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Starmans NLP, Wolters FJ, Leeuwis AE, Bron EE, de Bresser J, Brunner-La Rocca HP, Staals J, Muller M, Biessels GJ, Kappelle LJ. Orthostatic hypotension, cognition and structural brain imaging in hemodynamically impaired patients. J Neurol Sci 2024; 461:123026. [PMID: 38723328 DOI: 10.1016/j.jns.2024.123026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Orthostatic hypotension (OH) is associated with an increased risk of dementia, potentially attributable to cerebral hypoperfusion. We investigated which patterns and characteristics of OH are related to cognition or to potentially underlying structural brain injury in hemodynamically impaired patients and healthy reference participants. METHODS Participants with carotid occlusive disease or heart failure, and reference participants from the Heart-Brain Connection Study underwent OH measurements, neuropsychological assessment and brain MRI. We analyzed the association between OH, global cognitive functioning, white matter hyperintensity (WMH) volume and brain parenchymal fraction with linear regression. We stratified by participant group, severity and duration of OH, chronotropic incompetence and presence of orthostatic symptoms. RESULTS Of 337 participants (mean age 67.3 ± 8.8 years, 118 (35.0%) women), 113 (33.5%) had OH. Overall, presence of OH was not associated with cognitive functioning (β: -0.12 [-0.24-0.00]), but we did observe worse cognitive functioning in those with severe OH (≥ 30/15 mmHg; β: -0.18 [-0.34 to -0.02]) and clinically manifest OH (β: -0.30 [-0.52 to -0.08]). These associations did not differ significantly by OH duration or chronotropic incompetence, and were similar between patient groups and reference participants. Similarly, both severe OH and clinically manifest OH were associated with a lower brain parenchymal fraction, and severe OH also with a somewhat higher WMH volume. CONCLUSIONS Severe OH and clinically manifest OH are associated with worse cognitive functioning. This supports the notion that specific patterns and characteristics of OH determine its impact on brain health.
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Affiliation(s)
- Naomi L P Starmans
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA Utrecht, the Netherlands.
| | - Frank J Wolters
- Department of Epidemiology, Erasmus MC, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands; Department of Radiology & Nuclear Medicine and Alzheimer Centre Erasmus MC, Erasmus MC, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Anna E Leeuwis
- Alzheimer Centre Amsterdam, Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, location VUmc, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Esther E Bron
- Department of Radiology & Nuclear Medicine and Alzheimer Centre Erasmus MC, Erasmus MC, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, the Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, the Netherlands
| | - Majon Muller
- Department of Internal Medicine, Geriatrics Section, Amsterdam Cardiovascular Science, Amsterdam UMC, location VUmc, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Geert Jan Biessels
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA Utrecht, the Netherlands
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2
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Klop M, de Heus RAA, Maier AB, van Alphen A, Floor-Westerdijk MJ, Bronkhorst M, Melis RJF, Meskers CGM, Claassen JAHR, van Wezel RJA. Capturing postural blood pressure dynamics with near-infrared spectroscopy-measured cerebral oxygenation. GeroScience 2023; 45:2643-2657. [PMID: 37041313 PMCID: PMC10651596 DOI: 10.1007/s11357-023-00791-9] [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: 01/20/2023] [Accepted: 03/31/2023] [Indexed: 04/13/2023] Open
Abstract
Orthostatic hypotension (OH) is highly prevalent in older adults and associated with dizziness, falls, lower physical and cognitive function, cardiovascular disease, and mortality. OH is currently diagnosed in a clinical setting with single-time point cuff measurements. Continuous blood pressure (BP) devices can measure OH dynamics but cannot be used for daily life monitoring. Near-infrared spectroscopy (NIRS) has potential diagnostic value in measuring cerebral oxygenation continuously over a longer time period, but this needs further validation. This study aimed to compare NIRS-measured (cerebral) oxygenation with continuous BP and transcranial Doppler-measured cerebral blood velocity (CBv) during postural changes. This cross-sectional study included 41 participants between 20 and 88 years old. BP, CBv, and cerebral (long channels) and superficial (short channels) oxygenated hemoglobin (O2Hb) were measured continuously during various postural changes. Pearson correlations between BP, CBv, and O2Hb were calculated over curves and specific characteristics (maximum drop amplitude and recovery). BP and O2Hb only showed good curve-based correlations (0.58-0.75) in the initial 30 s after standing up. Early (30-40 s) and 1-min BP recovery associated significantly with O2Hb, but no consistent associations were found for maximum drop amplitude and late (60-175 s) recovery values. Associations between CBv and O2Hb were poor, but stronger for long-channel than short-channel measurements. BP associated well with NIRS-measured O2Hb in the first 30 s after postural change. Stronger associations for CBv with long-channel O2Hb suggest that long-channel NIRS specifically reflects cerebral blood flow during postural transitions, necessary to better understand the consequences of OH such as intolerance symptoms.
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Affiliation(s)
- Marjolein Klop
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands.
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Rianne A A de Heus
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore, Singapore
| | - Anne van Alphen
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - René J F Melis
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carel G M Meskers
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jurgen A H R Claassen
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Richard J A van Wezel
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands
- Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Enschede, the Netherlands
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3
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Raber I, Belanger MJ, Farahmand R, Aggarwal R, Chiu N, Al Rifai M, Jacobsen AP, Lipsitz LA, Juraschek SP. Orthostatic Hypotension in Hypertensive Adults: Harry Goldblatt Award for Early Career Investigators 2021. Hypertension 2022; 79:2388-2396. [PMID: 35924561 PMCID: PMC9669124 DOI: 10.1161/hypertensionaha.122.18557] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular disease, stroke, and death. Among adults with hypertension, orthostatic hypotension has also been shown to predict patterns of blood pressure dysregulation that may not be appreciated in the office setting, including nocturnal nondipping. Individuals with uncontrolled hypertension are at particular risk of orthostatic hypotension and may meet diagnostic criteria for the condition with a smaller relative reduction in blood pressure compared with normotensive individuals. Antihypertensive medications are commonly de-prescribed to address orthostatic hypotension; however, this approach may worsen supine or seated hypertension, which may be an important driver of adverse events in this population. There is significant variability between guidelines for the diagnosis of orthostatic hypotension with regards to timing and position of blood pressure measurements. Clinically relevant orthostatic hypotension may be missed when standing measurements are delayed or when taken after a seated rather than supine position. The treatment of orthostatic hypotension in patients with hypertension poses a significant management challenge for clinicians; however, recent evidence suggests that intensive blood pressure control may reduce the risk of orthostatic hypotension. A detailed characterization of blood pressure variability is essential to tailoring a treatment plan and can be accomplished using both in-office and out-of-office monitoring.
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Affiliation(s)
- Inbar Raber
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Matthew J Belanger
- Northeast Medical Group, Yale New Haven Hospital, New Haven, Connecticut
| | - Rosemary Farahmand
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Rahul Aggarwal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nicholas Chiu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Alan P. Jacobsen
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Lewis A. Lipsitz
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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4
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Wieling W, Kaufmann H, Claydon VE, van Wijnen VK, Harms MPM, Juraschek SP, Thijs RD. Diagnosis and treatment of orthostatic hypotension. Lancet Neurol 2022; 21:735-746. [PMID: 35841911 PMCID: PMC10024337 DOI: 10.1016/s1474-4422(22)00169-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/24/2023]
Abstract
Orthostatic hypotension is an unusually large decrease in blood pressure on standing that increases the risk of adverse outcomes even when asymptomatic. Improvements in haemodynamic profiling with continuous blood pressure measurements have uncovered four major subtypes: initial orthostatic hypotension, delayed blood pressure recovery, classic orthostatic hypotension, and delayed orthostatic hypotension. Clinical presentations are varied and range from cognitive slowing with hypotensive unawareness or unexplained falls to classic presyncope and syncope. Establishing whether symptoms are due to orthostatic hypotension requires careful history taking, a thorough physical examination, and supine and upright blood pressure measurements. Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic. Neurogenic orthostatic hypotension might be the earliest clinical manifestation of Parkinson's disease or related synucleinopathies, and often coincides with supine hypertension. The emerging variety of clinical presentations advocates a stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension. Such an approach could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures (eg, counterpressure manoeuvres), and treatment with pharmacological agents in selected cases.
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Affiliation(s)
- Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands; UCL Queen Square Institute of Neurology, University College London, London, UK; Stichting Epilepsie Instellingen Nederland, Heemstede, Netherlands.
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5
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Diagnostic criteria for initial orthostatic hypotension: a narrative review. Clin Auton Res 2021; 31:685-698. [PMID: 34677720 DOI: 10.1007/s10286-021-00833-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022]
Abstract
Abnormalities in orthostatic blood pressure changes upon active standing are associated with morbidity, mortality, and reduced quality of life. However, over the last decade, several population-based cohort studies have reported a remarkably high prevalence (between 25 and 70%) of initial orthostatic hypotension (IOH) among elderly individuals. This has raised the question as to whether the orthostatic blood pressure patterns in these community-dwelling elderly should truly be considered as pathological. If not, redefining of the systolic cutoff values for IOH (i.e., a value ≥ 40 mmHg in systolic blood pressure in the first 15 s after standing up) might be necessary to differ between normal aging and true pathology. Therefore, in this narrative review, we provide a critical analysis of the current reference values for the changes in systolic BP in the first 60 s after standing up and discuss how these values should be applied to large population studies. We will address factors that influence the magnitude of the systolic blood pressure changes following active standing and the importance of standardization of the stand-up test, which is a prerequisite for quantitative, between-subject comparisons of the postural hemodynamic response.
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6
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Spectrum of Hemodynamic Responses in the First 60 Seconds after Active Standing Up: Importance of Time Course of Blood Pressure Changes and Definitions. J Am Med Dir Assoc 2021; 22:2401-2403. [PMID: 34126059 DOI: 10.1016/j.jamda.2021.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 12/21/2022]
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7
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Sabino-Carvalho JL, Fisher JP, Vianna LC. Autonomic Function in Patients With Parkinson's Disease: From Rest to Exercise. Front Physiol 2021; 12:626640. [PMID: 33815139 PMCID: PMC8017184 DOI: 10.3389/fphys.2021.626640] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/24/2021] [Indexed: 12/16/2022] Open
Abstract
Parkinson’s disease (PD) is a common neurodegenerative disorder classically characterized by symptoms of motor impairment (e.g., tremor and rigidity), but also presenting with important non-motor impairments. There is evidence for the reduced activity of both the parasympathetic and sympathetic limbs of the autonomic nervous system at rest in PD. Moreover, inappropriate autonomic adjustments accompany exercise, which can lead to inadequate hemodynamic responses, the failure to match the metabolic demands of working skeletal muscle and exercise intolerance. The underlying mechanisms remain unclear, but relevant alterations in several discrete central regions (e.g., dorsal motor nucleus of the vagus nerve, intermediolateral cell column) have been identified. Herein, we critically evaluate the clinically significant and complex associations between the autonomic dysfunction, fatigue and exercise capacity in PD.
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Affiliation(s)
- Jeann L Sabino-Carvalho
- NeuroV̇ASQ̇ - Integrative Physiology Laboratory, Faculty of Physical Education, University of Brasília, Brasília, Brazil
| | - James P Fisher
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lauro C Vianna
- NeuroV̇ASQ̇ - Integrative Physiology Laboratory, Faculty of Physical Education, University of Brasília, Brasília, Brazil.,Graduate Program in Medical Sciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
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8
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Harms MPM, Finucane C, Pérez-Denia L, Juraschek SP, van Wijnen VK, Lipsitz LA, van Lieshout JJ, Wieling W. Systemic and cerebral circulatory adjustment within the first 60 s after active standing: An integrative physiological view. Auton Neurosci 2021; 231:102756. [PMID: 33385733 PMCID: PMC8103784 DOI: 10.1016/j.autneu.2020.102756] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/30/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023]
Abstract
Transient cardiovascular and cerebrovascular responses within the first minute of active standing provide the means to assess autonomic, cardiovascular and cerebrovascular regulation using a real-world everyday stimulus. Traditionally, these responses have been used to detect autonomic dysfunction, and to identify the hemodynamic correlates of patient symptoms and attributable causes of (pre)syncope and falls. This review addresses the physiology of systemic and cerebrovascular adjustment within the first 60 s after active standing. Mechanical factors induced by standing up cause a temporal mismatch between cardiac output and vascular conductance which leads to an initial blood pressure drops with a nadir around 10 s. The arterial baroreflex counteracts these initial blood pressure drops, but needs 2-3 s to be initiated with a maximal effect occurring at 10 s after standing while, in parallel, cerebral autoregulation buffers these changes within 10 s to maintain adequate cerebral perfusion. Interestingly, both the magnitude of the initial drop and these compensatory mechanisms are thought to be quite well-preserved in healthy aging. It is hoped that the present review serves as a reference for future pathophysiological investigations and epidemiological studies. Further experimental research is needed to unravel the causal mechanisms underlying the emergence of symptoms and relationship with aging and adverse outcomes in variants of orthostatic hypotension.
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Affiliation(s)
- Mark P M Harms
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ciáran Finucane
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Laura Pérez-Denia
- Department of Medical Physics & Bioengineering, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland; Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Ireland
| | - Stephen P Juraschek
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Veera K van Wijnen
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Johannes J van Lieshout
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; School of Life Sciences, The Medical School, MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, Nottingham, United Kingdom
| | - Wouter Wieling
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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9
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Juraschek SP, Hu JR, Cluett JL, Ishak A, Mita C, Lipsitz LA, Appel LJ, Beckett NS, Coleman RL, Cushman WC, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor AA, Thijs L, Wright JT, Mukamal KJ. Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension : A Systematic Review and Individual Participant-based Meta-analysis. Ann Intern Med 2021; 174:58-68. [PMID: 32909814 PMCID: PMC7855528 DOI: 10.7326/m20-4298] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH). PURPOSE To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults. DATA SOURCES MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions. STUDY SELECTION Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing. DATA EXTRACTION 2 investigators independently abstracted articles and rated risk of bias. DATA SYNTHESIS 5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged. LIMITATIONS Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available. CONCLUSION Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Jiun-Ruey Hu
- Vanderbilt University Medical Center, Nashville, Tennessee (J.H.)
| | - Jennifer L Cluett
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Anthony Ishak
- Healthcare Associates, Beth Israel-Lahey Health System, Boston, Massachusetts (A.I.)
| | - Carol Mita
- Countway Library, Harvard University, Boston, Massachusetts (C.M.)
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center, Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Harvard Medical School, Boston, Massachusetts (L.A.L.)
| | | | - Nigel S Beckett
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (N.S.B.)
| | - Ruth L Coleman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - William C Cushman
- University of Tennessee Health Science Center, Memphis, Tennessee (W.C.C.)
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas (B.R.D.)
| | - Greg Grandits
- School of Public Health, University of Minnesota, Minneapolis, Minnesota (G.G.)
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - Edgar R Miller
- Johns Hopkins University, Baltimore, Maryland (L.J.A., E.R.M.)
| | - Ruth Peters
- University of New South Wales, Sydney, and Neuroscience Research Australia, Randwick, New South Wales, Australia (R.P.)
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, and NPA Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (J.A.S.)
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas (A.A.T.)
| | - Lutgarde Thijs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, Belgium (L.T.)
| | - Jackson T Wright
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio (J.T.W.)
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
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10
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Stewart JM, Kota A, O'Donnell-Smith MB, Visintainer P, Terilli C, Medow MS. The preponderance of initial orthostatic hypotension in postural tachycardia syndrome. J Appl Physiol (1985) 2020; 129:459-466. [PMID: 32702262 DOI: 10.1152/japplphysiol.00540.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Reduced systolic/diastolic blood pressure (BP) by >40/20 mmHg defines initial orthostatic hypotension (IOH). Rapid resolution of hypotension and lightheadedness follows, but tachycardia may be prolonged. We aimed to examine IOH in controls and patients with postural tachycardia syndrome (POTS) using indices of spontaneous fluctuations of heart rate (HR) and systolic BP as measures of cardiac baroreflex differences. We recruited otherwise healthy IOH patients without POTS (n = 20, 16 ± 3 yr), healthy volunteers (n = 32, 17 ± 3 yr), and POTS patients (n = 39, 17 ± 4 yr). Subjects were instrumented for electrocardiography and beat-to-beat BP. After 10 min supine, subjects stood for 5 min. Following supine recovery, subjects underwent 70° head-up tilt for 10 min to test for POTS. BP, HR, and time, referenced to standing, were measured at events during standing: minimum BP, BP recovery, peak HR, HR minimum, and steady state. Baseline HR and BP were higher in POTS compared with healthy groups. IOH occurred in 13% of controls and 51% of POTS patients. The BP minimum was lower in POTS. Parasympathetic modulation of cardiac baroreflex was decreased in all POTS and control-IOH subjects. Sympathetic indices were increased. Events following BP minimum occurred progressively later in all POTS and control-IOH subjects compared with non-IOH controls. IOH is more frequent in POTS than in controls with a lower minimum BP. POTS has markedly reduced heart rate variability and baroreflex, indicating reduced HR buffering of BP. POTS-IOH and control-IOH subjects had similar peak HR despite decreased minimum BP in POTS. IOH data indicate modest parasympathetic and cardiovagal baroreflex deficits in control-IOH subjects. Parasympathetic deficits are more severe in all POTS patients.NEW & NOTEWORTHY Significant initial orthostatic hypotension (IOH) occurs in ~50% of postural tachycardia syndrome (POTS) patients and 13% of controls. Heart rate and blood pressure recovery are prolonged in IOH sustaining lightheadedness; IOH is more prevalent and severe in POTS. Altered cerebral blood flow and cardiorespiratory regulation are more prevalent in POTS. Altered heart rate variability and baroreflex gain may cause nearly instantaneous lightheadedness in POTS. IOH alone fails to confer a strong probability of POTS.
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Affiliation(s)
- Julian M Stewart
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
| | - Archana Kota
- Department of Pediatric, New York Medical College, Valhalla, New York
| | | | - Paul Visintainer
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts
| | - Courtney Terilli
- Department of Pediatric, New York Medical College, Valhalla, New York
| | - Marvin S Medow
- Department of Pediatric, New York Medical College, Valhalla, New York.,Department of Physiology, New York Medical College, Valhalla, New York
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11
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Juraschek SP, Lipsitz LA, Beach JL, Mukamal KJ. Association of Orthostatic Hypotension Timing With Clinical Events in Adults With Diabetes and Hypertension: Results From the ACCORD Trial. Am J Hypertens 2019; 32:684-694. [PMID: 30715100 PMCID: PMC6558664 DOI: 10.1093/ajh/hpz015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/22/2018] [Accepted: 01/17/2019] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To determine the effects of orthostatic hypotension (OH) measurement timing on its associations with dizziness, falls, fractures, cardiovascular disease (CVD), and mortality. METHODS We analyzed OH measurements from the Action to Control Cardiovascular Risk in Diabetes BP trial, which evaluated two blood pressure (BP) goals (systolic BP [SBP] < 120 mm Hg vs. SBP < 140 mm Hg) and incident CVD among adults with diabetes and hypertension. Seated BP was measured after 5 minutes of rest at baseline and follow-up visits (12 months, 48 months, and exit). Standing BP was measured 3 consecutive times (M1-M3) after standing, starting at 1 minute with each measurement separated by 1 minute. Consensus OH was defined as a drop in SBP ≥ 20 mm Hg or diastolic BP (DBP) ≥ 10 mm Hg. Participants were asked about orthostatic dizziness, recent falls, and recent fractures, and underwent surveillance for CVD events and all-cause mortality. RESULTS There were 4,268 participants with OH assessments over 8,450 visits (mean age 62.6 years [SD = 6.6]; 46.6% female; 22.3% black). Although all measures of consensus OH were significantly associated with dizziness, none were associated with falls, and only M2 (~3 minutes) was significantly associated with fractures. No measurements were associated with CVD events, but later measurements were significantly associated with mortality. BP treatment goal did not increase risk of OH regardless of timing. Associations were not consistently improved by the mean or minimum of M1-M3. CONCLUSION In this population of adults with hypertension and diabetes, neither single time nor set of measurements were clearly superior with regard to outcomes. These findings support the use of a flexibly timed, single measurement to assess OH in clinical practice. CLINICAL TRIALS REGISTRATION Trial Number NCT00000620.
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Affiliation(s)
- Stephen P Juraschek
- Section for Research, Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lewis A Lipsitz
- Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Marcus Institute for Aging Research, Hebrew Senor Life, & Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer L Beach
- Section for Research, Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth J Mukamal
- Section for Research, Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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van Wijnen VK, Hove DT, Finucane C, Wieling W, van Roon AM, Ter Maaten JC, Harms MP. Hemodynamic Mechanisms Underlying Initial Orthostatic Hypotension, Delayed Recovery and Orthostatic Hypotension. J Am Med Dir Assoc 2018; 19:786-792. [DOI: 10.1016/j.jamda.2018.05.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/24/2018] [Accepted: 05/05/2018] [Indexed: 01/18/2023]
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