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Liu Z, Lin S, Zhou J, Wang X, Wang Z, Yang Y, Ma H, Chen Z, Ren K, Wu L, Zhuang H, Ling Y, Feng T. Machine-learning model for the prediction of acute orthostatic hypotension after levodopa administration. CNS Neurosci Ther 2024; 30:e14575. [PMID: 38467597 PMCID: PMC10927600 DOI: 10.1111/cns.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/11/2023] [Accepted: 12/06/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Levodopa could induce orthostatic hypotension (OH) in Parkinson's disease (PD) patients. Accurate prediction of acute OH post levodopa (AOHPL) is important for rational drug use in PD patients. Here, we develop and validate a prediction model of AOHPL to facilitate physicians in identifying patients at higher probability of developing AOHPL. METHODS The study involved 497 PD inpatients who underwent a levodopa challenge test (LCT) and the supine-to-standing test (STS) four times during LCT. Patients were divided into two groups based on whether OH occurred during levodopa effectiveness (AOHPL) or not (non-AOHPL). The dataset was randomly split into training (80%) and independent test data (20%). Several models were trained and compared for discrimination between AOHPL and non-AOHPL. Final model was evaluated on independent test data. Shapley additive explanations (SHAP) values were employed to reveal how variables explain specific predictions for given observations in the independent test data. RESULTS We included 180 PD patients without AOHPL and 194 PD patients with AOHPL to develop and validate predictive models. Random Forest was selected as our final model as its leave-one-out cross validation performance [AUC_ROC 0.776, accuracy 73.6%, sensitivity 71.6%, specificity 75.7%] outperformed other models. The most crucial features in this predictive model were the maximal SBP drop and DBP drop of STS before medication (ΔSBP/ΔDBP). We achieved a prediction accuracy of 72% on independent test data. ΔSBP, ΔDBP, and standing mean artery pressure were the top three variables that contributed most to the predictions across all individual observations in the independent test data. CONCLUSIONS The validated classifier could serve as a valuable tool for clinicians, offering the probability of a patient developing AOHPL at an early stage. This supports clinical decision-making, potentially enhancing the quality of life for PD patients.
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Affiliation(s)
- Zhu Liu
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Shinuan Lin
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeRoslindaleMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Xuemei Wang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zhan Wang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Yaqin Yang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Huizi Ma
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zhonglue Chen
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Kang Ren
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Lingyu Wu
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Haimei Zhuang
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Yun Ling
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Tao Feng
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
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Clark CE. Hypertension and hypotension: getting the balance right. Br J Gen Pract 2023; 73:6-7. [PMID: 36543552 PMCID: PMC9799343 DOI: 10.3399/bjgp23x731493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Christopher E Clark
- Primary Care Research Group, Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter
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McDonagh STJ, Mejzner N, Clark CE. Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis. BMC FAMILY PRACTICE 2021; 22:1. [PMID: 33388038 PMCID: PMC7777418 DOI: 10.1186/s12875-020-01313-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postural hypotension (PH), the reduction in blood pressure when rising from sitting or lying 0to standing, is a risk factor for falls, cognitive decline and mortality. However, it is not often tested for in primary care. PH prevalence varies according to definition, population, care setting and measurement method. The aim of this study was to determine the prevalence of PH across different care settings and disease subgroups. METHODS Systematic review, meta-analyses and meta-regression. We searched Medline and Embase to October 2019 for studies based in primary, community or institutional care settings reporting PH prevalence. Data and study level demographics were extracted independently by two reviewers. Pooled estimates for mean PH prevalence were compared between care settings and disease subgroups using random effects meta-analyses. Predictors of PH were explored using meta-regression. Quality assessment was undertaken using an adapted Newcastle-Ottawa Scale. RESULTS One thousand eight hundred sixteen studies were identified; 61 contributed to analyses. Pooled prevalences for PH using the consensus definition were 17% (95% CI, 14-20%; I2 = 99%) for 34 community cohorts, 19% (15-25%; I2 = 98%) for 23 primary care cohorts and 31% (15-50%; I2 = 0%) for 3 residential care or nursing homes cohorts (P = 0.16 between groups). By condition, prevalences were 20% (16-23%; I2 = 98%) with hypertension (20 cohorts), 21% (16-26%; I2 = 92%) with diabetes (4 cohorts), 25% (18-33%; I2 = 88%) with Parkinson's disease (7 cohorts) and 29% (25-33%, I2 = 0%) with dementia (3 cohorts), compared to 14% (12-17%, I2 = 99%) without these conditions (P < 0.01 between groups). Multivariable meta-regression modelling identified increasing age and diabetes as predictors of PH (P < 0.01, P = 0.13, respectively; R2 = 36%). PH prevalence was not affected by blood pressure measurement device (P = 0.65) or sitting or supine resting position (P = 0.24), however, when the definition of PH did not fulfil the consensus description, but fell within its parameters, prevalence was underestimated (P = 0.01) irrespective of study quality (P = 0.04). CONCLUSIONS PH prevalence in populations relevant to primary care is substantial and the definition of PH used is important. Our findings emphasise the importance of considering checking for PH, particularly in vulnerable populations, to enable interventions to manage it. These data should contribute to future guidelines relevant to the detection and treatment of PH. PROSPERO CRD42017075423.
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Affiliation(s)
- Sinead T J McDonagh
- Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, St Luke's Campus, Magdalen Road, Exeter, Devon, EX1 2LU, England.
| | - Natasha Mejzner
- Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, St Luke's Campus, Magdalen Road, Exeter, Devon, EX1 2LU, England
| | - Christopher E Clark
- Primary Care Research Group, University of Exeter Medical School, College of Medicine and Health, St Luke's Campus, Magdalen Road, Exeter, Devon, EX1 2LU, England
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Soloveva A, Fedorova D, Villevalde S, Zvartau N, Mareev Y, Sitnikova M, Shlyakhto E, Fudim M. Addressing Orthostatic Hypotension in Heart Failure: Pathophysiology, Clinical Implications and Perspectives. J Cardiovasc Transl Res 2020; 13:549-569. [PMID: 32748206 DOI: 10.1007/s12265-020-10044-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022]
Abstract
Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities contributing to OH, as well as a high prevalence of medications with neurovascular and volume modulating properties. Early identification of OH in HF seems to be crucial as OH can have an impact on patient symptoms, activity level and independence, be a marker of specific pathophysiological changes or be an indicator of need for personalized treatment. OH might contribute significantly to bad enough prognosis in HF, as, besides a risk of falls and cognitive decline, it was found to be associated with cardiovascular morbidity and mortality. In this review, we aimed to incentivize the routine use of orthostatic testing in HF, as well as stimulate future research in this field, which could lead to significant advances in the treatment and outcomes.
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Affiliation(s)
- Anzhela Soloveva
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Darya Fedorova
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Svetlana Villevalde
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Nadezhda Zvartau
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Yury Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russian Federation
| | - Mariya Sitnikova
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Evgeny Shlyakhto
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
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Systolic inter-arm blood pressure difference and risk of cognitive decline in older people: a cohort study. Br J Gen Pract 2020; 70:e472-e480. [PMID: 32366532 DOI: 10.3399/bjgp20x709589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/08/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Systolic inter-arm difference in blood pressure (IAD) and cognitive decline are both associated with cardiovascular disease; therefore, it was hypothesised that IAD may be predictive of cognitive decline. AIM To examine associations of IAD with cognitive decline in a community population. DESIGN AND SETTING A prospective study of older Italian adults enrolled in the InCHIANTI study. METHOD Univariable and multivariable associations of IAD were explored with declines in mini mental state examination (MMSE) scores, Trail Making Test A and B scores, and a composite outcome representing substantial decline in any of these scores. Backward stepwise regression was used to adjust observed associations of IAD with cognitive decline. RESULTS The rate of decline for MMSE scores in 1133 participants was greater with IAD ≥5 mmHg or ≥10 mmHg. On univariable analyses continuous IAD was associated with the composite outcome (odds ratio [OR] 1.16 per 5 mmHg of IAD, 95% confidence interval [CI] = 1.02 to 1.31). Substantial decline in MMSE score was seen with IAD ≥5 mmHg (OR 1.41, 95% CI = 1.03 to 1.93), and in the composite outcome with IAD ≥5 mmHg (OR 1.44, 95% CI = 1.10 to 1.89) or ≥10 mmHg (OR 1.39, 95% CI = 1.03 to 1.88). After multivariable adjustment, an IAD ≥ 5 mmHg remained associated with reductions in the composite outcome, reflecting declining cognitive performance (OR 1.46, 95% CI = 1.05 to 2.03). CONCLUSION An IAD ≥5 mmHg is associated with cognitive decline in a representative older population. Given that systolic inter-arm differences in blood pressure are easily measured, confirmation of these findings could inform individualised treatment for the prevention of cognitive decline and dementia.
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Briggs R, Donoghue OA, Carey D, O'Connell MDL, Newman L, Kenny RA. What Is the Relationship Between Orthostatic Blood Pressure and Spatiotemporal Gait in Later Life? J Am Geriatr Soc 2020; 68:1286-1292. [PMID: 32170869 DOI: 10.1111/jgs.16379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES Little work to date has examined the relationship between gait performance and blood pressure (BP) recovery after standing in later life. The aim of this study is to clarify the association of orthostatic BP with spatiotemporal gait parameters in a large cohort of older people. DESIGN Cross-sectional study using multilevel linear regression to ascertain the difference in orthostatic BP patterns across tertiles of gait speed, and linear regression to analyze the association of orthostatic hypotension 30 seconds after standing (OH-30) with specific gait characteristics. SETTING The Irish Longitudinal Study on Ageing. PARTICIPANTS A total of 4311 community-dwelling adults, aged 50 years or older (mean age = 62.2 years; 54% female), one fifth (n = 791) of whom had OH-30. MEASUREMENTS Continuous orthostatic BP was measured during active stand. OH-30 was defined as a drop in systolic BP of 20 mm Hg or more or drop in diastolic BP of 10 mm Hg or more at 30 seconds. Spatiotemporal gait was assessed using the GAITRite system, reporting gait speed, step length, step width, and double support time in both single and dual (cognitive task) conditions. RESULTS OH-30 was associated with slower gait speed (β = -3.01; 95% confidence interval [CI] = -4.46 to -1.56) and shorter step length (β = -.73; 95% CI = -1.29 to -.16) in fully adjusted models during single task walking. Similar findings were observed in dual task conditions, in addition to increased double support phase (β = .45; 95% CI = .02-.88). Multilevel models demonstrated that participants in the slowest tertile for gait speed had a significantly larger drop in systolic BP poststanding compared to those with faster gait speeds in single and dual task conditions. CONCLUSIONS This study demonstrates that slower recovery of BP after standing is independently associated with poorer gait performance in community-dwelling older adults. Given the adverse outcomes independently associated with OH and gait problems in later life, increasing awareness that they commonly coexist is important, particularly as both are potentially modifiable. J Am Geriatr Soc 68:1286-1292, 2020.
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Affiliation(s)
- Robert Briggs
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland.,Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Orna A Donoghue
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Daniel Carey
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | | | - Louise Newman
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland.,Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
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Wojszel ZB, Kasiukiewicz A, Magnuszewski L. Health and Functional Determinants of Orthostatic Hypotension in Geriatric Ward Patients: A Retrospective Cross Sectional Cohort Study. J Nutr Health Aging 2019; 23:509-517. [PMID: 31233071 PMCID: PMC6586688 DOI: 10.1007/s12603-019-1201-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/22/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Orthostatic hypotension (OH) is a common problem in older people. Although it is indicated that OH can be a marker of frailty there are no studies that evaluate this relationship in hospitalized patients. The aim of the study was to assess the prevalence of OH in geriatric ward patients and its association with health and functional ability characteristics and patients' frailty status. DESIGN AND SETTING A retrospective cross-sectional cohort study was conducted among patients aged 60 or over hospitalized in the geriatric ward. PARTICIPANTS Patients' medical records were analyzed and those with Active Standing Test (AST) results were included in the study. MEASUREMENTS Orthostatic hypotension was defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3minutes of standing up in AST. The database included sociodemographic characteristics, nutritional, functional and cognitive state, comorbidity and medical treatment. Frailty syndrome was diagnosed with Clinical Frailty Scale. Correlations with OH were counted and multivariable logistic regression models were built. RESULTS 416 patients were hospitalized in the study period and 353 (84.9%) were included, 78 (22.1%) men and 298 (84.4%) 75+ year-old. AST was not available in patients significantly more dependent in ADL and more frail. OH was diagnosed in 57 (16.2%) patients, significantly more frequently in men (systolic- 45,5%, systolic-diastolic- 40,0%). The significant independent predictors of OH were lower diastolic blood pressure at admittance, nutritional risk in MNA-SF, Parkinson disease, α1-blockers, neuroleptics and memantine, and not the frailty syndrome diagnosed with Clinical Frailty Scale. CONCLUSIONS OH affects a significant percentage of patients in the geriatric ward, although this problem may be underestimated due to limitations in the performance of AST in very frail and functionally dependent patients.
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Affiliation(s)
- Z B Wojszel
- Zyta B. Wojszel, M.D., Ph.D. Department of Geriatrics, Medical University of Bialystok, Fabryczna str. 27, 15-471 Bialystok, Poland, Phone:+48 85 869 4982, e-mail:
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Chen L, Xu Y, Chen XJ, Lee WJ, Chen LK. Association between Orthostatic Hypotension and Frailty in Hospitalized Older Patients: a Geriatric Syndrome More Than a Cardiovascular Condition. J Nutr Health Aging 2019; 23:318-322. [PMID: 30932129 DOI: 10.1007/s12603-019-1180-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To explore the association between orthostatic hypotension (OH) and frailty for hospitalized older patients and their vulnerable subgroups. DESIGN A prospective, observational cross-sectional study. PARTICIPANTS 693 older patients admitted to a geriatric evaluation and management unit. MEASUREMENTS Barthel Index, Lawton's instrumental activities of daily living, clinical frailty scale, mini-mental state examination, geriatric depression scale, mini-nutritional assessment, and polypharmacy. RESULTS Overall, the prevalence of OH and frailty was 26% and 36%, respectively. Subjects with OH were older, thinner, more commonly to have weakness, slowness, poorer physical function and higher levels of frailty. The prevalence of OH was substantially increased as higher levels of CFS (p for trend <0.001). Multivariate logistic regression showed significant association between OH and frailty (OR: 1.8, 95% CI: 1.2-2.7), but the association attenuated after adjustment for physical function. (OR: 1.4, 95% CI: 0.7-2.6). Nevertheless, associations between OH and frailty remained significant among vulnerable subgroups like women, subjects having weakness, slowness, poor cognitive function, polypharmacy or any IADL limitation. CONCLUSIONS OH in hospitalized older patients was associated with frailty and multiple complex care needs, especially in the vulnerable subgroups. Further study is needed to clarify the roles of OH in clinical practice.
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Affiliation(s)
- L Chen
- Dr. Wei-Ju Lee. Department of Geriatric Medecine, School of Medicine, National Yang-Ming University. No. 155, Sec. 2, Linong St., Beitou Dist., Taipei City 112, Taiwan. Tel: +886-2-28239014, Fax: +886-2-28211451.
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