Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program

Chronic kidney disease and orthostatic hypotension in hospitalised older adults

PURPOSE

Orthostatic hypotension (OH) may predispose older adults to health complications leading to functional impairment. Despite the central role of the kidney in blood pressure control, the contribution of renal function in orthostatic hypotension is poorly investigated. To verify the association between Chronic Kidney Disease (CKD) and OH a population of hospitalised elderly patients with comorbidities was studied.

MATERIALS AND METHODS

174 patients were consecutively admitted to Acute Geriatric Wards. On admission, patients underwent postural systolic (SBP) and diastolic (DBP) blood pressure evaluation by automatic oscillometric device after 10 min rest in lying position, and in standing position at time 0, 1, 3 and 5 min. CKD was assumed for estimated glomerular filtration rate (e-GFR) less than 60 mL/min/1.73 m2.

RESULTS

The mean age of the population enrolled was 74.4 ± 7.0. OH was found in 46.0% and CKD in 56.3% of patients, respectively. A lower e-GFR was observed in patients with (56.1 ± 16.7 mL/min/1.73 m2) than in those without OH (61.1 ± 15.9 mL/min/1.73 m2) (p < 0.05). A greater fall in SBP at 0-min (12.8 ± 6.3 vs. 7.7 ± 3.2 mmHg) and at 1-min (8.4 ± 4.5 vs. 5.7 ± 2.8 mmHg) was found in CKD patients in respect to patients without CKD during active standing test (p < 0.05). Similarly, a DBP reduction at 0-min and at 1-min was observed in CKD patients in respect to patients without CKD (p < 0.05). A multivariate logistic regression analysis showed that CKD was associated to OH (OR 2.426; 95%CI 1.192-4.937; p = 0.014).

CONCLUSIONS

CKD is associated to OH in hospitalised older adults.

Which Components of the Haemodynamic Response to Active Stand Predict Cardiovascular Disease and Mortality? Data From The Irish Longitudinal Study on Ageing

Background

An integrated haemodynamic response during standing may serve as an integrative marker of neuro-cardiovascular function. Individual components of both heart rate (HR) and blood pressure (BP) responses to active stand (AS) have been linked with cardiovascular disease (CVD) and mortality. We assessed longitudinal associations between entire HR/BP response curves during AS, incident CVD and mortality over 12 years.

Methods

Beat-to-beat measurements of dynamic HR/BP responses to AS were conducted in 4,336 individuals (61.5±8.2 years; 53.7% female). Functional Principal Components Analysis was applied to HR/BP response curves and their association with CVD and mortality assessed. We hypothesised that integrating BP/HR information from the entire haemodynamic response curve may uncover novel associations with both CVD and mortality.

Results

Higher systolic BP (SBP) before AS and blunted recovery of SBP during AS was associated with all-cause mortality over 12-years (Hazard Ratio [HR]: 1.14; 1.04, 1.26; p=0.007). Higher baseline/peak HR and lower HR from 30 seconds post stand onwards were associated with lower mortality due to circulatory causes (HR: 0.78; 0.64, 0.95; p = 0.013). Higher HR throughout AS was associated with mortality from other causes (HR: 1.48; 1.22, 1.80; p<0.001). Findings persisted on robust covariate adjustment.

Conclusions

We observed distinct relationships between HR/BP responses to AS and 12-year incident CVD and mortality. Integrating the entire haemodynamic response may reveal more nuanced relationships between HR/BP responses to AS, CVD and mortality - serving as an integrative marker of neuro-cardiovascular health in midlife and beyond.

Autoimmunity in Syndromes of Orthostatic Intolerance: An Updated Review

Orthostatic intolerance is a broad term that represents a spectrum of dysautonomic disorders, including postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH), as manifestations of severe autonomic failure. While the etiology of orthostatic intolerance has not yet fully been uncovered, it has been associated with multiple underlying pathological processes, including peripheral neuropathy, altered renin-aldosterone levels, hypovolemia, and autoimmune processes. Studies have implicated adrenergic, cholinergic, and angiotensin II type I autoantibodies in the pathogenesis of orthostatic intolerance. Several case series have demonstrated that immunomodulation therapy resulted in favorable outcomes, improving autonomic symptoms in POTS and OH. In this review, we highlight the contemporary literature detailing the association of autoimmunity with POTS and OH.

Effect of orthostatic hypotension on long-term prognosis of elderly patients with stable coronary artery disease: a retrospective cohort study

Background

The long-term prognosis of patients with stable coronary artery disease (CAD) combined with orthostatic hypotension (OH) has rarely been reported. This research was designed to examine whether OH increases the risk of all-cause mortality and cardiovascular death among patients with stable CAD.

Methods

We retrospectively analyzed retired military personnel over 65 years of age who were hospitalized at the General Hospital of Southern Theater Command of the Chinese People's Liberation Army between March and July 2010. A total of 924 patients with stable CAD were included, among whom 263 had OH. The risk of all-cause mortality and cardiovascular death in OH and non-OH groups were analyzed with the Cox proportional hazards models, and restricted cubic spline plots were utilized for subgroup analyses. Furthermore, competing risk models were applied for sensitivity analyses.

Results

The median age of the patients was 82.00 (80.00-85.00) years. Over 159 months of follow-up, the loss to follow-up rate was 2.27%, and all-cause mortality was observed in 574 (63.57%) patients, including 184 with OH. Moreover, cardiovascular death occurred in 127 patients (13.73%), with 58 cases associated with OH. Although the relationship between OH and all-cause mortality was non-significant [body mass index (BMI) < 25 group, adjusted hazard ratio (HR) = 1.10 with a 95% confidence interval (CI): 0.82-1.40; BMI ≥ 25 group, adjusted HR = 1.30, 95% CI: 0.98-1.70], it was independently related to a growing risk of cardiovascular death (adjusted HR = 1.80, 95% CI: 1.20-2.60). This finding was further validated by using a competing risk model (subdistribution HR = 1.74, 95% CI: 1.22-2.49). Moreover, age, low-density lipoprotein cholesterol, and frequency of hospital admissions were identified as risk factors of cardiovascular death among patients with OH (P < 0.05).

Conclusion

Our study, based on retired military personnel with stable CAD, found that OH led to a significantly higher risk of cardiovascular death, but it was not noticeably associated with all-cause mortality on long-term prognosis.

Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition)

With the deepening of aging in China, the prevalence of diabetes in older people has increased noticeably, and standardized diabetes management is critical for improving clinical outcomes of diabetes in older people. In 2021, the National Center of Gerontology, Chinese Society of Geriatrics, and Diabetes Professional Committee of Chinese Aging Well Association organized experts to write the first guideline for diabetes diagnosis and treatment in older people in China, the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2021 Edition). The guideline emphasizes that older patients with diabetes are a highly heterogeneous group requiring comprehensive assessment and stratified and individualized management strategies. The guideline proposes simple treatments and de-intensified treatment strategies for older patients with diabetes. This edition of the guideline provides clinicians with practical and operable clinical guidance, thus greatly contributing to the comprehensive and full-cycle standardized management of older patients with diabetes in China and promoting the extensive development of clinical and basic research on diabetes in older people and related fields. In the past 3 years, evidence-based medicine for older patients with diabetes and related fields has further advanced, and new treatment concepts, drugs, and technologies have been developed. The guideline editorial committee promptly updated the first edition of the guideline and compiled the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition). More precise management paths for older patients with diabetes are proposed, for achieving continued standardization of the management of older Chinese patients with diabetes and improving their clinical outcomes.

A metabolomic signature of decelerated physiological aging in human plasma

The degenerative processes that occur during aging increase the risk of disease and impaired health. Meanwhile, interventions that target aging to promote healthy longevity are gaining interest, both academically and in the public. While nutritional and physical interventions exist, efficacy is often difficult to determine. It is therefore imperative that an aging score measuring the biological aging process is available to the wider public. However, simple, interpret, and accessible biological aging scores are lacking. Here, we developed PhysiAge, a physiological aging score based on five accessible parameters that have influence on or reflect the aging process: (1) average daily step count, (2) blood glucose, (3) systolic blood pressure, (4) sex, and (5) age. Here, we found that compared to calendar age alone, PhysiAge better predicts mortality, as well as established muscle aging markers such as decrease in NAD+ levels, increase in oxidative stress, and decline in physical functioning. In order to demonstrate the usefulness of PhysiAge in identifying relevant factors associated with decelerated aging, we calculated PhysiAges for a cohort of aged individuals and obtained mass spectrometry-based blood plasma metabolomic profiles for each individual. Here, we identified a metabolic signature of decelerated aging, which included components of the TCA cycle, including malate, citrate, and isocitrate. Higher abundance of these metabolites was associated with decelerated aging, in line with supplementation studies in model organisms. PhysiAge represents an accessible way for people to track and intervene in their aging trajectories, and identifies a metabolic signature of decelerated aging in human blood plasma, which can be further studied for its causal involvement in human aging.

Orthostatic Hypertension: A Newcomer Among the Hypertension Phenotypes

The prognostic role and the clinical significance of orthostatic hypertension (OHT) remained undefined for long because data were sparse and often inconsistent. In recent years, evidence has been accumulating that OHT is associated with an increased risk of masked and sustained hypertension, hypertension-mediated organ damage, cardiovascular disease, and mortality. Most evidence came from studies in which OHT was defined using systolic blood pressure (BP) whereas the clinical relevance of diastolic OHT is still unclear. Recently, the American Autonomic Society and the Japanese Society of Hypertension defined OHT as an orthostatic systolic BP increase ≥20 mm Hg associated with a systolic BP of at least 140 mm Hg while standing. However, also smaller orthostatic BP increases have shown clinical relevance especially in people ≤45 years of age. A possible limitation of the BP response to standing is poor reproducibility. OHT concordance is better when the between-assessment interval is shorter, when OHT is evaluated using a larger number of BP readings, and if home BP measurement is used. The pathogenetic mechanisms leading to OHT are still controversial and may vary according to age. Excessive neurohumoral activation seems to be the main determinant in younger adults whereas vascular stiffness plays a more important role in older individuals. Conditions associated with higher activity of the sympathetic nervous system and/or baroreflex dysregulation, such as diabetes, essential hypertension, and aging have been found to be often associated with OHT. Measurement of orthostatic BP should be included in routine clinical practice especially in people with high-normal BP.

Association of blood pressure measurements in sitting, supine, and standing positions with the 10-year risk of mortality in Korean adults

OBJECTIVES

This prospective cohort study investigated the association between blood pressure (BP) as measured in different body postures and all-cause and cardiovascular (CV) mortality risk.

METHODS

This population-based investigation included 8,901 Korean adults in 2001 and 2002. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured sequentially in the sitting, supine, and standing positions and classified into 4 categories: 1) normal, SBP <120 mmHg and DBP <80 mmHg; 2) high normal/prehypertension, SBP 120-129 mmHg and DBP <80 mmHg/SBP 130-139 mmHg or DBP 80-89 mmHg; 3) grade 1 hypertension (HTN), with SBP 140-159 mmHg or DBP 90-99 mmHg; and 4) grade 2 HTN, SBP ≥160 mmHg or DBP ≥100 mmHg. The date and cause of individual deaths were confirmed in the death record data compiled until 2013. Data were analyzed using Cox proportional hazard regression.

RESULTS

Significant associations were found between the BP categories and all-cause mortality, but only when BPs were measured in the supine position. The multivariate hazard ratios (95% confidence intervals) were 1.36 (1.06-1.75) and 1.59 (1.06-2.39) for grade 1 and grade 2 HTN, respectively, compared with the normal category. The associations between the BP categories and CV mortality were significant regardless of body posture among participants ≥65 years, whereas they were significant for supine BP measurements only in those <65 years.

CONCLUSIONS

BP measured in the supine position predicted all-cause mortality and CV mortality better than BP measured in other postures.

Can sitting and lying blood pressure measurements be considered interchangeable in older frail adults?

BACKGROUND

To compare blood pressure (BP) values in the lying and sitting positions, and the effect of orthostatism when moving from each of these positions to the upright position in a geriatric population with various frailty levels.

METHODS

In two sub-studies, we included a total of 157 consecutive patients, aged 75+ admitted to the Geriatric Department of Nancy University Hospital. BP and heart rate were sequentially measured three times in 1-min intervals each in lying, sitting and upright positions (Protocol#1, n = 107) or lying and upright positions (Protocol#2, n = 50) with an automatic validated Blood Pressure device. Patients were classified into two increasing frailty status (FS) categories: Low/Moderate (L/M-FS, n = 98) and High (H-FS, n = 59).

RESULTS

BP levels were similar in the lying and sitting positions (Protocol#1, SBP 141 ± 22 mmHg vs. 142 ± 21 mmHg, respectively, and DBP 72 ± 12 mmHg vs. 72 ± 12 mmHg, respectively) in both frailty groups. In the H-FS, orthostatic drop of SBP was more pronounced from the lying (22.1 ± 5.8 mmHg, Protocol#2) as compared to the sitting to upright position (9.4 ± 1.9 mmHg, Protocol#1) (p < 0.008), and the same trend was observed for DBP. No such differences were observed in the L-M/FS frailty individuals.

CONCLUSIONS

Orthostatic BP changes are more pronounced in the frailest patients when going from lying to the upright position than from the sitting to the upright position. Consequently, in these individuals, lying and sitting BP measurements cannot be interchangeable baseline positions to investigate orthostatic BP effects, and therefore, precise patient positioning should be specified when referring to "baseline BP measurements".

Geriatric Pharmacotherapy Case Series: Neurogenic Orthostatic Hypotension

This case illustrates the pharmacist’s role in the outpatient management of neurogenic orthostatic hypotension (nOH) in a community-dwelling older person. In this case, the patient has a long-standing history of asymptomatic hypotension with recent onset of falls with temporary loss of consciousness prompting initiation of pharmacologic therapy. This case reviews nonpharmacological and pharmacological treatment options for older people with symptomatic nOH.

Association of general and abdominal adiposity with postural changes in systolic blood pressure: results from the NAKO pretest and MetScan studies

The association between anthropometric measurements and postural changes in systolic blood pressure (SBP) has not been frequently reported. This study aimed to investigate the association of body mass index (BMI) and waist circumference (WC) with postural changes in SBP in two German cross-sectional studies. Data were derived from 506 participants of the population-based German National Cohort (NAKO) pretest and from 511 participants of the convenience sample-based MetScan studies. Linear regression models were used to estimate the association between BMI and WC with the difference between standing and sitting SBP (dSBP). Odds ratios (ORs) for an increase (dSBP > 10 mmHg) or decrease (dSBP ≤ -10 mmHg) in dSBP were calculated using logistic regression. The results were pooled by meta-analysis using an inverse variance model. In pooled analysis, a 5 kg/m² higher BMI was associated with a 1.46 mmHg (95% confidence interval (CI) 0.98-1.94) higher dSBP, while a 5 cm higher WC was associated with a 0.51 mmHg (95% CI 0.32-0.69) higher dSBP. BMI or WC were associated with a higher odds of an increase in dSBP (adjusted OR, 1.71; 95% CI 1.36-2.14 per 5 kg/m² higher BMI and 1.22; 95% CI 1.05-1.40 per 5 cm higher WC) but with a reduced odds of a decline in dSBP (adjusted OR, 0.67; 95% CI 0.44-1.00 per 5 kg/m² higher BMI and 0.84; 95% CI 0.72-0.99 per 5 cm higher WC). The associations between WC and dSBP were no longer statistically significant after BMI adjustments. In conclusion, higher BMI and higher WC were associated with higher postural increases in SBP; however, WC was not related to postural changes in SBP once adjusted for BMI.

Effects of Resistance Training Intensity on Heart Rate Variability at Rest and in Response to Orthostasis in Middle-Aged and Older Adults

OBJECTIVE

Aging and deficits related to decreased physical activity can lead to higher risks of autonomic nervous system (ANS) dysfunction. The aim of this study was to evaluate the effects of 24 weeks of resistance training (RT) at various intensities on hemodynamics as well as heart rate variability (HRV) at rest and in response to orthostatic tests in middle-aged and older adults.

METHODS

Forty adults were randomized into three groups: high-intensity (HEX) (80% 1-RM) (11 female, 4 male; 60 ± 4 years); low-moderate-intensity (LEX) (50% 1-RM) (nine female, four male; 61 ± 5 years); and a control group (CON) (eight female, four male; 60 ± 4 years). The RT program consisted of nine exercises, with two sets performed of each exercise two times per week for 24 weeks. Data collected included 1-RM, heart rate, and blood pressure and HRV at rest and in response to orthostasis.

RESULTS

Both the HEX (42-94%) and LEX (31.3-51.7%) groups showed increases in 1-RM (p < 0.01). The HEX group showed decreases in resting heart rate (-4.0%), diastolic blood pressure (-3.2 mmHg (-4.2%)), and low frequency/high frequency (LF/HF) (Ln ratio) (p < 0.05). Post-study, the HEX group had higher HF (Ln ms²) than the CON, adjusted for pre-study value and age (p < 0.05). Post-study, the supine-standing ratio (SSR) of LFn (normalized unit) in the HEX group was greater than that in the LEX and CON groups, while the SSR of LF/HF in the HEX group was greater than the CON (p < 0.05). In conclusion, high-intensity RT can improve resting heart rate and HRV by enhancing cardiac vagal control. High-intensity RT might also improve the orthostatic response in terms of HRV. High intensity RT might assist ANS modification and could perhaps decrease the risks of cardiovascular disease and orthostatic intolerance.

Management of Hypertension in the Elderly and Frail Patient

Hypertension is a frequent finding in elderly patients. Hypertension in older age can be both associated with frailty and represent a risk factor for frailty. Hypertension is recognized as a main risk factor for cardiovascular diseases such as heart failure, atrial fibrillation, and stroke and the occurrence of these diseases may provoke a decline in health status and/or worsen the degree of frailty. Blood pressure targets in hypertensive older and frail patients are not completely defined. However, specific evaluations of individual patients and their co-morbidities and assessment of domains and components of frailty, together with weighted consideration of drug use, may help in finding the appropriate therapy.

Long-term recurrences and mortality in patients with noncardiac syncope

INTRODUCTION AND OBJECTIVES

There are no in-depth studies of the long-term outcome of patients with syncope after exclusion of cardiac etiology. We therefore analyzed the long-term outcome of this population.

METHODS

For 147 months, we included all patients with syncope referred to our syncope unit after exclusion of a cardiac cause.

RESULTS

We included 589 consecutive patients. There were 313 (53.1%) women, and the median age was 52 [34-66] years. Of these, 405 (68.8%) were diagnosed with vasovagal syncope (VVS), 65 (11%) with orthostatic hypotension syncope (OHS), and 119 (20.2%) with syncope of unknown etiology (SUE). During a median follow-up of 52 [28-89] months, 220 (37.4%) had recurrences (21.7% ≥ 2 recurrences), and 39 died (6.6%). Syncope recurred in 41% of patients with VVS, 35.4% with OHS, and 25.2% with SUE (P=.006). In the Cox multivariate analysis, recurrence was correlated with age (P=.002), female sex (P <.0001), and the number of previous episodes (< 5 vs ≥ 5; P <.0001). Death occurred in 15 (3.5%) patients with VVS, 11 (16.9%) with OHS, and 13 (10.9%) with SUE (P=.001). In the multivariate analysis, death was associated with age (P=.0001), diabetes (P=.007), and diagnosis of OHS (P=.026) and SUE (P=.020).

CONCLUSIONS

In patients with noncardiac syncope, the recurrence rate after 52 months of follow-up was 37.4% and mortality was 6.6% per year. Recurrence was higher in patients with a neuromedial profile and mortality was higher in patients with a nonneuromedial profile.

Orthostatic hypotension and mortality risk in geriatric outpatients: the impact of duration and magnitude of the blood pressure drop

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.

Prognostic value of postural hypotension in hospitalized patients with heart failure

Although postural hypotension (PH) is reportedly associated with mortality in the general population, the prognostic value for heart failure is unclear. This was a post-hoc analysis of FRAGILE-HF, a prospective multicenter observational study focusing on frailty in elderly patients with heart failure. Overall, 730 patients aged ≥ 65 years who were hospitalized with heart failure were enrolled. PH was defined by evaluating seated PH, and was defined as a fall of ≥ 20 mmHg in systolic and/or ≥ 10 mmHg in diastolic blood pressure within 3 min after transition from a supine to sitting position. The study endpoints were all-cause death and heart failure readmission at 1 year. Predictive variables for the presence of PH were also evaluated. PH was observed in 160 patients (21.9%). Patients with PH were more likely than those without PH to be male with a New York Heart Association classification of III/IV. Logistic regression analysis showed that male sex, severe heart failure symptoms, and lack of administration of angiotensin-converting enzyme inhibitors were independently associated with PH. PH was not associated with 1-year mortality, but was associated with a lower incidence of readmission after discharge after adjustment for other covariates. In conclusion, PH was associated with reduced risk of heart failure readmission but not with 1-year mortality in older patients with heart failure.

Trajectory Analysis of Orthostatic Hypotension in Parkinson's Disease: Results From Parkinson's Progression Markers Initiative Cohort

Background: Orthostatic hypotension (OH) in Parkinson’s disease (PD) can lead to falls, impair quality of life, and increase mortality. A trajectory analysis of OH could be useful to predict and prevent the hypotension incidence early.

Methods: The longitudinal data of 660 patients with PD with disease duration up to 12 years were extracted from an integrated PD database. We used latent class mixed modeling (LCMM) to identify patient subgroups, demonstrating trajectories of changes in orthostatic blood pressure (BP) over time. The optimal number of subgroups was selected by several criteria including the Bayesian Information Criterion. Baseline information comparison between groups and backward stepwise logistic regression were conducted to define the distinguishing characteristics of these subgroups and to investigate the predictors for BP trajectory.

Results: We identified three trajectories for each orthostatic change of systolic blood pressure (ΔSBP), namely, Class 1 (i.e., the increasing class) consisted of 18 participants with low ΔSBP that increased continuously during the follow-up; Class 2 (i.e., the low-stable class) consisted of 610 participants with low ΔSBP that remained low throughout the follow-up; and Class 3 (i.e., the high-stable class) consisted of 32 participants with high ΔSBP at baseline that was relatively stable throughout the follow-up. Several parameters differed among subgroups, but only male sex [odds ratio (OR) = 4.687, 95% confidence interval (CI) = 1.024–21.459], lower supine diastolic blood pressure (DBP) (OR = 0.934, 95% CI = 0.876–0.996), and lower level of total protein at baseline (OR = 0.812, 95% CI = 0.700–0.941) were significant predictors of an increasing ΔSBP trajectory.

Conclusion: This study provides new information on the longitudinal development of ΔSBP in patients with PD with distinct trajectories of rapidly increasing, low-stable, and high-stable class. The parameters such as male sex, lower supine DBP, and lower total proteins help to identify the rapidly increasing class.

A community-based cross-sectional survey of orthostatic hypotension among elderly from south India

BACKGROUND

Orthostatic hypotension (OH) increases the risk of falls and associated morbidity and mortality in elderly. Hence, determining the prevalence of OH and its associated factors is important, especially in understudied LMIC settings.

METHODS

A community-based cross-sectional study was conducted among randomly selected 240 community-dwelling elderly from Thiruvananthapuram, Kerala. The OH symptoms were assessed by standard clinical measurements and frailty was assessed by modified Fried frailty phenotype. Logistic regression analysis was conducted to assess the factors associated with OH.

RESULTS

The prevalence of OH and frailty among participants was 9.6 and 29.2 percent respectively. In the first minute, OH was associated with increased odds of falls (OR = 1.97 [95%CI = 1.05, 3.72]). Increase in number of co-morbidities (OR_adj = 1.82 [95%CI = 1.36, 2.48]), number of medicines used (OR_adj = 1.73 [95%CI = 1.28, 2.34]), and orthostatic intolerance (OR_adj = 3.67 [95%CI = 1.13, 11.94]) increased the odds of having OH. Elderly with diabetes (OR_adj = 4.81 [95%CI = 1.57, 14.77]), hypertension (OR_adj = 4.97 [95%CI = 1.01, 24.46]) and cognitive impairment (OR_adj = 5.01 [95%CI = 1.40, 18.51]) were at a higher odds of having OH.

CONCLUSIONS

OH and frailty are prevalent in community dwelling elderly in Thiruvananthapuram district. Frailty may be a risk factor for OH in the first minute. The number of co-morbidities may be an independent risk factor for OH. Hence, elderly people with comorbidities and cognitive impairment may be actively assessed for OH to prevent falls and associated injuries.

Association of orthostatic blood pressure response with incident heart failure: The Framingham Heart Study

IMPORTANCE

Orthostatic hypotension (OH) and hypertension (OHT) are aberrant blood pressure (BP) regulation conditions associated with higher cardiovascular disease risk. The relations of OH and OHT with heart failure (HF) risk in the community are unclear and there remains a paucity of data on the relations with HF subtypes [HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)].

OBJECTIVE

Relate OH and OHT with HF risk and its subtypes.

DESIGN

Prospective observational cohort.

SETTING

Community-based individuals in the Framingham Heart Study Original Cohort.

PARTICIPANTS

1,914 participants (mean age 72 years; 1159 women) attending examination cycle 17 (1981-1984) followed until December 31, 2017 for incident HF or death.

EXPOSURES

OH or OHT, defined as a decrease or increase, respectively, of ≥20/10 mmHg in systolic/diastolic BP upon standing from supine position.

OUTCOMES AND MEASURES

At baseline, 1,241 participants had a normal BP response (749 women), 274 had OH (181 women), and 399 had OHT (229 women). Using Cox proportional hazards regression models, we related OH and OHT to risk of HF, HFrEF, and HFpEF compared to the absence of OH and OHT (reference), adjusting for age, sex, body mass index, systolic and diastolic BP, hypertension treatment, smoking, diabetes, and total cholesterol/high-density lipoprotein.

RESULTS

On follow-up (median 13 years) we observed 492 HF events (292 in women; 134 HFrEF, 116 HFpEF, 242 HF indeterminate EF). Compared to the referent, participants with OH [n = 84/274 (31%) HF events] had a higher HF risk (Hazards Ratio [HR] 1.47, 95% CI 1.13-1.91). Moreover, OH was associated with a higher HFrEF risk (HR 2.21, 95% CI 1.34-3.67). OHT was not associated with HF risk.

CONCLUSIONS AND RELEVANCE

Orthostatic BP response may serve as an early marker of HF risk. Findings suggest shared pathophysiology of BP regulation and HF, including HFrEF.

Management of Orthostatic Hypotension in the Hospitalized Patient: A Narrative Review

Orthostatic hypotension is a frequent cause of falls and syncope, impairing quality of life. It is an independent risk factor of mortality and a common cause of hospitalizations, which exponentially increases in the geriatric population. We present a management plan based on a systematic literature review and understanding of the underlying pathophysiology and relevant clinical pharmacology. Initial treatment measures include removing offending medications and avoiding large meals. Clinical assessment of the patients' residual sympathetic tone can aid in the selection of initial therapy between norepinephrine "enhancers" or "replacers." Role of splanchnic venous pooling is overlooked, and applying abdominal binders to improve venous return may be effective. The treatment goal is not normalizing upright blood pressure but increasing it above the cerebral autoregulation threshold required to improve symptoms. Hypertension is the most common associated comorbidity, and confining patients to bed while using pressor agents only increases supine blood pressure, leading to worsening pressure diuresis and orthostatic hypotension. Avoiding bedrest deconditioning and using pressors as part of an orthostatic rehab program are crucial in reducing hospital stay.

Orthostatic Hypotension in Male Hypertensive Patients: A Cross-Sectional Study at the University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia

Background

Orthostatic hypotension (OH) is defined as a fall in systolic blood pressure (SBP) ≥20 mmHg or diastolic BP (DBP) ≥10 mmHg within 3 minutes of standing. OH incidence is increased with hypertension, and management of these patients may pose challenges, as treatment of one can worsen the other.

Objective

This study aimed to determine the prevalence of OH and its associated factors among male hypertensive patients at the University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia.

Methods

A hospital-based cross-sectional design was employed. Seated BP was measured twice and the average of the two taken. After BP had been stabilized for 5 minutes, SBP within 3 minutes of standing was measured twice and the minimum of the two taken. A drop of ≥20 mmHg in SBP within 3 minutes of standing was taken as OH. All male hypertensive patients who were able to attain a standing position were included. Sociodemographic, anthropometric, and clinical status of the patients were taken using structured interviewer-administered questionnaires. Data were entered and analyzed using SPSS 21. Both bivariate and multivariate logistic regression analysis were done. P≤0.05 was considered statistically significant.

Results

The median age of study participants was 57 (25–96) years. The prevalence of OH was 17.6%. Uncontrolled hypertension (adjusted OR 2.08, 95% CI 1.125–3.872) and duration of hypertension ≥5 years (adjusted OR 2.04, 95% CI 1.069–3.895) were significantly associated with OH in hypertensive patients.

Conclusion

The prevalence of OH among male hypertensive patients was high. Hypertensive patients whose BP was uncontrolled and having had hypertension ≥5 years were risk factors of OH.

The Pathogenesis and Treatment of Cardiovascular Autonomic Dysfunction in Parkinson's Disease: What We Know and Where to Go

Cardiovascular autonomic dysfunctions (CAD) are prevalent in Parkinson’s disease (PD). It contributes to the development of cognitive dysfunction, falls and even mortality. Significant progress has been achieved in the last decade. However, the underlying mechanisms and effective treatments for CAD have not been established yet. This review aims to help clinicians to better understand the pathogenesis and therapeutic strategies. The literatures about CAD in patients with PD were reviewed. References for this review were identified by searches of PubMed between 1972 and March 2021, with the search term “cardiovascular autonomic dysfunctions, postural hypotension, orthostatic hypotension (OH), supine hypertension (SH), postprandial hypotension, and nondipping”. The pathogenesis, including the neurogenic and non-neurogenic mechanisms, and the current pharmaceutical and non-pharmaceutical treatment for CAD, were analyzed. CAD mainly includes four aspects, which are OH, SH, postprandial hypotension and nondipping, among them, OH is the main component. Both non-neurogenic and neurogenic mechanisms are involved in CAD. Failure of the baroreflex circulate, which includes the lesions at the afferent, efferent or central components, is an important pathogenesis of CAD. Both non-pharmacological and pharmacological treatment alleviate CAD-related symptoms by acting on the baroreflex reflex circulate. However, pharmacological strategy has the limitation of failing to enhance baroreflex sensitivity and life quality. Novel OH treatment drugs, such as pyridostigmine and atomoxetine, can effectively improve OH-related symptoms via enhancing residual sympathetic tone, without adverse reactions of supine hypertension. Baroreflex impairment is a crucial pathological mechanism associated with CAD in PD. Currently, non-pharmacological strategy was the preferred option for its advantage of enhancing baroreflex sensitivity. Pharmacological treatment is a second-line option. Therefore, to find drugs that can enhance baroreflex sensitivity, especially via acting on its central components, is urgently needed in the scientific research and clinical practice.

Relationships between subendocardial perfusion impairment, arterial stiffness and orthostatic hypotension in hospitalized elderly individuals

BACKGROUND

Orthostatic hypotension is an independent risk factor for cardiovascular morbidity and mortality. Arterial stiffness has been shown to be a pathophysiological mechanism linking orthostatic hypotension and increased cardiovascular risk. This study aims to evaluate the relationship between arterial stiffness, orthostatic hypotension and subendocardial viability ratio (SEVR) and moreover to identify the main predictors of orthostatic hypotension, carotid-femoral pulse wave velocity (PWV-cf) and SEVR.

METHODS

Seventy-five patients were enrolled (mean age 82.95 ± 6.45) in Verona's AOUI Geriatric ward. They underwent blood pressure, heart rate, body weight measurements and also comorbidity, arterial stiffness (PWV-cf measured by applanation tonometry), SEVR and biochemical indexes.

RESULTS

Prevalence of orthostatic hypotension was 46.6%. Even after adjustment for age, sex, glomerular filtration rate and mean arterial pressure, SEVR values corrected for arterial oxygen and haemoglobin content were statistically lower in orthostatic hypotension patients (P = 0.05) and PWV-cf values were statistically higher in orthostatic hypotension individuals (P = 0.042). In a binary logistic regression, PWV-cf was the only significant predictor of orthostatic hypotension (odds ratio 1.123; P = 0.039; confidence interval = 1.006--1.17).In a backward logistic regression model sex, creatinine clearance and orthostatic hypotension were significant predictors of SEVR corrected for O2 content. Mean arterial pressure, creatinine clearance and orthostatic hypotension were significant predictors of PWV-cf.

CONCLUSION

This study shows that orthostatic hypotension is related to increased arterial stiffness, confirming its higher prevalence in elderly patients. Orthostatic hypotension was also associated with reduced values of corrected SEVR, showing a relevant consequence of orthostatic hypotension on subendocardial perfusion impairment.

Cardiology meets neurology: clinical presentation and management of patients with primary neurogenic disorders and orthostatic intolerance

Patients with primary neurogenic disorders such as pure autonomic failure or multiple system atrophy may initially present with cardiocirculatory symptoms such as orthostatic intolerance or fluctuations in heart rate with symptomatic tachycardia. It is therefore clinically important to identify such patients since circulatory manifestations are only one of a series of symptoms resulting from autonomic dysfunction in various organ systems. These patients require a multimodal diagnostic and therapeutic approach and should undergo extensive evaluation in a specialized autonomic nervous system (ANS) outpatient unit. Based on a clinical case presentation, the current review summarizes the diagnostic and therapeutic approach to key cardiovascular symptoms of primary autonomic disorders and their neurological work-up in a specialized autonomic function laboratory.

Elderly Patient with Hypertension in General Practice: Clinical Features and Antihypertensive Therapy

The prevalence of arterial hypertension (AH) increases with age: among people over 60 years old this index is more than 2 times higher in the general population, 2/3 of people over 65 years old suffer from hypertension. Among patients 65–89 years old with hypertension, 2/3 patients have isolated systolic hypertension (ISAG). Features of hypertension in the elderly patients are: lability of blood pressure (BP), increasing frequency of pseudohypertension, high frequency of «white coat hypertension», decreased sensitivity of pressor factors for antihypertensive drugs, high frequency of resistant to treatment of hypertension. The new recommendations of the European Society of Cardiology for the diagnosis and treatment of hypertension emphasize 2 groups of elderly patients: 65–79 years old and ≥80 years old, which described the epidemiological features, the prevalence of risk factors for cardiovascular events, blood pressure levels for antihypertensive therapy and target blood pressure, and the recommended principles of drug therapy that are different from young and middle-aged patients. For most patients, fixed combinations are indicated as starting AGT, but monotherapy is recommended for the treatment of hypertension in very elderly patients (over 80 years old) and elderly patients over 65 years old with senile asthenia. The decreasing of blood pressure should be gradual, taking into consideration the increased risk of orthostatic reactions at this age. European and American experts recommend os first-line drugs low doses of thiazide diuretics and calcium channel antagonists (mainly dihydropyridine), which are especially indicated in isolated systolic arterial hypertension to effectively reduce the frequency of cardiovascular complications in the treatment of elderly patients with hypertension.

Aging steepens the slope of power spectrum density of 30-minute continuous blood pressure recording in healthy human subjects

BACKGROUND

The increase of blood pressure (BP) variability (BPV) is recognized as an important additional cardiovascular risk factor in both normotensive subjects and hypertensive patients. Aging-induced atherosclerosis and autonomic dysfunction impair the baroreflex and, in turn, augment 24-hour BPV. In small and large animal experiments, impaired baroreflex steepens the slope of the power spectrum density (PSD) of continuous BP in the frequency range of 0.01 to 0.1 Hz. Although the repeated oscillometric BP recording over 24 hours or longer is a prerequisite to quantify BPV in humans, how the very short-term continuous BP recording reflects BPV remains unknown. This study aimed to evaluate the impact of aging on the very short-term (30-min) BPV in healthy human subjects by frequency analysis.

METHODS

We recorded continuous BP tonometrically for 30 min in 56 healthy subjects aged between 28 and 85 years. Considering the frequency-dependence of the baroreflex dynamic function, we estimated the PSD of BP in the frequency range of 0.01 to 0.1 Hz, and compared the characteristics of PSD among four age groups (26-40, 41-55, 56-70 and 71-85 years).

RESULTS

Aging did not significantly alter mean and standard deviation (SD) of BP among four age groups. PSD was nearly flat around 0.01 Hz and decreased gradually as the frequency increased. The slope of PSD between 0.01 and 0.1 Hz was steeper in older subjects (71 years or older) than in younger subjects (55 years or younger) (p < 0.05).

CONCLUSIONS

Aging steepened the slope of PSD of BP between 0.01 and 0.1 Hz. This phenomenon may partly be related to the deterioration of the baroreflex in older subjects. Our proposed method to evaluate very short-term continuous BP recordings may contribute to the stratification of BPV.

Prevalence of postural hypotension in primary, community and institutional care: a systematic review and meta-analysis

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.

Management of Orthostatic Hypotension

PURPOSE OF REVIEW

This article reviews the management of orthostatic hypotension with emphasis on neurogenic orthostatic hypotension.

RECENT FINDINGS

Establishing whether the cause of orthostatic hypotension is a pathologic lesion in sympathetic neurons (ie, neurogenic orthostatic hypotension) or secondary to other medical causes (ie, non-neurogenic orthostatic hypotension) can be achieved by measuring blood pressure and heart rate at the bedside. Whereas fludrocortisone has been extensively used as first-line treatment in the past, it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization. Distinguishing whether neurogenic orthostatic hypotension is caused by central or peripheral dysfunction has therapeutic implications. Patients with peripheral sympathetic denervation respond better to norepinephrine agonists/precursors such as droxidopa, whereas patients with central autonomic dysfunction respond better to norepinephrine reuptake inhibitors.

SUMMARY

Management of orthostatic hypotension is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure. Nonpharmacologic measures are the key to success. Pharmacologic options include volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors. Neurogenic supine hypertension complicates management of orthostatic hypotension and is primarily ameliorated by avoiding the supine position and sleeping with the head of the bed elevated.

Increased Salt Intake for Orthostatic Intolerance Syndromes: A Systematic Review and Meta-Analysis

BACKGROUND

Guidelines recommend increased salt intake as a first-line recommendation in the management of symptomatic orthostatic hypotension and recurrent syncope. There have been no systematic reviews of this intervention. We sought to summarize the evidence for increased salt intake in patients with orthostatic intolerance syndromes.

METHODS

We conducted a systematic review and meta-analysis of studies in PubMed, EMBASE, and CINAHL. Interventional studies that increased salt intake in individuals with orthostatic intolerance syndromes were included. Primary outcome measures included incidence of falls and injuries, and rates of syncope and presyncope. Secondary outcome measures included other orthostatic intolerance symptoms, blood pressure, and heart rate.

RESULTS

A total of 14 studies were eligible, including participants with orthostatic hypotension, syncope, postural orthostatic tachycardia syndrome, and idiopathic orthostatic tachycardia (n = 391). Mean age was 35.6 (± 15) years. All studies were small and short-term (<60 mins-90 days). No study reported on the effect of increased salt intake on falls or injuries. Meta-analysis demonstrated that during head-up tilt, mean time to presyncope with salt intake increased by 1.57 minutes (95% confidence interval [CI], 1.26-1.88), mean systolic blood pressure increased by 12.27 mm Hg (95% CI, 10.86-13.68), and mean heart rate decreased by -3.97 beats per minute (95% CI, -4.08 to -3.86), compared with control. Increased salt increased supine blood pressure by 1.03 mm Hg (95% CI, 0.81 to 1.25). Increased salt intake resulted in an improvement or resolution of symptoms in 62.3% (95% CI, 51.6 to 72.6) of participants in short-term follow-up studies (mean follow-up of 44.3 days, 6 studies; n=91). Methodological quality of studies were low with high statistical heterogeneity in all meta-analyses.

CONCLUSIONS

Our meta-analysis provides low-quality evidence of a short-term improvement in orthostatic intolerance with increased salt intake. There were no clinical trials demonstrating the efficacy and safety of increased salt intake on long-term clinical outcomes. Overall, there is a paucity of clinical trial evidence to support a cornerstone recommendation in the management of orthostatic intolerance syndromes.

Blood Pressure and Mortality: Joint Effect of Blood Pressure Measures

We examine how combinations of systolic and diastolic blood pressure levels and pulse pressure levels predicted mortality risk. Respondents are those aged over 50 from the Health and Retirement Study (N=10,366) who provided blood pressure measures in 2006/2008. Systolic and diastolic blood pressures were measured three times; and we averaged the three readings. Pulse pressure was calculated as systolic minus diastolic blood pressure. Seven combinations of systolic and diastolic blood pressure (low/normal/high of each) and three levels of pulse pressure (low/normal/high) were used to categorize blood pressure. Over 1 to 10 years of follow-up (average follow-up time of 7.8 years), 2,820 respondents died after blood pressure measurement in 2006/2008. Potential covariates including age, gender, education, BMI, total cholesterol, HbA1c, antihypertensive medication intake and lifetime-smoking pack years were adjusted in Cox proportional hazard models and survival curves. The blood pressure subgroup with low systolic blood pressure (<90 mmHg) and low diastolic blood pressure (< 60 mmHg) had the highest relative risk of mortality (HR=2.34, 95% CI: 1.45-3.80), followed by those with normal systolic blood pressure but low diastolic blood pressure (HR=1.45, 95% CI: 1.17-1.81) among those with cardiovascular conditions at baseline. For those without cardiovascular conditions at baseline, low blood pressure, either systolic or diastolic, was not related to mortality. Those with high levels of both systolic and diastolic blood pressure had a higher risk of mortality than those with both blood pressures normal but no other subgroups with low blood pressure differed from normal/normal in predicting mortality. Pulse pressure did not predict mortality. How high and low blood pressures are related to mortality needs to be examined by jointly looking at systolic and diastolic blood pressure.

Clinical Trials for Neurogenic Orthostatic Hypotension: A Comprehensive Review of Endpoints, Pitfalls, and Challenges

Neurogenic orthostatic hypotension (nOH) is among the most debilitating nonmotor features of patients with Parkinson's disease (PD) and other synucleinopathies. Patients with PD and nOH generate more hospitalizations, make more emergency room visits, create more telephone calls/mails to doctors, and have earlier mortality than those with PD but without nOH. Overall, the health-related cost in patients with PD and OH is 2.5-fold higher compared with patients with PD without OH. Hence, developing effective therapies for nOH should be a research priority. In the last few decades, improved understanding of the pathophysiology of nOH has led to the identification of therapeutic targets and the development and approval of two drugs, midodrine and droxidopa. More effective and safer therapies, however, are still needed, particularly agents that could selectively increase blood pressure only in the standing position because supine hypertension is the main limitation of available drugs. Here we review the design and conduct of nOH clinical trials in patients with PD and other synucleinopathies, summarize the results of the most recently completed and ongoing trials, and discuss challenges, bottlenecks, and potential remedies.

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.

Neurogenic Orthostatic Hypotension: State of the Art and Therapeutic Strategies

Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension in which patients have impaired regulation of standing blood pressure due to autonomic dysfunction. Several primary and secondary causes of this disease exist. Patients may present with an array of symptoms making diagnosis difficult. This review article addresses the epidemiology, pathophysiology, causes, clinical features, and management of nOH. We highlight various pharmacological and non-pharmacological approaches to treatment, and review the recent guidelines and our approach to nOH.

The Prevalence of Orthostatic Hypotension: A Systematic Review and Meta-Analysis

BACKGROUND

Orthostatic hypotension (OH) is associated with increased risk of falls, cognitive impairment and death, as well as a reduced quality of life. Although it is presumed to be common in older people, estimates of its prevalence vary widely. This study aims to address this by pooling the results of epidemiological studies.

METHODS

MEDLINE, EMBASE, PubMed, Web of Science, and ProQuest were searched. Studies were included if participants were more than 60 years, were set within the community or within long-term care and diagnosis was based on a postural drop in systolic blood pressure (BP) ≥20 mmHg or diastolic BP ≥10 mmHg. Data were extracted independently by two reviewers. Random and quality effects models were used for pooled analysis.

RESULTS

Of 23,090 identified records, 20 studies were included for community-dwelling older people (n = 24,967) and six were included for older people in long-term settings (n = 2,694). There was substantial variation in methods used to identify OH with differing supine rest duration, frequency and timing of standing BP, measurement device, use of standing and tilt-tables and interpretation of the diagnostic drop in BP. The pooled prevalence of OH in community-dwelling older people was 22.2% (95% CI = 17, 28) and 23.9% (95% CI = 18.2, 30.1) in long-term settings. There was significant heterogeneity in both pooled results (I2 > 90%).

CONCLUSIONS

OH is very common, affecting one in five community-dwelling older people and almost one in four older people in long-term care. There is great variability in methods used to identify OH.

Orthostatic change in systolic blood pressure associated with cold pressor reflection and heart rate variability in the elderly

Background: Impaired orthostatic blood pressure (BP) response is a frequent finding in the elderly. The goal of the study was to investigate the association of variability of supine-to-orthostatic BP with cold pressor reflection and heart rate variability in the elderly.Methods: From June 2010 to September 2013, 287 elderly aged ≥ 60 years were enrolled in Jinan area, China. The elderly were classified into lower (n = 96), intermediate (n = 95), and higher (n = 96) tertile groups according to the tertile of the percentage change of supine-to-orthostatic systolic BP.Results: There were significant increasing trends in systolic BP response to the CPT at 0 and 60 sec; the plasma levels of epinephrine, norepinephrine, and angiotensin II; and decreasing trends in DNN, SDNN index, and SDANN from the lower to the higher tertile group, and differences between any two groups were significant (P < .05). The percentage change of supine-to-orthostatic systolic BP was positively correlated with systolic BP response to CPT at 0 and 60 sec, VLF, epinephrine, norepinephrine, and angiotensin II (P < .001) and negatively correlated with SDNN, SDNN index, SDANN, rMSSD, pNN50, LF, and ratio of LF/HF (P < .001). The BP response to CPT, parameters of HRV, and the plasma levels of norepinephrine and angiotensin II were independently associated with the percentage change of supine-to-orthostatic systolic BP after adjustment for confounders.Conclusion: Aggressive variability of supine-to-orthostatic systolic BP might be significantly associated with the imbalance of sympathetic and parasympathetic activity, especially high sensitivity sympathetic response in the elderly.Abbreviations: BP: blood pressure; BMI: body mass index; CPT: cold pressor test; HRV: heart rate variability; SDNN: standard deviation of all normal-to-normal R-R intervals; SDNN index: mean of the standard deviations of all 5-min normal-to-normal R-R intervals of the entire recording; SDANN: standard deviation of the averages of normal-to-normal R-R intervals during all 5-min periods of the entire recording; rMSSD: square root of the mean squared differences between successive normal R-R intervals; pNN50: number of adjacent normal R-R intervals differing by more than 50 ms; VLF: very low frequency; LF: low frequency; HF: high frequency; TCHO: total cholesterol; HDL-c: high-density lipoprotein cholesterol; LDL-c: low-density lipoprotein cholesterol; FPG: fasting plasma glucose; SD: standard deviation.

Rationale and design of the EMPYREAN study

Aims

A sodium glucose cotransporter 2 (SGLT2) inhibitor was recently found to reduce heart failure hospitalization in the EMPA‐REG OUTCOME trial. We have hypothesized that autonomic nerve activity may be modulated by SGLT2 inhibition. The current study aims to investigate the impact of empagliflozin on sympathetic and parasympathetic nerve activity in patients with type 2 diabetes mellitus.

Methods and results

This ongoing study is a prospective, randomized, open‐label, multicentre investigation of 134 patients with type 2 diabetes mellitus. The patients are randomly allocated to receive either empagliflozin or sitagliptin with the treatment goal of the Japan Diabetes Society guidelines. Ambulatory electrocardiographic monitoring is performed at the baseline and at 12 and 24 weeks of treatment. Analyses of heart rate variability are conducted using the MemCalc method, which is a combination of the maximum entropy method for spectral analysis and the non‐linear least squares method for square analysis. The primary endpoint is the change in the low‐frequency (0.04–0.15 Hz)/high‐frequency (0.15–0.4 Hz) ratio from baseline to 24 weeks.

Conclusions

This investigation on the effect of EMPagliflozin on cardiac sYmpathetic and parasympathetic neRve activity in JapanEse pAtieNts with type 2 diabetes (EMPYREAN study) offers an important opportunity to understand the impact of SGLT2 inhibition on autonomic nerve activity in patients with type 2 diabetes.

What do we really know about supine hypertension in patients with orthostatic hypotension

PURPOSE OF REVIEW

Patients with severe orthostatic hypotension due to autonomic failure may be hypertensive in the supine position. Until recently, there were no internationally recognized diagnostic criteria for supine hypertension. This review covers diagnostic criteria, mechanisms, and management of supine hypertension in autonomic failure patients.

RECENT FINDINGS

Recently, an international consensus group defined supine hypertension in patients with neurogenic orthostatic hypotension as brachial SBP at least 140 mmHg and/or DBP at least 90 mmHg while supine. Using these criteria, a large proportion of patients with orthostatic hypotension is diagnosed with supine hypertension. Recent research supports the concept that the hypertension can be mediated through residual sympathetic nervous system function and independently from sympathetic activity, for example via mineralocorticoid receptor activation.

SUMMARY

The clear definition of supine hypertension is an important step that will hopefully foster clinical research in this area. Supine hypertension promotes renal sodium excretion, thus, worsening orthostatic hypotension the next morning. Supine hypertension may promote cardiovascular and renal disease. Yet, long-term benefits of treating supine hypertension be it through non pharmacological or pharmacological means have not been proven by sufficiently large clinical trials.

Low Systolic Blood Pressure and Mortality in Elderly Patients After Acute Myocardial Infarction

Background

Optimal blood pressure in elderly patients after acute myocardial infarction is still a matter of debate. In a prospective observational study, we aimed to identify optimal systolic blood pressure during the 48 first hours after admission for acute myocardial infarction and its prognostic value for cardiovascular mortality.

Methods and Results

From the Observatoire des Infarctus de Côte d'Or survey, all consecutive patients aged >75 years admitted for an acute myocardial infarction in a coronary care unit from 2012 to 2015 and discharged alive were included (n=814). Exclusion criteria were in‐hospital death, cardiogenic shock, and end‐stage renal disease. Average systolic blood pressure (aSBP) values over the first 48 hours after admission were recorded, and the population was dichotomized into 2 groups: low aSBP group (<125 mm Hg) and control group (aSBP ≥125 mm Hg). When compared with patients without cardiovascular death at 1‐year follow‐up, patients who died from a cardiovascular cause had higher rate of cardiovascular risks factors, including age, diabetes mellitus, comorbidities, and cardiovascular history. They had higher rates of low body mass index (<21 kg/m²) and more elevated Global Registry of Acute Coronary Events risk score. Patients with aSBP <125 mm Hg had a 2‐fold risk of 1‐year cardiovascular death (47 [12.0%] versus 28 [6.6%]; P=0.008). By multivariable logistic regression analysis, low aSBP (odds ratio [95% CI], 1.91 [1.07–3.41]) remained a strong and independent predictor of 1‐year cardiovascular mortality.

Conclusions

In our large population‐based study in elderly patients with acute myocardial infarction, low aSBP was an independent and powerful predictor of 1‐year cardiovascular mortality. Early aSBP measurement could help to improve risk stratification. Moreover, our results may suggest an optimal blood pressure target in elderly patients.

Cardiac changes associated with vascular aging

Cardiovascular aging is a complex process of adaptive structural and functional changes over time. With advancing age, the arterial tree thickens and decreases in compliance, resulting in increased pulse wave velocity, systolic blood pressure, and left ventricular afterload. In response to these arterial changes, the myocardium remodels to maintain systolic function and diastolic filling. These adaptive mechanisms are not necessarily pathologic but increase the susceptibility for myocardial ischemia and heart failure in the presence of common age-associated comorbidities. This article reviews the pathophysiology of cardiovascular aging and discusses therapeutic interventions that may ameliorate these processes.

Orthostatic hypotension is associated with new-onset atrial fibrillation: Systemic review and meta-analysis

Introduction

Orthostatic hypotension (OH) is common among elderly patients. Its presence may herald severe underlying comorbidities and be associated with a higher risk of mortality. Interestingly, recent studies suggest that OH is associated with new-onset atrial fibrillation (AF). However, a systematic review and meta-analysis of the literature has not been performed. We assessed the association between AF and OH through a systematic review of the literature and a meta-analysis.

Methods

We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2018. Published prospective or retrospective cohort studies that compared new-onset AF between male patients with and without OH were included. Data from each study were combined using the random-effects, generic inverse-variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals.

Results

Four studies from October 2010 to March 2018 were included in the meta-analysis involving 76,963 subjects (of which 3318 were diagnosed with OH). The presence of OH was associated with new-onset AF (pooled risk ratio 1.48; 95% confidence interval [1.21, 1.81], p?< 0.001; I2 = 69.4%). In hypertensive patients, analysis revealed an association between OH and the occurrence of new-onset AF (OR 1.46; 95% CI [1.27, 1.68], p < 0.001 with I2 = 0).

Conclusions

OH was associated with new-onset AF up to 1.5-fold compared with those subjects without OH. The interplay between OH and AF is likely bidirectional.

Aortic stiffness and central systolic pressure are associated with ambulatory orthostatic BP fall in chronic kidney disease

OBJECTIVE

Orthostatic hypotension (OH) has a significant association with cardiovascular disease. OH becomes more common in older age, as does arterial stiffness, shown to be independently associated with impaired baroreflex sensitivity and OH. Measurement of arterial compliance and central blood pressures are increasingly important, with evidence that central BP more closely correlates to end-organ damage and mortality than peripheral measurements. Patients with chronic kidney disease (CKD) are high risk for cardiovascular events, which can be predicted through measures of arterial compliance. We hypothesised that OH is associated with arterial stiffness and central blood pressure in CKD patients.

DESIGN/SETTING

We tested this hypothesis within the arterial compliance and oxidant stress as predictors of loss of renal function, morbidity and mortality in chronic kidney disease (ACADEMIC) study, a single-centre prospective observational study of the progression of arterial stiffness and renal function.

PARTICIPANTS

One hundred and forty-six patients with CKD 3 or 4.

MEASUREMENTS

Twenty-four-hour ambulatory BP monitoring with postural sensing (DIASYS Integra 2, Novacor France); central systolic and diastolic BP (cSBP and cDBP) and aortic Augmentation Index using Sphygmocor^® (Atcor, Australia); Carotid-femoral pulse wave velocity (cfPWV) using Complior^® (ALAM Medical, France).

RESULTS

Twenty-three patients had a postural SBP fall (prevalence 15.8%), with mean drop 7 mmHg. Patients with OH had higher cfPWV (15.2 m/s vs 12.7 m/s in patients without OH, p < 0.001) and central SBP (147.5 vs 135.7, p = 0.012). Regression analysis gave an odds ratio (OR) of orthostatic SBP fall for cfPWV of 1.46 (95% CI 1.16-1.84, p = 0.001) and 1.03 for cSBP (95% CI 1.004-1.06, p = 0.024) after adjustment for cardiovascular risk factors.

CONCLUSION

Aortic stiffness and central SBP are independently associated with orthostatic SBP fall in CKD patients. This suggests that enhanced arterial stiffness may be an underlying mechanism in baroreflex dysfunction, and may partly explain the vascular risk in CKD patients.

Orthostatic Hypotension in Parkinson Disease

Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing that can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions. OH can be caused by volume depletion, blood loss, cardiac pump failure, large varicose veins, medications, or defective activation of sympathetic nerves and reduced norepinephrine release upon standing. Neurogenic OH is a frequent and disabling problem in patients with synucleinopathies such as Parkinson disease, multiple system atrophy, and pure autonomic failure, and it is commonly associated with supine hypertension. Several therapeutic options are available.

Association between invasively measured aortic pulse pressure and orthostatic hypotension in patients undergoing invasive coronary angiography

OBJECTIVE

Underlying pathophysiology of orthostatic hypotension has been poorly understood. We hypothesized that aortic pulse pressure (APP) reflecting aortic stiffness may be involved in the development of orthostatic hypotension.

METHODS

A total of 200 patients (age 64.3 ± 10.9 years, 62.5% men) who underwent invasive coronary angiography (ICA) were prospectively recruited. Orthostatic hypotension was defined as SBP drop at least 20 mmHg or DBP drop at least 10 mmHg within 3 min of the standing position compared with the supine position. Hemodynamic parameters were measured at the ascending aorta using a pig-tail catheter immediately before ICA. APP was calculated as a difference between the aortic peak systolic pressure and the end-diastolic pressure.

RESULTS

A total of 156 patients (78.0%) had obstructive coronary artery disease on ICA. Orthostatic hypotension was present in 58 patients (29.0%). Diabetes mellitus was more prevalent in patients with orthostatic hypotension than those without (48.3% vs. 23.2%; P < 0.001). Other clinical parameters including age, cardiovascular risk factors, laboratory findings and concomitant medications were not different between patients with and without orthostatic hypotension (P > 0.05 for each). In hemodynamic parameters, APP was higher in patients with orthostatic hypotension than those without (78.4 ± 25.8 vs. 68.3 ± 21.3 mmHg; P = 0.005). Higher APP was significantly associated with the presence of orthostatic hypotension even after controlling for potential confounders (odds ratio, 2.99; 95% confidence interval 1.15-7.78; P = 0.025).

CONCLUSION

In patients undergoing ICA, APP was associated with increased risk of orthostatic hypotension. Central aortic stiffness may play a role in the development of orthostatic hypotension.

Orthostatic hypotension in internal medicine wards

OBJECTIVES

Most studies of orthostatic hypotension (OH) have focused on community-dwelling and institutionalized patient populations. Less is known about OH in hospitalized patients. Moreover, a comprehensive review of OH in internal medicine wards has not been published in the English literature. Our purpose is to provide current information regarding OH in internal medicine inpatients.

METHODS

A comprehensive search of medical databases was performed for potentially relevant articles, using the following keywords: postural or orthostatic hypotension, with the combination of hospitalization or internal medicine. Inclusion criteria were: population of patients hospitalized for acute disorders in internal medicine or geriatric wards with a sample size of ≥50 and publication as an original full-length article in the English language. Data from 14 selected studies are reviewed, including: pathophysiology, evaluation, prevalence, manifestations, risk factors, prognosis, and management.

RESULTS

OH is a common and often symptomatic disorder in elderly internal medicine patients. The prevalence of OH in this population ranges from 22-75%. There are substantial discrepancies between the studies reviewed regarding definitions and means of evaluating OH. OH in internal medicine wards is largely non-neurogenic and multifactorial. The main predisposing factors for OH are prolonged bed rest, hypertension, and heart failure. OH in internal medicine wards is managed mainly with non-pharmacologic interventions, and is frequently reversible.

CONCLUSIONS

In internal medicine inpatients, OH warrants attention because this disorder is common, potentially dangerous, and treatable. In the hospital setting, OH should be routinely assessed on ambulation, following the current guidelines for OH definition and meaning.

Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review

Neurogenic orthostatic hypotension (nOH) is a sustained reduction in blood pressure (BP) upon standing that is caused by autonomic dysfunction and is common among patients with a variety of neurodegenerative disorders (eg, Parkinson's disease, multiple system atrophy, pure autonomic failure). A systolic BP drop of ≥20 mmHg (or ≥10 mmHg diastolic) upon standing with little or no compensatory increase in heart rate is consistent with nOH. Symptoms of nOH include light-headedness, dizziness, presyncope, and syncope; these symptoms can severely impact patients' activities of daily living and increase the likelihood of potentially dangerous falls. Because of their patient contact, nurses and nurse practitioners can play a key role in identifying and evaluating patients at risk for nOH. It is advisable to screen for nOH in patients presenting with one or more of the following characteristics: those who have disorders associated with autonomic failure, those with episodes of falls or syncope, those with symptoms upon standing, those who are elderly or frail, or those taking multiple medications. Initial evaluations should include questions about postural symptoms and measurement of orthostatic BP and heart rate. A review of medications for potential agents that can have hypotensive effects should be performed before initiating treatment. Treatment for nOH may include non-pharmacologic measures and pharmacologic therapy. Droxidopa and midodrine are approved by the US Food and Drug Administration for the treatment of symptomatic nOH and symptomatic OH, respectively. nOH is associated with the coexistence of supine hypertension, and the two disorders must be carefully managed. In conclusion, timely screening and diagnosis of patients with nOH can streamline the path to disease management and treatment, potentially improving patient outcomes.

Six-Month Use of Droxidopa for Neurogenic Orthostatic Hypotension

Background

Droxidopa is approved for adult patients with symptomatic neurogenic orthostatic hypotension (nOH); there is limited information regarding effects on symptoms, outcomes, and quality of life (QOL) beyond two weeks of treatment.

Objective

Examine the real‐world experience of patients taking droxidopa after six months of treatment.

Methods

This non‐interventional, US‐based, prospective cohort study utilized a pharmacy hub, identifying patients who recently started droxidopa for nOH treatment. Questionnaires for fall frequency and other patient‐reported outcomes (PROs) were completed at baseline and one, three, and six months following droxidopa initiation.

Results

179 enrolled patients completed baseline surveys. Droxidopa continuation rates were high at months one, three, and six (87%, 79%, and 75%, respectively). From baseline to month one, there was significant reduction in the proportion of patients reporting falling at least once (54.1% vs. 43.0%; P = 0.0039), with similar observations at month three (52.9% vs. 44.5%; P = 0.0588) and month six (51.4% vs. 40.0%; P = 0.0339). Significant improvements from baseline to month one were observed and maintained at months three and six for most PROs, including the Orthostatic Hypotension Symptom Assessment Item 1, Short Falls Efficacy Scale‐International, Sheehan Disability Scale, Physical Component of the 8‐item Short‐Form Health Survey, and Patient Health Questionnaire‐9.

Conclusions

In this non‐interventional prospective study, fewer nOH patients reported falling after one, three, and six months of droxidopa treatment. Further, improvements reported in nOH symptoms, physical function, and QOL measures were maintained for six months following treatment initiation. Results from randomized clinical trials are required to validate the findings.

Association of orthostatic hypertension with mortality in the Systolic Hypertension in the Elderly Program

We examined the association of orthostatic hypertension with all-cause mortality in the active treatment and placebo randomized groups of the Systolic Hypertension in the Elderly Program (SHEP). SHEP was a multicenter, randomized, double-blind, placebo-controlled clinical trial of the effect of chlorthalidone-based antihypertensive treatment on the rate of occurrence of stroke among older persons with isolated systolic hypertension (ISH). Men and women aged 60 years and above with ISH defined by a systolic blood pressure (SBP) of 160 mm Hg or higher and diastolic blood pressure lower than 90 mm Hg were randomized to chlorthalidone-based stepped care therapy or matching placebo. Among 4736 SHEP participants, 4073 had a normal orthostatic response, 203 had orthostatic hypertension, and 438 had orthostatic hypotension. Compared with normal response, orthostatic hypertension was associated with higher all-cause mortality at 4.5 and 17 years in analyses adjusted for age, gender, treatment, SBP, and pulse pressure (PP, HR 1.87, 95% CI 1.30–2.69, p = 0.0007; HR 1.40, 95% CI 1.17–1.68, p = 0.0003, respectively). These associations remained significant after additional adjustment for risk factors and comorbidities (HR 1.43, 95% CI 0.99–0.08, p = 0.0566 at 4.5 years, and HR 1.27, 95% CI 1.06–1.53, p = 0.0096 at 17 years). The increased risk of all-cause mortality associated with orthostatic hypertension was observed in both the active and placebo groups without significant interaction between randomization group and the effect on mortality. Orthostatic hypertension is associated with future mortality risk, is easily detected, and can be used in refining cardiovascular risk assessment.

[Hypotensions in the elderly: Clinical and therapeutic features]

Hypotension and especially very low diastolic blood pressure could be an at-risk situation in very old and frail patients and in those with coronary heart disease. Chronic hypotension in people with heart failure is an indicator of poor prognosis and hinders the management of therapy. Orthostatic hypotension is a decrease in blood pressure>20mmHg for systolic and/or>10mmHg for diastolic within 3minutes after transition from supine to upright. Orthostatic hypotension may be symptomatic or not. The search for orthostatic hypotension is part of the clinical examination of elderly patients with hypertension, falling, diabetes and or polymedication. First intention treatment aims to correct modifiable modifying factors and to limit the circulatory consequences of orthostatism by elastic venous compression.