Intra-individual postural blood pressure variability and stroke in elderly nursing home residents

Variability of blood pressure response to orthostatism and reproducibility of orthostatic hypotension in hospitalized patients with acute ischemic stroke

OBJECTIVE

Orthostatic hypotension (OH) which diagnosis is based on the measurement of the blood pressure response to orthostatism (BPRO) is a common condition associated with adverse cerebrovascular and cognitive prognosis. It is likely that the single measurement might underestimate the true prevalence of OH. This study investigated the prevalence and reproducibility of the diagnosis of OH and related risk factors in hospitalized acute ischemic stroke (AIS) patients with multiple measurements.

MATERIALS AND METHODS

This study was a prospective cohort analysis of consecutive AIS patients admitted to the hospital. A total of 211 patients were included. BPRO was assessed five times at the same time on different days.

RESULTS

OH was found in 33 cases (15.6%) in the initial set of measurements of the first day. A cumulative diagnosis of OH after five BPRO tests was found in 75 cases (35.5%). The reproducibility of the diagnosis of OH was mild or poor. In patients with a cumulative diagnosis of OH, 29 (38.7%) patients had orthostatic hypertension (OHTN). In multivariate analysis, the Fazekas scale (odds radio = 1.28, 95% confidence interval (CI), 1.04-1.59, P  = 0.023) and extracranial carotid stenosis (≥70%) (odds radio = 3.64, 95% CI, 1.19-11.13, P  = 0.023) were independent risk factors for OH.

CONCLUSION

The reproducibility of OH is poor and the concurrent appearance of OH and OHTN is common in hospitalized AIS patients. Multiple measurements should be taken in hospitalized AIS patients when screening for OH especially patients with higher Fazekas scale and extracranial carotid stenosis (≥70%).

Exploring the Dynamics of Week-to-Week Blood Pressure in Nursing Home Residents Before Death

BACKGROUND

Aging is accompanied by an overall dysregulation of many dynamic physiologic processes including those related to blood pressure (BP). While year-to-year BP variability is associated with cardiovascular events and mortality, no studies have examined this trend with more frequent BP assessments. Our study objective is to take the next step to examine week-to-week BP dynamics-pattern, variability, and complexity-before death.

METHODS

Using a retrospective study design, we assessed BP dynamics in the 6 months before death in long-term nursing home residents between 1 October 2006 and 30 September 2017. Variability was characterized using SD and mean squared error after adjusting for diurnal variations. Complexity (i.e., amount of novel information in a trend) was examined using Shannon's entropy (bits). Generalized linear models were used to examine factors associated with overall BP variability.

RESULTS

We identified 17,953 nursing home residents (98.0% male, 82.5% White, mean age 80.2 years, and mean BP 125.7/68.6 mm Hg). Despite a slight trend of decreasing systolic week-to-week BP over time (delta = 7.2 mm Hg), week-to-week complexity did not change in the 6 months before death (delta = 0.02 bits). Average weekly BP variability was stable until the last 3-4 weeks of life, at which point variability increased by 30% for both systolic and diastolic BP. Factors associated with BP variability include average weekly systolic/diastolic BP, days in the nursing home, days in the hospital, and changes to antihypertensive medications.

CONCLUSIONS

Week-to-week BP variability increases substantially in the last month of life, but complexity does not change. Changes in care patterns may drive the increase in BP variability as one approaches death.

Morbidity and mortality in orthostatic hypotension

This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as neurogenic OH (nOH); these two conditions have distinct pathophysiologies and affect different patient populations. The prevalence of OH in the elderly varies depending on the study population. In community dwellers, OH prevalence is estimated at 16%, whereas in institutionalized patients, it may be as high as 60%. The prevalence of OH increases exponentially with age, particularly in those 75 years and older. Multiple epidemiological studies have identified OH as a risk factor for all-cause mortality and cardiovascular disease including heart failure and stroke. Real-world data from administrative databases found polypharmacy, multiple co-morbid conditions, and high health-care utilization as common characteristics in OH patients. A comprehensive evaluation of medications associated with OH is discussed with particular emphasis on the use of anti-hypertensive therapy from two large clinical trials on high-intensive versus standard blood pressure management. Finally, we also review the epidemiology of nOH based on the underlying neurodegenerative disorder (either Parkinson's disease or multiple system atrophy), and the presence of co-morbid conditions such as hypertension and cognitive impairment.

Orthostatic hypotension, dizziness, neurology outcomes, and death in older adults

OBJECTIVE

To test the hypothesis that orthostatic hypotension (OH) might cause cerebral hypoperfusion and injury, we examined the longitudinal relationship between OH or orthostatic symptoms and incident neurologic outcomes in a community population of older adults.

METHODS

Cardiovascular Health Study participants (≥65 years) without dementia or stroke had blood pressure (BP) measured after lying down for 20 minutes and after standing 3 for minutes. Participants reported dizziness immediately upon standing and any dizziness in the past 2 weeks. OH was defined as a drop in standing systolic/diastolic BP ≥20/≥10 mm Hg. We determined the association between OH or dizziness with (1) MRI brain findings (ventricular size, white matter hyperintensities, brain infarcts) using linear or logistic regression, (2) cognitive function (baseline and over time) using generalized estimating equations, and (3) prospective adjudicated events (dementia, stroke, death) using Cox models. Models were adjusted for demographic characteristics and OH risk factors. We used multiple imputation to account for missing OH or dizziness (n = 534).

RESULTS

Prior to imputation, there were 5,007 participants (mean age 72.7 ± 5.5 years, 57.6% women, 10.9% Black, 16% with OH). OH was modestly associated with death (hazard ratio [HR] 1.11; 95% confidence interval 1.02-1.20), but not MRI findings, cognition, dementia, or stroke. In contrast, dizziness upon standing was associated with lower baseline cognition (β = -1.20; -1.94 to -0.47), incident dementia (HR 1.32; 1.04-1.62), incident stroke (HR 1.22; 1.06-1.41), and death (HR 1.13; 1.06-1.21). Similarly, dizziness over the past 2 weeks was associated with higher white matter grade (β = 0.16; 0.03-0.30), brain infarcts (OR 1.31; 1.06-1.63), lower baseline cognition (β = -1.18; -2.01 to -0.34), and death (HR 1.13; 1.04-1.22).

CONCLUSIONS

Dizziness was more consistently associated with neurologic outcomes than OH 3 minutes after standing. Delayed OH assessments may miss pathologic information related to cerebral injury.

Systolic blood pressure postural changes variability is associated with greater dementia risk

OBJECTIVE

To determine whether orthostatic hypotension (OHYPO) and visit-to-visit blood pressure (BP) postural changes variability are associated with incident dementia.

METHODS

We studied 2,131 older adults from the Health, Aging, and Body Composition cohort study. Orthostatic BP was repeatedly assessed over a 5-year baseline period. OHYPO was defined as a fall ≥15 mm Hg in systolic or ≥7 mm Hg in diastolic BP after standing from a sitting position for one-third or more of the visits. Systolic OHYPO and diastolic OHYPO were also examined separately. BP postural changes variability over time was evaluated with several indicators, including SD and coefficient of variation (CV). Incident dementia was determined over 12 years after the baseline period by dementia medication use, ≥1.5 SD decline in Modified Mini-Mental State Examination score, or hospitalization records.

RESULTS

Of 2,131 participants (mean age 73 years, 53% female, 39% Black), 309 (14.5%) had OHYPO, 192 (9.0%) had systolic OHYPO, 132 (6.2%) had diastolic OHYPO, and 462 (21.7%) developed dementia. After adjustment for demographics, seated systolic BP (SBP), antihypertensive drugs, cerebrovascular disease, diabetes mellitus, depressive symptoms, smoking, alcohol, body mass index, and presence of 1 or 2 APOE ε4 alleles, systolic OHYPO was associated with greater dementia risk (adjusted hazard ratio [HR] 1.37, 95% confidence interval [CI] 1.01-1.88), unlike diastolic OHYPO and OHYPO. SBP postural changes variability was also associated with higher dementia risk (highest tertile of variability [CV]: adjusted HR 1.35, 95% CI 1.06-1.71).

CONCLUSION

Systolic OHYPO and visit-to-visit SBP postural changes variability were associated with greater dementia risk. Our findings raise the question of potential preventive interventions to control orthostatic SBP and its fluctuations.

Orthostatic hypotension: clinical review and case study

Transient loss of consciousness (TLOC) accounts for 3% of all attendance in emergency departments within the UK. More than 90% of TLOC presentations are due to epileptic seizures, psychogenic seizures or syncope. However, in England and Wales in 2002, it was estimated that 92 000 patients were incorrectly diagnosed with epilepsy, at an additional annual cost to the NHS of up to £189 million. This article will reflect on the case study of a 54-year-old female patient who presented with a possible TLOC, and had a background of long-term depression. Differential diagnoses will be discussed, but the article will focus on orthostatic hypotension. Being diagnosed with this condition is independently associated with an increased risk of all-cause mortality. Causes of orthostatic hypotension and the pathophysiology behind the condition will be discussed, highlighting the importance of obtaining an accurate clinical history. This is extremely pertinent if a patient collapses in an NHS setting and this is witnessed by nurses because they can contribute to the history of the type of collapse, to aid diagnosis and correct treatment. In addition, nurses have a valuable role to play in highlighting polypharmacy to doctors, and non-medical prescribers, as a contributing factor to orthostatic hypotension is polypharmacy. It is therefore important to accurately distinguish TLOC aetiology, not only to provide appropriate management, but to also identify patients at risk of morbidity/mortality related to underlying disease.

Orthostatic Hypotension, Cardiovascular Outcomes, and Adverse Events: Results From SPRINT

Orthostatic hypotension (OH) is frequently observed with hypertension treatment, but its contribution to adverse outcomes is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) was a randomized trial of adults, age ≥50 years at high risk for cardiovascular disease with a seated systolic blood pressure (BP) of 130 to 180 mm Hg and a standing systolic BP ≥110 mm Hg. Participants were randomized to a systolic BP treatment goal of either <120 or <140 mm Hg. OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mm Hg 1 minute after standing from a seated position. We used Cox models to examine the association of OH with cardiovascular disease or adverse study events by randomized BP goal. During the follow-up period (median 3years), there were 1170 (5.7%) instances of OH among those assigned a standard BP goal and 1057 (5.0%) among those assigned the intensive BP goal. OH was not associated with higher risk of cardiovascular disease events (primary outcome: hazard ratio 1.06 [95% CI, 0.78-1.44]). Moreover, OH was not associated with syncope, electrolyte abnormalities, injurious falls, or acute renal failure. OH was associated with hypotension-related hospitalizations or emergency department visits (hazard ratio, 1.77 [95% CI, 1.11-2.82]) and bradycardia (hazard ratio, 1.94 [95% CI, 1.19-3.15]), but these associations did not differ by BP treatment goal. OH was not associated with a higher risk of cardiovascular disease events, and BP treatment goal had no effect on OH's association with hypotension and bradycardia. Symptomless OH during hypertension treatment should not be viewed as a reason to down-titrate therapy even in the setting of a lower BP goal. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Acute reduction in cerebral blood velocity on supine-to-stand transition increases postural instability in young adults

We tested the hypothesis that transient deficits in cerebral blood flow are associated with postural sway. In 19 young, healthy adults, we examined the association between the drop in cerebral blood flow during supine-to-stand transitions, indexed by transcranial Doppler ultrasound [middle cerebral artery blood velocity at diastole (MCAdv)] and near-infrared spectroscopy [tissue saturation index (TSI)] and the center of pressure displacement while standing. Participants performed transitions under three conditions aimed at progressively increasing the drop in MCAdv, in a randomized order: 1) a control transition (Con); 2) a transition that coincided with deflation of bilateral thigh cuffs; and 3) a transition that coincided with both thigh-cuff deflation and 90 s of prior hyperventilation (HTC). The deficit in diastolic blood velocity (MCAdv deficit) was quantified as the difference between MCAdv and its preceding baseline value, summed over 10 s, beginning at the MCAdv nadir. Compared with Con, HTC led to greater drops in MCAdv (P = 0.003) and TSI (P < 0.001) at nadir. The MCAdv deficit was positively associated with the center of pressure displacement vector-average using repeated-measures correlation (repeated-measures correlation coefficient = 0.56, P < 0.001). An a posteriori analysis identified a sub-group of participants that showed an exaggerated increase in MCAdv deficit and greater postural instability in both the anterior-posterior (P = 0.002) and medial-lateral (P = 0.021) directions in response to the interventions. These findings support the theory that individuals who experience greater initial cerebral hypoperfusion on standing may be at a greater risk for falls.NEW & NOTEWORTHY Dizziness and risk for falls after standing might link directly to reduced delivery of oxygen to the brain. By introducing challenges that increased the drop in brain blood flow in healthy young adults, we have shown for the first time a direct link to greater postural instability. These results point to a need to measure cerebral blood flow and/or oxygenation after postural transitions in populations, such as older adults, to assist in fall risk assessment.

Hypertension Treatment Effects on Orthostatic Hypotension and Its Relationship With Cardiovascular Disease

Although orthostatic hypotension (OH) is often considered a contraindication to blood pressure (BP) treatment, evidence is lacking. We examined the effect of BP goal or initial medication choice on OH in AASK (African American Study of Kidney Disease and Hypertension), a 2×3 factorial trial. Blacks with chronic kidney disease attributed to hypertension were randomly assigned 1 of 2 BP goals: intensive (mean arterial pressure, ≤92 mm Hg) or standard (mean arterial pressure, 102-107 mm Hg) and 1 of 3 initial medications (ramipril, metoprolol, and amlodipine). Postural changes in systolic BP, diastolic BP, or heart rate (HR) were determined after 2 minutes and 45 seconds of standing. OH was assessed each visit and defined using the consensus definition (drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg). Median follow-up was 4 years. Outcomes were congestive heart failure, stroke, nonfatal cardiovascular disease (CVD), fatal CVD, any CVD (composite of preceding events), and all-cause mortality. There were 1094 participants (mean age, 54.5±10.7 years; 38.8% female; OH was assessed at 52 864 visits). Mean seated systolic BP, diastolic BP, and HR were 150.3±23.9 mm Hg, 95.5±14.2 mm Hg, and 72.0±12.6 bpm, respectively. A more intensive BP goal did not alter the distributions of standing BP and was not associated with OH, but metoprolol was associated with systolic OH compared with ramipril (odds ratio, 1.68; 95% CI, 1.15-2.46) and amlodipine (odds ratio, 1.94; 95% CI, 1.09-3.44). Although consensus OH was associated with stroke (HR, 5.01; 95% CI, 1.80-13.92), nonfatal CVD (HR, 2.28; 95% CI, 1.21-4.30), and any CVD event (HR, 2.12; 95% CI, 1.12-3.98), neither BP goal or medication altered this risk. Concerns about causing OH or its CVD consequences should not deter a lower BP goal among adults with chronic kidney disease attributed to hypertension.

Orthostatic Hypotension and Risk of Clinical and Subclinical Cardiovascular Disease in Middle-Aged Adults

Background

Although orthostatic hypotension (OH) is a well‐recognized manifestation of neuropathy and hypovolemia, its contribution to cardiovascular disease (CVD) risk is controversial.

Methods and Results

Participants with OH, defined as a decrease in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, were identified during the first visit of the ARIC (Atherosclerosis Risk in Communities) Study (1987–1989) within 2 minutes of standing. All participants were followed up for the development of myocardial infarction, heart failure, stroke, fatal coronary heart disease (CHD), any CHD (combination of silent, nonfatal, and fatal CHD or cardiac procedures), and all‐cause mortality. Participants were assessed for carotid intimal thickness and plaque during the first visit. Detectable high‐sensitivity troponin T (≥5 ng/L) and elevated NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide; ≥100 pg/mL) were determined in blood collected during the second visit (1990–1992). All associations were adjusted for known CVD risk factors. In 9139 participants (57% women; 23% black; mean age, 54±5.7 years), 3% had OH. During follow‐up (median, 26 years), OH was associated with myocardial infarction (hazard ratio [HR], 1.88; 95% confidence interval [CI], 1.44–2.46), congestive heart failure (HR, 1.65; 95% CI, 1.34–2.04), stroke (HR, 1.83; 95% CI, 1.35–2.48), fatal CHD (HR, 2.77; 95% CI, 1.93–3.98), any CHD (HR, 2.00; 95% CI, 1.64–2.44), and all‐cause mortality (HR, 1.68; 95% CI, 1.45–1.95). OH was also associated with carotid intimal thickness (β, 0.05 mm; 95% CI, 0.04–0.07 mm), carotid plaque (odds ratio, 1.51; 95% CI, 1.18–1.93), detectable high‐sensitivity troponin T (odds ratio, 1.49; 95% CI, 1.16–1.93), and elevated NT‐proBNP (odds ratio, 1.92; 95% CI, 1.48–2.49).

Conclusions

OH identified in community‐dwelling middle‐aged adults was associated with future CVD events and subclinical CVD. Further research is necessary to establish a causal role for OH in the pathogenesis of CVD.

Orthostatic hypotension and drug therapy in patients at an outpatient comprehensive geriatric assessment unit

OBJECTIVE

To assess the rate of orthostatic hypotension and factors associated with it among elderly patients who underwent a comprehensive, ambulatory geriatric assessment.

METHODS

The study included patients 65 years and older who were assessed in the outpatient comprehensive geriatric assessment unit. Data were collected from the computerized medical record including sociodemographic data, lifestyle, falls, blood pressure, BMI, functional and cognitive status, medications, and comorbidity.

RESULTS

The study population consisted of 571 patients who underwent assessment over a nine-year period. The mean age was 83.7 ± 6.1, 35.9% were men, and 183 (32.1%) were diagnosed with orthostatic hypotension. Multiple drugs, in general, and multiple drugs with the potential to cause orthostatic hypotension in particular increased the risk for orthostatic hypotension after adjustment for age, sex, chronic comorbidity, and supine systolic blood pressure ≥150 mmHg [odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.03-1.14 and OR = 1.22, 95% CI: 1.08-1.37, respectively]. In addition, α-blockers and calcium channel blockers increased the risk for orthostatic hypotension after similar adjustments (OR = 1.82, 95% CI: 1.01-3.16 and OR = 1.66, 95% CI: 1.11-2.48, respectively). Similarly, two additional drug types increased the risk for orthostatic hypotension: selective serotonin reuptake inhibitors (OR = 2.09, 95% CI: 1.33-3.19) and tricyclic antidepressants (OR = 4.36, 95% CI: 1.85-10.06). There were no specific associations between age, cognitive and functional state, morbidity (as measured by the Charlson Comorbidity Index), and specific diseases, and orthostatic hypotension.

CONCLUSION

The results of the present study reinforce evidence of an association between drug therapy and orthostatic hypotension.

The association between orthostatic hypotension and cognitive state among adults 65 years and older who underwent a comprehensive geriatric assessment

The prevalence of cognitive impairment and orthostatic hypotension (OH) increases with age, but the results of studies that assessed possible associations between them are inconsistent.The aim of this study is to assess possible associations between cognitive impairment and OH in patients ≥65 years of age who underwent a comprehensive geriatric assessment.A retrospective analysis was conducted of the computerized medical records of the study population from 2005 to 2013. Data collected included blood pressure measurements that enabled the calculation of OH, results of the mini-mental state examination (MMSE), results of the Montreal cognitive assessment (MoCA) test, and cognitive diagnoses that were determined over the course of the assessment.The rate of OH in the study population of 571 adults was 32.1%. The mean MMSE score was 22.5 ± 5.2 among participants with OH and 21.6 ± 5.8 among those without OH (P = 0.09). The absence of a significant association between OH and MMSE remained after adjusting the MMSE score for age and education level. The mean MoCA score was 16.4 ± 5.0 among participants with OH and 16.4 ± 4.8 among those without (P = 0.33). The prevalence of OH was 39% among participants without cognitive impairment, 28.9% among those with mild cognitive impairment (MCI), and 30.6% among those with dementia (P = 0.13).There was no association between OH and cognitive impairment in adults who underwent a comprehensive geriatric assessment.

Orthostatic Hypotension Predicts a Poor Prognosis in Elderly People with Dementia

Objective The purpose of the present study was to assess the prevalence of orthostatic hypotension (OH) and elucidate its associations with the demographic characteristics and the prognosis in elderly subjects with dementia who visited a hospital for elderly daycare. Methods A total of 64 outpatients (44 females) with a mean age of 84±6 years who visited a hospital for daycare were enrolled in the study. The prevalence of OH and demographic characteristics were examined. Then, the subjects were followed up for 1 year. The blood pressure was measured in the supine position and immediately, 1, 3 and 5 minutes after standing. Poor outcome measures included death, hospitalization for any reason, and admission to a nursing home or geriatric facility. Results OH was present in 17 patients (26.6%). The presence of OH was associated with a higher supine systolic blood pressure. The increase in heart rate in the standing position was also reduced in subjects with OH compared with those without. The presence of OH was associated with faster time in the timed up-and-go test compared with those without OH. During the follow-up period, 22 patients (34.4%) had a poor prognosis, of which 8 (36.4%) had OH, which tended to be higher than those with a favorable prognosis. The event-free survival rate appeared to be lower in subjects with OH than in those without. Conclusion OH is relatively common in frail elderly patients with dementia, and it also appears to be associated with a poor prognosis.

Cardiovascular responses to orthostasis and their association with falls in older adults

Background

Orthostatic hypotension (OH) refers to a marked decline in blood pressure when upright. OH has a high incidence and prevalence in older adults and represents a potential intrinsic risk factor for falls in these individuals. Previous studies have not included more recent definitions for blood pressure responses to orthostasis, including initial, delayed, and recovery blood pressure responses. Furthermore, there is little research examining the relationships between cerebrovascular functioning and falling risk. Therefore, we aimed to: (i) test the association between different blood pressure responses to orthostatic stress and retrospective falling history and; (ii) test the association between cerebrovascular responses to orthostatic stress and falling history.

Methods

We tested 59 elderly residents in long term care facilities who underwent a passive seated orthostatic stress test. Beat-to-beat blood pressure and cerebral blood flow velocity (CBFV) responses were assessed throughout testing. Risk factors for falls and falling history were collected from facility records. Cardiovascular responses to orthostasis were compared between retrospective fallers (≥1 fall in the previous year) and non-fallers.

Results

Retrospective fallers had larger delayed declines in systolic arterial pressure (SAP) compared to non-fallers (p = 0.015). Fallers also showed poorer early (2 min) and late (15 min) recovery of SAP. Fallers had a greater decline in systolic CBFV.

Conclusions

Older adults with a positive falling history have impaired orthostatic control of blood pressure and CBFV. With better identification and understanding of orthostatic blood pressure impairments earlier intervention and management can be implemented, potentially reducing the associated risk of morbidity and mortality. Future studies should utilize the updated OH definitions using beat-to-beat technology, rather than conventional methods that may offer less accurate detection.

Orthostatic Hypotension and Mortality in Elderly Frail Patients: A Retrospective Cross-Sectional Study

Orthostatic hypotension (OH) is a common problem in the elderly age group, and some studies have reported an association between OH and increased mortality. We evaluated possible associations between OH and mortality in a retrospective study of frail elderly patients who came for a comprehensive geriatric assessment. The study included all patients ≥ 65 years who were assessed in the outpatient Comprehensive Geriatric Assessment Unit. Data were collected from the computerized medical record, including blood pressure, sociodemographic data, lifestyle, falls, pulse rate, body mass index, functional and cognitive status, and comorbidity. Data on mortality were also collected. The study population consisted of 571 patients who underwent assessment over a 9-year study period. The mean age was 83.7 ± 6.1, 35.9% were males, and 183 (32.1%) were diagnosed with OH. Systolic OH (OHS) was more common than diastolic OH (25.2% vs 15.6%). In univariate analyses, OHS was associated with increased overall mortality. Over the follow-up period, 30.2% of the OHS patients died compared with 22.3% (P = 0.037), but in the Cox models there was no statistically significant associations between OHS and overall mortality. In contrast, age, burden of comorbidity, a low high-density lipoprotein level, and low creatinine clearance were independent predictors of increased overall mortality. In a population of frail elderly patients with a high burden of comorbidity, OH was not an independent risk factor for overall mortality.

Cardiovascular morbidity and mortality related to orthostatic hypotension: a meta-analysis of prospective observational studies

BACKGROUND

Whether orthostatic hypotension (OH) is a risk factor for cardiovascular morbidity and death is uncertain. Currently available evidence derives from non-homogeneous and partly ambiguous studies.

OBJECTIVE

We aimed at assessing the relationship between OH and death or major adverse cardiac and cerebrovascular events (MACCEs) by integrating results of previous studies.

METHODS

We performed a meta-analysis of prospective observational studies reporting on the association between prevalent OH, mortality, and incident MACCE, published from 1966 through 2013. Mantel-Haenszel pooled estimates of relative risk (RR) and 95% confidence intervals (CIs) for all-cause death were assessed as the primary endpoint at the longest follow-up; incident coronary heart disease (CHD), heart failure (HF), and stroke were assessed as secondary endpoints. We also performed post hoc subgroup analyses stratified by age and a meta-regression analysis.

RESULTS

We identified a total of 13 studies, including an overall population of 121 913 patients, with a median follow-up of 6 years. Compared with the absence of OH, the occurrence of OH was associated with a significantly increased risk of all-cause death (RR 1.50; 95% CI 1.24-1.81), incident CHD (RR 1.41; 95% CI 1.22-1.63), HF (RR 2.25; 95% CI 1.52-3.33), and stroke (RR 1.64; 95% CI 1.13-2.37). When analysed according to age, pooled estimates of RR (95% CI) for all-cause death were 1.78 (1.25-2.52) for patients <65 years old, and 1.26 (0.99-1.62) in the older subgroup.

CONCLUSION

Orthostatic hypotension is associated with a significantly increased risk of all-cause death, incident CHD, HF, and stroke.

Orthostatic Hypotension in Older Nursing Home Residents Who Fall

Orthostatic hypotension (OH) and dizziness have been linked to older adult falls. As a treatable condition, the detection of OH is of clinical importance to falls prevention. Gaps in the literature about symptoms associated with OH among older adult fallers, such as dizziness led to this secondary analysis of blood pressure data and reported symptoms. Of the 194 Registered Nurse (RN) documented falls, most ( n = 91; 46.9%) failed to meet the prevailing diagnostic criteria for OH; 18 (9.2%) met criteria; and 8 (4%) nearly met the OH criteria. OH determinations were incomplete or absent in 41% ( n = 77). Of the 18 residents with OH, none reported dizziness, instead half reported loss of balance. We conclude, older residents did not report symptoms of dizziness prior to OH drops in blood pressure and falls. Further study is warranted to identify other predictive symptoms of OH and to evaluate nursing staff’s understanding of OH.

Orthostatic hypotension: a common, serious and underrecognized problem in hospitalized patients

Orthostatic hypotension (OH) is strongly age-dependent, with a prevalence ranging from 5% to 11% in middle age to 30% or higher in the elderly. It is also closely associated with other common chronic diseases, including hypertension, congestive heart failure, diabetes mellitus, and Parkinson's disease. Most studies of OH have been performed in population cohorts or elderly residents of extended care facilities, but in this review, we draw attention to a problem little studied to date: OH in hospitalized patients. The prevalence of OH in all hospitalized patients is not known because most studies have included only older individuals with multiple comorbid diseases, but in some settings as many as 60% of hospitalized adults have postural hypotension. Hospitalized patients are particularly vulnerable to the consequences of OH, particularly falls, because postural blood pressure (BP) regulation may be disturbed by many common acute illnesses as well as by bed rest and drug treatment. The temporal course of OH in hospitalized patients is uncertain, both because the reproducibility of OH is poor and because conditions affecting postural BP regulation may vary during hospitalization. Finally, OH during hospitalization often persists after discharge, where, in addition to creating an ongoing risk of falls and syncope, it is strongly associated with risk of incident cardiovascular complications, including myocardial infarction, heart failure, stroke, and all-cause mortality. Because OH is a common, easily diagnosable, remediable condition with important clinical implications, we encourage caregivers to monitor postural BP change in patients throughout hospitalization.

Does blood pressure variability modulate cardiovascular risk?

Exactly how hypertension causes end organ damage and vascular events is poorly understood. Yet the concept that underlying "usual" blood pressure (BP) accounts for all BP-related risk of vascular events and for the benefits of BP-lowering drugs has come to underpin clinical guidelines on the diagnosis and treatment of hypertension. This article reviews evidence that variability in BP also predicts risk of stroke and other vascular events independently of mean BP and evidence that drug-class effects on variability in BP explain differences in the effectiveness of BP-lowering drugs in preventing stroke.

The relationship between blood pressure and cognitive function

The relationship between blood pressure (BP) and cognitive outcomes in elderly adults has implications for global health care. Both hypertension and hypotension affect brain perfusion and worsen cognitive outcomes. The presence of hypertension and other vascular risk factors has been associated with decreased performance in executive function and attention tests. Cerebrovascular reserve has emerged as a potential biomarker for monitoring pressure-perfusion-cognition relationships. A decline in vascular reserve capacity can lead to impaired neurovascular coupling and decreased cognitive ability. Endothelial dysfunction, microvascular disease, and mascrovascular disease in midlife could also have an important role in the manifestations and severity of multiple medical conditions underlying cognitive decline late in life. However, questions remain about the role of antihypertensive therapies for long-term prevention of cognitive decline. In this Review, we address the underlying pathophysiology and the existing evidence supporting the role of vascular factors in late-life cognitive decline.

Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension

Although hypertension is the most prevalent treatable vascular risk factor, how it causes end-organ damage and vascular events is poorly understood. Yet, a widespread belief exists that underlying usual blood pressure can alone account for all blood-pressure-related risk of vascular events and for the benefits of antihypertensive drugs, and this notion has come to underpin all major clinical guidelines on diagnosis and treatment of hypertension. Other potentially informative measures, such as variability in clinic blood pressure or maximum blood pressure reached, have been neglected, and effects of antihypertensive drugs on such measures are largely unknown. Clinical guidelines recommend that episodic hypertension is not treated, and the potential risks of residual variability in blood pressure in treated hypertensive patients have been ignored. This Review discusses shortcomings of the usual blood-pressure hypothesis, provides background to accompanying reports on the importance of blood-pressure variability in prediction of risk of vascular events and in accounting for benefits of antihypertensive drugs, and draws attention to clinical implications and directions for future research.

Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project)

Aims

Orthostatic hypotension (OH) has been linked to increased mortality and incidence of cardiovascular disease in various risk groups, but determinants and consequences of OH in the general population are poorly studied.

Methods and results

Prospective data of the Swedish ‘Malmö Preventive Project’ (n = 33 346, 67.3% men, mean age 45.7 ± 7.4 years, mean follow-up 22.7 ± 6.0 years) were analysed. Orthostatic hypotension was found in 6.2% of study participants and was associated with age, female gender, hypertension, antihypertensive treatment, increased heart rate, diabetes, low BMI, and current smoking. In Cox regression analysis, individuals with OH had significantly increased all-cause mortality (in particular those aged less than 42 years) and coronary event (CE) risk. Mortality and CE risk were distinctly higher in those with systolic blood pressure (BP) fall ≥30 mmHg [hazard ratio (HR): 1.6, 95% CI 1.3–1.9, P < 0.0001 and 1.6, 95% CI 1.2–2.1, P = 0.001] and diastolic BP fall ≥15 mmHg (HR: 1.4, 95% CI 1.1–1.9, P = 0.024 and 1.7, 95% CI 1.1–2.5, P = 0.01). In addition, impaired diastolic BP response had relatively greater impact (per mmHg) on CE incidence than systolic reaction.

Conclusion

Orthostatic hypotension can be detected in ∼6% of middle-aged individuals and is often associated with such comorbidities as hypertension or diabetes. Presence of OH increases mortality and CE risk, independently of traditional risk factors. Although both impaired systolic and diastolic responses predict adverse events, the diastolic impairment shows stronger association with coronary disease.

Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study

OBJECTIVES

To determine the prognostic role of orthostatic hypotension for cardiovascular disease (CVD) and all-cause mortality in elderly people.

DESIGN

Prospective study.

SETTING

Community based.

PARTICIPANTS

Five thousand sixty-four subjects from the Rotterdam study aged 55 and older.

MEASUREMENTS

Orthostatic hypotension was measured using a Dinamap automatic blood pressure recorder. Orthostatic hypotension is defined as a decline in systolic blood pressure of 20 mmHg or more or a decline in diastolic blood pressure of 10 mmHg or more from supine to standing position at any of three measurements taken 1, 2, and 3 minutes after standing.

RESULTS

At baseline, 901 subjects had orthostatic hypotension. During follow-up, 668 subjects had coronary heart disease (CHD) (mean follow-up 6.0 +/- 3.5 years), and 1,835 subjects died (mean follow-up period 7.8 +/- 3.8 years). Orthostatic hypotension increased the risk of CHD (hazard ratio (HR)=1.31, 95% confidence interval (CI)=1.08-1.57) and all-cause mortality (HR=1.22, 95% CI=1.09-1.36), in models adjusted for age and sex. The risk was slightly lower after additional adjustment for cardiovascular risk factors. In analyses stratified for age, the HRs for all-cause mortality were 1.80 (95% CI 1.25-2.60), 1.13 (0.89-1.42), and 1.27 (95% CI=1.11-1.44), in the first, second, and third tertile of age, respectively.

CONCLUSION

Orthostatic hypotension increases the risk of CHD and all-cause mortality in elderly people. The risk of CVD and mortality is strongest in younger and very old subjects.

The MOBILIZE Boston Study: design and methods of a prospective cohort study of novel risk factors for falls in an older population

Background

Falls are the sixth leading cause of death in elderly people in the U.S. Despite progress in understanding risk factors for falls, many suspected risk factors have not been adequately studied. Putative risk factors for falls such as pain, reductions in cerebral blood flow, somatosensory deficits, and foot disorders are poorly understood, in part because they pose measurement challenges, particularly for large observational studies.

Methods

The MOBILIZE Boston Study (MBS), an NIA-funded Program Project, is a prospective cohort study of a unique set of risk factors for falls in seniors in the Boston area. Using a door-to-door population-based recruitment, we have enrolled 765 persons aged 70 and older. The baseline assessment was conducted in 2 segments: a 3-hour home interview followed within 4 weeks by a 3-hour clinic examination. Measures included pain, cerebral hemodynamics, and foot disorders as well as established fall risk factors. For the falls follow-up, participants return fall calendar postcards to the research center at the end of each month. Reports of falls are followed-up with a telephone interview to assess circumstances and consequences of each fall. A second assessment is performed 18 months following baseline.

Results

Of the 2382 who met all eligibility criteria at the door, 1616 (67.8%) agreed to participate and were referred to the research center for further screening. The primary reason for ineligibility was inability to communicate in English. Results from the first 600 participants showed that participants are largely representative of seniors in the Boston area in terms of age, sex, race and Hispanic ethnicity. The average age of study participants was 77.9 years (s.d. 5.5) and nearly two-thirds were women. The study cohort was 78% white and 17% black. Many participants (39%) reported having fallen at least once in the year before baseline.

Conclusion

Our results demonstrate the feasibility of conducting comprehensive assessments, including rigorous physiologic measurements, in a diverse population of older adults to study non-traditional risk factors for falls and disability. The MBS will provide an important new data resource for examining novel risk factors for falls and mobility problems in the older population.

Influence of orthostatic hypotension on mortality among patients discharged from an acute geriatric ward

BACKGROUND

Orthostatic hypotension (OH) is a common finding among older patients. The impact of OH on mortality is unknown.

OBJECTIVE

To study the long-term effect of OH on total and cardiovascular mortality.

PATIENTS AND METHODS

A total of 471 inpatients (227 males and 244 females), with a mean age of 81.5 years who were hospitalized in an acute geriatric ward between the years 1999 and 2000 were included in the study. Orthostatic tests were performed 3 times during the day on all patients near the time of discharge. Orthostatic hypotension was defined as a fall of at least 20 mmHg in systolic blood pressure (BP) and/or 10 mmHg in diastolic BP upon assuming an upright posture at least twice during the day. Patients were followed until August 31, 2004. Mortality data were taken from death certificates.

RESULTS

One hundred and sixty-one patients (34.2%) experienced OH at least twice. Orthostatic hypotension had no effect on all cause and cause specific mortality. Over a follow-up of 3.47+/-1.87 years 249 patients (52.8%) had died 83 of whom (33.3%) had OH. Age-adjusted mortality rates in those with and without OH were 13.4 and 15.7 per 100 person-years, respectively. Cox proportional hazards model analysis demonstrated that male gender, age, diabetes mellitus, and congestive heart failure increased and high body mass index decreased total mortality.

CONCLUSIONS

Orthostatic hypotension is relatively common in elderly patients discharged from acute geriatric wards, but has no impact on vascular and nonvascular mortality.

Tilting-Induced Decrease in Systolic Blood Pressure in Bedridden Hypertensive Elderly Inpatients: Effects of Azelnidipine

The object of this study was to examine blood pressure (BP) variability due to postural change in elderly hypertensive patients. The subjects studied were 154 elderly inpatients in a hospital for the elderly (48 male and 106 female; median age: 82 years), consisting of age- and sex-matched bedridden (n=39) and non-bedridden (n=39) normotensive controls and bedridden (n=38) and non-bedridden (n=38) hypertensive patients. BP and pulse rate (PR) were measured in the supine position, then again after a 2-min, 45 deg head-up tilt with the legs horizontal. The decrease in systolic BP (SBP) on tilting in the bedridden hypertensive group (median: -10 mmHg; range: -32 to 9 mmHg) was significantly (p<0.008) greater than those in the other three groups. Monotherapy with azeinidipine, a long-acting calcium channel blocker, for 3 months not only significantly reduced the basal BP and PR of hypertensive patients in the two groups, but also significantly (p<0.05) attenuated the tilt-induced decrease in the SBP to -3 mmHg (-19 to 25 mmHg) and enhanced the change in PR from -1 bpm (-10 to 7 bpm) to 1 bpm (-4 to 23 bpm) in the bedridden hypertensive group. Our findings indicate that tilt-induced decrease in SBP is a rather common phenomenon in bedridden elderly hypertensive patients, and that treatment with azelnidipine attenuates tilt-induced decrease in SBP, probably through an improvement of baroreceptor sensitivity.

High Prevalence of Postprandial and Orthostatic Hypotension Among Geriatric Patients Admitted to Dutch Hospitals

BACKGROUND

Previous studies have indicated that postprandial hypotension (PPH) and orthostatic hypotension (OH) occur infrequently together. As data on geriatric patients in hospitals are scarce, we investigated the prevalence of PPH and OH and their combined occurrence. Our study sample included patients admitted to two geriatric departments in Dutch hospitals.

METHODS

During 9 months, hemodynamic changes were measured with Spacelab 90207 after standing and after meals in all eligible patients. PPH is defined as a meal-related decline in systolic blood pressure (SBP) > or =20 mmHg, OH after standing up.

RESULTS

Eighty-five patients (44 men), mean age 80 +/- 7 years (range 60-98 years), with 4 +/- 2 diseases and 6 +/- 3 prescriptions, were included. PPH was present in 57 patients (67%) with a significant postmeal SBP decrease of 34 +/- 4 mmHg. OH was present in 44 patients (52%) with a mean SBP decline of 44 +/- 4 mmHg after standing. Thirty-two patients (37%) had OH and PPH. Only 16 patients (19%) had neither OH nor PPH. Symptoms of PPH were present in 65% of patients, with syncope (in five patients) and sleepiness as the most common symptoms. OH was symptomatic in 61% of patients, with dizziness and risk for falls as the most common symptoms.

CONCLUSIONS

PPH and OH are more common in geriatric patients than was previously appreciated, with a high statistical probability that OH and PPH occur simultaneously. There is little overlap in symptoms of OH (dizziness, fall risk) versus PPH (sleepiness, syncope), which can play an important role in diagnosis. Because of the high prevalence of symptomatic PPH and OH, blood pressure measurements for diagnosing hypotensive syndromes should be part of a comprehensive geriatric assessment.

Postprandial hypotension predicts all-cause mortality in older, low-level care residents

OBJECTIVES

To evaluate which indices of blood pressure (BP) homeostasis are the strongest predictors of mortality in older low-level-care residents in long-term health facilities.

DESIGN

Prospective cohort study.

SETTING

Eight long-term healthcare facilities in Canberra, Australia.

PARTICIPANTS

A total of 179 randomly selected semi-independent residents aged 65 and older (mean age+/-standard deviation 83.2+/-7.0; 80% women).

MEASUREMENTS

Baseline BP levels taken while lying, after standing for 1 and 3 minutes, and sitting before and 1 hour after meal intake were recorded, as well as demographic information, chronic medical conditions, medications, and all-cause mortality during follow-up. Postprandial hypotension (PPH) was defined as a fall in systolic BP (SBP) of 20 mmHg or more 1 hour postmeal while sitting. Orthostatic hypotension (OH) was defined as a fall in SBP of 20 mmHg or more or in diastolic BP (DBP) of 10 mmHg or more within 3 minutes of standing from a supine position. Hypertension was defined as BP greater than 160/90 mmHg at commencement of the study. Mean arterial pressure (MAP) and pulse pressure (PP) were calculated.

RESULTS

At baseline, 47% of participants had hypertension, 38% PPH, and 23% OH; PP was 70 mmHg or greater in 54%, and DBP was 65 mmHg or lower in 6%. Over 4.7 years, 97 (54%) participants died. Those who died were significantly older and more likely to have PPH (47% vs 28%) and atrial fibrillation (35% vs 17%) and a significantly greater decrease in BP after meal intake. Mortality rates in those with and without PPH were 145.0 and 98.5 per 1,000 person-years, respectively. Using multivariate Cox proportional hazards models after adjustment for age, sex, presence of atrial fibrillation, Parkinson's disease, and use of diuretics, PPH was the only BP parameter that significantly and independently predicted 4.7-year all-cause mortality (relative risk (RR)=1.79; 95% confidence interval (CI)=1.19-2.68; P=.005). Further adjustment for the presence of OH, hypertension, low resting BP, coronary artery disease, cerebrovascular disease, congestive heart failure, history of syncope, cognitive impairment, cancer, diabetes mellitus, chronic obstructive pulmonary disease, and history of smoking did not reveal any new statistically significant associations. There was a dose-response relationship between postprandial fall in SBP and mortality rates. Absolute postprandial SBP of 120 mmHg or less was also significantly associated with total mortality (RR=1.69, 95% CI=1.04-2.78; P=.04). Low DBP was also associated with increased mortality (RR=1.10, 95% CI=1.01-1.13; P=.03), although this association became nonsignificant in multivariate analysis.

CONCLUSION

In older low-level-care residents, PPH is an independent predictor of all-cause mortality with no added predictive value explained by other BP indices: OH, hypertension, PP, MAP.

Hypertension in the Elderly

Hypertension is predictive of a wide variety of subsequent adverse events in elderly patients, at least up to the age of 80 years. Treatment can reduce these adverse outcomes, although the benefits in the very elderly remain somewhat unclear. In the very elderly, there appears to be a reduction in cardiovascular events, but this reduction is perhaps at the expense of an increase in overall mortality. Target BPs in the elderly remain controversial. Among patients who have not had previous stroke or significant cardiovascular or renal disease, the benefits of reducing the SBP below 159 mm Hg are well documented. There is some evidence to suggest, however, that if doing so increases the day-night difference in BP by more than 20% or is associated with a decline in DBP below 65 mm Hg, then the benefits of treatment may be attenuated or lost. In addition, there is some suggestion that reducing SBP consistently below 135 mm Hg may accelerate cognitive decline. There appears to be a role for sodium restriction in those who can comply without otherwise compromising nutrient intake. Likewise, exercise may be beneficial and have benefits beyond simply lowering BP. Weight loss in those who are overweight may also help in lowering the BP. For most patients, low-dose thiazides such as hydrochlorothiazide are likely to be the appropriate first-line therapy (even in patients who have diabetes) unless they exacerbate or precipitate urinary incontinence or gout or complicate concomitant drug therapy (eg, lithium treatment of bipolar disorder). In very elderly patients, the apparent beneficial effects on strokes, major cardiovascular events, and heart failure rates may justify treating despite lack of benefit on overall mortality.

Do atypical antipsychotics cause stroke?

Post hoc analyses of pooled results from 11 randomised controlled trials of risperidone and olanzapine in elderly dementia subjects revealed an increased incidence of cerebrovascular adverse events compared with placebo. Reanalysis of the risperidone trials suggests that some of the increased incidence may be accounted for by nonspecific events that were not strokes. Large observational administrative health database studies appear to confirm that risperidone and olanzapine are not associated with an increased risk of stroke in elderly patients compared with typical antipsychotics or untreated dementia patients. A larger number of subjects with vascular and mixed dementias were included in the risperidone studies compared with the olanzapine studies, which likely accounts for the increased incidence of cerebrovascular adverse events in the risperidone trials compared with the olanzapine studies. Potential mechanisms proposed to explain an association between atypical antipsychotics and cerebrovascular adverse events include thromboembolic effects, cardiovascular effects (e.g. orthostatic hypotension, arrhythmias), excessive sedation resulting in dehydration and haemoconcentration, and hyperprolactinaemia. However, there is little evidence to support these hypothesised mechanisms at present. The association between atypical antipsychotics and cerebrovascular adverse events requires further clarification. At the present time, this association is another factor that clinicians should consider when weighing the risks and benefits of treating behavioural and psychological disturbances in elderly dementia patients.

Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly

OBJECTIVES

We investigated the prognostic significance of orthostatic hypotension on the risk of myocardial infarction (MI) amongst the elderly.

DESIGN

Prospective population-based study.

SETTING

Home-dwelling population.

SUBJECTS

Orthostatic testing was performed between 8 a.m. and 2 p.m., irrespective of having had meals, on 792 persons, representing 82% of all home-dwelling persons aged > or =70 years living in five municipalities around the city of Oulu.

MAIN OUTCOME MEASURES

Occurrence of cases of MI were recorded during mean 3.58 (SD 1.09) years follow-up period, from national mortality statistics and local hospital discharge registers.

RESULTS

Ninety cases of MI, of which 40 were fatal after initial hospitalization, occurred during the follow-up period. Orthostatic diastolic blood pressure (BP) drop 1 min after standing up was associated with subsequent MI, but systolic BP reactions had no predictive value. According to the Cox regression model, the strongest predictor of the occurrence of subsequent MI was found in regard to > or =8 mmHg drop in diastolic BP 1 min after standing up; adjusted for history of MI, diabetes mellitus, chest pain, use of calcium antagonist, beta-blocker, nitrate and diuretic medication, hazard ratio of MI being 2.00 (1.11-3.59).

CONCLUSIONS

Orthostatic testing offers a novel means to assess the risk of MI amongst elderly persons. Diastolic BP drop immediately after standing up identifies elderly subjects at a high risk of subsequent MI.

U-curve relationship between orthostatic blood pressure change and silent cerebrovascular disease in elderly hypertensives: orthostatic hypertension as a new cardiovascular risk factor

OBJECTIVES

The study investigated the clinical significance and mechanism of orthostatic blood pressure (BP) dysregulation in elderly hypertensive patients.

BACKGROUND

Although orthostatic hypotension (OHYPO), often found in elderly hypertensive patients, has been recognized as a risk factor for syncope and cardiovascular disease, both the clinical significance and the mechanism of orthostatic hypertension (OHT) remain unclear.

METHODS

We performed a head-up tilting test and brain magnetic resonance imaging (MRI) in 241 elderly subjects with sustained hypertension as indicated by ambulatory BP monitoring. We classified the patients into an OHT group with orthostatic increase of systolic blood pressure (SBP) of >or=20 mm Hg (n = 26), an OHYPO group with orthostatic SBP decrease of >or=20 mm Hg (n = 23), and a normal group with neither of these two patterns (n = 192).

RESULTS

Silent cerebral infarcts were more common in the OHT (3.4/person, p < 0.0001) and OHYPO groups (2.7/person, p = 0.04) than in the normal group (1.4/person). Morning SBP was higher in the OHT group than in the normal group (159 vs. 149 mm Hg, p = 0.007), while there were no significant differences of these ambulatory BPs between the two groups during other periods. The OHT (21 mm Hg, p < 0.0001) and OHYPO (20 mm Hg, p = 0.01) groups had higher BP variability (standard deviation of awake SBP) than the normal group (17 mm Hg). The associations between orthostatic BP change and silent cerebrovascular disease remained significant after controlling for confounders, including ambulatory BP. The orthostatic BP increase was selectively abolished by alpha-adrenergic blocking, indicating that alpha-adrenergic activity is the predominant pathophysiologic mechanism of OHT.

CONCLUSIONS

Silent cerebrovascular disease is advanced in elderly hypertensives having OHT. Elderly hypertensives with OHT or OHYPO may have an elevated risk of developing hypertensive cerebrovascular disease.