Greater Change of Orthostatic Blood Pressure Is Related to Silent Cerebral Infarct and Cardiac Overload in Hypertensive Subjects

Assessment and management of exaggerated blood pressure response to standing and orthostatic hypertension: consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability

Recent evidence suggests that an exaggerated blood pressure (BP) response to standing (ERTS) is associated with an increased risk of adverse outcomes, both in young and old individuals. In addition, ERTS has been shown to be an independent predictor of masked hypertension. In the vast majority of studies reporting on the prognostic value of orthostatic hypertension (OHT), the definition was based only on systolic office BP measurements. This consensus statement provides recommendations on the assessment and management of individuals with ERTS and/or OHT. ERTS is defined as an orthostatic increase in SBP at least 20 mmHg and OHT as an ERTS with standing SBP at least 140 mmHg. This statement recommends a standardized methodology to assess ERTS, by considering body and arm position, and the number and timing of BP measurements. ERTS/OHT should be confirmed in a second visit, to account for its limited reproducibility. The second assessment should evaluate BP changes from the supine to the standing posture. Ambulatory BP monitoring is recommended in most individuals with ERTS/OHT, especially if they have high-normal seated office BP. Implementation of lifestyle changes and close follow-up are recommended in individuals with ERTS/OHT and normotensive seated office BP. Whether antihypertensive treatment should be administered in the latter is unknown. Hypertensive patients with ERTS/OHT should be managed as any other hypertensive patient. Standardized standing BP measurement should be implemented in future epidemiological and interventional studies.

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.

Exaggerated blood pressure response to standing in young-to-middle-age subjects: prevalence and factors involved

PURPOSE

To investigate the prevalence of orthostatic hypertension and the association of the blood pressure (BP) level, supine BP decline, and white-coat effect with the orthostatic pressor response.

METHODS

We studied 1275 young-to-middle-age individuals with stage-1 hypertension. Orthostatic response was assessed three times over a 3 month period. The white-coat effect was assessed at baseline and after 3 months, and was calculated as the difference between office and average 24 h BP. In 660 participants, urinary epinephrine and norepinephrine were also measured.

RESULTS

An orthostatic systolic BP increase ≥ 20 mmHg was observed in 0.6-1.2% of the subjects during the three visits. Using the 20 mmHg cut-off, the prevalence of orthostatic hypertension was 0.6%. An orthostatic BP increase of ≥ 5 mmHg was found in 14.4% of participants. At baseline, the orthostatic response to standing showed an independent negative association with the supine BP level (p < 0.001), the supine BP change from the first to third measurement (p < 0.001), and the white-coat effect (p < 0.001). Similar results were obtained in the 1080 participants assessed at the third visit. Urinary epinephrine showed higher values in the top BP response decile (systolic BP increase ≥ 6 mmHg, p = 0.002 versus rest of the group).

CONCLUSION

An orthostatic systolic BP reaction ≥ 20 mmHg is rare in young adults. However, even lower BP increases may be clinically relevant. The BP level, the supine BP decline over repeated measurement, and the white-coat effect can influence the estimate of the BP response to standing and should be considered in clinical and pathogenetic studies.

Prevalence of orthostatic hypertension and its association with cerebrovascular diagnoses in patients with suspected TIA and minor stroke

Purpose

We aimed to compare the rate of stroke, transient ischemic attack, and cerebrovascular disease diagnoses across groups of patients based on their orthostatic blood pressure response in a transients ischemic attack clinic setting.

Materials and Methods

We retrospectively analysed prospectively collected data from 3201 patients referred to a transient ischemic attack (TIA)/minor stroke outpatients clinic. Trained nurses measured supine and standing blood pressure using an automated blood pressure device and the patients were categorized based on their orthostatic blood pressure change into four groups: no orthostatic blood pressure rise, systolic orthostatic hypertension, diastolic orthostatic hypertension, and combined orthostatic hypertension. Then, four stroke physicians, who were unaware of patients' orthostatic BP response, assessed the patients and made diagnoses based on clinical and imaging data. We compared the rate of stroke, TIA, and cerebrovascular disease (either stroke or TIA) diagnoses across the study groups using Pearson's χ² test. The effect of confounders was adjusted using a multivariate logistic regression analysis.

Results

Cerebrovascular disease was significantly less common in patients with combined systolic and diastolic orthostatic hypertension compared to the "no rise" group [OR = 0.56 (95% CI 0.35–0.89]. The odds were even lower among the subgroups of patients with obesity [OR = 0.31 (0.12–0.80)], without history of smoking [OR 0.34 (0.15–0.80)], and without hypertension [OR = 0.42 (95% CI 0.19–0.92)]. We found no significant relationship between orthostatic blood pressure rise with the diagnosis of stroke. However, the odds of TIA were significantly lower in patients with diastolic [OR 0.82 (0.68–0.98)] and combined types of orthostatic hypertension [OR = 0.54 (0.32–0.93)]; especially in patients younger than 65 years [OR = 0.17 (0.04–0.73)] without a history of hypertension [OR = 0.34 (0.13–0.91)], and patients who did not take antihypertensive therapy [OR = 0.35 (0.14–0.86)].

Conclusion

Our data suggest that orthostatic hypertension may be a protective factor for TIA among younger and normotensive patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02600-1.

Association between orthostatic blood pressure dysregulation and geriatric syndromes: a cross-sectional study

Background

Orthostatic blood pressure dysregulation, including orthostatic hypotension (OH) and orthostatic hypertension (OHT), is common in the elderly. The association between OH and, to a lesser extent, OHT with geriatric syndromes is controversial and little investigated.

Our objective was to assess the association between orthostatic blood pressure dysregulation and geriatric syndromes in an ambulatory outpatient population.

Methods

This observational study included all outpatients for whom a one-visit comprehensive geriatric assessment was performed during a year. OH was defined as a decrease of at least 20 mmHg in systolic blood pressure (SBP) and/or 10 mmHg in diastolic blood pressure (DBP) after 1 or 3 min of standing. OHT was defined as an increase of more than 20 mmHg in SBP after 1 or 3 min of standing. Comorbidities, drugs regimen, a history of previous falls, nutritional, frailty, functional and cognitive status were compared between patients with OHT or OH and controls (NOR).

Results

Five hundred thirty patients (mean age: 82.9 ± 5.1 years) were included. 19.6% had an OH and 22.3% an OHT. OHT patients were more frequently female, had more diabetes and a lower resting SBP than patients with NOR. OH patients had a higher resting SBP than NOR. After adjusting for age, sex, resting SBP and diabetes, OHT was associated with a low walking speed (OR = 1.332[1.009–1.758]; p = 0.043) and severe cognitive impairment at MMSe score (OR = 1.629[1.070–1.956]; p = 0.016) compared to NOR. Conversely, OH was associated with a lower grip strength (p = 0.016) than NOR.

Conclusion

OHT and OH are common in elderly but associated with different geriatric phenotypes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02844-8.

Orthostatic intolerance: a frailty marker for older adults

PURPOSE

Frailty, orthostatic blood pressure changes (OBPC), and orthostatic intolerance syndrome (OIS) are common in geriatric patients. However, the results of the studies evaluating the relationship between these entities are discordant. We aimed to investigate the association between frailty and OIS with or without OBPC.

METHODS

Comprehensive geriatric assessment (CGA), frailty assessment, OBPC evaluations in the active-standing test (1st, 3rd, 5th, and 10th min), OIS investigation both in history before the test (self-reported OIS) and emerged during the active-standing test, and sarcopenia assessment via BIA and handgrip strength (HGS) were performed in 102 geriatric outpatients.

RESULTS

Patients were divided into three categories according to their frailty status (non-frail, prefrail, and frail) by Modified Fried Frailty Index (FFI) and Clinical Frailty Scale (CFS). Prevalence of self-reported OIS and OIS during the test were statistically higher in the frail group assessed by both frailty scales (P value: 0.001 for CFS, P value < 0.0001 for FFI, and P value: 0.001 for CFS, P value: 0.007 for FFI, respectively). Logistic regression analysis showed that OIS significantly increased frailty assessed both by FFI and CFS, when adjusted for age, sex, comorbidities, CGA, and sarcopenia (For FFI, OR: 19.37; 95% CI: 2.38-157.14; P value: 0.006 and for CFS OR: 4.32; 95% CI: 1.184-11.47; P value: 0.003, respectively).

CONCLUSION

To the best of our knowledge, this is the first study defining OIS as symptoms both self-reported and provoked during the test, and showed a strong correlation between OIS and frailty. OIS may be defined as a multifactorial and independent marker for frailty, regardless of OBPC. Further prospective investigations are warranted to support the relationships between OIS and frailty.

Time in range, as an emerging metric of glycemic control, is associated with orthostatic blood pressure changes in type 2 diabetes

AIMS

To exlpore whether time in range(TIR) was associated with orthostatic blood pressure(BP) changes in type 2 diabetes(T2DM).

METHODS

A total of 342 T2DM patients were recruited. TIR was defined as the time percentage spent within the target range(3.9-10.0 mmol/L). Orthostatic hypotension(OH) and orthostatic hypertension(OHT) were defined as a decrease or an increase of at least 20 mmHg in SBP and/or 10 mmHg in DBP after standing for 3 min.

RESULTS

Compared with orthostatic normotension group, patients with OH or OHT showed lower levels of TIR (P < 0.001). The prevalences of OH and OHT both decreased with ascending TIR tertiles (OH, P < 0.001; OHT, P = 0.019), and both absolute SBP and DBP changes were negatively correlated with TIR (r = -0.171, -0.190, P < 0.05). After stratifying by BMI, only the prevalence of OH in the lower layer and the prevalence of OHT in the higher layer remained significant difference among tertiles of TIR. Multivariate logistics regression revealed that lower TIR and lower BMI were risk factors for OH, whereas lower TIR but higher BMI were risk factors for OHT.

CONCLUSIONS

We find a differential correlation dependent of BMI milieus between TIR and orthostatic BP status.

Sympathetic Overactivation From Supine to Upright Is Associated With Orthostatic Hypertension in Children and Adolescents

There are no prior publications or submissions with any overlapping information, including studies and patients. The study data have not been presented as an abstract or poster before the submission. Objectives: The study was conducted to analyze the changes of baroreflex sensitivity and heart rate variability from supine to upright standing in children and adolescents with orthostatic hypertension to explore whether and how the autonomic nerve regulation was involved in the development of pediatric orthostatic hypertension. Methods: This case-control study included twenty-five children with orthostatic hypertension (the patient group) and twenty-six healthy controls (the control group). All subjects underwent a standing test, during which their hemodynamic parameters were continuously monitored by a Finapres Medical System, and baroreflex sensitivity and heart rate variability were calculated. Results: The demographic characteristics, supine baroreflex sensitivity, and supine heart rate variability including time domain and frequency domain indices did not differ between the patients with orthostatic hypertension and healthy subjects (P > 0.05). However, a more obvious drop of baroreflex sensitivity and a greater increase of low frequency/high frequency ratio from supine to upright were observed in subjects with orthostatic hypertension compared with those in the healthy children (P < 0.001 and P < 0.01, respectively). Changes of baroreflex sensitivity were negatively related to mean arterial pressure changes from supine to upright in all subjects (P < 0.01), and the increases in low frequency/high frequency ratio from supine to standing were positively correlated with those in mean arterial pressure in the study subjects (P < 0.001). Conclusion: Upright sympathetic overactivation is associated with pediatric orthostatic hypertension.

The association between orthostatic blood pressure changes and subclinical target organ damage in subjects over 60 years old

Background

Although recent studies have indicated that both orthostatic hypotension and orthostatic hypertension independently predict cardiovascular events, the underlying mechanisms are still controversial. The aim of the study was to investigate the relationships between orthostatic changes and organ damage in subjects over 60 years old.

Methods

This is a prospective observational cohort study. One thousand nine hundred and ninety-seven subjects over 60 years old were enrolled. Participants were grouped according to whether they had a drop ≥ 20 mmHg in systolic or ≥ 10 mmHg in diastolic BP (orthostatic hypotension), an increase in mean orthostatic systolic blood pressure ≥ 20 mm Hg (orthostatic hypertension), or normal changes within 3 min of orthostatism. Multiple regression modeling was used to investigate the relationship between orthostatic hypotension, orthostatic hypertension and subclinical organ damage with adjustment for confounders.

Results

Orthostatic hypotension and orthostatic hypertension were found in 461 (23.1%) and 189 (9.5%) participants, respectively. Measurement of carotid intima-media thickness (IMT), brachial-ankle pulse wave velocity (baPWV), clearance of creatinine, and microalbuminuria were associated with orthostatic hypotension; measurement of IMT and baPWV were associated with orthostatic hypertension in a cruse model. After adjustment, IMT [odds ratio (OR), 95% confidence interval (CI) per one-SD increment: 1.385, 1.052–1.823; P = 0.02], baPWV (OR = 1.627, 95% CI: 1.041–2.544; P = 0.033) and microalbuminuria (OR = 1.401, 95% CI: 1.002–1.958; P = 0.049) were still associated with orthostatic hypotension, while orthostatic hypertension was only associated with IMT (OR = 1.730, 95% CI: 1.143–2.618; P = 0.009).

Conclusions

Orthostatic hypotension seems to be independently correlated with increased carotid atherosclerosis, arterial stiffness and renal damage in subjects over 60 years old. Orthostatic hypertension correlates with carotid atherosclerosis only.

Effect of Postural Hypotension on Recurrent Stroke: Secondary Prevention of Small Subcortical Strokes (SPS3) Study

BACKGROUND

Orthostatic hypotension (OH) has been independently associated with increased risk of stroke and other cardiovascular events. We sought to investigate the relationship between OH at follow-up and recurrent stroke risk in SPS3 (Secondary Prevention of Small Subcortical Strokes) trial patient cohort. This is a retrospective cohort analysis.

METHODS

We included all SPS3 trial participants with blood pressure measurements in both sitting and standing position per protocol at baseline, with at least 1 follow-up visit to establish the relationship between OH at follow-up and recurrent stroke risk (primary outcome). Secondary outcomes included major vascular events, myocardial infarction, all-cause mortality, and, ischemic and hemorrhagic stroke subtypes. Participants were classified as having OH at baseline and at each follow-up visit based on a systolic BP decline ≥20 mm Hg or a diastolic BP decline ≥10 mm Hg on position change from sitting to standing. We used Cox proportional hazards regression modeling to compare the risk of outcomes among those with and without OH.

RESULTS

A total of 2275 patients were included with a mean follow up time 3.2 years (standard deviation = 1.6 years). 39% (881/2275) had OH at some point during their follow-up. Of these, 41% (366/881) had orthostatic symptoms accompanying the BP drop. In a fully adjusted model, those with OH had a 1.8 times higher risk of recurrent stroke than those without OH (95% confidence interval: 1.1-3.0). The risk of ischemic stroke, major vascular events, and all-cause mortality was similarly elevated among the OH group.

CONCLUSION

OH was associated with increased recurrent stroke risk, vascular events, and all-cause death in this large cohort of lacunar stroke patients. Whether minimizing OH in the management of poststroke hypertension in patients with lacunar stroke reduces recurrent stroke risk deserves further study.

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.

Labile hypertension: a new disease or a variability phenomenon?

Blood pressure (BP) is a physiological parameter with short- and long-term variability caused by complex interactions between intrinsic cardiovascular (CV) mechanisms and extrinsic environmental and behavioral factors. Available evidence suggests that not only mean BP values are important, but also BP variability (BPV) might contribute to CV events. Labile hypertension (HTN) is referred to sudden rises in BP and it seems to be linked with unfavorable outcomes. The aim of this article was to review and summarize recent evidence on BPV phenomenon, unraveling the labile HTN concept along with the prognostic value of these conditions.

Relation between cognitive impairment and treatment adherence in elderly hypertensive patients

Background

Nonadherence to medical treatment and lack of cooperation in hypertensive patients >65 years of age are believed to be caused by a number of age-related problems, such as cognitive impairment. Numerous epidemiological and prospective studies have demonstrated that hypertension that remains untreated for many years or is unsuccessfully treated for reasons such as poor compliance and adherence of the patient may lead to cognitive impairment.

Objective

The objective of this study was to investigate the occurrence of cognitive impairment and its effect on treatment compliance and adherence in elderly hypertensive patients.

Design

This study was an analytical cross-sectional study.

Patients and methods

The study was conducted on 300 patients aged 65-91 years (mean age=71.8 years, SD=7.8 years) diagnosed with hypertension. The following research tools were used: 1) Hill-Bone High Blood Pressure Compliance Scale (HBCS) and 2) Mini-Mental State Examination (MMSE). We also analyzed medical documentation to obtain basic sociodemographic and clinical data. The study was approved by the Bioethics Committee of the Medical University of Wrocław (no KB-144/2016).

Results

Cognitive impairment occurred in 60% of the patients. A group of 63% patients complied with antihypertensive therapy, with the mean score of 20.8 points. Cognitive impairment was strongly correlated with the total score of the HBCS questionnaire (p<0.001) and two of its subscales: "appointment keeping" (p<0.001) and "medication taking" (p<0.001).

Conclusion

Compliance and adherence levels are higher in patients with a higher educational level, whereas male sex adversely affects treatment adherence in elderly hypertensive patients.

Detecting Risk Of Postural hypotension (DROP): derivation and validation of a prediction score for primary care

OBJECTIVES

Falls are a common problem in older people. Postural hypotension contributes to falls but is often asymptomatic. In the absence of symptoms, postural hypotension is only infrequently checked for in clinical practice. We undertook this study to derive, validate and explore the prospective associations of a prediction tool to identify people likely to have unrecognised postural hypotension.

DESIGN AND SETTING

Cross-sectional and prospective multivariable cohort analysis.

PARTICIPANTS

1317 participants of the Invecchiare in Chianti study, a population-based cohort representative of the older Italian population.

PRIMARY OUTCOME MEASURES

Predictive value of score to suggest presence of postural hypotension.

METHODS

Subjects were randomised 1:1 to derivation or validation cohorts. Within the derivation cohort, univariable associations for candidate predictors of postural hypotension were tested. Variables with p<0.1 entered multivariable linear regression models. Factors retaining multivariable significance were incorporated into unweighted and weighted Detecting Risk Of Postural hypotension (DROP) scores. These scores were tested in the validation cohort against prediction of postural hypotension, cognitive decline and mortality over 9 years of follow-up.

RESULTS

Postural hypotension was present in 203 (15.4%) of participants. Factors predicting postural hypotension were: digoxin use, Parkinson's disease, hypertension, stroke or cardiovascular disease and an interarm systolic blood pressure difference. Area under the curve was consistent at 0.65 for all models, with significant ORs of 1.8 to 2.4 per unit increase in score for predicting postural hypotension. For a DROP score ≥1, five cases need to be tested to identify one with postural hypotension.Increasing DROP scores predicted mortality (OR 1.8 to 2.8 per unit rise) and increasing rates of decline of Mini Mental State Examination score (analysis of variance p<0.001) over 9 years of follow-up.

CONCLUSIONS

The DROP score provides a simple method to identify people likely to have postural hypotension and increased risks to health who require further evaluation.

Impact of variations in blood pressure with orthostatism on mortality: the HOMO study

OBJECTIVE

The aim of this study was to determine the impact of orthostatic hypotension (OH) and orthostatic hypertension (OHT) on all-cause mortality.

PATIENTS AND METHODS

A total of, 1176 adults from the community over 18 years of age were included in this ambispective study. The mean follow-up was 9.4 years. OH and OHT were defined as a decrease or an increase, respectively, in systolic blood pressure (BP) of at least 20 mmHg and/or diastolic BP of at least 10 mmHg from sitting to standing position at 1 and/or 3 min after standing. The impact of systolic or diastolic OH and systolic or diastolic OHT at 1 and 3 min after standing was also analyzed separately.

RESULTS

In total, 135 individuals died during the follow-up. Neither OH [hazard ratio (HR) 1.23; 95% confidence interval (CI): 0.72-2.10] nor OHT (HR 0.90; 95% CI: 0.59-1.38) was associated with all-cause mortality in the adjusted models. In contrast, systolic OHT at 3 min (HR 2.31; 95% CI: 1.14-4.68) was independently associated with global mortality.

CONCLUSION

Systolic OHT at 3 min is associated with all-cause mortality. The determination of this parameter could add valuable prognostic information during the routine examination of patients.

Cognitive Status, Gray Matter Atrophy, and Lower Orthostatic Blood Pressure in Older Adults

BACKGROUND

Associations between orthostatic blood pressure and cognitive status (CS) have been described with conflicting results.

OBJECTIVE

We hypothesize that long-term exposure to lower orthostatic blood pressure is related to having worse CS later in life and that atrophy of regions involved in central regulation of autonomic function mediate these associations.

METHODS

Three-to-four measures of orthostatic blood pressure were obtained from 1997-2003 in a longitudinal cohort of aging, and average systolic orthostatic blood pressure response (ASOBPR) was computed as % change in systolic blood pressure from sit-to-stand measured at one minute post stand. CS was determined in 2010-2012 by clinician-adjudication (n = 240; age = 87.1±2.6; 59% women; 37% black) with a subsample also undergoing concurrent structural neuroimaging (n = 129). Gray matter volume of regions related to autonomic function was measured. Multinomial regression was used to compare ASOBPR in those who were cognitively intact versus those with a diagnosis of mild cognitive impairment or dementia, controlling for demographics, trajectories of seated blood pressure, incident cardiovascular risk/events and medications measured from 1997 to 2012. Models were repeated in the subsample with neuroimaging, before and after adjustment for regional gray matter volume.

RESULTS

There was an inverse association between ASOBPR and probability of dementia diagnosis (9% lower probability for each % point higher ASOBPR: OR 0.91, CI95%  = 0.85-0.98; p = 0.01). Associations were similar in the subgroup with neuroimaging before and after adjustment for regional gray matter volume.

CONCLUSION

ASOBPR may be an early marker of risk of dementia in older adults living in the community.

Left ventricular hypertrophy and cognitive function: a systematic review

Cognitive impairment is common in patients with hypertension. Left ventricular hypertrophy (LVH) is recognised as a marker of hypertension-related organ damage and is a strong predictor of coronary artery disease, heart failure and stroke. There is evidence that LVH is independently associated with cognitive impairment, even after adjustment for the presence of hypertension. We conducted a systematic review that examined cognitive impairment in adults with LVH. Independent searches were performed in Ovid MEDLINE, Ovid psycInfo and PubMed with the terms left ventricular hypertrophy and cognition. Seventy-three studies were identified when both searches were combined. After limiting the search to studies that were: (1) reported in English; (2) conducted in humans; (3) in adults aged 50 years and older; and (4) investigated the relationship between LVH and cognitive performance, nine papers were included in this systematic review. The majority of studies found an association between LVH and cognitive performance. Inspection of results indicated that individuals with LVH exhibited a lower performance in cognitive tests, when compared to individuals without LVH. Memory and executive functions were the cognitive domains that showed a specific vulnerability to the presence of LVH. A possible mechanism for the relationship between LVH and cognition is the presence of cerebral white matter damage. White matter lesions occur frequently in patients with LVH and may contribute to cognitive dysfunction. Together, the results of this review suggest that memory impairment and executive dysfunction are the cognitive domains that showed a particular association with the presence of LVH.

Hypertension and Frailty Syndrome in Old Age: Current Perspectives

Hypertension is both a health problem and a financial one globally. It affects nearly 30 % of the general population. Elderly people, aged ≥65 years, are a special group of hypertensive patients. In this group, the overall prevalence of the disease reaches 60 %, rising to 70 % in those aged ≥80 years. In the elderly population, isolated systolic hypertension is quite common. High systolic blood pressure is associated with an increased risk of cardiovascular disease, cerebrovascular disease, peripheral artery disease, cognitive impairment and kidney disease. Considering the physiological changes resulting from ageing alongside multiple comorbidities, treatment of hypertension in elderly patients poses a significant challenge to treatment teams. Progressive disability with regard to the activities of daily life, more frequent hospitalisations and low quality of life are often seen in elderly patients. There is discussion in the literature regarding frailty syndrome associated with old age. Frailty is understood to involve decreased resistance to stressors, depleted adaptive and physiological reserves of a number of organs, endocrine dysregulation and immune dysfunction. The primary dilemma concerning frailty is whether it should only be defined on the basis of physical factors, or whether psychological and social factors should also be included. Proper nutrition and motor rehabilitation should be prioritised in care for frail patients. The risk of orthostatic hypotension is a significant issue in elderly patients. It results from an autonomic nervous system dysfunction and involves maladjustment of the cardiovascular system to sudden changes in the position of the body. Other significant issues in elderly patients include polypharmacy, increased risk of falls and cognitive impairment. Chronic diseases, including hypertension, deteriorate baroreceptor function and result in irreversible changes in cerebral and coronary circulation. Concurrent frailty or other components of geriatric syndrome in elderly patients are associated with a worse perception of health, an increased number of comorbidities and social isolation of the patient. It may also interfere with treatment adherence. Identifying causes of non-adherence to pharmaceutical treatment is a key factor in planning therapeutic interventions aimed at increasing control, preventing complications, and improving long-term outcomes and any adverse effects of treatment. Diagnosis of frailty and awareness of the associated difficulties in adhering to treatment may allow targeting of those elderly patients who have a poorer prognosis or may be at risk of complications from untreated or undertreated hypertension, and for the planning of interventions to improve hypertension control.

The impaired subjective perception of verticality independent of peripheral vestibular function in dizzy elderly with orthostatic hypotension

BACKGROUND

The elderly often complain of faintness, lightheadedness, dizziness, and unsteadiness, which may be associated with the orthostatic hypotension (OH), but most of them are subclinical. The pathogenic mechanism of subjective symptoms in the elderly with OH is controversial.

AIMS

The aim of this study was to assess the involvement of the irregularity of the vertical perception in the dizzy elderly with OH.

METHODS

This study consisted of 403 patients seeking treatment for dizziness in our hospital. The neurotological examinations include the subjective visual vertical (SVV) test and the bithermal caloric test. The self-perceived handicapping effects imposed by dizziness were assessed by the dizziness handicap inventory (DHI). The variability (standard deviation) and the average deviation of eight trials (four trials in each direction) were calculated. In addition, they underwent the orthostatic Schellong test for the diagnosis of the OH. They were separated into three groups, including patients aged ≥65 years, patients aged 50-64 years, and patients aged <50 years.

RESULTS

The variability of the SVV in the patients aged ≥65 years with OH was significantly larger than that in the patients aged ≥65 years without OH. There was no significant difference in the average deviation of the SVV, the canal paresis % by the bithermal caloric test, and the DHI score among groups.

CONCLUSIONS

The result suggests that the elderly patients with OH have subclinical impairment in the perception of the verticality independent of the peripheral vestibular function.

Orthostatic Hypotension Predicts a Poor Prognosis in Elderly People with Dementia

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

Orthostatic hypotension and orthostatic hypertension in American veterans

PURPOSE

Abnormal blood pressure (BP) response to orthostatic maneuvers may predict adverse health outcomes. Orthostatic hypotension (OH) is defined as a fall in BP of ≥20/10 mmHg, and orthostatic hypertension (OHTN) is defined as an increase in systolic BP (SBP) of ≥20 mmHg, with standing. Herein, we document the prevalence of OH and OHTN in American veterans.

METHODS

The influence of demographic characteristics, life habits, co-incident medical conditions, and prescription medication use on these prevalence rates and associations between abnormal orthostatic BP responses and severity of self-reported symptoms of fatigue, dizziness, trouble concentrating, and head and neck discomfort were determined.

RESULTS

286 veterans participated; 14 % were classified with OH, 22 % with OHTN, and 64 % with normal BP responses to standing (reference group). An increased prevalence of the diagnosis of diabetes mellitus (27 %) and hypertension (63 %) was noted, which did not differ by orthostatic BP classification. Veterans with OH were older than the reference group and were prescribed more antihypertensive medications than the reference and OHTN groups. While the prevalence of OH increased with age, the prevalence of OHTN was comparable in young (20-30 years) and old (70+ years) veterans (17 vs. 19 %, respectively). The severity of fatigue and dizziness was increased in veterans with OH and OHTN compared to the reference group.

CONCLUSION

These data suggest a relatively high prevalence of OH and OHTN, which is associated with increased self-reported severity of fatigue and dizziness in American veterans, findings which may adversely impact long-term health outcomes.

Evidence for a Prognostic Role of Orthostatic Hypertension on Survival in a Very Old Institutionalized Population

In old individuals, regulation of blood pressure during postural changes is impaired. Several studies have assessed the clinical impact of orthostatic hypotension (OHypoT) during the aging process. By contrast, the prevalence and prognostic role of the increase in blood pressure in upright position (orthostatic hypertension, OHyperT) in old adults remain unknown. We investigated the association of OHyperT with cardiovascular morbidity and mortality in a population of old institutionalized subjects. A 2-year follow-up longitudinal study was conducted on 972 subjects (mean age [SD] 88 [5]) from the PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study, able to maintain a standing position. OHyperT was defined as an increase in systolic blood pressure ≥20 mm Hg during the first and third minute of standing. Three groups of subjects were compared: orthostatic normotension (n=540), OHypoT (n=157), and OHyperT (n=275). OHyperT prevalence (28%) was higher than OHypoT (16%). Sitting systolic blood pressure was higher in OHypoT compared with orthostatic normotension and OHyperT groups (146 [23] versus 136 [21] and 136 [20] mm Hg, respectively, P<0.001). The OHyperT group was associated with a greater risk of cardiovascular morbidity and mortality than orthostatic normotension (hazard ratio 1.51 [1.09-2.08], P<0.01) and remained unchanged after adjustment for age, sex, sitting systolic blood pressure, and comorbidities. No difference in cardiovascular morbidity and mortality was observed between OHyperT and OHypoT groups. In conclusion, in a old frail population, the increase in systolic blood pressure during upright position occurs frequently and is associated with higher cardiovascular morbidity and mortality independently of sitting blood pressure levels and major comorbidities. Health professional should take into account not only the decrease but also the increase in blood pressure when standing up.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00901355.

Orthostatic Changes in Blood Pressure and Mortality in the Elderly: The Pro.V.A Study

BACKGROUND

An extensive, albeit contrasting literature has suggested a possible role for orthostatic hypotension as a risk factor for cardiovascular (CVD) and non-CVD mortality, while no data are available for orthostatic hypertension. We investigated whether orthostatic changes in blood pressure (BP) were associated with any increased risk of all-cause, CVD or non-CVD mortality in a group of elderly people.

METHODS

Two thousand seven hundred and eighty six community-dwelling older participants were followed for 4.4 years. Participants were grouped according to whether they had a drop ≤20 mm Hg in systolic, or ≤10 mm Hg in diastolic BP (orthostatic hypotension), an increase in mean orthostatic systolic BP ≥20 (orthostatic hypertension), or normal changes within 3 minutes of orthostatism.

RESULTS

During follow-up, 640 subjects died, 208 of them for CVD-related reasons. Adjusted Cox's regression analysis revealed that, compared with normal changes, orthostatic hypertension was associated with higher all-cause (HR = 1.23; 95% CI: 1.02-1.39) and CVD-related mortality (HR = 1.41; 95% CI: 1.08-1.74), while orthostatic hypotension was only associated with a higher non-CVD mortality (HR = 1.19; 95% CI: 1.01-1.60). Orthostatic hypertension emerged as a predictor of all-cause mortality for: participants over 75 years old; participants with a BMI below 25 kg/m2; participants with no CVD or disabilities; and those taking less than three medications. Orthostatic hypertension also predicted CVD-related mortality in individuals with no hypertension, heart failure, coronary artery disease, or atrial fibrillation.

CONCLUSIONS

Orthostatic hypertension and hypotension both seem to be relevant risk factors for mortality in the elderly, orthostatic hypertension correlating with all-cause and CVD-related mortality and orthostatic hypotension with non-CVD mortality.

Errata Corrige. Orthostatic Reactivity in Patients with Ischemic Stroke in the Chronic Period. http://dx.doi.org/10.3889/oamjms.2015.090

AIM:

This study aims to trace the influence of specialized kinesitherapeutic methodology (SKTM) on orthostatic reactivity in patients with ischemic stroke in the chronic period (ISChP).

MATERIAL AND METHODS:

An active orthostatic test is used for the evaluation of the orthostatic reactions. The arterial blood pressure and heart rate were defined in the 10 minutes of supine position, before and after 1, 5 and 10 minutes of active upright position. The orthostatic autoregulation is evaluated four times - at the beginning of the study, on the 10th day, on the 1st month and three months after the start of the KT. The classification by Thulesius was used to separate the patients into two groups depending on the type of their orthostatic reactivity.

RESULTS:

At the beginning of the study of infringements symptomatic type orthostatic reactivity (SOR) was observed in 24 patients and hypertensive type orthostatic reactivity (HOR) was observed in the remaining 32 patients. Once applied SKTM establish improvement of orthostatic autoregulation for the groups SOR and HOR at the 10th day and the 1st month with a level of significance p <0.05.

CONCLUSION:

The applied specialized kinesitherapeutic methodology continued later as an adapted exercise program at home, has significantly improved the orthostatic reactivity in patients with orthostatic dysregulation due to the ISChP.

Orthostatic Reactivity in Patients with Ischemic Stroke in the Chronic Period

AIM:

This study aims to trace the influence of specialized kinesitherapeutic methodology (SKTM) on orthostatic reactivity in patients with ischemic stroke in the chronic period (ISChP).

MATERIAL AND METHODS:

An active orthostatic test is used for the evaluation of the orthostatic reactions. The arterial blood pressure and heart rate were defined in the 10 minutes of supine position, before and after 1, 5 and 10 minutes of active upright position. The orthostatic autoregulation is evaluated four times - at the beginning of the study, on the 10th day, on the 1st month and three months after the start of the KT. The classification by Thulesius was used to separate the patients into two groups depending on the type of their orthostatic reactivity.

RESULTS:

At the beginning of the study of infringements symptomatic type orthostatic reactivity (SOR) was observed in 24 patients and hypertensive type orthostatic reactivity (HOR) was observed in the remaining 32 patients. Once applied SKTM establish improvement of orthostatic autoregulation for the groups SOR and HOR at the 10th day and the 1st month with a level of significance p <0.05.

CONCLUSION:

The applied specialized kinesitherapeutic methodology continued later as an adapted exercise program at home, has significantly improved the orthostatic reactivity in patients with orthostatic dysregulation due to the ISChP.

Prevalence of Orthostatic Hypertension in Elderly Patients with Type 2 Diabetes

Background. The aim of the present study was to determine the prevalence of orthostatic hypertension (OHT) in elderly patients with type 2 diabetes and its relation to metabolic and echocardiographic parameters. Methods. This was an analytical cross-sectional study in 97 patients normotensive or hypertensive. OHT was defined as a ≥10 mmHg increase in systolic blood pressure after four minutes in the standing position. Results. The prevalence of OHT was 20.6%. The mean body mass index was significantly higher in patients with OHT than in those without it (29.80 ± 4.10 versus 27.51 ± 3.98 kg/m(2); P = 0.026). There were no statistically significant differences between the two groups for other metabolic parameters. Among the 68 patients who had an echocardiographic examination 27% of those with OHT had an increase in their left atrial volume index (LAVi) compared with 75% of those who did not have OHT (P = 0.004). The mean LAVi of patients with OHT was significantly lower than that of those without OHT (26.27 ± 6.37 versus 32.65 ± 7.54, resp.; P = 0.011). Conclusion. We found a high prevalence of orthostatic hypertension and a lower left atrial volume indexed in the patients with orthostatic hypertension.

Postprandial hypotension as a risk marker for asymptomatic lacunar infarction

OBJECTIVE

Increasing blood pressure (BP) variability is reported to be a cardiovascular risk factor. However, the clinical implications of postprandial hypotension (PHYPO), a commonly observed BP variability in elderly persons, are poorly understood. Here, we investigated the possible associations between postprandial BP decline and asymptomatic cerebral damage in community residents.

METHODS

Study participants consisted of 1308 general community residents (65 ± 9 years old). Postprandial BP change was calculated from SBP measured just before and 30 min after lunch. PHYPO was defined as a decline in SBP of more than 20 mmHg. The presence of asymptomatic cerebrovascular damage was evaluated by brain MRI.

RESULTS

Prevalence of lacunar infarction was significantly higher in participants with PHYPO (P = 0.004). A postprandial decline in SBP was linearly increased with the number of lacunar lesions (none, n = 1200, -3.4± 11.3 mmHg; one lesion, n = 82, -5.2 ± 11.8; two lesions, n = 18, -6.9 ± 11.5; three lesions, n = 7, -13.4 ± 11.3; and four lesions, n = 1, -27; P = 0.012). Although participants with PHYPO were older (P < 0.001) and had higher preprandial BP (P < 0.001) and faster pulse wave velocity (P = 0.001), multivariate analysis adjusted for these covariates indicated that postprandial BP decline was an independent determinant for the number of lacunar infarctions (P = 0.004). No significant associations were observed with grade of periventricular hyperintensity or frequency of microbleeds. These relationships were also found in an analysis based on central BP, whereas no superiority was seen in the analysis based on central BP.

CONCLUSION

Postprandial BP decline is an overlooked risk marker for asymptomatic lacunar infarction in community residents.

Orthostatic hypertension-a new haemodynamic cardiovascular risk factor

Orthostatic hypertension-a condition characterized by a hyperactive pressor response to orthostatic stress-is an emerging risk factor for cardiovascular disease and is associated with hypertensive target-organ damage (resulting in silent cerebrovascular disease, left ventricular hypertrophy, carotid atherosclerosis and/or chronic kidney disease) and cardiovascular events (such as coronary artery disease and lacunar stroke). The condition is also considered to be a form of prehypertension as it precedes hypertension in young, normotensive adults. Orthostatic blood pressure changes can be assessed using orthostatic stress tests, including clinic active standing tests, home blood pressure monitoring and the head-up tilting test. Devices for home and for ambulatory blood pressure monitoring that are equipped with position sensors and do not induce a white-coat effect have increased the sensitivity and specificity of diagnosis of out-of-clinic orthostatic hypertension. Potential major mechanisms of orthostatic hypertension are sympathetic hyperactivity (as a result of hypersensitivity of the cardiopulmonary and arterial baroreceptor reflex) and α-adrenergic hyperactivation. Orthostatic hypertension is also associated with morning blood pressure surge and extreme nocturnal blood pressure dipping, both of which increase the pulsatile haemodynamic stress of central arterial pressure and blood flow in patients with systemic haemodynamic atherothrombotic syndrome.

Orthostatic and supine blood pressures are associated with white matter hyperintensities in Parkinson disease

BACKGROUND AND PURPOSE

Several reports on the elderly population have suggested that orthostatic hypotension is associated with white matter hyperintensities (WMH); however, little information is available on patients with Parkinson's disease (PD).

METHODS

We analyzed the association blood pressure profiles during tilt table testing with WMH scores in 117 patients with PD. WMH were rated using the semiquantitative visual rating system proposed by Scheltens et al.

RESULTS

The presence of orthostatic hypotension was associated with increasing tendency of WMH score and the blood pressure changes during tilting and supine blood pressure were positively correlated with increasing WMH score.

CONCLUSIONS

This finding indicates that hemodynamic changes associated with orthostatic hypotension may be associated with white matter changes in patients with PD.

Aortic stiffness and hypotension episodes are associated with impaired cognitive function in older subjects with subjective complaints of memory loss

OBJECTIVE

Though CV risk factors and markers of arterial aging are recognized risky for cognition, no study has simultaneously investigated the impact of multiple cardiac, arterial (large and small vessels), and hemodynamic parameters on cognitive function in older subjects.

METHODS

Two hundred eighty older subjects with subjective complaints of memory loss and no previous stroke (mean age 78.3 ± 6.3 years) were studied. Global cognitive function was evaluated with the Mini-Mental State Examination (MMSE). Cognitive impairment was defined as a MMSE < 21. We measured: traditional CV risk factors; aorta stiffness (Pulse Wave Velocity, PWV); LV mass; presence of WML at neuroimaging; episodes of hypotension (SBP <100 mmHg during 24 h Ambulatory Blood Pressure Monitoring).

RESULTS

In both cross-sectional and longitudinal analyses PWV, WML, and episodes of hypotension were significantly associated with poorer cognitive function-controlling for age, sex, education, depression, traditional CV risk factors, and medications. LV mass was no longer associated with cognition in multiple regression. Older subjects with stiffer arteries or episodes of hypotension presented a 4-fold and an 11-fold, respectively, greater odds for progression from normal cognitive function to cognitive impairment. A synergistic effect between PWV, WML, and hypotension was observed: the occurrence of any two of PWV, WML, or hypotension was accompanied by lower MMSE; in the presence of all three factors, a further significant decline in cognitive function was observed.

INTERPRETATION

Systemic hemodynamic parameters (higher PWV and hypotension) together with cerebral microvascular damage (WML) are significantly associated with poorer cognitive function and may identify older subjects with subjective complaints of memory loss at higher risk of cognitive decline.

Orthostatic hypertension: recognizing an underappreciated clinical condition

Orthostatic hypertension refers to an increase in the blood pressure upon assuming an upright posture. This clinical condition has been understudied and is often underappreciated in clinical practice probably because of its unfamiliarity to many clinicians including subspecialists. We report a case of severely symptomatic orthostatic hypertension in a Caucasian female, which was likely secondary to an autonomic dysfunction caused by an underlying vascular adrenergic hypersensitivity and possibly also due to uncontrolled diabetes mellitus (causing baroreflex dysfunction associated with excessive sympathetic stimulation). The case work-up also illustrates a schematic diagnostic and management approach to this rarely encountered clinical entity.

Orthostatic hypotension and the risk of congestive heart failure: a meta-analysis of prospective cohort studies

BACKGROUND

Orthostatic hypotension (OH) has been related to the increased risk of future congestive heart failure (CHF) events. However, the overall quantitative estimate of predictive ability of OH for CHF has not been determined. We therefore performed a meta-analysis to investigate the association between OH and incident CHF.

METHODS

Prospective cohort studies relevant to the aim of the study were identified by searching of Medline and Embase databases up to December 25, 2012 without restrictions and by reviewing the reference lists from retrieved articles.

RESULTS

A total of 51270 subjects and 3603 incident CHF cases from 4 prospective cohorts were included in the meta-analysis. Using random effect model, the pooled result indicated that presence of OH at baseline was significantly associated with an increased risk for future CHF outcomes (adjusted hazard ratio: 1.30, 95% confidence interval 1.09-1.55; p = 0.004). Results of stratified analysis suggested that the association between OH and CHF incidence seemed to be significant in middle-age subjects, or the individuals with hypertension and diabetes at baseline, but did not significant in the elderly subjects or those without hypertension or diabetes.

CONCLUSIONS

Our meta-analysis confirmed that presence of OH is related to a significant increased risk for development of CHF in the future. Studies are needed to explore the potential mechanisms underlying this association. More importantly, screen for OH may be of great clinical significance for the early identification of subjects at higher risk for development of CHF.

Syncope and orthostatic intolerance increase risk of brain lesions in migraineurs and controls

OBJECTIVES

We and others showed that migraineurs are at increased risk of subclinical and clinical ischemic brain lesions. Migraineurs also have a higher prevalence of frequent syncope and orthostatic intolerance, symptoms that are associated with transient reductions in cerebral blood flow. In this study, we assessed whether these autonomic symptoms may contribute to the increased risk of brain lesions in migraine.

METHODS

Migraineurs (n = 291) and controls (n = 140) from the population-based, cross-sectional CAMERA (Cerebral Abnormalities in Migraine, an Epidemiologic Risk Analysis) cohort (aged 30-60 years, and free of other neurologic symptoms) underwent 1) brain MRI scan, and 2) structured telephone interview including questions on frequent syncope (≥5/lifetime) and orthostatic intolerance.

RESULTS

Frequent syncope (odds ratio [OR] = 2.7; 95% confidence interval: 1.3-5.5) and orthostatic intolerance (OR = 2.0 [1.1-3.6]) were independent risk factors for high load of deep white matter lesions. Effects were strongest in women and similar in migraineurs and controls. Migraine diagnosis did not mediate or moderate these associations. Individuals with orthostatic intolerance had higher prevalence of high periventricular white matter lesion load (OR = 1.9 [1.1-3.5]). Syncope and orthostatic intolerance were not related to subclinical infarcts or infratentorial lesions.

CONCLUSIONS

Frequent syncope, orthostatic intolerance, and migraine independently increase the risk of white matter lesions, particularly in females.

The potential prognostic role of cardiovascular autonomic failure in α-synucleinopathies

Cardiovascular autonomic failure is the second most common dysautonomic feature of α-synucleinopathies and has significant impact on daily activities and quality of life. Here we provide a systematic review of cardiovascular autonomic failure in α-synucleinopathies, emphasizing its impact on cognitive functions and disease outcomes. Articles spanning the period between January 1985 and April 2012 were identified from the PubMed database using a keyword-based search. Epidemiological studies highlight the negative prognostic effect of cardiovascular autonomic failure on cardiovascular and cerebrovascular outcomes and overall mortality in all α-synucleinopathies. Altered cerebral perfusion, vascular pressure stress, and related disruption of the blood-brain barrier may also contribute to the white matter hyperintensities and cognitive dysfunction frequently found in patients affected by neurocardiovascular instability. These findings support the hypothesis that cardiovascular autonomic failure may play a negative prognostic role in α-synucleinopathies and suggest that precocious screening and therapeutic management of cardiovascular autonomic failure may positively impact disease course.

Autoimmune autonomic ganglionopathy with reversible cognitive impairment

BACKGROUND

Autoimmune autonomic ganglionopathy (AAG) is a rare disorder of antibody-mediated impaired transmission across the autonomic ganglia resulting in severe autonomic failure. Some patients with AAG report cognitive impairment of unclear etiology despite treatment of autonomic symptoms.

OBJECTIVE

To investigate the relationship between orthostatic hypotension, antibody titers, and cognitive impairment in patients with AAG.

DESIGN

Prospective cohort.

SETTING

Academic medical center.

PARTICIPANTS

Three patients with AAG underwent neuropsychological testing before and after cycles of plasma exchange in both the seated and standing positions.

MAIN OUTCOME MEASURES

Patients' responses to neuropsychological tests were measured by percentage change from baseline in the seated and standing positions before and after plasma exchange to determine the effects of orthostatic hypotension and antibody titers on cognition.

RESULTS

Orthostatic hypotension and elevated antibody titer were associated independently with neuropsychological impairment (P < .05), particularly in domains of executive function, sustained attention, and working memory. Cognitive dysfunction improved, even in the seated normotensive position, after plasmapheresis and consequent reduction in antibody levels.

CONCLUSION

Reversible cognitive impairment is independently associated with both orthostatic hypotension and elevated nicotinic acetylcholine receptor autoantibodies, thereby expanding the clinical spectrum of autonomic ganglionopathy and, in so doing, providing an additional treatable cause of cognitive impairment.

Orthostatic hypertension: home blood pressure monitoring for detection and assessment of treatment with doxazosin

To determine the role of home blood pressure (BP) monitoring for a reproducible assessment of orthostatic hypertension (OHT) and the effectiveness of hypertension control by doxazosin. In this study, 605 medicated hypertensive outpatients were enrolled. Home BP in the sitting and standing positions was monitored in all patients in the morning and evening for 6 months. According to an open-label multicenter trial design, the patients were randomly allocated to either an intervention group that took doxazosin (1-4 mg) at bedtime or to a control group that did not receive any add-on medication. The patients were divided into deciles of orthostatic BP change as evaluated by home BP monitoring at baseline. Those in the top decile, in the lowest decile and in deciles two through eight were then assigned to the OHT group, the orthostatic hypotension group and the orthostatic normotension group, respectively.Orthostatic BP in the OHYPO group did not change, whereas that of the OHT group was markedly reduced by doxazosin (P<0.01). In the control group, classification into orthostatic BP categories using home BP monitoring was more reproducible (κ coefficient: 0.42-0.50) than when using clinical BP (κ coefficient: 0.13-0.24). In all groups, a reduction in the urinary albumin/creatinine ratio was significantly associated with a reduction in orthostatic BP doxazosin (P<0.001).The identification of OHT based on home BP monitoring was highly reproducible. The administration of doxazosin might control OHT and consequently prevent target organ damage.

An Emerging Role for Understanding Orthostatic Hyp'er'tension in the Cardiorenal Syndrome

Orthostatic hypertension (OHT) is a clinically important problem increasingly recognized in persons with borderline hypertension, diabetes mellitus, and autonomic neuropathies, and in the elderly. Moreover, the association of OHT with progression of target end-organ damage, especially coronary heart disease and chronic kidney disease (CKD), and the attendant increased cardiovascular disease (CVD) and CKD risk, is gaining attention but is still underappreciated. There are various mechanisms that contribute to the development of OHT: excessive vascular adrenergic sensitivity, baroreceptor reflex abnormalities, and inappropriate activation of the renin-angiotensin-aldosterone system, which are also mechanisms that lead to cardiorenal metabolic disease (CRS). While the evidence is compelling for the clinical importance of OHT, more investigation is needed to evaluate the effects of OHT on CKD and CVD. The notion that the development of OHT is a risk factor for the development of CRS raises the need for further clinical and investigational attention to this clinical dilemma.

Aging and hypertension

Aging is known to be a dominant risk factor in the progression of hypertension. Thus, accompanied by an increasing mean age of the population in developed countries, prevention and management of hypertension in the elderly is a task of pressing urgency. Age-associated blood pressure elevation is a result of the aging process in organ systems, which play a key role in the regulation of blood pressure. In addition, advanced aging of the cardiovascular system contributes to the presence of a varied phenotype in elderly hypertension, such as nocturnal hypertension and morning hypertension. Therefore, in order to detect and treat age-associated hypertension appropriately, it is important to assess ambulatory blood pressure monitoring throughout the 24-h period.

Postural changes in blood pressure and incidence of ischemic stroke subtypes: the ARIC study

The relation of orthostatic blood pressure decrease, or increase, with occurrence of ischemic stroke subtypes has not been examined. We investigated the association of orthostatic blood pressure change (within 2 minutes after supine to standing) obtained at baseline (1987 to 1989) in the Atherosclerosis Risk in Communities Study with incidence of ischemic stroke subtypes through 2007. Among 12 817 black and white individuals without a history of stroke at baseline, 680 ischemic strokes (153 lacunar, 383 nonlacunar thrombotic, and 144 cardioembolic strokes) occurred during a median follow-up of 18.7 years. There was a U-shaped association between orthostatic systolic blood pressure change and lacunar stroke incidence (quadratic P=0.004). In contrast, orthostatic systolic blood pressure decrease of 20 mm Hg or more was associated with increased occurrence of nonlacunar thrombotic and cardioembolic strokes independent of sitting systolic blood pressure, antihypertensive medication use, diabetes, and other lifestyle, physiological, biochemical, and medical conditions at baseline (for nonlacunar thrombotic: hazard ratio, 2.02; 95% CI, 1.43 to 2.84; for cardioembolic: hazard ratio, 1.85, 95% CI, 1.01 to 3.39). Orthostatic diastolic blood pressure decrease was associated with increased risk of nonlacunar thrombotic and cardioembolic strokes; the hazard ratios (95% CI) associated with 10 mm Hg lower orthostatic diastolic blood pressure (continuous) were 1.26 (1.06 to 1.50) and 1.41 (1.06 to 1.88), respectively, in fully adjusted models. In conclusion, the present study found that nonlacunar ischemic stroke incidence was positively associated with an orthostatic decrease of systolic and diastolic blood pressure, whereas greater lacunar stroke incidence was associated with both orthostatic increases and decreases in systolic blood pressure.

Interleukin-6 and silent cerebral infarction in hemodialysis patients: a cross-sectional study

BACKGROUND

In patients with chronic renal failure undergoing hemodialysis (HD), silent cerebral infarctions (SCI) are associated with high mortality. Levels of interleukin-6 (IL-6) increase with renal dysfunction and may be a novel predictor for cerebrovascular events. We tested the hypothesis that increased IL-6 levels correlate with the occurrence of SCI in HD patients.

METHODS

Using cranial magnetic resonance imaging findings, we divided 50 Japanese patients undergoing HD into two groups: with SCI (60 ± 7 years, mean ± SD, n = 27) and without SCI (60 ± 6 years, n = 23). We compared the gender, body mass index, metabolic profiles, IL-6 levels, and smoking habits between the two groups.

RESULTS

We made the following observations: (i) The prevalence of diabetes or hypertension did not differ between the two groups, (ii) the level of IL-6 was higher in the with-SCI group than in the without-SCI group (P < 0.0001), (iii) the proportion of smokers was higher in the with-SCI group (P < 0.05), (iv) plasma level of high-density lipoprotein cholesterol was lower, whilst uric acid level was higher, in the with-SCI group (P < 0.05 and P < 0.05, respectively), and (v) multiple logistic regression analysis identified IL-6 levels as being significantly associated with the presence of SCI (odds ratio 3.13, 95% CI = 1.42-7.89, P < 0.0001).

CONCLUSIONS

This study indicates that patients with chronic renal failure who are maintained on HD exhibit an increased prevalence of SCI and that IL-6 is significantly associated with the presence of SCI in HD patients.

Cerebro- and cardiovascular reactivity and neuropsychological performance in hypertensive patients

BACKGROUND

Hypertensive (HT) patients are at higher risk of cognitive decline than normotensive individuals, because high blood pressure is a risk factor for mild cognitive deterioration. In this study cardio- and cerebrovascular reactivity along with cognitive performance was assessed on newly diagnosed HT patients.

METHODS

Diagnosis of hypertension was based on international recommendations. None of the patients had diabetes, and all of them had normal cerebral CT scan. Eighty-one patients (43.5±10.2 years, male/female ratio: 42/39) were compared with 94 healthy controls (44±9.4 years, male/female ratio: 50/44). In both groups continuous, non-invasive and simultaneous monitoring of cerebral and cardiac hemodynamical parameters were recorded during head-up tilt table testing (HUTT). Reaction time, attention and memory skills, anxiety and depression rate were determined by neuropsychological tests.

RESULTS

During HUTT significant differences were found in certain cardiovascular parameters (blood pressure, total peripheral resistance index, stroke index), but no differences were detected in cerebral blood flow velocity. While there was no significant difference in reaction time between the two groups, tests estimating short-term memory (Digit Span Test) differed significantly. Moreover, sum of standardized test scores was significantly lower, while anxiety level was significantly increased in HT patients compared to controls.

CONCLUSION

Decrease in neuropsychological performance along with alterations of cardiovascular parameters is an early manifestation of hypertension. Aim for an early intervention and accurate treatment is crucial for preventing further impairments.

Association of an abnormal blood glucose level and morning blood pressure surge in elderly subjects with hypertension

BACKGROUND

We previously reported that morning blood pressure (BP) surge (MBPS) was an independent risk factor for stroke. We evaluated the determinants of MBPS in hypertensive patients.

METHODS

We analyzed 24-h ambulatory BP monitoring (ABPM) records in 458 hypertensive patients (mean: 72.2 +/- 8.5 years). The MBPS was calculated as the mean systolic BP (SBP) over 2 h after waking minus mean SBP during the hour of sleep that included the lowest nighttime BP. The cutoff value for identifying the top decile (the MBPS group) was defined as > or =55 mm Hg.

RESULTS

The MBPS was associated with age, fasting plasma glucose, and 24-h SBP, and they were independent and significant determinants of MBPS in multivariate analysis (age, P = 0.01; fasting plasma glucose, P < 0.01; 24-h SBP, P = 0.04) after adjustment for confounding factors of gender, body mass index (BMI), and smoking status. The subjects in the MBPS group (n = 45) were older in age (76.4 years vs. 71.8 years, P < 0.01) and had higher fasting plasma glucose (97.6 mg/dl vs. 91.4 mg/dl, P = 0.04) than those in the non-MBPS group. In logistic regression analysis, the MBPS group was associated with older age (10 years older: odds ratio (OR) 1.85, 95% confidence interval (CI) 1.26-2.72, P < 0.01) and higher fasting plasma glucose (10-mg/dl increase: OR 1.16, 95% CI 1.01-1.33, P = 0.03).

CONCLUSION

In addition to older age and higher mean 24-h SBP, higher fasting plasma glucose was associated with MBPS.