Single Agent Antihypertensive Therapy and Orthostatic Blood Pressure Behaviour in Older Adults Using Beat-to-Beat Measurements: The Irish Longitudinal Study on Ageing

Orthostatic Hypotension and Antihypertensive Treatment in Lung Transplant Recipients: A Cross-Sectional Study

OBJECTIVES

Lung transplant is the ultimate treatment of many end-stage lung diseases. Calcineurin inhibitors, crucial in immunosuppression for lung transplant recipients, are linked to secondary hypertension, necessitating antihypertensive treatment. In addition, lung transplant recipients frequently experience orthostatic hypotension, occasionally stemming from autonomic dysfunction, but also commonly attributed as a negative side effect of antihypertensive treatment. Our study aimed to evaluate the frequency of orthostatic blood pressure irregularities and investigate the involvement of antihypertensive treatment as a potential risk factor in the occurrence among lung transplant recipients.

MATERIALS AND METHODS

Fifty-six consecutive lung transplant recipients, both inpatient and outpatient, at the University Hospital Zurich (Switzerland) were monitored from 1999 to 2013. Transplant recipients underwent a Schellong test (an active standing test). Our evaluation encompassed their initial traits, such as the existence of supine hypertension. We computed the odds ratio for the comparison of the likelihood of experiencing orthostatic hypotension while using a minimum of 1 type of antihypertensive medication versus absence of antihypertensive drugs.

RESULTS

Of the lung transplant recipients, 25% showed a positive Schellong test. Within this group, 64% had supine hypertension, and 29% displayed symptoms of orthostatic hypotension. Among the patients, 71% were using at least 1 type of antihypertensive medication. The odds ratio for showing orthostatic hypotension while taking at least 1 type of antihypertensive drug versus the absence of antihypertensive medications was 1.64 (95% exact CI, 0.39-6.90) with P = .50. This finding remained consistent regardless of age, sex, inpatient or outpatient status, and the duration since transplant.

CONCLUSIONS

Orthostatic blood pressure dysregulation is prevalent among lung transplant recipients, frequently without noticeable symptoms. In our cohort, the use of antihypertensive medications did not elevate the risk of orthostatic hypotension.

Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association

Although orthostatic hypotension (OH) has long been recognized as a manifestation of autonomic dysfunction, a growing body of literature has identified OH as a common comorbidity of hypertension. This connection is complex, related to pathophysiology in blood pressure regulation and the manner by which OH is derived as the difference between 2 blood pressure measurements. While traditional therapeutic approaches to OH among patients with neurodegenerative disorders focus on increasing upright blood pressure to prevent cerebral hypoperfusion, the management of OH among patients with hypertension is more nuanced; resting hypertension is itself associated with adverse outcomes among these patients. Although there is substantial evidence that intensive blood pressure treatment does not cause OH in the majority of patients with essential hypertension, some classes of antihypertensive agents may unmask OH in patients with an underlying autonomic impairment. Practical steps to manage OH among adults with hypertension start with (1) a thorough characterization of its patterns, triggers, and cause; (2) review and removal of aggravating factors (often pharmacological agents not related to hypertension treatment); (3) optimization of an antihypertensive regimen; and (4) adoption of a tailored treatment strategy that avoids exacerbating hypertension. These strategies include countermaneuvers and short-acting vasoactive agents (midodrine, droxidopa). Ultimately, further research is needed on the epidemiology of OH, the impact of hypertension treatment on OH, approaches to the screening and diagnosis of OH, and OH treatment among adults with hypertension to improve the care of these patients and their complex blood pressure pathophysiology.

Body Position and Orthostatic Hypotension in Hypertensive Adults: Results from the Syst-Eur Trial

BACKGROUND

We recently demonstrated that more intensive blood pressure (BP) treatment lowered risk of orthostatic hypotension (OH) measured with a seated-to-standing protocol. However, seated-to-standing OH assessments are less sensitive than supine-to-standing and could miss clinically relevant OH.

OBJECTIVES

Using data from the Syst-Eur trial (Systolic Hypertension in Europe), we examined the effect of hypertension treatment on incidence of OH based on the difference in BP from 3 body positions.

METHODS

Syst-Eur was a multi-center, randomized trial that enrolled adults with isolated systolic hypertension to investigate whether active hypertension treatment could reduce cardiovascular events. Participants underwent BP measurement in supine, seated, and standing positions. Using differences in BP between the 3 body positions (seated minus supine, standing minus seated, and standing minus supine), we defined OH as a drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg. We included measurements from baseline and follow-up visits.

RESULTS

Among 4695 participants (mean age, 70.2±6.7 years; 66.9% female) with 42 636 BP measurements, OH was present in 4.9% of measures with supine-to-seated, 7.9% with seated-to-standing, and 11.4% with supine-to-standing protocols, respectively. Compared with placebo, BP treatment did not increase OH with any set of maneuvers, OR, 0.79 (95% CI, 0.65-0.95) with seated-to standing, 1.03 (95% CI, 0.86-1.24) with supine-to-seated, and 0.99 (95% CI, 0.86-1.15) with supine-to-standing.

CONCLUSIONS

Regardless of protocol, active hypertension treatment did not increase the risk of OH, reinforcing evidence that OH should not be viewed as a complication of hypertension treatment.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02088450.

Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication

BACKGROUND

Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported.

METHODS

Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls.

RESULTS

Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers.

CONCLUSIONS

Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.

Age and sex related differences in orthostatic cerebral oxygenation: Findings from 2764 older adults in the Irish Longitudinal Study on Ageing (TILDA)

AIMS

Cerebral hypoperfusion is implicated in the pathogenesis of associations between orthostatic hypotension and adverse outcome such as falls, cognitive impairment, depression, and mortality. Although the blood pressure response to orthostasis has been well studied there is a lack of information on orthostatic cerebrovascular responses in older populations.

METHODS AND RESULTS

We measured cerebral hemodynamics, utilizing near infrared spectroscopy, coupled with peripheral blood pressure during an active stand in a large population of well-phenotyped older adults (N = 2764). Multi-level mixed effect models were utilized to investigate associations with age and sex, as well as confounders including anti-hypertensive medications. Normative cerebral oxygenation responses were also modelled utilizing generalized additive models for location, scale, and shape (GAMLSS). Older age groups experienced larger initial drops in oxygenation and a slower recovery, and responses also differed by sex. The drop after standing ranged from -1.85 % (CI: -2.02 to -1.68) in the males aged 54-59 years vs -1.15 % (CI: -1.31 to -1.00 %) in females aged 54-59 years, to -2.67 % (CI: -3.01 to -2.33) in males aged ≥ 80 years vs -1.97 % (CI: -2.32 to -1.62) females aged ≥ 80 years. Reduced oxygenation levels were also evident in those taking anti-hypertensive medications.

CONCLUSION

Cerebral autoregulation is impaired with age, particularly in older women and those taking anti-hypertensives. SBP during the stand explained some of the age gradient in the late recovery stage of the stand for the oldest age group. Reported orthostatic symptoms did not correlate with hypoperfusion. Therefore, measures of orthostatic cerebral flow should be assessed in addition to peripheral BP in older patients irrespective of symptoms. Further studies are required to investigate the relationship between NIRS measurements and clinical outcomes such as falls, cognitive impairment and depression.

Drug-induced orthostatic hypotension: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Drug-induced orthostatic hypotension (OH) is common, and its resulting cerebral hypoperfusion is linked to adverse outcomes including falls, strokes, cognitive impairment, and increased mortality. The extent to which specific medications are associated with OH remains unclear.

METHODS AND FINDINGS

We conducted a systematic review and meta-analysis to evaluate the extent to which specific drug groups are associated with OH. EMBASE, MEDLINE, and Web of Science databases were searched from inception through 23 November 2020. Placebo-controlled randomised controlled trials (RCTs) on any drug reporting on OH as an adverse effect in adults (≥18 years) were eligible. Three authors extracted data on the drug, OH, dose, participant characteristics, and study setting. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) was used to appraise evidence. Summary odds ratios (ORs) were estimated for OH using fixed effects Mantel-Haenszel statistics. We conducted subgroup analysis on validity of OH measurement, drug dose, risk of bias, age, and comorbidity. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to summarise the certainty of evidence. Of 36,940 citations, 69 eligible RCTs were included in the meta-analysis comprising 27,079 participants. Compared with placebo, beta-blockers and tricyclic antidepressants were associated with increased odds of OH (OR 7.76 [95% CI 2.51, 24.03]; OR 6.30 [95% CI 2.86, 13.91]). Alpha-blockers, antipsychotics, and SGLT-2 inhibitors were associated with up to 2-fold increased odds of OH, compared to placebo. There was no statistically significant difference in odds of OH with vasodilators (CCBs, ACE inhibitors/ARBs, SSRIs), compared to placebo. Limitations of this study are as follows: data limited to placebo-controlled studies, (excluding head-to-head trials), many RCTs excluded older participants; therefore results may be amplified in older patients in the clinical setting. The study protocol is publicly available on PROSPERO (CRD42020168697).

CONCLUSIONS

Medications prescribed for common conditions (including depression, diabetes, and lower urinary tract symptoms) were associated with significantly increased odds of OH. Drugs causing sympathetic inhibition were associated with significantly increased odds of OH, while most vasodilators were associated with small nonsignificant differences in odds of OH, compared to placebo. Drugs targeting multiple parts of the orthostatic blood pressure (BP) reflex pathway (e.g. sympathetic inhibition, vasodilation, cardio-inhibitory effects) may carry cumulative risk, suggesting that individuals with polypharmacy could benefit from postural BP monitoring.

Diagnostic criteria for initial orthostatic hypotension: a narrative review

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.

Impaired Stabilisation of Orthostatic Cerebral Oxygenation is Associated with Slower Gait Speed: Evidence from The Irish Longitudinal Study on Ageing

Background

Cerebral autoregulation (CAR) systems maintain blood flow to the brain across a wide range of blood pressures. Deficits in CAR have been linked to gait speed (GS) but previous studies had small sample sizes and used specialized equipment which impede clinical translation. The purpose of this work was to assess the association between GS and orthostatic cerebral oxygenation in a large, community-dwelling sample of older adults.

Method

Data for this study came from the Irish Longitudinal Study on Ageing. A near-infrared spectroscopy (NIRS) device attached to the forehead of each participant (n = 2 708) was used to track tissue saturation index (TSI; the ratio of oxygenated to total hemoglobin) during standing. GS was assessed using a portable walkway.

Results

Recovery was impaired in slower GS participants with a TSI value at 20 seconds (after standing) of −0.55% (95% CI: −0.67, −0.42) below baseline in the slowest GS quartile versus −0.14% (95% CI: −0.25, −0.04) in the fastest quartile. Slower GS predicted a lower TSI throughout the 3-minute monitoring period. Results were not substantially altered by adjusting for orthostatic hypotension. Adjustment for clinical and demographic covariates attenuated the association between but differences remained between GS quartiles from 20 seconds to 3 minutes after standing.

Conclusion

This study reported evidence for impaired recovery of orthostatic cerebral oxygenation depending on GS in community-dwelling older adults. Future work assessing NIRS as a clinical tool for monitoring the relationship between GS and cerebral regulation is warranted.

Evaluation of Patients with Syncope in the Emergency Department: How to Adjust Pharmacological Therapy

The rate of syncope in the Emergency Department ranges between 0.9 and 1.7%. Syncope is mostly related to a underlying reflex or orthostatic mechanism. A bradycardic or a hypotensive phenotype, may be identified. The latter is the most common and could be constitutional or drug induced. Consequently, obtaining an accurate drug history is an important step of the initial assessment of syncope. As anti-hypertensive medication might be responsible for orthostatic hypotension, managing hypertension in patients with syncope requires finding an ideal balance between hypotensive and cardiovascular risks. The choice of anti-hypertensive molecule as well as the therapeutic regimen and dosage, influences the risk of syncope. Not only could anti-hypertensive drugs have a hypotensive effect but opioids and psychoactive medications may also be involved in the mechanism of syncope. Proper drug management could reduce syncope recurrences and their consequences.

Supine Hypertension Is Associated With an Impaired Cerebral Oxygenation Response to Orthostasis: Finding From The Irish Longitudinal Study on Ageing

[Figure: see text].

Older Adults' Drop in Cerebral Oxygenation on Standing Correlates With Postural Instability and May Improve With Sitting Prior to Standing

BACKGROUND

Impaired blood pressure (BP) recovery with orthostatic hypotension on standing occurs in 20% of older adults. Low BP is associated with low cerebral blood flow but mechanistic links to postural instability and falls are not established. We investigated whether posture-related reductions in cerebral tissue oxygenation (tSO2) in older adults impaired stability upon standing, if a brief sit before standing improved tSO2 and stability, and if Low-tSO2 predicted future falls.

METHOD

Seventy-seven older adults (87 ± 7 years) completed (i) supine-stand, (ii) supine-sit-stand, and (iii) sit-stand transitions with continuous measurements of tSO2 (near-infrared spectroscopy). Total path length (TPL) of the center of pressure sway quantified stability. K-cluster analysis grouped participants into High-tSO2 (n = 62) and Low-tSO2 (n = 15). Fall history was followed up for 6 months.

RESULTS

Change in tSO2 during supine-stand was associated with increased TPL (R = -.356, p = .001). When separated into groups and across all transitions, the Low-tSO2 group had significantly lower tSO2 (all p < .01) and poorer postural stability (p < .04) through 3 minutes of standing compared to the High-tSO2 group. There were no effects of transition type on tSO2 or TPL for the High-tSO2 group, but a 10-second sitting pause improved tSO2 and enhanced postural stability in the Low-tSO2 group (all p < .05). During 6-month follow-up, the Low-tSO2 group had a trend (p < .1) for increased fall risk.

CONCLUSIONS

This is the first study to show an association between posture-related cerebral hypoperfusion and quantitatively assessed instability. Importantly, we found differences among older adults suggesting those with lower tSO2 and greater instability might be at increased risk of a future fall.

Orthostatic hypotension: a marker of blood pressure variability and arterial stiffness: a cross-sectional study on an elderly population: the 3-City study

BACKGROUND

Orthostatic hypotension, blood pressure (BP) variability, and arterial stiffness are three markers of cardiovascular risk beyond the average BP. However, the relationships between these three parameters are not well known.

AIM

To examine the relationships between orthostatic hypotension, BP variability, and arterial stiffness.

METHODS AND RESULTS

In the Three-City study, a sample of 1151 elderly participants (mean age = 80 ± 3 years) was screened for orthostatic hypotension, undertook home BP and pulse wave velocity (PWV) measurements. We performed logistic regression analyses to look at the associations between orthostatic hypotension and both day-to-day (D-to-D) BP variability quartiles and PWV quartiles. Orthostatic hypotension was detected in 210 participants who were more likely to be hypertensive, exhibit higher BP variability and have increased arterial stiffness. In the multivariate logistic regression analysis, the frequency of orthostatic hypotension increased by 20% with every quartile of D-to-D SBP variability and by 20% with every quartile of PWV. PWV and D-to-D BP variability were not associated. In stratified analysis, the use of beta-blocker changes these relationships: orthostatic hypotension was not associated to PWV anymore but its association with D-to-D SBP variability was apparently stronger.

CONCLUSION

In this large sample of elderly individuals, orthostatic hypotension was independently associated with both BP variability and PWV. BP variability being more indicative of a baroreflex dysfunction and PWV being a marker of vascular ageing, these two components would participate to the orthostatic hypotension mechanisms.

Hypertension, hypotension and syncope

Hypertension and hypotension are strictly related phenomena, that frequently coexist within the spectrum of cardiovascular autonomic dysfunction, especially at advanced age. Indeed, antihypertensive treatment may predispose to orthostatic and post-prandial hypotension, while intensive blood pressure lowering may be responsible for systemic hypotension. Over recent years, systemic and orthostatic hypotension have emerged as important although often neglected risk factors for adverse outcomes, paralleling the widely recognized arterial hypertension. Both hypertension and hypotension are associated with detrimental effects on target organs and survival, thus significantly impacting patients' prognosis, functional autonomy and quality of life. Balancing low and high blood pressure requires accurate diagnostic assessment of blood pressure values and patients' hypotensive susceptibility, which allow for the development of customized treatment strategies based on individual hypo/hypertensive risk profile. The present review illustrates the complex interrelationship between hypotension and hypertension and discusses the relevant prognostic role of these conditions. Additionally, it provides an overview on hypotension detection and treatment in patients with hypertension, focusing on customized diagnostic and therapeutic strategies.

Correlation of body mass index and orthostatic hypotension in patients with hypertension on ACE inhibitor monotherapy

Background/Aim: Orthostatic hypotension (OH) is considered to be a drop in the systolic and diastolic blood pressure (> 20 mmHg; > 10 mmHg) 3 minutes from postural changes. The objective of this study was to analyse the correlation of body mass index (BMI) and OH during the treatment with trandolapril, as a single-drug treatment of hypertension. Methods: The study involved 255 patients (average age 54.3 ± 11.7; 54.1 % men) with poorly regulated hypertension, who were given trandolapril as a single-drug treatment. The patients were divided into two groups regarding stage of hypertension: first-degree arterial hypertension (140-149 mmHg for systolic and 90-109 mmHg for diastolic blood pressure) and second-degree arterial hypertension (> 150 for systolic and > 110 mmHg for diastolic blood pressure). Incidence of OH occurrence was then analysed regarding hypertension stage and BMI during 6 months of follow-up, on 4 control examinations. Results: During 24-week period after trandolapril introduction into the treatment of hypertension, a statistically significant difference in systolic, diastolic and mean blood pressure values was observed. No statistically significant difference was observed in incidence of OH between the first and second as well as between third and fourth examination during the study. Regarding the incidence of OH in normal body weight and obese patients, there was also no statistically significant difference. Conclusion: As shown in this study, trandolapril, along with some other ACE inhibitors, has shown good balance in hypertension control and OH occurrence.

Orthostatic Hypotension: An Important Risk Factor for Clinical Progression to Mild Cognitive Impairment or Dementia. The Amsterdam Dementia Cohort

Background:

Orthostatic hypotension (OH) has been cross-sectionally and longitudinally related to dementia in the general population. Whether OH contributes to clinical progression to mild cognitive impairment (MCI) or dementia is less certain. Also, differences in risk of progression between patients with early OH (EOH) versus delayed and/or prolonged OH (DPOH) are unclear.

Objective:

Assess the prevalence of EOH and DPOH, investigate the longitudinal association between EOH and DPOH and either incident MCI or dementia.

Methods:

1,882 patients from the Amsterdam Dementia Cohort [64±8 years; 43% female; n = 500 with subjective cognitive decline (SCD), n = 341 MCI, n = 758 Alzheimer’s disease (AD), n = 49 vascular dementia (VaD), n = 146 frontotemporal dementia (FTD), n = 88 Lewy body dementia (DLB)]. Definition OH: systolic blood pressure (BP) drop≥20 mmHg and/or a diastolic BP drop≥10 mmHg at 1 and/or 3 minutes after standing. EOH: OH only at 1 minute, DPOH: OH at (1 and) 3 minutes.

Results:

Prevalence OH: 19% SCD, 28% MCI, 41% dementia. Compared to SCD, odds of having OH were highest in patients with VaD and DLB; ORs (95% CI) were 2.6 (1.4–4.7) and 5.1 (3.1–8.4), respectively. After a mean (SD) follow-up of 2.2 (1.4) years, 105 (22%) of SCD or MCI patients showed clinical progression. Compared to patients without OH, those with DPOH had an increased risk of progression; hazard ratio (95% CI) was 1.7 (1.1–2.7), and those with EOH did not; 0.8 (0.3–1.9).

Conclusion:

Compared to SCD, prevalence of OH was higher in MCI and highest in dementia, particularly in VaD and DLB. DPOH, more likely associated with autonomic dysfunction, is a risk factor for incident MCI or dementia.

Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications

Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.

[Syncopes]

Syncopes are defined as sudden and short unconsciousness with loss of muscular tonus which are reversible without further intervention. Differentiation from other short-lasting changes of consciousness as in seizures, blood flow abnormalities of brainstem, metabolic disorders, intoxication or traumatic loss of consciousness is important for further diagnostic and adequate treatment.

Addressing Orthostatic Hypotension in Heart Failure: Pathophysiology, Clinical Implications and Perspectives

Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities contributing to OH, as well as a high prevalence of medications with neurovascular and volume modulating properties. Early identification of OH in HF seems to be crucial as OH can have an impact on patient symptoms, activity level and independence, be a marker of specific pathophysiological changes or be an indicator of need for personalized treatment. OH might contribute significantly to bad enough prognosis in HF, as, besides a risk of falls and cognitive decline, it was found to be associated with cardiovascular morbidity and mortality. In this review, we aimed to incentivize the routine use of orthostatic testing in HF, as well as stimulate future research in this field, which could lead to significant advances in the treatment and outcomes.

Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: The ALLHAT Trial

Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

[Evaluation of orthostatic hypotension frequency and associated factors in type 2 diabetics]

Orthostatic hypotension is a major criterion for diabetic autonomic cardiac neuropathy. It increases overall and cardiovascular mortality.

PURPOSE

The aim of our study was to evaluate the orthostatic hypotension frequency in type 2 diabetics and to investigate the associated factors.

METHODS

This prospective cross-sectional study included adult patients with type 2 diabetes. Orthostatic hypotension was defined as a decrease in the systolic arterial pressure>20mm-Hg or a decrease in the diastolic arterial pressure>10mm-Hg, after 3minutes of standing position. The arterial pressure was measured with a validated electronic device. Vascular risk factors and micro and macro-vascular complications were systematically investigated by the appropriate diagnostic means.

RESULTS

We evaluated 300 diabetic patients. Of these women represented 57%. The mean age was 58 years old. The average duration of diabetes was 8 years. The antidiabetic drugs were metformin (82%), sulfonylureas (36%) and insulin (40%). High blood pressure was present in 49% among whom 50% of patients received angiotensin II receptor blockers, 47% diuretics, 24% angiotensin converting enzyme inhibitors, 17% beta blockers, and 17% calcium channel blockers. Orthostatic hypotension has been identified in 26 patients (8.6%). In multivariate analysis, the associated factors with orthostatic hypotension were elevated systolic blood pressure and insulin treatment.

CONCLUSION

The frequency of orthostatic hypotension is relatively low in our patients with type 2 diabetes and it was significantly associated with systolic blood pressure and insulin treatment.

Blood Pressure Lowering With Nilvadipine in Patients With Mild-to-Moderate Alzheimer Disease Does Not Increase the Prevalence of Orthostatic Hypotension

Background Hypertension is common among patients with Alzheimer disease. Because this group has been excluded from hypertension trials, evidence regarding safety of treatment is lacking. This secondary analysis of a randomized controlled trial assessed whether antihypertensive treatment increases the prevalence of orthostatic hypotension (OH) in patients with Alzheimer disease. Methods and Results Four hundred seventy-seven patients with mild-to-moderate Alzheimer disease were randomized to the calcium-channel blocker nilvadipine 8 mg/day or placebo for 78 weeks. Presence of OH (blood pressure drop ≥20/≥10 mm Hg after 1 minute of standing) and OH-related adverse events (dizziness, syncope, falls, and fractures) was determined at 7 follow-up visits. Mean age of the study population was 72.2±8.2 years and mean Mini-Mental State Examination score was 20.4±3.8. Baseline blood pressure was 137.8±14.0/77.0±8.6 mm Hg. Grade I hypertension was present in 53.4% (n=255). After 13 weeks, blood pressure had fallen by -7.8/-3.9 mm Hg for nilvadipine and by -0.4/-0.8 mm Hg for placebo ( P<0.001). Across the 78-week intervention period, there was no difference between groups in the proportion of patients with OH at a study visit (odds ratio [95% CI]=1.1 [0.8-1.5], P=0.62), nor in the proportion of visits where a patient met criteria for OH, corrected for number of visits (7.7±13.8% versus 7.3±11.6%). OH-related adverse events were not more often reported in the intervention group compared with placebo. Results were similar for those with baseline hypertension. Conclusions This study suggests that initiation of a low dose of antihypertensive treatment does not significantly increase the risk of OH in patients with mild-to-moderate Alzheimer disease. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02017340.

Orthostatic Hypotension in the Hypertensive Patient

Orthostatic hypotension (OH) is an important and common medical problem, particularly in the frail elderly with multiple comorbidities and polypharmacy. OH is an independent risk factor for falls and overall mortality. Hypertension is among the most common comorbidities associated with OH, and its presence complicates the management of these patients because treatment of one can worsen the other. However, there is evidence that uncontrolled hypertension worsens OH so that both should be managed. The limited data available suggest that angiotensin receptor blockers and calcium channel blockers are preferable antihypertensives for these patients. Patients with isolated supine hypertension can be treated with bedtime doses of short-acting antihypertensives. Treatment of OH in the hypertensive patients should focus foremost on the removal of drugs that can worsen OH, including ones that are easily overlooked, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol. OH and postprandial hypotension can be prevented with abdominal binders and acarbose, respectively, without the need to increase baseline blood pressure. Upright blood pressure can be improved by harnessing residual sympathetic tone with atomoxetine, which blocks norepinephrine reuptake in nerve terminals, and pyridostigmine, which facilitates cholinergic neurotransmission in autonomic ganglia. Oral water bolus acutely but transiently increases blood pressure in autonomic failure patients. If traditional pressor agents are needed, midodrine and droxidopa can be used, administered at the lowest dose and frequency that improves symptoms. Management of OH in the hypertensive patient is challenging, but a management strategy based on understanding the underlying pathophysiology can be effective in most patients.

Hypertension Treatment Effects on Orthostatic Hypotension and Its Relationship With Cardiovascular Disease

Although orthostatic hypotension (OH) is often considered a contraindication to blood pressure (BP) treatment, evidence is lacking. We examined the effect of BP goal or initial medication choice on OH in AASK (African American Study of Kidney Disease and Hypertension), a 2×3 factorial trial. Blacks with chronic kidney disease attributed to hypertension were randomly assigned 1 of 2 BP goals: intensive (mean arterial pressure, ≤92 mm Hg) or standard (mean arterial pressure, 102-107 mm Hg) and 1 of 3 initial medications (ramipril, metoprolol, and amlodipine). Postural changes in systolic BP, diastolic BP, or heart rate (HR) were determined after 2 minutes and 45 seconds of standing. OH was assessed each visit and defined using the consensus definition (drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg). Median follow-up was 4 years. Outcomes were congestive heart failure, stroke, nonfatal cardiovascular disease (CVD), fatal CVD, any CVD (composite of preceding events), and all-cause mortality. There were 1094 participants (mean age, 54.5±10.7 years; 38.8% female; OH was assessed at 52 864 visits). Mean seated systolic BP, diastolic BP, and HR were 150.3±23.9 mm Hg, 95.5±14.2 mm Hg, and 72.0±12.6 bpm, respectively. A more intensive BP goal did not alter the distributions of standing BP and was not associated with OH, but metoprolol was associated with systolic OH compared with ramipril (odds ratio, 1.68; 95% CI, 1.15-2.46) and amlodipine (odds ratio, 1.94; 95% CI, 1.09-3.44). Although consensus OH was associated with stroke (HR, 5.01; 95% CI, 1.80-13.92), nonfatal CVD (HR, 2.28; 95% CI, 1.21-4.30), and any CVD event (HR, 2.12; 95% CI, 1.12-3.98), neither BP goal or medication altered this risk. Concerns about causing OH or its CVD consequences should not deter a lower BP goal among adults with chronic kidney disease attributed to hypertension.

Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE)

Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.

The association between antidepressant use and orthostatic hypotension in older people: a matched cohort study

Orthostatic hypotension (OH) is often reported as a significant potential adverse effect of antidepressant use but the association between phasic blood pressure (BP) and antidepressants has not yet been investigated. This cross-sectional study compares continuously measured phasic BP and prevalence of OH in a cohort of antidepressant users ≥50 years compared with an age- and sex-matched cohort not taking antidepressants. OH was defined as a drop in systolic BP ≥ 20 mm Hg or in diastolic BP ≥ 10 mm Hg at 30 seconds after standing, measured using continuous beat-to-beat finometry. Multilevel time × group interactions revealed significantly greater systolic and diastolic BP drop in antidepressant users than nonusers at 30 seconds after stand. The prevalence of OH among antidepressant users was 31% (63/206), compared with 17% in nonusers (X² = 9.7; P = .002). Unadjusted logistic regression models demonstrated that selective serotonin reuptake inhibitor use was associated with OH at an odds ratio of 2.11 (95% confidence interval: 1.25-3.57); P = .005, and this association was not attenuated when covariates including cardiac disease and depressive symptom burden were added. There was no statistically significant association between serotonin noradrenaline reuptake inhibitor or tricyclic antidepressant use and OH in unadjusted models although the study was not powered to detect changes within these subgroups. Older people taking antidepressants have a two-fold higher prevalence of OH than nonusers, highlighting the importance of screening the older antidepressant user for OH and dizziness and rationalizing medications to reduce the risk of falls within this vulnerable cohort.

Orthostatic hypotension: A review

Orthostatic hypotension, defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3minutes of standing up, is a frequent finding, particularly in elderly patients. It is associated with a significant increase in morbidity and mortality. Although it is often multifactorial, the first favoring factor is medications. Other etiologies are divided in neurogenic orthostatic hypotension, characterized by autonomic failure due to central or peripheral nervous system disorders, and non-neurogenic orthostatic hypotension, mainly favoured by hypovolemia. Treatment always requires education of the patient regarding triggering situations and physiological countermanoeuvers. Pharmacological treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine. There is no predefined blood pressure target, the goal of therapy being the relief of symptoms and fall prevention.

Is orthostatic hypotension more common in individuals with atrial fibrillation?-Findings from The Irish Longitudinal Study on Ageing (TILDA)

Introduction

atrial fibrillation (AF) and orthostatic hypotension (OH) share common risk factors such as age, hypertension and cardiovascular (CV) disease. The autonomic nervous system (ANS) also plays a role in the pathogenesis of both AF and OH. The aim of this study is to assess whether individuals with AF are more likely to have OH than those without AF.

Methods

data from wave 1 of The Irish Longitudinal Study on Ageing were used. Beat-to-beat blood pressure was measured during active stand lasting 110 s. OH, defined as a drop in systolic blood pressure (SBP) ≥20 mmHg or a drop in diastolic blood pressure ≥10 mmHg at 30, 60 and 90 s was assessed. Initial OH (IOH) was assessed as a drop in SBP ≥40 mmHg or a drop in diastolic BP≥20 mmHg.

Results

in total 4,408 participants aged ≥50 had active stand and electrocardiogram data suitable for analysis. AF was identified in 101 of these. Logistic regression found participants with AF were more likely to have OH at 30 (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.24-3.06) and 60 (OR 2.13, 95% CI 1.18-3.87) seconds, and IOH (OR 1.81, 95% CI 1.21-2.70). The association between IOH and OH at 30 s remained significant following adjustment for confounders (age, sex, baseline HR, education, BP, smoking, frailty, beta blocker (BB) use, anti-hypertensive use (excluding BBs) and number of CV conditions).

Conclusion

OH is more common in individuals with AF, this may reflect the role of the ANS in both AF and OH.

Orthostatic Hypotension and Therapy with an Ace Inhibitor in Hypertensive Patients

Orthostatic hypotension (OH) is defined as a drop in the systolic blood pressure greater than 20 mmHg and that of the diastolic blood pressure greater than 10 mmHg within 3 minutes from the change of the body’s position from lying or sitting down to standing up. The objective of this study is to analyse the incidence and severity of orthostatic hypertension when taking one of the generic representatives of the ACE inhibitor group (trandolapril) as a monotherapy in patients with essential hypertension. Th e study involved 314 patients (medium age of 54±4 years; 52.5% men) with poorly regulated hypertension for whom trandolapril was introduced as monotherapy. Th e incidence rates of patients with and without orthostatic hypotension between the first and second examination were not statistically significantly different. At the second control examination, 7 patients (2,3%) still had orthostatic hypotension, as was the case at the first examination. Between the third and fourth controls, a statistically significant decrease in the number of patients with orthostatic hypotension was recorded. No statistically significant difference in the incidence of orthostatic hypotension between patients with normal body mass and those who were overweight was observed. Our study has shown that certain ACE inhibitors, such as Trandolapril, do not have a pronounced adverse effect with regard to orthostatic hypotension and that in long-term application, they can have a positive role in the prevention of hypotensive episodes and improving patient compliance.

Sensitive detection of hemodynamic failure during orthostatic stress in patients with diabetic polyneuropathy using a mini laser Doppler blood flowmeter

Autonomic dysfunction in diabetes is serious but often underestimated. The purpose of this study was to evaluate hemodynamics within the important initial phase just after standing, which cannot be evaluated by conventional instruments for orthostatic hypotension. Earlobe blood flow (EBF), which indirectly reflects the blood pressure response on standing, was evaluated using a mini laser Doppler flowmeter during standing from the sitting position in 58 healthy controls and 56 diabetic patients categorized as without (11), mild (27), and advanced diabetic polyneuropathy (18). The response area of the EBF waveform within 30 seconds after standing was calculated. An increased response area indicates poor recovery of EBF. Response area increased significantly with the degree of neuropathy (P < .001 for linear trend). Orthostatic hypotension was detected in two patients in the mild neuropathy group. The present approach may be sensitive and practical for detecting autonomic dysfunction not detected with the conventional orthostatic test.

The management of vasovagal syncope

Vasovagal syncope, or the "common faint", is the most common cause of syncope. Although it is considered a benign condition, there is a significant economic burden and significant impact on quality of life in patients with recurrent syncope, particularly in older adults. Typical vasovagal syncope usually occurs in young adults, and can often be diagnosed on the basis of history, in the absence of structural heart disease. Atypical vasovagal syncope, which is more common in older adults, can be more difficult to diagnose, however. In atypical vasovagal syncope, there is often a short or absent prodrome, and amnesia for loss of consciousness is common and it can, therefore, often be misdiagnosed, for example as falls. A more standardized approach to the diagnosis and management of patients presenting with syncope or unexplained falls is required, and it is anticipated that the number of Syncope Units will increase. Treatment of vasovagal syncope is largely conservative; however, medical or device therapy may be required when syncope is severe and refractory to conservative treatment, as there is significant impact on quality of life and it can be associated with injury. The aim of this article is to provide an overview of the diagnosis and management of vasovagal syncope.

Diastolic orthostatic hypertension and cardiovascular prognosis in type 2 diabetes: a prospective cohort study

BACKGROUND

In patients with type 2 diabetes, the prognostic impact of an orthostatic rise in blood pressure is not known. Therefore, the aim of this study was to determine the prognostic implications of the diastolic orthostatic blood pressure response in a cohort of patients with type 2 diabetes. We also evaluated associations between different orthostatic blood pressure responses and markers of subclinical cardiovascular organ damage.

METHODS

Office blood pressures were measured in the sitting and in the standing position in 749 patients with type 2 diabetes who participated in the CARDIPP study (Cardiovascular Risk factors in Patients with Diabetes-a Prospective study in Primary care). Diastolic orthostatic hypertension was defined as a rise of diastolic blood pressure ≥10 mmHg and diastolic orthostatic hypotension was defined as a drop of diastolic blood pressure ≥10 mmHg. Recruitment took place between the years 2005-2008, and patients were followed until any of the primary outcome events (cardiovascular death or hospitalization for either myocardial infarction or stroke) occurred or until December 31st, 2014. Measurements of aortic pulse wave velocity and of carotid intima-media thickness were performed at base-line.

RESULTS

Diastolic orthostatic hypertension was found in 140 patients (18.7 %) and was associated with significantly lower risk of cardiovascular events (crude hazard ratio compared with patients with normal systolic and diastolic orthostatic blood pressure response: 0.450, 95 % C.I. 0.206-0.987, P = 0.046). Diastolic orthostatic hypotension was found in 31 patients (4.1 %) and was associated with higher values for aortic pulse wave velocity and carotid intima-media thickness, compared with patients with normal systolic and diastolic orthostatic blood pressure response.

CONCLUSIONS

Diastolic orthostatic hypertension is common in patients with type 2 diabetes, and may be a novel marker for decreased cardiovascular risk in these patients.