - Jurgen A H R Claassen
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Rianne A A de Heus
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.
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Arvin S, Kristensen PN, Glud AN. Medial longitudinal fasciculus (MLF)-syndrome in a multimorbid patient with alcohol use disorder: a case report. AME Case Rep 2024; 8:69. [PMID: 39091561 PMCID: PMC11292078 DOI: 10.21037/acr-23-177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/11/2024] [Indexed: 08/04/2024]
Abstract
Background Patients with multiple comorbidities can present as a diagnostic challenge as overlapping symptomatology complicates the discovery of emergent pathology. Symptoms of alcohol misuse or orthostatic hypotension may especially cloud the diagnosis of insidious neurological disease, such as posterior circulation infarct. With a growing elderly population, it is expected that the complex multimorbid patient will represent a growing challenge to prompt stroke detection and treatment. Case Description Herein, we present a 69-year-old male with a history of alcohol abuse, chronic obstructive pulmonary disease, type 2 diabetes mellitus, paroxysmal atrial fibrillation, and congestive heart disease. The patient arrived at our emergency department with dizziness, ataxia, and diplopia. His symptoms had a sudden onset and gradual exacerbation over a span of 2 days, notably aggravated by standing and walking, but relieved when seated or supine. Notably, a month before admission, the patient had been treated with anti-congestive medications for severe congestive heart failure leading to a weight loss of 55 lbs over period of 2 weeks. The initial differential diagnoses were orthostatism, Wernicke's encephalopathy (WE), and ischemic stroke. Magnetic resonance imaging (MRI) revealed a subacute infarct in the medial longitudinal fasciculus (MLF). Conclusions The case underscores the challenge in diagnosing neurological conditions in multimorbid individuals. The combination of various underlying conditions may drastically complicate the diagnosis. Successful diagnosis and treatment necessitates meticulous evaluation of clinical observations, medical history, current medications, and pertinent diagnostic evaluations to effectively narrow down the potential differential diagnoses.
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Affiliation(s)
- Simon Arvin
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience-CENSE, Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Emergency Department, Randers Regional Hospital, Randers, Denmark
| | | | - Andreas Nørgaard Glud
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Center for Experimental Neuroscience-CENSE, Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Fedorowski A, Fanciulli A, Raj SR, Sheldon R, Shibao CA, Sutton R. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat Rev Cardiol 2024; 21:379-395. [PMID: 38163814 DOI: 10.1038/s41569-023-00962-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Cardiovascular autonomic dysfunction (CVAD) is a malfunction of the cardiovascular system caused by deranged autonomic control of circulatory homeostasis. CVAD is an important component of post-COVID-19 syndrome, also termed long COVID, and might affect one-third of highly symptomatic patients with COVID-19. The effects of CVAD can be seen at both the whole-body level, with impairment of heart rate and blood pressure control, and in specific body regions, typically manifesting as microvascular dysfunction. Many severely affected patients with long COVID meet the diagnostic criteria for two common presentations of CVAD: postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. CVAD can also manifest as disorders associated with hypotension, such as orthostatic or postprandial hypotension, and recurrent reflex syncope. Advances in research, accelerated by the COVID-19 pandemic, have identified new potential pathophysiological mechanisms, diagnostic methods and therapeutic targets in CVAD. For clinicians who daily see patients with CVAD, knowledge of its symptomatology, detection and appropriate management is more important than ever. In this Review, we define CVAD and its major forms that are encountered in post-COVID-19 syndrome, describe possible CVAD aetiologies, and discuss how CVAD, as a component of post-COVID-19 syndrome, can be diagnosed and managed. Moreover, we outline directions for future research to discover more efficient ways to cope with this prevalent and long-lasting condition.
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Affiliation(s)
- Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
- Department of Medicine, Karolinska Institute, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cyndya A Shibao
- Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Hammersmith Hospital, National Heart & Lung Institute, Imperial College, London, UK
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7
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Peltier AC. Autonomic Dysfunction from Diagnosis to Treatment. Prim Care 2024; 51:359-373. [PMID: 38692780 DOI: 10.1016/j.pop.2024.02.006] [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] [Indexed: 05/03/2024]
Abstract
Autonomic disorders can present with hypotension, gastrointestinal, genitourinary symptoms, and heat intolerance. Diabetes is the most common causes of autonomic failure, and management should focus on glucose control to prevent developing autonomic symptoms. The most prevalent cause of dysautonomia, or autonomic dysfunction, is Postural Orthostatic Tachycardia Syndrome (POTS). Autonomic testing characterizes causes for nonspecific symptoms but is not necessary in patients with classic presentations. Treatment for autonomic dysfunction and failure focus on discontinuing offending medications, behavioral modification, and pharmacologic therapy to decrease symptom severity. Autonomic failure has no cure; therefore, the focus remains on improving quality of life.
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Affiliation(s)
- Amanda C Peltier
- Department of Neurology, Vanderbilt University Medical Center, 1611 21st Avenue South, Nashville, TN 37232, USA; Department of Medicine, Vanderbilt University Medical Center, 1611 21st Avenue South, Nashville, TN 37232, USA.
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Groppelli A, Rivasi G, Fedorowski A, de Lange F, Russo V, Maggi R, Capacci M, Nawaz S, Comune A, Ungar A, Parati G, Brignole M. Targets for deprescribing in patients with hypertension and reflex syncope. Eur J Intern Med 2024:S0953-6205(24)00217-6. [PMID: 38789289 DOI: 10.1016/j.ejim.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/22/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND We aimed to identify the target of deprescribing, i.e. the 24-hour SBP increase needed to achieve the greatest reduction of SBP drops. METHOD Forty hypertensive patients (mean age 73.6 ± 9.3 years, 26 females) with reflex syncope and SBP drops on a screening ABPM were advised to withdraw or to reduce their therapy. The study objective was the reduction of SBP drops <90 mmHg and <100 mmHg on a second ABPM performed within 3 months. RESULTS Out of a total of 98 drugs taken during ABPM 1, 44 were withdrawn, 16 had a dose reduction and 38 remained unchanged at the time of ABPM 2. 24-hour SBP increased from 119.7 ± 10.1 mmHg to 129.4 ± 13.2 mmHg during ABPM2. Total disappearance of daytime SBP drops <100 mmHg was achieved in 20 (50 %) patients who had 24-hour SBP of 134±13 mmHg and an increase from ABPM 1 of 12 (IQR 5-20) mmHg. Compared with the 20 patients who had persistence of drops, these patients had a greater reduction of the number of hypotensive drugs (67 % versus 19 %, p = 0.002) and a greater rate of withdrawals (62 % versus 29 %, p = 0.003). CONCLUSION In hypertensive patients with reflex syncope, an increase of 12 mmHg and an absolute value of 24-hour SBP of 134 mmHg appear to represent the optimal goals aimed to prevent SBP drops. Drugs withdrawal, rather than simply dose reduction, is mostly required to achieve the above target.
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Affiliation(s)
- Antonella Groppelli
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Frederik de Lange
- Amsterdam UMC, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Heart Centre, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli'-Monaldi Hospital, Piazzale E. Ruggeri, 80126 Naples, Italy
| | - Roberto Maggi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sara Nawaz
- Amsterdam UMC, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, University of Amsterdam, Heart Centre, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli'-Monaldi Hospital, Piazzale E. Ruggeri, 80126 Naples, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gianfranco Parati
- Department of Cardiology, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy.
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Rivasi G, Coscarelli A, Capacci M, Ceolin L, Turrin G, Tortù V, D'Andria MF, Testa GD, Ungar A. Tolerability of Antihypertensive Medications: The Influence of Age. High Blood Press Cardiovasc Prev 2024; 31:261-269. [PMID: 38658522 PMCID: PMC11161422 DOI: 10.1007/s40292-024-00639-z] [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: 02/19/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Despite high prevalence of hypertension, few studies have analysed the adverse effects (AEs) of antihypertensive medications, especially in older patients. AIM To investigate the prevalence and associated factors of antihypertensive-related AEs, focusing on the influence of age on treatment tolerability. METHODS We retrospectively investigated antihypertensive-related AEs in patients evaluated at the Hypertension Clinic of Careggi Hospital, Florence, Italy, between January 2017 and July 2020. Multivariable regression models were generated to analyse variables associated with AEs in the overall sample and in participants ≥75 years. RESULTS Among 622 subjects (mean age 64.8 years, 51.4% female), the most frequently reported AEs were calcium-channel blockers (CCB)-related ankle swelling (26.8%) and ACEi-induced cough (15.1%). Ankle swelling was more common in older patients (35.7% vs 22.3%, p = 0.001; odds ratio [OR] 1.94, 95%CI 1.289-2.912) and was independently associated with Body Mass Index (BMI, adjOR 1.073) and angiotensin-receptor antagonists (adjOR 1.864). The association with BMI was confirmed in older patients (adjOR 1.134). ACEi-induced cough showed similar prevalence in younger and older patients (13.9% vs 15.6%, p = 0.634), being independently associated with female sex (adjOR 2.118), gastroesophageal reflux disease (GERD, adjOR 2.488) and SNRI therapy (adjOR 8.114). The association with GERD was confirmed in older patients (adjOR 3.238). CONCLUSIONS CCB-related ankle swelling and ACEi-induced cough represent the most common antihypertensive-related AEs, also at old age. Older patients showed a two-fold increased risk of ankle swelling, that was also independently associated with BMI. ACEi-induced cough had similar prevalence at younger and old ages, being independently associated with GERD.
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Affiliation(s)
- Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.
| | - Antonio Coscarelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Ludovica Ceolin
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Giada Turrin
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Virginia Tortù
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Maria Flora D'Andria
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Referral Centre for Hypertension in Older Adults, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
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Iwański MA, Sokołowska A, Sokołowski A, Wojdyła R, Styczkiewicz K. The Prevalence of Orthostatic Hypotension in Cancer Patients. Cancers (Basel) 2024; 16:1541. [PMID: 38672623 PMCID: PMC11049507 DOI: 10.3390/cancers16081541] [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: 03/17/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) is associated with a higher risk of mortality in the general population; however, it has not been studied in the cancer population. This study aimed to assess the prevalence of OH in cancer patients compared to that in the noncancer population. METHODS A total of 411 patients (mean age 63.5 ± 10.6 years) were recruited: patients with active cancer (n = 223) and patients hospitalised for other reasons, but without a cancer diagnosis (n = 188). Medical histories were collected and an orthostatic challenge test was performed. OH was defined as a blood pressure (BP) decrease upon standing of ≥20 mmHg for the systolic or ≥10 mmHg for the diastolic BP after 1 or 3 min; or a systolic BP decrease <90 mmHg. RESULTS The prevalence of OH in the subjects with cancer was significantly higher than in the subjects without cancer (28.7% vs. 16.5%, respectively, p = 0.003). OH was the most common in the lung cancer patients (57.5%). In a single-variable analysis, the predictors of OH were cancer presence, age ≥ 65 years, and body mass index (BMI) ≥ 30 kg/m2. In the multivariable model, the strongest independent predictor of OH was cancer status, which doubled the risk of OH, and BMI ≥ 30 kg/m2 and diabetes. CONCLUSIONS Cancer patients are characterised by a high prevalence of OH. In this population, the recommendation of routine orthostatic challenge tests should be considered.
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Affiliation(s)
- Mateusz A. Iwański
- Institute of Medical Sciences, College of Medical Sciences, University of Rzeszow, 1a Warzywna St., 35-310 Rzeszow, Poland; (M.A.I.); (A.S.)
| | - Aldona Sokołowska
- Institute of Medical Sciences, College of Medical Sciences, University of Rzeszow, 1a Warzywna St., 35-310 Rzeszow, Poland; (M.A.I.); (A.S.)
| | - Andrzej Sokołowski
- Collegium Humanum, Warsaw Management University, 133A Aleje Jerozolimskie St., 02-304 Warsaw, Poland;
| | - Roman Wojdyła
- New Medical Techniques Specialist Hospital of the Holy Family, Rudna Mała 600, 36-060 Rzeszow, Poland;
- 2nd Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego St., 30-688 Krakow, Poland
| | - Katarzyna Styczkiewicz
- Institute of Medical Sciences, College of Medical Sciences, University of Rzeszow, 1a Warzywna St., 35-310 Rzeszow, Poland; (M.A.I.); (A.S.)
- Subcarpathian Oncological Centre, Frederic Chopin University Clinical Hospital, 2 Fryderyka Szopena St., 35-055 Rzeszow, Poland
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11
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Leys F, Eschlböck S, Campese N, Mahlknecht P, Peball M, Goebel G, Sidoroff V, Krismer F, Granata R, Kiechl S, Poewe W, Seppi K, Wenning GK, Fanciulli A. Sex-related differences in the clinical presentation of multiple system atrophy. Clin Auton Res 2024; 34:253-268. [PMID: 38630378 PMCID: PMC11127878 DOI: 10.1007/s10286-024-01028-1] [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: 12/03/2023] [Accepted: 03/20/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE To investigate sex-related differences in the clinical presentation of multiple system atrophy (MSA) through a literature review and an analysis of a retrospective cohort. METHODS The PubMed database was searched for articles including sex-related information in MSA. In a retrospective Innsbruck cohort, we investigated the baseline to last available follow-up clinical-demographic differences between men and women with MSA in a univariate fashion, followed by multivariable binary regression analysis. RESULTS The literature search yielded 46 publications with sex-related information in MSA. Most studies found comparable survival rates between the sexes, while some recent reports suggested a potential survival benefit for women, possibly due to initial motor onset and overall less severe autonomic failure compared to men. The retrospective Innsbruck MSA cohort comprised 56 female and 60 male individuals with a comparable median follow-up of 27 months. At baseline, female sex was independently associated with depression (odds ratio [OR] 4.7; p = 0.007) and male sex with severe orthostatic hypotension (OR 5.5; p = 0.016). In addition, at last follow-up, female sex was associated with the intake of central nervous system-active drugs (OR 4.1; p = 0.029), whereas male sex was associated with the presence of supine hypertension (OR 3.0; p = 0.020) and the intake of antihypertensive medications (OR 8.7; p = 0.001). Male sex was also associated with initiation of antihypertensive medications over the observation period (OR 12.4; p = 0.004). CONCLUSION The available literature and findings of the present study indicate sex-related differences in the clinical presentation of MSA and its evolution over time, highlighting the importance of considering sex in symptom exploration, therapeutic decision-making, and future clinical trial design.
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Affiliation(s)
- Fabian Leys
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine Eschlböck
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Hochzirl-Natters Hospital, Zirl, Austria
| | - Nicole Campese
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Mahlknecht
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marina Peball
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Goebel
- Institute of Medical Statistics and Informatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Victoria Sidoroff
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Krismer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Roberta Granata
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Provincial Hospital of Kufstein, Kufstein, Austria
| | - Gregor K Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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12
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Numeroso F, Bottaro L, Younes A, Ungar A, Cabassi A. Incidence and risk factors for non-cardiac syncope in a cohort of patients addressing an accredited Arterial Hypertension Center: the Innocent Study. Minerva Med 2024; 115:143-150. [PMID: 38629908 DOI: 10.23736/s0026-4806.24.09200-0] [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: 07/18/2024]
Abstract
BACKGROUND Hypotensive susceptibility in hypertensive patients could facilitate orthostatic hypotension, syncope and fall. The aim of this study was to identify incidence, clinical form, complications and risk factors for non-cardiac syncope in a cohort of hypertensive patients. METHODS This is an observational, case-controlled, retrospective study carried out on 168 patients, evaluated at the Hypertension Center of the University Hospital of Parma (Italy). Based on the presence of episodes of syncope during the six months prior to enrolment, we identified cases and controls and then we compared them to personal data, comorbidities, current drug regimens, presence of orthostatic hypotension, office and ambulatory blood pressure monitoring (ABPM) blood pressure (BP) values. RESULTS In patients with previous syncopal episodes (29.8% of total), we more frequently found female gender, comorbidities associated with autonomic dysfunction, diuretics and non-CV drugs potentially associated with hypotension in their current drug regimen, orthostatic hypotension and lower office and ABPM BP values. CONCLUSIONS To identify hypertensive patients at higher risk for syncope and falls, physicians should focus on comorbidities and current drug regimens, systematically perform an active standing test to identify orthostatic hypotension, employ ABPM to compare BP values with the pre-established target and highlight systolic BP drops and abnormalities suggesting concomitant autonomic dysfunction. The modulation of antihypertensive therapy is an effective tool to counteract the risk of non-cardiac syncope, with possible trauma or other negative influences.
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Affiliation(s)
- Filippo Numeroso
- Emergency Department, University Hospital of Parma, Parma, Italy -
| | - Luca Bottaro
- Postgraduate School of Internal Medicine, University of Parma, Parma, Italy
| | - Ali Younes
- Postgraduate School of Internal Medicine, University of Parma, Parma, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Aderville Cabassi
- Unit of Cardiorenal and Hypertension Research, Clinic of General Medicine and Medical Therapy, Parma, Italy
- Unit of Physiopathology, University Hospital of Parma, University of Parma, Parma, Italy
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13
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Brignole M, Rivasi G, Fedorowski A. Mechanism-based therapy of non-cardiac syncope: a practical guide. Europace 2024; 26:euae073. [PMID: 38529800 PMCID: PMC10988836 DOI: 10.1093/europace/euae073] [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: 02/20/2024] [Accepted: 03/08/2024] [Indexed: 03/27/2024] Open
Abstract
The term non-cardiac syncope includes all forms of syncope, in which primary intrinsic cardiac mechanism and non-syncopal transient loss of consciousness can be ruled out. Reflex syncope and orthostatic hypotension are the most frequent aetiologies of non-cardiac syncope. As no specific therapy is effective for all types of non-cardiac syncope, identifying the underlying haemodynamic mechanism is the essential prerequisite for an effective personalized therapy and prevention of syncope recurrences. Indeed, choice of appropriate therapy and its efficacy are largely determined by the syncope mechanism rather than its aetiology and clinical presentation. The two main haemodynamic phenomena leading to non-cardiac syncope include either profound hypotension or extrinsic asystole/pronounced bradycardia, corresponding to two different haemodynamic syncope phenotypes, the hypotensive and bradycardic phenotypes. The choice of therapy-aimed at counteracting hypotension or bradycardia-depends on the given phenotype. Discontinuation of blood pressure-lowering drugs, elastic garments, and blood pressure-elevating agents such as fludrocortisone and midodrine are the most effective therapies in patients with hypotensive phenotype. Cardiac pacing, cardioneuroablation, and drugs preventing bradycardia such as theophylline are the most effective therapies in patients with bradycardic phenotype of extrinsic cause.
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Affiliation(s)
- Michele Brignole
- IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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14
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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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15
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Anisman SD, Erickson SB, Fodor KM. Thiazide diuretics. BMJ 2024; 384:e075174. [PMID: 38316445 DOI: 10.1136/bmj-2023-075174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Affiliation(s)
| | - Stephen B Erickson
- Mayo Clinic, Division of Nephrology and Hypertension, Rochester, MN, USA
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16
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Groppelli A, Rivasi G, Fedorowski A, de Lange FJ, Russo V, Maggi R, Capacci M, Nawaz S, Comune A, Bianchi L, Zambon A, Soranna D, Ungar A, Parati G, Brignole M. Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance. Europace 2024; 26:euae026. [PMID: 38262617 PMCID: PMC10849184 DOI: 10.1093/europace/euae026] [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: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
AIMS Systolic blood pressure (SBP) drops recorded by 24-h ambulatory blood pressure (BP) monitoring (ABPM) identify patients with susceptibility to reflex syncope and orthostatic intolerance. We tested the hypothesis that treatments aimed to increase BP (reassurance, education, and lifestyle measures plus pharmacological strategies) can reduce SBP drops. METHODS AND RESULTS This was a multicentre, observational proof-of-concept study performed in patients with reflex syncope and/or orthostatic intolerance and with SBP drops on a screening ABPM. Among 144 eligible patients, 111 underwent a second ABPM on average 2.5 months after start of treatment. Overall, mean 24-h SBP increased from 114.1 ± 12.1 to 121.4 ± 14.5 mmHg (P < 0.0001). The number of SBP drops <90 and <100 mmHg decreased by 61%, 46% during daytime, and by 48% and 37% during 24-h period, respectively (P < 0.0001 for all). The dose-response relationship between difference in 24-h average SBP increase and reduction in number of SBP drops reached a plateau around ∼15 mmHg increase of 24-h SBP. The reduction in SBP drop rate was consistent and significant in patients who underwent deprescription of hypotensive medications (n = 44) and in patients who received BP-rising drugs (n = 67). CONCLUSION In patients with reflex syncope and/or orthostatic intolerance, an increase in average 24-h SBP, regardless of the implemented strategy, significantly reduced the number of SBP drops and symptom burden. A 13 mmHg increase in 24-h SBP appears to represent the optimal goal for aborting the maximal number of SBP drops, representing a possible target for future interventions. ClincalTrials.gov identifier: NCT05729724.
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Affiliation(s)
- Antonella Groppelli
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Roberto Maggi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sara Nawaz
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Lorenzo Bianchi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Antonella Zambon
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gianfranco Parati
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dei daini 2, 20126 Milan, Italy
| | - Michele Brignole
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
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17
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Srinivas V, Choubey U, Kapparath S, Shaik T, Singh B, Mahmood R, Garg N, Aggarwal P, Jain R. Age-Related Orthostatic Hypotension: A Comprehensive Analysis of Prevalence, Mechanisms, and Management in the Geriatric Population. Cardiol Rev 2024:00045415-990000000-00186. [PMID: 38189438 DOI: 10.1097/crd.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Geriatric patients frequently encounter orthostatic hypotension (OH), a multifaceted condition characterized by a significant drop in blood pressure upon assuming an upright position. As the elderly population is particularly susceptible to OH, our review endeavors to comprehensively explore the complex nature of this condition and various factors contributing to its development. We investigate the impact of comorbidities, polypharmacy, age-related physiological changes, and autonomic dysfunction in the pathogenesis of OH. Geriatric patients with OH are faced with an elevated risk of falls, syncope, a decline in their overall quality of life, and hence increased mortality. These implications require careful consideration, necessitating a thorough examination of therapeutic strategies. We evaluate various pharmaceutical and nonpharmacological therapies, delving into the effectiveness and safety of each approach in managing OH within geriatric populations. We explore the role of pharmacotherapy in alleviating symptoms and mitigating OH-related complications, as well as the potential benefits of volume expansion techniques to augment blood volume and stabilize blood pressure. We place particular emphasis on the significance of lifestyle changes and nonpharmacological interventions in enhancing OH management among the elderly. These interventions encompass dietary modifications, regular physical activity, and postural training, all tailored to the unique needs of the individual patient. To optimize outcomes and ensure patient safety, we underscore the importance of individualized treatment plans that take into account the geriatric patient's overall health status, existing comorbidities, and potential interactions with other medications. This review aims to improve clinical practice and patient outcomes by advocating for early detection, properly tailored management, and targeted interventions to address OH in the elderly population. By raising awareness of OH's prevalence and complexities among healthcare professionals, we hope to foster a comprehensive understanding of OH and contribute to the overall wellness and quality of life of this vulnerable demographic.
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Affiliation(s)
- Varsha Srinivas
- From the PES Institute of Medical Sciences and Research, India
| | | | | | - Tanveer Shaik
- Avalon University School Of Medicine, Willemstad, Curacao
| | | | - Ramsha Mahmood
- Avalon University School Of Medicine, Willemstad, Curacao
| | - Nikita Garg
- Children's Hospital of Michigan, Detroit, MI
| | - Priyanka Aggarwal
- Maharishi Markandeshwar Institute of Medical Science & Research, Mullana, Haryana, India
| | - Rohit Jain
- Department of Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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18
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Vidal-Petiot E, Pathak A, Azulay JP, Pavy-Le Traon A, Hanon O. Orthostatic hypotension: Review and expert position statement. Rev Neurol (Paris) 2024; 180:53-64. [PMID: 38123372 DOI: 10.1016/j.neurol.2023.11.001] [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: 09/26/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20mmHg or a drop in diastolic blood pressure of at least 10mmHg within 3minutes of standing. It is a common disorder, especially in high-risk populations such as elderly subjects and patients with neurological diseases, and is associated with markedly increased morbidity and mortality. Its management can be challenging, particularly in cases where supine hypertension is associated with severe orthostatic hypotension. Education of the patient, non-pharmacological measures, and drug adaptation are the cornerstones of treatment. Pharmacological treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions. First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases.
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Affiliation(s)
- E Vidal-Petiot
- Service de physiologie, ESH Excellence Center, hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; INSERM U1148, Université Paris-Cité and Université Sorbonne Paris Nord, LVTS, 75018 Paris, France.
| | - A Pathak
- Service de cardiologie, ESH Excellence Center, centre hospitalier Princesse Grace, 1, avenue Pasteur, 98000 Monaco, France
| | - J-P Azulay
- Service de neurologie et pathologie du mouvement, hôpital de la Timone, 13385 Marseille cedex 05, France
| | - A Pavy-Le Traon
- Service de neurologie, CHU de Toulouse, 31059 Toulouse cedex, France; UMR 1297, institut des maladies métaboliques et cardiovasculaires, Toulouse, France
| | - O Hanon
- Service de gériatrie, université Paris-Cité, EA4468, hôpital Broca, AP-HP, 75013 Paris, France
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19
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Babar BA, Kettunen R, Tiihonen M, Hartikainen S, Tolppanen AM. Prevalence of Cardiovascular Drugs and Oral Anticoagulant Use among Persons with and without Parkinson's Disease. Cardiology 2023; 149:127-136. [PMID: 38071963 PMCID: PMC10994629 DOI: 10.1159/000535691] [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: 07/11/2023] [Accepted: 12/02/2023] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Cardio- and cerebrovascular diseases are common among persons with Parkinson's disease (PD), but it is unknown how the prevalence of cardiovascular drug and oral anticoagulant use changes in relation to PD diagnosis. METHODS We investigated the prevalence of cardiovascular drug and oral anticoagulant use among persons with and without PD among 17,541 persons who received incident PD diagnosis in 2001-2015 in Finland and their 116,829 matched comparison persons. Prevalence was calculated in 6-month time windows from 5 years before to 5 years after PD diagnosis (index date) and compared to a matched cohort without PD using generalized estimating equations. RESULTS Persons with PD had higher prevalence of any cardiovascular drugs (unadjusted OR = 1.15; 95% CI: 1.11-1.18) and oral anticoagulants (unadjusted OR = 1.16; 95% CI: 1.11-1.22) before index date than those without PD. After index date, persons with PD had lower prevalence of cardiovascular drugs (0.94; 95% CI: 0.91-0.96), and no difference was observed for oral anticoagulants. Prevalence of any cardiovascular drugs on the index date was 66 and 61% for persons with and without PD, respectively. β-blockers were the most common cardiovascular drugs in both cohorts. Warfarin was the most common oral anticoagulant, but the use of direct oral anticoagulants increased during the last years of follow-up. CONCLUSION Orthostatic hypotension and weight loss likely explain the decreased cardiovascular drug use after PD diagnosis. Results with oral anticoagulants may reflect clinical assessment of benefits being larger than risks, despite the risks associated with their use in persons with PD.
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Affiliation(s)
- Barkat Ali Babar
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- Kuopio Research Center of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Raimo Kettunen
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- Kuopio Research Center of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Sirpa Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- Kuopio Research Center of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Tolppanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- Kuopio Research Center of Geriatric Care, University of Eastern Finland, Kuopio, Finland
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20
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Kaye MG, Rutowski J, Aftab H, Pandey R, Khan R, Kalot MA, Anand R, Graham SP. Screening for orthostatic hypotension in the geriatric population in a real-world primary care setting reduces prescribed antihypertensive medications. Blood Press Monit 2023; 28:338-342. [PMID: 37661718 DOI: 10.1097/mbp.0000000000000673] [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: 09/05/2023]
Abstract
BACKGROUND To determine if outpatient screening for orthostatic hypotension (OH) in the geriatric population results in fewer prescribed antihypertensive medications and if a relationship exists between OH and specific pharmacologic classes of antihypertensive medications. MATERIALS AND METHODS Patients ≥ 65 years were screened for OH, defined as a decrease in systolic blood pressure (SBP) ≥ 20 mm Hg or a decrease in diastolic blood pressure (DBP) ≥ 10 mm Hg after standing for 3 minutes. Sitting blood pressure (BP) was measured after patients had been seated quietly in an exam room. Patients then stood for approximately 3 minutes at which time standing BP was recorded. RESULTS OH prevalence was 18%. Standing DBP was significantly different between the two groups (70 mmHg ± 18, 80 mmHg ± 13, P = 0.007). Compared to patients without OH, patients with OH were more likely to have been previously prescribed beta-blockers (56% vs. 32%, P = 0.056) and potassium-sparing diuretics (11% vs. 1%, P = 0.026). Physicians discontinued an antihypertensive medication more often in patients who screened positive for OH than in to those who did not (17% vs. 4%, P = 0.037). Calcium channel blockers were the most frequently discontinued class of medication. CONCLUSION Asymptomatic OH is prevalent in geriatric patients. Screening for OH may lead to de-escalation of antihypertensive regimen and a reduction in polypharmacy. Positive screening for OH was associated with de-prescribing of antihypertensive medications. Prior use of beta-blockers and potassium-sparing diuretics was most largely associated with OH.
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Affiliation(s)
- Matthew G Kaye
- Department of Medicine, University at Buffalo (State University of New York)
| | - James Rutowski
- Department of Medicine, University at Buffalo (State University of New York)
| | - Hamza Aftab
- Department of Medicine, University at Buffalo (State University of New York)
| | - Rohan Pandey
- Department of Medicine, University at Buffalo (State University of New York)
| | - Raheel Khan
- Department of Medicine, University at Buffalo (State University of New York)
| | - Mohamad A Kalot
- Department of Medicine, University at Buffalo (State University of New York)
| | - Renata Anand
- Department of Medicine, University at Buffalo (State University of New York)
| | - Susan P Graham
- Division of Cardiology, Department of Medicine, University at Buffalo (State University of New York), Buffalo General Medical Center, Buffalo, New York, USA
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Han J, Park J, Kang H, Lee H, Kim N. The Effect of a Biofeedback-Based Integrated Program on Improving Orthostatic Hypotension in Community-Dwelling Older Adults: A Pilot Study. J Cardiovasc Nurs 2023:00005082-990000000-00120. [PMID: 37615610 DOI: 10.1097/jcn.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH) is prevalent among community-dwelling older adults and is associated with multiple negative health outcomes. Older adults are susceptible to developing OH because aging alters autonomic nervous system function. Biofeedback is a noninvasive, nonpharmacological intervention that can modulate autonomic nervous system dysfunction in older adults. OBJECTIVES Our aim in this study was to examine the effect of a biofeedback-based integrated program on community-dwelling older adults with OH. METHODS We conducted a controlled pilot study. Community-dwelling older adults 65 years or older who had nonneurogenic OH were eligible. Data from 51 participants, comprising 27 in the intervention group and 24 in the control group, were analyzed. Weekly biofeedback-based integrated program consisting of biofeedback training along with group education about behavioral modification, physical activities, and telephone counseling was provided for 12 weeks. Orthostatic hypotension was evaluated by measuring the drop in systolic and diastolic blood pressure after postural changes. Autonomic nervous system function was measured using heart rate variability. RESULTS Among the indicators of heart rate variability, total power (P = .037) and low frequency (P = .017) increased significantly, suggesting that autonomic function improved. Severity of orthostatic symptoms (P < .001) and drops in systolic (P = .003) and diastolic (P = .012) blood pressure after postural changes decreased significantly in the intervention group. CONCLUSION Biofeedback-based integrated program was effective in improving autonomic nervous system function and alleviated OH. Therefore, biofeedback-based integrated program should be tested in a larger randomized controlled study with long-term follow-up.
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van Poelgeest EP, Handoko ML, Muller M, van der Velde N. Diuretics, SGLT2 inhibitors and falls in older heart failure patients: to prescribe or to deprescribe? A clinical review. Eur Geriatr Med 2023; 14:659-674. [PMID: 36732414 PMCID: PMC10447274 DOI: 10.1007/s41999-023-00752-7] [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: 08/30/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Both heart failure and its treatment with diuretics or SGLT2 inhibitors increase fall risk in older adults. Therefore, decisions to continue or deprescribe diuretics or SGLT2 inhibitors in older heart failure patients who have fallen are generally highly complex and challenging for clinicians. However, a comprehensive overview of information required for rationale and safe decision-making is lacking. The aim of this clinical review was to assist clinicians in safe (de)prescribing of these drug classes in older heart failure patients. METHODS We comprehensively searched and summarized published literature and international guidelines on the efficacy, fall-related safety issues, and deprescribing of the commonly prescribed diuretics and SGLT2 inhibitors in older adults. RESULTS Both diuretics and SGLT2 inhibitors potentially cause various fall-related adverse effects. Their fall-related side effect profiles partly overlap (e.g., tendency to cause hypotension), but there are also important differences; based on the currently available evidence of this relatively new drug class, SGLT2 inhibitors seem to have a favorable fall-related adverse effect profile compared to diuretics (e.g., low/absent tendency to cause hyperglycemia or electrolyte abnormalities, low risk of worsening chronic kidney disease). In addition, SGLT2 inhibitors have potential beneficial effects (e.g., disease-modifying effects in heart failure, renoprotective effects), whereas diuretic effects are merely symptomatic. CONCLUSION (De)prescribing diuretics and SGLT2 inhibitors in older heart failure patients who have fallen is often highly challenging, but this clinical review paper assists clinicians in individualized and patient-centered rational clinical decision-making: we provide a summary of available literature on efficacy and (subclass-specific) safety profiles of diuretics and SGLT2 inhibitors, and practical guidance on safe (de)prescribing of these drugs (e.g. a clinical decision tree for deprescribing diuretics in older adults who have fallen).
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Affiliation(s)
- Eveline P van Poelgeest
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Majon Muller
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
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Nguyen T, Wanjala SS, Brake MB. Management of Labile Blood Pressure due to COVID-19 Infection and Radiation Induced Baroreceptor Dysfunction. Kans J Med 2023; 16:182-184. [PMID: 37539372 PMCID: PMC10395768 DOI: 10.17161/kjm.vol16.19691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/22/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Timothy Nguyen
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Stephen S Wanjala
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Mona B Brake
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
- Robert J. Dole Veterans Affairs Medical Center, Wichita, KS
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Jung YS, Suh D, Kim E, Park HD, Suh DC, Jung SY. Medications influencing the risk of fall-related injuries in older adults: case-control and case-crossover design studies. BMC Geriatr 2023; 23:452. [PMID: 37481554 PMCID: PMC10363319 DOI: 10.1186/s12877-023-04138-z] [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: 09/08/2021] [Accepted: 06/27/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Medications influencing the risk of fall-related injuries (FRIs) in older adults have been inconsistent in previous guidelines. This study employed case-control design to assess the association between FRIs and medications, and an additional case-crossover design was conducted to examine the consistency of the associations and the transient effects of the medications on FRIs. METHODS This study was conducted using a national claims database (2002-2015) in Korea. Older adults (≥ 65 years) who had their first FRI between 2007 and 2015 were matched with non-cases in 1:2 ratio. Drug exposure was examined for 60 days prior to the date of the first FRI (index date) in the case-control design. The hazard period (1-60 days) and two control periods (121-180 and 181-240 days prior to the index date) were investigated in the case-crossover design. The risk of FRIs with 32 medications was examined using conditional logistic regression after adjusting for other medications that were significant in the univariate analysis. In the case-crossover study, the same conditional model was applied. RESULTS In the case-control design, the five medications associated with the highest risk of FRIs were muscle relaxants (adjusted odd ratio(AOR) = 1.35, 95% confidence interval (CI) = 1.31-1.39), anti-Parkinson agents (AOR = 1.30, 95%CI = 1.19-1.40), opioids (AOR = 1.23, 95%CI = 1.19-1.27), antiepileptics (AOR = 1.19, 95%CI = 1.12-1.26), and antipsychotics (AOR = 1.16, 95%CI = 1.06-1.27). In the case-crossover design, the five medications associated with the highest risk of FRIs were angiotensin II antagonists (AOR = 1.87, 95%CI = 1.77-1.97), antipsychotics (AOR = 1.63, 95%CI = 1.42-1.83), anti-Parkinson agents (AOR = 1.58, 95%CI = 1.32-1.85), muscle relaxants (AOR = 1.42, 95%CI = 1.35-1.48), and opioids (AOR = 1.35, 95%CI = 1.30-1.39). CONCLUSIONS Anti-Parkinson agents, opioids, antiepileptics, antipsychotics, antidepressants, hypnotics and sedatives, anxiolytics, muscle relaxants, and NSAIDs/antirheumatic agents increased the risk of FRIs in both designs among older adults. Medications with a significant risk only in the case-crossover analysis, such as antithrombotic agents, calcium channel blockers, angiotensin II antagonists, lipid modifying agents, and benign prostatic hypertrophy agents, may have transient effects on FRIs at the time of initiation. Corticosteroids, which were only associated with risk of FRIs in the case-control analysis, had more of cumulative than transient effects on FRIs.
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Affiliation(s)
- Yu-Seon Jung
- Chung-Ang University College of Pharmacy, 84 Heukseok-Ro, Dongjak-Gu, Seoul, South Korea
| | - David Suh
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Eunyoung Kim
- Chung-Ang University College of Pharmacy, 84 Heukseok-Ro, Dongjak-Gu, Seoul, South Korea
| | - Hee-Deok Park
- Chung-Ang University College of Pharmacy, 84 Heukseok-Ro, Dongjak-Gu, Seoul, South Korea
| | - Dong-Churl Suh
- Rutgers, The State University of New Jersey School of Pharmacy, 160 Frelinghuysen Rd, Piscataway, NJ, USA.
| | - Sun-Young Jung
- Chung-Ang University College of Pharmacy, 84 Heukseok-Ro, Dongjak-Gu, Seoul, South Korea.
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Ali F, Wang D, Cheng Y, Wu M, Saleem MZ, Wei L, Xie Y, Yan M, Chu J, Yang Y, Shen A, Peng J. Quercetin attenuates angiotensin II-induced proliferation of vascular smooth muscle cells and p53 pathway activation in vitro and in vivo. Biofactors 2023; 49:956-970. [PMID: 37296538 DOI: 10.1002/biof.1959] [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] [Accepted: 04/23/2023] [Indexed: 06/12/2023]
Abstract
Quercetin is an essential flavonoid mostly found in herbal plants, fruits, and vegetables, which exhibits anti-hypertension properties. However, its pharmacological impact on angiotensin II (Ang II) induced the increase of blood pressure along with in-depth mechanism needs further exploration. The present study pointed out the anti-hypertensive role of quercetin and its comprehensive fundamental mechanisms. Our data showed that quercetin treatment substantially reduced the increase in blood pressure, pulse wave velocity, and aortic thickness of abdominal aorta in Ang II-infused C57BL/6 mice. RNA sequencing revealed that quercetin treatment reversed 464 differentially expressed transcripts in the abdominal aorta of Ang II-infused mice. Moreover, overlapping KEGG-enriched signaling pathways identified multiple common pathways between the comparison of Ang II versus control and Ang II + quercetin versus Ang II. Likewise, these pathways included cell cycle as well as p53 pathways. Transcriptome was further validated by immunohistochemistry, indicating that quercetin treatment significantly decreased the Ang II-induced expression of proliferating cell nuclear antigen (PCNA), cyclin-dependent kinase-4 (CDK4), and cyclin D1, while increased protein expression of p53, and p21 in abdominal aortic tissues of mice. In vitro, quercetin treatment meaningfully decreased the cell viability, arrested cell cycle at G0/G1 phase, and up-regulated the p53 and p21 proteins expression, as well as down-regulated the protein expression of cell cycle-related markers, for example, CDK4, cyclin D1 in Ang II stimulated vascular smooth muscle cells (VSMCs). This study addresses pharmacologic and mechanistic perspectives of quercetin against Ang-II-induced vascular injury and the increase of blood pressure.
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Affiliation(s)
- Farman Ali
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
| | - Di Wang
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
| | - Ying Cheng
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
| | - Meizhu Wu
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
| | - Muhammad Zubair Saleem
- Fujian Key Laboratory of Natural Medicine Pharmacology, Fujian Medical University, Fuzhou, Fujian, China
| | - Lihui Wei
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
- Center for Innovation and Transformation of Science and Technology, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Yi Xie
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
| | - Mengchao Yan
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
| | - Jiangfeng Chu
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
| | - Yanyan Yang
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
- Center for Innovation and Transformation of Science and Technology, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Aling Shen
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
- Center for Innovation and Transformation of Science and Technology, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Jun Peng
- Clinical Research Institute, the Second Affiliated Hospital and Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Key Laboratory of Integrative Medicine on Geriatrics, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
- Fujian Collaborative Innovation Center for Integrative Medicine in Prevention and Treatment of Major Chronic Cardiovascular Diseases, Fuzhou, Fujian, China
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Bai X, Han B, Zhang M, Liu J, Cui Y, Jiang H. The association between diuretics and falls in older adults: A systematic review and meta-analysis. Geriatr Nurs 2023; 52:106-114. [PMID: 37290215 DOI: 10.1016/j.gerinurse.2023.05.009] [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: 03/10/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Diuretic intake increases the risk of falling. However, previous studies have shown inconsistent correlations between diuretics and falls. This meta-analysis aimed to provide a comprehensive overview of the relationship between diuretic use and risk of falls in older adult individuals. METHODS Six databases (Cochrane Library, PubMed, Medline, CINAHL, Web of Science, and EMBASE) were searched from their inception to November 9, 2022. The risk of bias was independently evaluated using the Newcastle-Ottawa Quality Assessment Scale. A comprehensive meta-analysis was used to analyze the eligible studies. RESULTS Fifteen articles were analyzed. Studies have shown that diuretics can increase the risk of falls in older adult individuals. The probability of falls in older adult individuals who used diuretics was 1.185 times higher than in those who did not take diuretics. CONCLUSION Diuretics were significantly associated with an increased risk of falls.
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Affiliation(s)
- Xue Bai
- School of Nursing, Fudan University, Shanghai, China; Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Bing Han
- Department of Nursing, Beijing Ji Shui Tan Hospital, Beijing, China
| | - Man Zhang
- School of Medical, Yan'an University, Yan'an City, Shaanxi Province, China
| | - Jinfeng Liu
- Mianyang Central Hospital, Mianyang City, Sichuan Province, China
| | - Yi Cui
- Department of Nursing, Air Force Medical University, Xi'an City, Shaanxi Province, China
| | - Hong Jiang
- Huashan Hospital affiliated to Fudan University, Shanghai, China.
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Pinkoh R, Rodsiri R, Wainipitapong S. Retrospective cohort observation on psychotropic drug-drug interaction and identification utility from 3 databases: Drugs.com®, Lexicomp®, and Epocrates®. PLoS One 2023; 18:e0287575. [PMID: 37347788 PMCID: PMC10287001 DOI: 10.1371/journal.pone.0287575] [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: 02/14/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Pharmacotherapy is necessary for many people with psychiatric disorders and polypharmacy is common. The psychotropic drug-drug interaction (DDI) should be concerned and efficiently monitored by a proper instrument. OBJECTIVES This study aimed to investigate the prevalence and associated factors of psychotropic DDI and to compare the identification utility from three databases: Drugs.com®, Lexicomp®, and Epocrates®. METHODS This was a retrospective cohort design. We collected demographic and clinical data of all patients hospitalised in the psychiatric inpatient unit in 2020. Psychotropic DDI profiles were examined through three databases. Descriptive statistics were used to report comprehensiveness of each database and prevalence of psychotropic DDI. The Fleiss' kappa index would be analysed to indicate agreement strength of DDI severity classification among three databases. RESULTS From 149 total admissions, the psychotropic DDIs were found in 148 admissions (99.3%). Thorough the study, there were 182 of both psychotropic and other agents prescribed under 1,357 prescriptions. In total, 2,825 psychotropic DDIs were identified by using Drugs.com® 2,500 times, Epocrates® 2,269 times, and Lexicomp® 2,265 times. Interactions with clonazepam was the three most frequent agents when co-administrated with quetiapine (n = 56), risperidone (n = 36), and valproic acid and derivatives (n = 36). Serious DDIs were comparatively lower in incidence and there was no evidence of its association with reported clinical adverse consequences. The study revealed slight and fair agreement regarding severity classification among the three databases was found. DDI events detected by Drugs.com® were greatest in number, but Lexicomp® provided the broadest list of medications prescribed in our study. CONCLUSION Among three databases, interactions detected by Drugs.com® were greatest in number, whereas Lexicomp® provided the broadest list of medications. Development of such databases, based on both theoretical and clinical conceptions, should be focused to balance safety of patients and weariness of healthcare providers.
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Affiliation(s)
- Ravi Pinkoh
- Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Ratchanee Rodsiri
- Department of Pharmacology and Physiology, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Sorawit Wainipitapong
- Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
- Department of Psychiatry and Center of Excellence in Transgender Health (CETH), Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
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Gallagher E, Mehmood M, Lavan A, Kenny RA, Briggs R. Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA. Eur Geriatr Med 2023:10.1007/s41999-023-00786-x. [PMID: 37157012 DOI: 10.1007/s41999-023-00786-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/13/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people. METHODS Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates. RESULTS Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures. CONCLUSION Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.
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Affiliation(s)
- Eleanor Gallagher
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Mustafa Mehmood
- Department of Emergency Medicine, St James's Hospital, Dublin, Ireland
| | - Amanda Lavan
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Robert Briggs
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland.
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland.
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland.
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COVID-19 Induced Postural Orthostatic Tachycardia Syndrome (POTS): A Review. Cureus 2023; 15:e36955. [PMID: 37009342 PMCID: PMC10065129 DOI: 10.7759/cureus.36955] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
POTS (Postural Orthostatic Tachycardia Syndrome) is a multisystem disorder characterized by the abnormal autonomic response to an upright posture, causing orthostatic intolerance and excessive tachycardia without hypotension. Recent reports suggest that a significant percentage of COVID-19 survivors develop POTS within 6 to 8 months of infection. Prominent symptoms of POTS include fatigue, orthostatic intolerance, tachycardia, and cognitive impairment. The exact mechanisms of post-COVID-19 POTS are unclear. Still, different hypotheses have been given, including autoantibody production against autonomic nerve fibers, direct toxic effects of SARS-CoV-2, or sympathetic nervous system stimulation secondary to infection. Physicians should have a high suspicion of POTS in COVID-19 survival when presented with symptoms of autonomic dysfunction and should conduct diagnostic tests like the Tilt table and others to confirm it. The management of COVID-19-related POTS requires a comprehensive approach. Most patients respond to initial non-pharmacological options, but when the symptoms become more severe and they do not respond to the non-pharmacological approach, pharmacological options are considered. We have limited understanding and knowledge of post-COVID-19 POTS, and further research is warranted to improve our understanding and formulate a better management plan.
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Can We Predict Imbalance in Patients? Analysis of the CDC National Health and Nutrition Examination Survey. J Clin Med 2023; 12:jcm12051943. [PMID: 36902730 PMCID: PMC10004139 DOI: 10.3390/jcm12051943] [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: 01/07/2023] [Revised: 02/06/2023] [Accepted: 02/16/2023] [Indexed: 03/06/2023] Open
Abstract
Understanding global body balance can optimize the postoperative course for patients undergoing spinal or lower limb surgical realignment. This observational cohort study aimed to characterize patients with reported imbalance and identify predictors. The CDC establishes a representative sample annually via the NHANES. All participants who said "yes" (Imbalanced) or "no" (Balanced) to the following question were identified from 1999-2004: "During the past 12 months, have you had dizziness, difficulty with balance or difficulty with falling?" Univariate analyses compared Imbalanced versus Balanced subjects and binary logistic regression modeling predicted for Imbalance. Of 9964 patients, imbalanced (26.5%) were older (65.4 vs. 60.6 years), with more females (60% vs. 48%). Imbalanced subjects reported higher rates of comorbidities, including osteoporosis (14.4% vs. 6.6%), arthritis (51.6% vs. 31.9%), and low back pain (54.4% vs 32.7%). Imbalanced patients had more difficulty with activities, including climbing 10 steps (43.8% vs. 21%) and stooping/crouching/kneeling (74.3% vs. 44.7%), and they needed greater time to walk 20 feet (9.5 vs. 7.1 s). Imbalanced subjects had significantly lower caloric and dietary intake. Regression revealed that difficulties using fingers to grasp small objects (OR: 1.73), female gender (OR: 1.43), difficulties with prolonged standing (OR: 1.29), difficulties stooping/crouching/kneeling (OR: 1.28), and increased time to walk 20 feet (OR: 1.06) were independent predictors of Imbalance (all p < 0.05). Imbalanced patients were found to have identifiable comorbidities and were detectable using simple functional assessments. Structured tests that assess dynamic functional status may be useful for preoperative optimization and risk-stratification for patients undergoing spinal or lower limb surgical realignment.
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Brignole M, Rivasi G, Fedorowski A, Ståhlberg M, Groppelli A, Ungar A. Tests for the identification of reflex syncope mechanism. Expert Rev Med Devices 2023; 20:109-119. [PMID: 36814102 DOI: 10.1080/17434440.2023.2174428] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Treatment efficacy of reflex syncope is mainly related to the mechanism underlying syncope rather than its etiology or clinical presentation. The predominant mechanism underlying reflex syncope can be assigned to hypotensive or to bradycardic phenotypes. AREAS COVERED Methodology and diagnostic criteria of the most useful tests for the identification of hypotensive and bradycardic phenotypes are discussed. Diagnostic tests for the hypotensive phenotype include office blood pressure measurement with active standing test, home, and wearable blood pressure monitoring, 24-h ambulatory blood pressure monitoring and tilt table test. Diagnostic tests for the bradycardic phenotype include carotid sinus massage, tilt table test and prolonged ECG monitoring. EXPERT OPINION In reflex syncope, the documentation of bradycardia/asystole during a syncopal episode does not rule out the possibility that a preceding or parallel hypotensive reflex plays an important role. Similarly, even when a hypotensive mechanism is established, the possibility of an associated cardioinhibitory reflex should be investigated. Investigating the mechanism of reflex syncope is mandatory in patients with severe recurrent episodes, with the final aim to develop a personalized treatment strategy. Recent trials have demonstrated the benefits of personalized mechanism-based therapy, thus highlighting the importance of a comprehensive assessment of the mechanisms underlying syncope.
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Affiliation(s)
- Michele Brignole
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Marcus Ståhlberg
- Department of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Sweden
| | - Antonella Groppelli
- Department of Cardiology, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Chen C, Hennessy S, Brensinger CM, Bilker WB, Dublin S, Chung SP, Horn JR, Bogar KF, Leonard CE. Antidepressant drug-drug-drug interactions associated with unintentional traumatic injury: Screening for signals in real-world data. Clin Transl Sci 2023; 16:326-337. [PMID: 36415144 PMCID: PMC9926061 DOI: 10.1111/cts.13452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/23/2022] [Accepted: 10/27/2022] [Indexed: 11/24/2022] Open
Abstract
Antidepressants are associated with traumatic injury and are widely used with other medications. It remains unknown how drug-drug-drug interactions (3DIs) between antidepressants and two other drugs may impact potential injury risks associated with antidepressants. We aimed to generate hypotheses regarding antidepressant 3DI signals associated with elevated injury rates. Using 2000-2020 Optum's de-identified Clinformatics Data Mart, we performed a self-controlled case series study for each drug triad consisting of an antidepressant + codispensed drug (base-pair) with a candidate interacting medication (precipitant). We included persons aged greater than or equal to 16 years who (1) experienced an injury and (2) used a candidate precipitant, during base-pair therapy. We compared injury rates during observation time exposed to the drug triad versus the base-pair only, adjusting for time-varying covariates. We calculated adjusted rate ratios (RRs) using conditional Poisson regression and accounted for multiple comparisons via semi-Bayes shrinkage. Among 147,747 eligible antidepressant users with an injury, we studied 120,714 antidepressant triads, of which 334 (0.3%) were positively associated with elevated injury rates and thus considered potential 3DI signals. Adjusted RRs for signals ranged from 1.31 (1.04-1.65) for sertraline + levothyroxine with tramadol (vs. without tramadol) to 6.60 (3.23-13.46) for escitalopram + simvastatin with aripiprazole (vs. without aripiprazole). Nearly half of the signals (137, 41.0%) had adjusted RRs greater than or equal to 2, suggesting strong associations with injury. The identified signals may represent antidepressant 3DIs of potential clinical concern and warrant future etiologic studies to test these hypotheses.
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Affiliation(s)
- Cheng Chen
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sean Hennessy
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Colleen M. Brensinger
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Warren B. Bilker
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Psychiatry, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
- Department of Epidemiology, School of Public HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Sophie P. Chung
- Epocrates Medical InformationAthenaHealth, Inc.WatertownMassachusettsUSA
| | - John R. Horn
- Department of Pharmacy, School of PharmacyUniversity of WashingtonSeattleWashingtonUSA
| | - Kacie F. Bogar
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Charles E. Leonard
- Center for Real‐World Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and BiostatisticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Dalli LL, Olaiya MT, Kim J, Andrew NE, Cadilhac DA, Ung D, Lindley RI, Sanfilippo FM, Thrift AG, Nelson MR, Gall SL, Kilkenny MF. Antihypertensive Medication Adherence and the Risk of Vascular Events and Falls After Stroke: A Real-World Effectiveness Study Using Linked Registry Data. Hypertension 2023; 80:182-191. [PMID: 36330805 DOI: 10.1161/hypertensionaha.122.19883] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Real-world evidence is limited on whether antihypertensive medications help avert major adverse cardiovascular events (MACE) after stroke without increasing the risk of falls. We investigated the association of adherence to antihypertensive medications on the incidence of MACE and falls requiring hospitalization after stroke. METHODS A retrospective cohort study of adults who were newly dispensed antihypertensive medications after an acute stroke (Australian Stroke Clinical Registry 2012-2016; Queensland and Victoria). Pharmaceutical dispensing records were used to determine medication adherence according to the proportion of days covered in the first 6 months poststroke. Outcomes between 6 and 18 months postdischarge included: (i) MACE, a composite outcome of all-cause death, recurrent stroke or acute coronary syndrome; and (ii) falls requiring hospitalization. Estimates were derived using Cox models, adjusted for >30 confounders using inverse probability treatment weights. RESULTS Among 4076 eligible participants (median age 68 years; 37% women), 55% had a proportion of days covered ≥80% within 6 months postdischarge. In the subsequent 12 months, 360 (9%) participants experienced a MACE and 337 (8%) experienced a fall requiring hospitalization. After achieving balance between groups, participants with a proportion of days covered ≥80% had a reduced risk of MACE (hazard ratio: 0.68; 95% CI: 0.54-0.84) and falls requiring hospitalization (subdistribution hazard ratio: 0.78; 95% CI: 0.62-0.98) than those with a proportion of days covered <80%. CONCLUSIONS High adherence to antihypertensive medications within 6 months poststroke was associated with reduced risks of both MACE and falls requiring hospitalization. Patients should be encouraged to adhere to their antihypertensive medications to maximize poststroke outcomes.
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Affiliation(s)
- Lachlan L Dalli
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.)
| | - Muideen T Olaiya
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.)
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia (N.E.A., D.U.)
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - David Ung
- Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia (N.E.A., D.U.)
| | - Richard I Lindley
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia (R.I.L.)
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia (F.M.S.)
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.)
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia (M.R.N., S.L.G.)
| | - Seana L Gall
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia (M.R.N., S.L.G.)
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (L.L.D., M.T.O., J.K., D.A.C., A.G.T., S.L.G., M.F.K.).,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
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34
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Cacciatore S, Spadafora L, Landi F. Orthostatic hypotension in elderly: Do you measure orthostatic and clinostatic blood pressure? HEART, VESSELS AND TRANSPLANTATION 2022. [DOI: 10.24969/hvt.2022.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this article we highlighted the blood pressure management in elderly patients with orthostatic hypotension.
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35
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Pogge EK, Davis LE. Geriatric Pharmacotherapy Case Series: Neurogenic Orthostatic Hypotension. Sr Care Pharm 2022; 37:546-554. [DOI: 10.4140/tcp.n.2022.546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This case illustrates the pharmacist’s role in the outpatient management of neurogenic orthostatic hypotension (nOH) in a community-dwelling older person. In this case, the patient has a long-standing history of asymptomatic hypotension with recent onset of falls with temporary
loss of consciousness prompting initiation of pharmacologic therapy. This case reviews nonpharmacological and pharmacological treatment options for older people with symptomatic nOH.
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Affiliation(s)
| | - Lindsay E. Davis
- Midwestern University College of Pharmacy-Glendale, Glendale, Arizona
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36
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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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37
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Hui G, Xiahuan C, Yanjun W, Wenyi L, Meilin L. Influencing factors and hemodynamic study of initial and sustained orthostatic hypotension in middle-aged and elderly patients. J Clin Hypertens (Greenwich) 2022; 24:1491-1497. [PMID: 36263516 DOI: 10.1111/jch.14588] [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: 07/22/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 12/01/2022]
Abstract
Orthostatic hypotension (OH) is a common autonomic disorder. This study aimed to investigate the influencing factors and hemodynamic mechanisms of initial and sustained OH in middle-aged and elderly patients. The authors analyzed the clinical characteristics and hemodynamic variables of patients aged ≥ 50 years according to the various forms of OH, diagnosed by an active orthostatic test using the CNAP monitor. The study included 473 participants; 119 (25.2%) patients had initial (54, 45.4%) or sustained (65, 54.6%) OH. Age, comorbidities, or medications did not differ significantly between the initial OH and non-OH groups. Sustained OH was associated with age and diabetes (p = .003 and p = .015, respectively). Hemodynamic analysis revealed higher cardiac output (CO) in the sustained OH group within 15 s than in the non-OH and initial OH groups (both p < .001); no difference in CO was observed between the initial OH and non-OH groups. The systemic vascular resistance (SVR) in both initial OH and sustained OH groups within 15 s was lower than that in the non-OH group (both p < .001). No differences in SVR at 3 min were observed between the initial OH and non-OH groups. The SVR at 3 min in the sustained OH group was significantly lower than in non-OH and initial OH groups (both p < .001). Age and diabetes emerged as the independent risk factors associated with sustained OH. Initial OH is associated with a mismatch of increase in CO and decrease in SVR. Sustained OH is mainly associated with sustained inadequate adjustment in SVR.
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Affiliation(s)
- Geng Hui
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Chen Xiahuan
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Wang Yanjun
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Liang Wenyi
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Liu Meilin
- Department of Geriatrics, Peking University First Hospital, Beijing, China
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38
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Personalised physiological medicine: Orthostatic hypotension. Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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39
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Hidalgo-Lozada GM, Villarruel-López A, Martínez-Abundis E, Vázquez-Paulino O, González-Ortiz M, Pérez-Rubio KG. Ellagic Acid Effect on the Components of Metabolic Syndrome, Insulin Sensitivity and Insulin Secretion: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. J Clin Med 2022; 11:jcm11195741. [PMID: 36233611 PMCID: PMC9572658 DOI: 10.3390/jcm11195741] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/22/2022] [Accepted: 09/24/2022] [Indexed: 11/16/2022] Open
Abstract
Metabolic syndrome (MetS) is a cluster of cardiovascular risk factors, usually with a common pathophysiological origin in insulin resistance and abdominal obesity. Considering the reported effects of ellagic acid (EA) on insulin resistance and abdominal obesity, the aim of this study was to evaluate the effect of EA on the components of MetS, insulin sensitivity and insulin secretion by conducting a randomized, double-blind, placebo-controlled, clinical trial with 32 volunteers diagnosed with MetS. Sixteen patients were randomly allocated, received 500 mg of EA orally twice a day for 12 weeks, and the other 16 received a placebo. Clinical and laboratory determinations were obtained at baseline and at the end of the study. After EA administration, patients reduced their waist circumference (females: 102.2 ± 4.2 to 99.5 ± 3.2 cm (p < 0.05); males: 99.8 ± 6.7 to 96.0 ± 4.7 cm (p < 0.01)), systolic blood pressure (118.1 ± 10.1 to 113.7 ± 7.8 mmHg (p < 0.01)), diastolic blood pressure (118.1 ± 10.1 to 113.7 ± 7.8 mmHg (p < 0.01)), triglycerides (2.8 ± 1.1 to 2.1 ± 0.7 mmol/L (p < 0.01)), fasting plasma glucose (6.5 ± 0.5 to 5.7 ± 0.6 mmol/L (p < 0.01)), fasting plasma insulin (p < 0.01), and insulin secretion (p < 0.05), with an increase of insulin sensitivity (p < 0.01). In male patients, high-density lipoprotein cholesterol increased (p < 0.05). In conclusion, EA improved the components of MetS, reduced hyperinsulinemia, and improved insulin sensitivity.
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Affiliation(s)
- Gladys Maribel Hidalgo-Lozada
- Institute of Experimental and Clinical Therapeutics, Department of Physiology, Health Sciences University Center, University of Guadalajara, Guadalajar 44340, Mexico
| | - Angélica Villarruel-López
- Department of Pharmacobiology, University Center for Exact and Engineering Sciences, University of Guadalajara, Guadalajara 44430, Mexico
- Correspondence: (A.V.-L.); (K.G.P.-R.)
| | - Esperanza Martínez-Abundis
- Institute of Experimental and Clinical Therapeutics, Department of Physiology, Health Sciences University Center, University of Guadalajara, Guadalajar 44340, Mexico
- Health Biomedical Research Center, Guadalajara 44140, Mexico
| | - Olga Vázquez-Paulino
- Department of Pharmacobiology, University Center for Exact and Engineering Sciences, University of Guadalajara, Guadalajara 44430, Mexico
| | | | - Karina Griselda Pérez-Rubio
- Institute of Experimental and Clinical Therapeutics, Department of Physiology, Health Sciences University Center, University of Guadalajara, Guadalajar 44340, Mexico
- Health Biomedical Research Center, Guadalajara 44140, Mexico
- Correspondence: (A.V.-L.); (K.G.P.-R.)
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40
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Loh GOC, Wong EYL, Tan YTF, Wee HC, Ng RS, Syed HK, Kok Khiang P. Simple and high sample throughput LC/ESI-MS/MS method for bioequivalence study of prazosin, a drug with risk of orthostatic hypotension. Drug Dev Ind Pharm 2022; 48:470-479. [DOI: 10.1080/03639045.2022.2125985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Gabriel Onn Cit Loh
- Bioxis Sdn. Bhd. PMT 1241, Jalan Perindustrian Bukit Minyak 8, Taman Perindustrian Bukit Minyak, 14100 Simpang Ampat, Penang, Malaysia
| | - Emily Yii Ling Wong
- Bioxis Sdn. Bhd. PMT 1241, Jalan Perindustrian Bukit Minyak 8, Taman Perindustrian Bukit Minyak, 14100 Simpang Ampat, Penang, Malaysia
| | - Yvonne Tze Fung Tan
- Bioxis Sdn. Bhd. PMT 1241, Jalan Perindustrian Bukit Minyak 8, Taman Perindustrian Bukit Minyak, 14100 Simpang Ampat, Penang, Malaysia
| | - Hong Chin Wee
- Clinical Research Centre, Hospital Pulau Pinang, Jalan Residensi, 10990 Georgetown, Penang, Malaysia
| | - Ru Shing Ng
- Clinical Research Centre, Hospital Pulau Pinang, Jalan Residensi, 10990 Georgetown, Penang, Malaysia
| | - Haroon Khalid Syed
- Department of Pharmaceutics, Faculty of Pharmaceutical Sciences, Government College University, Faisalabad 38000, Pakistan
| | - Peh Kok Khiang
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Minden, Penang, Malaysia
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41
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Hussain SM, Ernst ME, Barker AL, Margolis KL, Reid CM, Neumann JT, Tonkin AM, Phuong TLT, Beilin LJ, Pham T, Chowdhury EK, Cicuttini FM, Gilmartin-Thomas JFM, Carr PR, McNeil JJ. Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication. Hypertension 2022; 79:2051-2061. [PMID: 35722878 PMCID: PMC9378722 DOI: 10.1161/hypertensionaha.122.19356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported. METHODS Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls. RESULTS Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers. CONCLUSIONS Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.
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Affiliation(s)
- Sultana Monira Hussain
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Victoria 3010 Australia
| | - Michael E. Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy; and, Department of Family Medicine, Carver College of Medicine. The University of Iowa, Iowa City, Iowa. USA
| | - Anna L Barker
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | | | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Johannes T Neumann
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- Department of Cardiology, University Heart & Vascular Center Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Andrew M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Thao Le Thi Phuong
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Lawrence J Beilin
- Medical School, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Thao Pham
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Enayet K Chowdhury
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Flavia M Cicuttini
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - Julia FM Gilmartin-Thomas
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
- College of Health and Biomedicine, and Institute for Health & Sport, Victoria University, Victoria, Australia
- Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Prudence R Carr
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
| | - John J McNeil
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004 Australia
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42
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Zhao M. Comment on "Orthostatic changes in blood pressure and survival in elderly cardiopaths". Rev Assoc Med Bras (1992) 2022; 68:875-876. [PMID: 35766705 PMCID: PMC9575885 DOI: 10.1590/1806-9282.20220366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/26/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Ming Zhao
- Cangzhou Central Hospital, Department of Cardiology - Cangzhou, China
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43
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Oren G, Jolkovsky S, Tal S. Falls in oldest-old adults hospitalized in acute geriatric ward. Eur Geriatr Med 2022; 13:859-866. [PMID: 35776410 DOI: 10.1007/s41999-022-00660-2] [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: 11/24/2021] [Accepted: 05/09/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE The study aims to identify risk factors for falling among acutely ill older patients, hospitalized in acute geriatric ward. METHODS A retrospective study of 260 cases of patients who had fallen and 439 controls was conducted in a geriatric ward. We retrieved from the electronic hospital records data including patient demographics, medical diagnoses, and laboratory results, and drugs taken prior to the fall were reviewed. In addition, data on functional and cognitive status were recorded. Admission Morse Falls Scale for every patient was also retrieved. RESULTS The following on-admission diagnoses were associated with a higher incidence of falls during hospitalization: hypertension (84% vs. 38%), congestive heart failure (CHF), 74% vs 16%, dementia (36% vs. 5%), and delirium (36% vs 5%). A higher percentage of fallers compared to controls consumed beta blockers (69% vs. 53%), benzodiazepines (46% vs. 32%), antidepressants (33% vs. 23%), oral diabetes drugs (20% vs. 11%) and opiates (8% vs. 4%). On-admission Morse Falls Scale score was found to be higher in the patients who fell (59 vs.53). The strongest predictors of falling during hospitalization were CHF, hypertension, dementia, delirium, assisted mobility and dependence. CONCLUSION A systematic screening of risk factors for falls and identification of them might contribute to reducing the risk associated with falls during hospitalization.
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Affiliation(s)
- Gal Oren
- Acute Geriatrics Department at Kaplan Medical Center, Affiliated with the Hebrew University of Jerusalem, 1, Derech Pasternak, st., Rehovot, Israel
| | - Svetlana Jolkovsky
- Geriatrics Department, Hartzfeld Hospital, Kaplan Medical Center, Gedera, Affiliated with the Hebrew University of Jerusalem, Rehovot, Israel
| | - Sari Tal
- Acute Geriatrics Department at Kaplan Medical Center, Affiliated with the Hebrew University of Jerusalem, 1, Derech Pasternak, st., Rehovot, Israel. .,Geriatrics Department, Hartzfeld Hospital, Kaplan Medical Center, Gedera, Affiliated with the Hebrew University of Jerusalem, Rehovot, Israel.
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Denfeld QE, Turrise S, MacLaughlin EJ, Chang PS, Clair WK, Lewis EF, Forman DE, Goodlin SJ. Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000108. [PMID: 35587567 DOI: 10.1161/hcq.0000000000000108] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.
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Morillo CA, Brignole M. Pacing for vasovagal syncope: Tips for use in practice. Auton Neurosci 2022; 241:102998. [DOI: 10.1016/j.autneu.2022.102998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 05/17/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
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Osman A, Kamkar N, Speechley M, Ali S, Montero-Odasso M. Fall risk-increasing drugs and gait performance in community-dwelling older adults: A systematic review. Ageing Res Rev 2022; 77:101599. [PMID: 35219903 DOI: 10.1016/j.arr.2022.101599] [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: 08/07/2021] [Revised: 02/12/2022] [Accepted: 02/23/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE Medication use, and gait impairment are two major risk factors for falls in older adults. There are several mechanisms linking fall risk-increasing drugs (FRIDs) and increased fall risk. One pathway involves gait performance as an intermediate variable. It is plausible that FRIDs indirectly increase fall risk by causing gait impairment. The purpose of this review was to systematically review the existing evidence on the association between FRIDs and gait performance in community-dwelling older adults without neurological movement disorders. METHODS Two searches were performed using MeSH terms and keywords in the electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL and grey literature. We included clinical trials and observational studies that assessed the association between a FRID class and any quantitative measure of gait performance. Quality assessment was performed using the Newcastle-Ottawa scale for observational studies and the Cochrane risk-of-bias tool for clinical trials. Study characteristics and findings were summarized in a descriptive approach for each drug class. RESULTS A total of 11,197 studies were retrieved from both searches at the first step and a total of 23 studies met the final inclusion criteria. Fourteen studies assessed the association between psychotropic FRIDs and gait performance and nine assessed cardiovascular FRIDs. Four out of five studies found that drugs with sedative properties are associated with reduced gait speed in older adults. Three out of four studies found no association between statin use and gait speed. There is insufficient evidence on the association between FRIDs and other gait performance measures. CONCLUSION Caution should be taken when prescribing drugs with sedative properties to older adults at risk of falls. Further research is required to assess the impact of the use FRIDs on gait performance measures other than gait speed.
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Kraut R, Lundby C, Babenko O, Kamal A, Sadowski CA. Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100166. [PMID: 38559885 PMCID: PMC10978346 DOI: 10.1016/j.ahjo.2022.100166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 04/04/2024]
Abstract
Purpose of review The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults. Results Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making. Conclusion Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.
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Affiliation(s)
- Roni Kraut
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| | - Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Oksana Babenko
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| | - Ahmad Kamal
- Faculty of Science, University of Alberta, Edmonton, Canada
| | - Cheryl A. Sadowski
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
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Assessment of Abdominal Constrictor's Forces for Informing Computational Models of Orthostatic Hypotension. MATERIALS 2022; 15:ma15093116. [PMID: 35591450 PMCID: PMC9101553 DOI: 10.3390/ma15093116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/13/2022] [Accepted: 04/21/2022] [Indexed: 02/04/2023]
Abstract
Orthostatic hypotension is defined as a sudden drop in blood pressure upon standing from a sitting or supine position. The prevalence of this condition increases exponentially with age. Nonpharmacological treatments are always the first step in the management of this condition, such as the use of an abdominal constriction belt to optimize the blood volume in the abdomen. A multitude of clinical trials have shown the efficacy of elastic abdominal compression as well as compression using an inflatable bladder; however, there are currently few accessible consumer products that can provide abdominal compression by using an inflatable bladder that ensures the correct amount of pressure is being exerted on the subject. This study serves to quantitatively analyze forces exerted in inflatable abdominal binders, a novel treatment that fits the criterion for a first-line intervention for orthostatic hypotension. Quantitative values aim to indicate both the anatomic regions of the body subjected to the highest pressure by abdominal binding. Quantitative values will also create a model that can correlate the amount of compression on the subject with varying levels of pressure in the inflatable bladder. Inflatable binders of varying levels of inflation are used and localized pressure values are recorded at 5 different vertical points along the abdomen in the midsternal line and midclavicular line, at the locations of the splanchnic veins. These findings indicate both the differences in the compressive force applied through elastic and inflatable binding, as well the regions on the abdomen subject to the highest force load during compression by an abdominal binder. A medical manikin called the iStan Manikin was used to collect data. The pressure values on a manikin were sensed by the JUZO pressure monitor, a special device created for the purpose of measuring the force under compressive garments. The pressure inside the inflatable bladder was extrapolated from a pressure gauge and the pressure was recorded at different degrees of inflation of the belt (mmHG) along two different areas of the abdomen, the midsternal line and the midclavicular line, to discern differences in force exerted on the patient (mmHG). Computational studies on the data from the JUZO pressure monitor as well as the data from the pressure gauge on the inflatable bladder allow us to create a model that can correlate the amount of pressure in the inflatable bladder to the amount of pressure exerted on the belt, thus making sure that the patient is not being harmed by the compressive force. The results of our study indicate that there is no significant difference between the pressures exerted on the midsternal and midclavicular lines of the body by the abdominal binder and that no significant difference exists between the external pressure measured by the inflatable belt and the pressure sensed on the human body by the JUZO sensor; however, we were able to extrapolate an equation that can tell the user the amount of pressure that is actually being exerted on them based on the pressure in the inflatable bladder as recorded by the gauge.
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Virnes RE, Tiihonen M, Karttunen N, van Poelgeest EP, van der Velde N, Hartikainen S. Opioids and Falls Risk in Older Adults: A Narrative Review. Drugs Aging 2022; 39:199-207. [PMID: 35288864 PMCID: PMC8934763 DOI: 10.1007/s40266-022-00929-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
Abstract
Pain treatment is important in older adults but may result in adverse events such as falls. Opioids are effective for nociceptive pain but the evidence for neuropathic pain is weak. Nevertheless, both pain and opioids may increase the risk of falls. This narrative literature review aims to summarize the existing knowledge on the opioid-related fall risk in older adults, including the pharmacokinetics and pharmacodynamics, and assist clinicians in prescribing and deprescribing opioids in older persons. We systematically searched relevant literature on opioid-related fall risk in older adults in PubMed and Scopus in December 2020. We reviewed the literature and evaluated fall-related adverse effects of opioids, explaining how to optimally approach deprescribing of opioids in older adults. Opioid use increases fall risk through drowsiness, (orthostatic) hypotension and also through hyponatremia caused by weak opioids. When prescribing, opioids should be started with low dosages if possible, keeping in mind their metabolic genetic variation. Falls are clinically significant adverse effects of all opioids, and the risk may be dose dependent and highest with strong opioids. The risk is most prominent in older adults prone to falls. To reduce the risk of falls, both pain and the need for opioids should be assessed on a regular basis, and deprescribing or changing to a lower dosage or safer alternative should be considered if the clinical condition allows. Deprescribing should be done by reducing the dosage gradually and by assessing and monitoring the pain and withdrawal symptoms at the same time. Weighing the risks and benefits is necessary before prescribing opioids, especially to older persons at high risk of falls. Clinical decision tools assist prescribers in clinical decisions regarding (de-) prescribing.
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Affiliation(s)
- Roosa-Emilia Virnes
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland. .,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.
| | - Niina Karttunen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Eveline P van Poelgeest
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Natalie van der Velde
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Sirpa Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
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Tran J, Mol A, Iseli RK, Lim WK, Meskers CGM, Maier AB. Feasibility of Diagnosing Initial Orthostatic Hypotension Using a Continuous Blood Pressure Device in Geriatric Rehabilitation Inpatients: RESORT. Gerontology 2022; 68:951-960. [PMID: 35038699 PMCID: PMC9501774 DOI: 10.1159/000521411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022] Open
Abstract
Background Initial orthostatic hypotension (IOH) is highly prevalent in older adults and may interfere with the ability to regain function after acute hospitalization. IOH assessment requires a non-invasive, beat-to-beat continuous blood pressure device, which is not widely used in geriatric rehabilitation. Our aim was to test the feasibility of diagnosing IOH using a continuous blood pressure device in geriatric rehabilitation inpatients. Methods Geriatric rehabilitation inpatients of the REStORing Health of Acutely Unwell AdulTs (RESORT) cohort admitted to a tertiary hospital were randomly selected to undergo continuous blood pressure monitoring (Finapres) for 5 min in the supine position and 3 min of standing or sitting when unable to stand. Interventions to warm hands and adjusting the cuff pressure sizes were attempted if no signal was obtained or an error message occurred. Results Of 37 randomly selected inpatients, 29 {55.2% female; mean age 82.8 (standard deviation [SD]) 6.6 years} agreed to the continuous blood pressure measurement. Successful measurements were achieved in 20 out of 29 inpatients, two after hand warming. Patients with unsuccessful measurements were likely to be older (mean age 87.2 [SD] 4.4 years, p = 0.03), have cerebrovascular disease (p = 0.006), lower body mass index (p = 0.012), and a lower short physical performance battery score (p = 0.039). Eight out of 20 patients had IOH. Conclusion The number of unsuccessful continuous blood pressure measurements was high in a population with high IOH prevalence despite multiple interventions to establish a signal. Future research should focus on improving the efficiency of continuous blood pressure devices in hospitalized patients with unsuccessful signals.
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Affiliation(s)
- Jennifer Tran
- Department of Medicine and Aged Care, the Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Arjen Mol
- Department of Human Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rebecca K Iseli
- Department of Medicine and Aged Care, the Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Wen Kwang Lim
- Department of Medicine and Aged Care, the Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Carel G M Meskers
- Department of Human Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, the Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences, Amsterdam, The Netherlands.,Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Centre for Healthy Longevity, National University Health System, Singapore, Singapore
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