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Geijerstam PA, Harris K, Johansson MM, Chalmers J, Nägga K, Rådholm K. Orthostatic Hypotension and Cognitive Function in Individuals 85 Years of Age: A Longitudinal Cohort Study in Sweden. Aging Dis 2024:AD.2024.0205. [PMID: 38421828 DOI: 10.14336/ad.2024.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/05/2024] [Indexed: 03/02/2024] Open
Abstract
Orthostatic hypotension (OH) is more common in the elderly and associated with increased mortality. However, its implications for 85-year-olds are not known. In the prospective observational cohort study Elderly in Linköping Screening Assessment (ELSA 85), 496 individuals in Linköping, Sweden, were followed from age 85 years with cognitive assessments. Blood pressure (BP) was measured supine and after 1, 3, 5, and 10 minutes of standing. Participants with a BP fall of ≥20 mmHg systolic or ≥10 mmHg diastolic after 1 or 3 minutes were classified as classical continuous or classical transient OH depending on whether the BP fall was sustained or not, at subsequent measurements. Those with a BP fall of the same magnitude, but only after 5 or 10 minutes were classified as delayed OH. Of participants, 329 took part in BP measurements and were included. Of these, 156 (47.4%) had classical OH (113 [34.3%] continuous classical, 38 [11.6%] transient classical), and 15 (4.6%) had delayed OH. Cognitive assessments were not markedly different between groups. After 8.6 years, 195 (59.3%) of the participants had died, and delayed vs no OH was associated with twice the risk of all-cause mortality, HR 2.15 (95% CI 1.12-4.12). Transient classical OH was associated with reduced mortality, HR 0.58 (95% CI 0.33-0.99), but not after multiple adjustments, and continuous classical OH was not associated with mortality. OH may have different implications for morbidity and mortality in 85-year-olds compared with younger populations.
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Affiliation(s)
- Peder Af Geijerstam
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Katie Harris
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Maria M Johansson
- Department of Activity and Health, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Acute Internal Medicine and Geriatrics, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Katarina Nägga
- Department of Acute Internal Medicine and Geriatrics, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Karin Rådholm
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Park JW, Okamoto LE, Kim SH, Baek SH, Sung JH, Jeon N, Gamboa A, Shibao CA, Diedrich A, Kim BJ, Biaggioni I. Use of Valsalva Maneuver to Detect Late-Onset Delayed Orthostatic Hypotension. Hypertension 2023; 80:792-801. [PMID: 36695176 PMCID: PMC10023507 DOI: 10.1161/hypertensionaha.122.20098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/08/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Standard autonomic testing includes a 10-minute head-up tilt table test to detect orthostatic hypotension. Although this test can detect delayed orthostatic hypotension (dOH) between 3 and 10 minutes of standing, it cannot detect late-onset dOH after 10 minutes of standing. METHODS To determine whether Valsalva maneuver responses can identify patients who would require prolonged head-up tilt table test to diagnose late-onset dOH; patients with immediate orthostatic hypotension (onset <3 minutes; n=176), early-onset dOH (onset between 3 and 10 minutes; n=68), and late-onset dOH (onset >10 minutes; n=32) were retrospectively compared with controls (n=114) with normal head-up tilt table test and composite autonomic scoring scale score of 0. RESULTS Changes in baseline systolic blood pressure at late phase 2 (∆SBPVM2), heart rate difference between baseline and phase 3 (∆HRVM3), and Valsalva ratio were lower and pressure recovery time (PRT) at phase 4 was longer in late-onset dOH patients than in controls. Differences in PRT and ∆HRVM3 remained significant after correcting for age. A PRT ≥2.14 s and ∆HRVM3 ≤15 bpm distinguished late-onset dOH from age- and sex-matched controls. Patients with longer PRT (relative risk ratio, 2.189 [1.579-3.036]) and lower ∆HRVM3 (relative risk ratio, 0.897 [0.847-0.951]) were more likely to have late-onset dOH. Patients with longer PRT (relative risk ratio, 1.075 [1.012-1.133]) were more likely to have early-onset than late-onset dOH. CONCLUSIONS Long PRT and short ∆HRVM3 can help to identify patients who require prolonged head-up tilt table test to diagnose late-onset dOH.
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Affiliation(s)
- Jin-Woo Park
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Sung-Hwan Kim
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Seol-Hee Baek
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Joo Hye Sung
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Namjoon Jeon
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN (A.D.)
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medicine, Seoul (J.-W.P., S.-H.K., S.-H.B., J.H.S., N.J., B.-J.K.)
- BK21 FOUR Program in Learning Health Systems, Korea University, Seoul (B.-J.K.)
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (J.-W.P., L.E.O., A.G., C.A.S., A.D., I.B.)
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Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol 2022; 21:735-746. [PMID: 35841911 PMCID: PMC10024337 DOI: 10.1016/s1474-4422(22)00169-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/24/2023]
Abstract
Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.
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Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; UCL Queen Square Institute of Neurology, University College London, London, UK; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
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Orthostatic hypotension and mortality risk in geriatric outpatients: the impact of duration and magnitude of the blood pressure drop. J Hypertens 2022; 40:1107-1114. [PMID: 35703878 DOI: 10.1097/hjh.0000000000003097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Orthostatic hypotension is a common condition associated with an increased mortality risk. This study investigates this association specifically in geriatric outpatients and additionally focuses on the duration and magnitude of orthostatic hypotension. METHODS In this observational prospective cohort study with geriatric outpatients from the Amsterdam Ageing cohort, we differentiated orthostatic hypotension in early orthostatic hypotension (EOH) and delayed/prolonged orthostatic hypotension (DPOH). The magnitude of drop in both SBP and DBP after either 1 or 3 min was quantified. Mortality data was obtained from the Dutch municipal register. Cox proportional hazard models were used to determine the association between orthostatic hypotension and mortality, adjusted for sex and age (model 1), additionally adjusted for orthostatic hypotension-inducing drugs + SBP (model 2) and the presence of cardiovascular disease and diabetes (model 3). Stratified analyses in patients with geriatric deficits were performed. RESULTS We included 1240 patients (mean age 79.4 ± 6.9 years, 52.6% women). Prevalence of orthostatic hypotension was 443 (34.9%); 148 (11.9%) patients had EOH and 285 (23%) DPOH. DPOH was associated with a higher mortality risk [hazard ratio, 95% CI 1.69 (1.28-2.22)] whereas EOH was not associated with mortality risk. This association did not differ in patients with geriatric deficits. Furthermore, the magnitude of drop in both SBP and DBP was associated with a higher mortality risk. CONCLUSION The presence of DPOH and the magnitude of both systolic and diastolic orthostatic hypotension are related to an increased mortality risk in geriatric outpatients. Whether the duration of orthostatic hypotension and magnitude of the drop in blood pressure is causally related to mortality risk or whether it is a sign of decreased resilience remains to be elucidated.
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