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Juraschek SP, Cortez MM, Flack JM, Ghazi L, Kenny RA, Rahman M, Spikes T, Shibao CA, Biaggioni I. Orthostatic Hypotension in Adults With Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2024; 81:e16-e30. [PMID: 38205630 PMCID: PMC11067441 DOI: 10.1161/hyp.0000000000000236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
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.
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Ghazi L, Cohen JB, Townsend RR, Drawz PE, Rahman M, Pradhan N, Cohen DL, Weir MR, Rincon-Choles H, Juraschek SP. Orthostatic hypotension, orthostatic hypertension, and ambulatory blood pressure in patients with chronic kidney disease in CRIC. J Hypertens 2024; 42:329-336. [PMID: 37889527 PMCID: PMC10842034 DOI: 10.1097/hjh.0000000000003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Orthostatic changes in blood pressure (BP), either orthostatic hypotension or orthostatic hypertension (OHTN), are common among patients with chronic kidney disease. Whether they are associated with unique out-of-office BP phenotypes is unknown. METHODS CRIC is a prospective, multicenter, observational cohort study of participants with CKD. BP measured at 2 min after standing and ambulatory BP monitoring (ABPM) were obtained on 1386 participants. Orthostatic hypotension was defined as a 20 mmHg drop in SBP or 10 mmHg drop in DBP when changing from seated to standing positions. Systolic and diastolic night-to-day ratio was also calculated. OHTN was defined as a 20 or 10 mmHg rise in SBP or DBP when changing from a seated to a standing position. White-coat effect (WCE) was defined as seated minus daytime ambulatory BP. RESULTS Of the 1386 participants (age: 58 ± 10 years, 44% female, 39% black), 68 had orthostatic hypotension and 153 had OHTN. Postural reduction in SBP or DBP was positively associated with greater systolic and diastolic WCE and systolic and diastolic night-to-day ratio. Orthostatic hypotension was positively associated with diastolic WCE (β = 3 [0.2, 5.9]). Diastolic OHTN was negatively associated with systolic WCE (β = -4 [-7.2, -0.5]) and diastolic WCE (β = -6 [-8.1, -4.2]). CONCLUSION Postural change in BP was associated with WCE and night-to-day-ratio. Orthostatic hypotension was positively associated with WCE and OHTN was negatively associated with WCE. These findings strengthen observations that postural changes in BP may associate with distinct BP patterns throughout the day. These observations are informative for subsequent research tailoring orthostatic hypotension and OHTN treatment to specific BP phenotypes.
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Affiliation(s)
- Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, PA
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paul E Drawz
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, OH
| | - Nishigandha Pradhan
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, OH
| | - Debbie L Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, PA
| | - Matthew R. Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD
| | - Hernan Rincon-Choles
- Cleveland Clinic Foundation, Glickman Urological & Kidney Institute, Department of Nephrology, Cleveland, OH
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Earle WB, Kondo JK, Kendrick KN, Turkson-Ocran RA, Ngo L, Cluett JL, Mukamal KJ, Daya Malek N, Selvin E, Lutsey PL, Coresh J, Juraschek SP. Association of Supine Hypertension Versus Standing Hypotension With Adverse Events Among Middle-Aged Adults. Hypertension 2023; 80:2437-2446. [PMID: 37646155 PMCID: PMC10640713 DOI: 10.1161/hypertensionaha.123.21215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Management of orthostatic hypotension (OH) prioritizes prevention of standing hypotension, sometimes at the expense of supine hypertension. It is unclear whether supine hypertension is associated with adverse outcomes relative to standing hypotension. OBJECTIVES To compare the long-term clinical consequences of supine hypertension and standing hypotension among middle-aged adults with and without OH. METHODS The ARIC study (Atherosclerosis Risk in Communities) measured supine and standing blood pressure (BP) in adults aged 45 to 64 years, without neurogenic OH, between 1987 and 1989. We defined OH as a positional drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg, supine hypertension as supine BP≥140/≥90 mm Hg, and standing hypotension as standing BP≤105/≤65 mm Hg. Participants were followed for >30 years. We used Cox regression models to examine associations with cardiovascular disease events, all-cause mortality, falls, and syncope. RESULTS Of 12 489 participants (55% female, 26% Black, mean age 54 years, SD 6), 4.4% had OH. Among those without OH (N=11 943), 19% had supine hypertension and 21% had standing hypotension, while among those with OH (N=546), 58% had supine hypertension and 38% had standing hypotension. Associations with outcomes did not differ by OH status (P-interactions >0.25). Supine hypertension was associated with heart failure (hazard ratio, 1.83 [95% CI, 1.68-1.99]), falls (hazard ratio, 1.12 [95% CI, 1.02-1.22]), and all-cause mortality (hazard ratio, 1.45 [95% CI, 1.37-1.54]), while standing hypotension was only significantly associated with mortality (hazard ratio, 1.06 [95% CI, 1.00-1.14]). CONCLUSIONS Supine hypertension was associated with higher risk of adverse events than standing hypotension, regardless of OH status. This challenges conventional OH management, which prioritizes standing hypotension over supine hypertension.
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Affiliation(s)
- William B Earle
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Jordan K Kondo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Karla N Kendrick
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Ruth-Alma Turkson-Ocran
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Jennifer L Cluett
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
| | - Natalie Daya Malek
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN (P.L.L.)
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (N.D.M., E.S., J.C.)
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (W.B.E., J.K.K., K.N.K., R.-A.T.-O., L.N., J.L.C., K.J.M., S.P.J.)
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Juraschek SP, Hu JR, Cluett JL, Ishak AM, Mita C, Lipsitz LA, Appel LJ, Beckett NS, Coleman RL, Cushman WC, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor AA, Thijs L, Wright JT, Mukamal KJ. Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis. JAMA 2023; 330:1459-1471. [PMID: 37847274 PMCID: PMC10582789 DOI: 10.1001/jama.2023.18497] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/28/2023] [Indexed: 10/18/2023]
Abstract
Importance There are ongoing concerns about the benefits of intensive vs standard blood pressure (BP) treatment among adults with orthostatic hypotension or standing hypotension. Objective To determine the effect of a lower BP treatment goal or active therapy vs a standard BP treatment goal or placebo on cardiovascular disease (CVD) or all-cause mortality in strata of baseline orthostatic hypotension or baseline standing hypotension. Data Sources Individual participant data meta-analysis based on a systematic review of MEDLINE, EMBASE, and CENTRAL databases through May 13, 2022. Study Selection Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) with orthostatic hypotension assessments. Data Extraction and Synthesis Individual participant data meta-analysis extracted following PRISMA guidelines. Effects were determined using Cox proportional hazard models using a single-stage approach. Main Outcomes and Measures Main outcomes were CVD or all-cause mortality. Orthostatic hypotension was defined as a decrease in systolic BP of at least 20 mm Hg and/or diastolic BP of at least 10 mm Hg after changing position from sitting to standing. Standing hypotension was defined as a standing systolic BP of 110 mm Hg or less or standing diastolic BP of 60 mm Hg or less. Results The 9 trials included 29 235 participants followed up for a median of 4 years (mean age, 69.0 [SD, 10.9] years; 48% women). There were 9% with orthostatic hypotension and 5% with standing hypotension at baseline. More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline orthostatic hypotension (hazard ratio [HR], 0.81; 95% CI, 0.76-0.86) similarly to those with baseline orthostatic hypotension (HR, 0.83; 95% CI, 0.70-1.00; P = .68 for interaction of treatment with baseline orthostatic hypotension). More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline standing hypotension (HR, 0.80; 95% CI, 0.75-0.85), and nonsignificantly among those with baseline standing hypotension (HR, 0.94; 95% CI, 0.75-1.18). Effects did not differ by baseline standing hypotension (P = .16 for interaction of treatment with baseline standing hypotension). Conclusions and Relevance In this population of hypertension trial participants, intensive therapy reduced risk of CVD or all-cause mortality regardless of orthostatic hypotension without evidence for different effects among those with standing hypotension.
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Affiliation(s)
- Stephen P. Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer L. Cluett
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anthony M. Ishak
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Healthcare Associates, Beth Israel–Lahey Health System, Boston, Massachusetts
| | - Carol Mita
- Countway Library, Harvard University, Boston, Massachusetts
| | - Lewis A. Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research and Harvard Medical School, Boston, Massachusetts
| | | | | | - Ruth L. Coleman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, England
| | - William C. Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Barry R. Davis
- Department of Biostatistics and Data Science, Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston
| | - Greg Grandits
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Rury R. Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, England
| | | | - Ruth Peters
- The George Institute for Global Health, Sydney, Australia
- Department of Biomedical Sciences, University of New South Wales, Sydney, Australia
- School of Public Health, Imperial College London, London, England
| | | | - Addison A. Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
| | | | - Jackson T. Wright
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Kenneth J. Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Bailey R, Mortimore G. Orthostatic hypotension: clinical review and case study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:506-511. [PMID: 32407222 DOI: 10.12968/bjon.2020.29.9.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Transient loss of consciousness (TLOC) accounts for 3% of all attendance in emergency departments within the UK. More than 90% of TLOC presentations are due to epileptic seizures, psychogenic seizures or syncope. However, in England and Wales in 2002, it was estimated that 92 000 patients were incorrectly diagnosed with epilepsy, at an additional annual cost to the NHS of up to £189 million. This article will reflect on the case study of a 54-year-old female patient who presented with a possible TLOC, and had a background of long-term depression. Differential diagnoses will be discussed, but the article will focus on orthostatic hypotension. Being diagnosed with this condition is independently associated with an increased risk of all-cause mortality. Causes of orthostatic hypotension and the pathophysiology behind the condition will be discussed, highlighting the importance of obtaining an accurate clinical history. This is extremely pertinent if a patient collapses in an NHS setting and this is witnessed by nurses because they can contribute to the history of the type of collapse, to aid diagnosis and correct treatment. In addition, nurses have a valuable role to play in highlighting polypharmacy to doctors, and non-medical prescribers, as a contributing factor to orthostatic hypotension is polypharmacy. It is therefore important to accurately distinguish TLOC aetiology, not only to provide appropriate management, but to also identify patients at risk of morbidity/mortality related to underlying disease.
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Affiliation(s)
- Rachael Bailey
- Trainee Advanced Clinical Practitioner, Department of Health and Social Care, University of Derby
| | - Gerri Mortimore
- Lecturer in Advanced Practice, Department of Health and Social Care, University of Derby
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Affiliation(s)
- Michiko Shimada
- Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Amardeep Singh
- Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Abutaleb A Ejaz
- Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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7
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Orthostatic hypotension is associated with new-onset atrial fibrillation: Systemic review and meta-analysis. Indian Heart J 2019; 71:320-327. [PMID: 31779860 PMCID: PMC6890958 DOI: 10.1016/j.ihj.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/02/2019] [Accepted: 07/24/2019] [Indexed: 01/11/2023] Open
Abstract
Introduction Orthostatic hypotension (OH) is common among elderly patients. Its presence may herald severe underlying comorbidities and be associated with a higher risk of mortality. Interestingly, recent studies suggest that OH is associated with new-onset atrial fibrillation (AF). However, a systematic review and meta-analysis of the literature has not been performed. We assessed the association between AF and OH through a systematic review of the literature and a meta-analysis. Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2018. Published prospective or retrospective cohort studies that compared new-onset AF between male patients with and without OH were included. Data from each study were combined using the random-effects, generic inverse-variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Results Four studies from October 2010 to March 2018 were included in the meta-analysis involving 76,963 subjects (of which 3318 were diagnosed with OH). The presence of OH was associated with new-onset AF (pooled risk ratio 1.48; 95% confidence interval [1.21, 1.81], p?< 0.001; I2 = 69.4%). In hypertensive patients, analysis revealed an association between OH and the occurrence of new-onset AF (OR 1.46; 95% CI [1.27, 1.68], p < 0.001 with I2 = 0). Conclusions OH was associated with new-onset AF up to 1.5-fold compared with those subjects without OH. The interplay between OH and AF is likely bidirectional.
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Tai Y, Saeki K, Yamagami Y, Yoshimoto K, Kurumatani N, Nishio K, Obayashi K. Association between timing of hot water bathing before bedtime and night-/sleep-time blood pressure and dipping in the elderly: a longitudinal analysis for repeated measurements in home settings. Chronobiol Int 2019; 36:1714-1722. [DOI: 10.1080/07420528.2019.1675685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Yoshiaki Tai
- Department of General Medicine, Nara Medical University School of Medicine, Nara, Japan
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Keigo Saeki
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Yuki Yamagami
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Kiyomi Yoshimoto
- Department of General Medicine, Nara Medical University School of Medicine, Nara, Japan
| | - Norio Kurumatani
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
| | - Kenji Nishio
- Department of General Medicine, Nara Medical University School of Medicine, Nara, Japan
| | - Kenji Obayashi
- Department of Epidemiology, Nara Medical University School of Medicine, Nara, Japan
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Mehta T, McClure LA, White CL, Taylor A, Benavente OR, Lakshminarayan K. Effect of Postural Hypotension on Recurrent Stroke: Secondary Prevention of Small Subcortical Strokes (SPS3) Study. J Stroke Cerebrovasc Dis 2019; 28:2124-2131. [PMID: 31147254 DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/27/2019] [Accepted: 04/05/2019] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Tapan Mehta
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota
| | - Leslie A McClure
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | | | - Addison Taylor
- Michael E. DeBakey VA Medical Center & Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Oscar R Benavente
- Department of Medicine, Division of Neurology University of British Columbia, Vancouver, British Columbia, Canada
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota.
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Biswas D, Karabin B, Turner D. Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review. Int J Gen Med 2019; 12:173-184. [PMID: 31118743 PMCID: PMC6501706 DOI: 10.2147/ijgm.s170655] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Neurogenic orthostatic hypotension (nOH) is a sustained reduction in blood pressure (BP) upon standing that is caused by autonomic dysfunction and is common among patients with a variety of neurodegenerative disorders (eg, Parkinson's disease, multiple system atrophy, pure autonomic failure). A systolic BP drop of ≥20 mmHg (or ≥10 mmHg diastolic) upon standing with little or no compensatory increase in heart rate is consistent with nOH. Symptoms of nOH include light-headedness, dizziness, presyncope, and syncope; these symptoms can severely impact patients' activities of daily living and increase the likelihood of potentially dangerous falls. Because of their patient contact, nurses and nurse practitioners can play a key role in identifying and evaluating patients at risk for nOH. It is advisable to screen for nOH in patients presenting with one or more of the following characteristics: those who have disorders associated with autonomic failure, those with episodes of falls or syncope, those with symptoms upon standing, those who are elderly or frail, or those taking multiple medications. Initial evaluations should include questions about postural symptoms and measurement of orthostatic BP and heart rate. A review of medications for potential agents that can have hypotensive effects should be performed before initiating treatment. Treatment for nOH may include non-pharmacologic measures and pharmacologic therapy. Droxidopa and midodrine are approved by the US Food and Drug Administration for the treatment of symptomatic nOH and symptomatic OH, respectively. nOH is associated with the coexistence of supine hypertension, and the two disorders must be carefully managed. In conclusion, timely screening and diagnosis of patients with nOH can streamline the path to disease management and treatment, potentially improving patient outcomes.
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Affiliation(s)
- Debashis Biswas
- Neurology, Baptist Memorial Hospital-Memphis, Memphis, TN, USA,
| | - Beverly Karabin
- Cardiovascular Medicine, University of Toledo, Toledo, OH, USA
| | - Debra Turner
- Autonomic Services, Semmes Murphey Clinic, Memphis, TN, USA
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11
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Alquadan KF, Singhania G, Koratala A, Ejaz AA. Office orthostatic blood pressure measurements and ambulatory blood pressure monitoring in the prediction of autonomic dysfunction. Clin Hypertens 2017; 23:3. [PMID: 28331633 PMCID: PMC5351249 DOI: 10.1186/s40885-016-0059-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 12/26/2016] [Indexed: 11/30/2022] Open
Abstract
Background In this retrospective analysis we investigated the predictive performance of orthostatic hypotension (OH) and ambulatory blood pressure monitoring (ABP) to predict autonomic dysfunction. Methods Statistical associations among the candidate variables were investigated and comparisons of predictive performances were performed using Receiver Operating Characteristics (ROC) curves. Results Ninety-four patients were included for analysis. No significant correlations could be demonstrated between OH and components of ABP (reversal of circadian pattern, postprandial hypotension and heart rate variability), nor between OH and autonomic reflex screen. Reversal of circadian pattern did not demonstrate significant correlation (r = 0.12, p = 0.237) with autonomic reflex screen, but postprandial hypotension (r = 0.39, p = 0.003) and heart rate variability (r = 0.27, p = 0.009) demonstrated significant correlations. Postprandial hypotension was associated with a five-fold (OR 4.83, CI95% 1.6–14.4, p = 0.005) increased risk and heart rate variability with a four-fold (OR 3.75, CI95% 1.3–10.6, p = 0.013) increased risk for autonomic dysfunction. Per ROC curves, heart rate variability (0.671, CI95% 0.53–0.81, p = 0.025) and postprandial hypotension (0.668, CI95% 0.52–0.72, p = 0.027) were among the best predictors of autonomic dysfunction in routine clinical practice. Conclusion Postprandial hypotension and heart rate variability on ambulatory blood pressure monitoring are among the best predictors of autonomic dysfunction in routine clinical practice.
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Affiliation(s)
- Kawther F Alquadan
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, P.O. Box 100224, Gainesville, FL 32610-0224 USA
| | - Girish Singhania
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, USA
| | - Abhilash Koratala
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, P.O. Box 100224, Gainesville, FL 32610-0224 USA
| | - Abutaleb A Ejaz
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, P.O. Box 100224, Gainesville, FL 32610-0224 USA
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12
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Abstract
Background orthostatic hypotension (OH) is a common disabling condition associated with increased morbidity and mortality. Much of the evidence available is derived from younger populations with chronic neurological disease leading to uncertainty for the diagnosis and management of older people. Objective to provide an overview of recent and emerging evidence for the diagnosis, management and prognosis of OH in older persons. Methods a narrative review of recent studies, emerging therapies and relevant regulatory updates. Findings revisions to the diagnostic criteria for OH include the duration of the blood pressure drop, specific criteria for initial and delayed OH and OH with hypertension. Non-drug therapies remain the first-line treatment option and Comprehensive Geriatric Assessment appears to result in lower rates of OH. Recent evidence concerning withdrawal of causative medication is inconsistent. Midodrine has recently become the only licenced medication for OH in the UK. Other emerging treatments include atomoxetine and droxidopa but these require further evaluation. Many other agents may be used but are not supported by high-quality evidence. The increase in mortality associated with OH is less apparent in older people. Summary OH remains common in older people, the new diagnostic criteria address some of the previous uncertainty but evidence concerning withdrawal of antihypertensives is conflicting. Midodrine is now the only licenced medication for OH in the UK, but non-drug therapies remain first line and fludrocortisone may be considered before midodrine. We may see other agents such as droxidopa becoming increasingly used over the coming years.
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Affiliation(s)
- James Frith
- Newcastle University-Institute of Cellular Medicine, Newcastle upon Tyne NE1 7RU, United Kingdom of Great Britain and Northern Ireland
- The Newcastle upon Tyne Hospitals NHS Foundation Trust-Falls and Syncope Service, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Steve W Parry
- Newcastle University-Institute of Cellular Medicine, Newcastle upon Tyne NE1 7RU, United Kingdom of Great Britain and Northern Ireland
- The Newcastle upon Tyne Hospitals NHS Foundation Trust-Falls and Syncope Service, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
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Krishnan B, Patarroyo-Aponte M, Duprez D, Pritzker M, Missov E, Benditt DG. Orthostatic hypotension of unknown cause: Unanticipated association with elevated circulating N-terminal brain natriuretic peptide (NT-proBNP). Heart Rhythm 2015; 12:1287-94. [DOI: 10.1016/j.hrthm.2015.02.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Indexed: 10/24/2022]
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14
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Trahair LG, Horowitz M, Jones KL. Postprandial hypotension: a systematic review. J Am Med Dir Assoc 2014; 15:394-409. [PMID: 24630686 DOI: 10.1016/j.jamda.2014.01.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 01/24/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postprandial hypotension (PPH) is an important clinical problem, which has received inappropriately little attention. METHODS A systematic search of the databases PubMed, Embase, Cochrane Library, and Web of Knowledge, from their inception to the present time, was conducted to identify studies relevant to the epidemiology, pathophysiology, and/or management of PPH. RESULTS A total of 417 full-text papers were retrieved from database searching and, following screening, 248 were retained. Of these, 167 papers were considered eligible for inclusion. CONCLUSIONS PPH occurs commonly in older people and represents a major cause of morbidity. Although the pathophysiology of PPH remains poorly defined, diverse factors, including impairments in sympathetic and baroreflex function, release of vasodilatory peptides, the rate of small intestinal nutrient delivery, gastric distension, and splanchnic blood pooling, appear important. Current pharmacologic and nonpharmacologic management is suboptimal. Research into the pathophysiology of PPH represents a priority so that management can be targeted more effectively.
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Affiliation(s)
- Laurence G Trahair
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; NHMRC Center of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; NHMRC Center of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; NHMRC Center of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.
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Momeyer MA. Orthostatic hypotension in older adults with dementia. J Gerontol Nurs 2014; 40:22-9; quiz 30-1. [PMID: 24779368 DOI: 10.3928/00989134-20140421-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 03/28/2014] [Indexed: 11/20/2022]
Abstract
Orthostatic hypotension (OH) in older adults with dementia is associated with increased confusion, dizziness, syncope, and falls. These problems may result in a negative, downward spiral accompanied by high morbidity and mortality. The literature supports that nonpharmacological interventions are effective in the reduction of symptoms and prevention of orthostasis. The purpose of this quality improvement project was to increase staff knowledge and skill in the assessment, documentation, and care of residents with OH in dementia care units within a continuing care retirement community. An in-service program using a protocol based on clinical practice guidelines was presented to RNs, licensed practical nurses, therapists, and unlicensed caregivers. Assessments, documentation of assessments, and interventions for residents with OH increased following the in-service program. As staff continue to apply their knowledge in care routines, it is expected that this evidence-based practice will reduce symptoms of OH and increase safety and quality of life within this specific population.
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Mader SL. Identification and management of orthostatic hypotension in older and medically complex patients. Expert Rev Cardiovasc Ther 2014; 10:387-95. [DOI: 10.1586/erc.12.11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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17
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Management of neurogenic orthostatic hypotension. J Am Med Dir Assoc 2014; 15:234-9. [PMID: 24388946 DOI: 10.1016/j.jamda.2013.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/25/2013] [Accepted: 10/25/2013] [Indexed: 11/20/2022]
Abstract
The burden of orthostatic hypotension (OH) on public health is a universally recognized enigmatic clinical condition that is associated with significant increases on morbidity and mortality rates, and can take a major toll on one's quality of life. Orthostatic hypotension is predictive of vascular deaths from acute myocardial infarction, strokes in the middle aged population, and increases mortality rates when associated with diabetes, hypertension, Parkinson's disease, and patients receiving renal dialysis. The consensus definition for OH is a fall in systolic blood pressure of at least 20 mm Hg and/or diastolic blood pressure of at least 10 mm Hg within 3 minutes of quiet standing. Because neurogenic OH is often accompanied by supine hypertension, the treatment program should aim toward minimizing OH and the potential fall injuries related to cerebral hypoperfusion without exacerbating nocturnal hypertension that may lead to excessive cardiovascular complications.
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A Review of the Etiology, Asssociated Comorbidities, and Treatment of Orthostatic Hypotension. Am J Ther 2013; 20:279-91. [DOI: 10.1097/mjt.0b013e31828bfb7f] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Orthostatic hypotension is associated with nocturnal change in systolic blood pressure. Am J Hypertens 2012; 25:159-64. [PMID: 22012209 DOI: 10.1038/ajh.2011.191] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The circadian pattern of blood pressure (BP) has yet to be defined among individuals with orthostatic hypotension (OH). The objective of this study was to evaluate whether OH is associated with nocturnal change in systolic BP. METHODS In a prospective study, we evaluated patients who were referred for 24-h ambulatory blood pressure monitoring (ABPM). All subjects underwent orthostatic BP testing before recording their respective 24-h ABPM. RESULTS The study includes 185 subjects, 114 males, mean age 58 ± 18 years (range 19-89). Participants were classified, based on pattern of systolic BP changes at night, as dippers (greater than 10% decrease; n = 74), nondippers (0-10% decrease; n = 77), and reverse-dippers (increase; n = 34). Nineteen patients (10.3%) had OH. Almost all participants with OH (95%) had an abnormal diurnal BP pattern, and most of them (58%) were reverse-dippers, whereas only 56% of the participants without OH had an abnormal diurnal BP variation, and only 14% were reverse-dippers (P < 0.001). Systolic BP decreased with upright posture by 12 and 2 mm Hg in the reverse-dippers and the nondippers, respectively, and increased by 2 mm Hg in the dippers (P < 0.001). Postural changes in systolic BP were inversely related to the changes between day and night BP readings(r = -0.43; P < 0.01). In a multivariate linear regression analysis, orthostatic BP change, use of ≥2 antihypertensive drugs and female sex were related to nocturnal BP changes. CONCLUSIONS The decrease in BP during upright posture may be a marker of nondipping or reverse-dipping pattern of diurnal BP.
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Abstract
SummaryOrthostatic hypotension (OH) occurs in up to 30% of community-dwelling older people. Its presence confers a greater risk of incident co-morbid disease and all-cause mortality. As per guidelines, first-line treatment should consist of non-pharmacological therapies. Effective lifestyle modification advice includes the avoidance of rapid postural changes and large meals. Physical counter-manoeuvres, when comprehensively described, effectively abate symptom progression. Patients should drink 1.5 to 2 litres of water daily, though reports suggest only half of older people comply with this regime. Moderate salt consumption is advised, though with caution as supine hypertension often co-exists. Compression hosiery benefits older people and, contrary to popular opinion, is well tolerated. Potential, future therapies include impedance threshold devices. Older patients with OH frequently have co-morbid disease such that a pharmacological approach is ill-advised. They respond well to non-pharmacological therapies and these should form the primary therapeutic approach.
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Feldstein C, Weder AB. Orthostatic hypotension: a common, serious and underrecognized problem in hospitalized patients. ACTA ACUST UNITED AC 2011; 6:27-39. [PMID: 22099697 DOI: 10.1016/j.jash.2011.08.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 08/24/2011] [Accepted: 08/28/2011] [Indexed: 12/30/2022]
Abstract
Orthostatic hypotension (OH) is strongly age-dependent, with a prevalence ranging from 5% to 11% in middle age to 30% or higher in the elderly. It is also closely associated with other common chronic diseases, including hypertension, congestive heart failure, diabetes mellitus, and Parkinson's disease. Most studies of OH have been performed in population cohorts or elderly residents of extended care facilities, but in this review, we draw attention to a problem little studied to date: OH in hospitalized patients. The prevalence of OH in all hospitalized patients is not known because most studies have included only older individuals with multiple comorbid diseases, but in some settings as many as 60% of hospitalized adults have postural hypotension. Hospitalized patients are particularly vulnerable to the consequences of OH, particularly falls, because postural blood pressure (BP) regulation may be disturbed by many common acute illnesses as well as by bed rest and drug treatment. The temporal course of OH in hospitalized patients is uncertain, both because the reproducibility of OH is poor and because conditions affecting postural BP regulation may vary during hospitalization. Finally, OH during hospitalization often persists after discharge, where, in addition to creating an ongoing risk of falls and syncope, it is strongly associated with risk of incident cardiovascular complications, including myocardial infarction, heart failure, stroke, and all-cause mortality. Because OH is a common, easily diagnosable, remediable condition with important clinical implications, we encourage caregivers to monitor postural BP change in patients throughout hospitalization.
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Affiliation(s)
- Carlos Feldstein
- Hospital de Clínicas José de San Martín, University of Buenos Aires, Argentina
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22
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A review of orthostatic blood pressure regulation and its association with mood and cognition. Clin Auton Res 2011; 22:99-107. [PMID: 21948454 DOI: 10.1007/s10286-011-0145-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Accepted: 08/24/2011] [Indexed: 10/17/2022]
Abstract
AIMS This paper will review literature that examines the psychological and neuropsychological correlates of orthostatic blood pressure regulation. RESULTS The pattern of change in systolic blood pressure in response to the shift from supine to upright posture reflects the adequacy of orthostatic regulation. Orthostatic integrity involves the skeletal muscle pump, neurovascular compensation, neurohumoral effects and cerebral flow regulation. Various physiological states and disease conditions may disrupt these mechanisms. Clinical and subclinical orthostatic hypotension has been associated with impaired cognitive function, decreased effort, reduced motivation and increased hopelessness as well as dementia, diabetes mellitus, and Parkinson's disease. Furthermore, inadequate blood pressure regulation in response to orthostasis has been linked to increased depression and anxiety as well as to intergenerational behavioral sequalae. CONCLUSIONS Identifying possible causes and consequences of subclinical and clinical OH are critical in improving quality of life for both children and older adults.
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Fagard RH, De Cort P. Orthostatic Hypotension Is a More Robust Predictor of Cardiovascular Events Than Nighttime Reverse Dipping in Elderly. Hypertension 2010; 56:56-61. [DOI: 10.1161/hypertensionaha.110.151654] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Robert H. Fagard
- From the Hypertension and Cardiovascular Rehabilitation Unit, Department of Cardiovascular Diseases, Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Paul De Cort
- From the Hypertension and Cardiovascular Rehabilitation Unit, Department of Cardiovascular Diseases, Faculty of Medicine, KU Leuven University, Leuven, Belgium
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Mostile G, Jankovic J. Treatment of dysautonomia associated with Parkinson's disease. Parkinsonism Relat Disord 2009; 15 Suppl 3:S224-32. [DOI: 10.1016/s1353-8020(09)70820-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Garland EM, Gamboa A, Okamoto L, Raj SR, Black BK, Davis TL, Biaggioni I, Robertson D. Renal impairment of pure autonomic failure. Hypertension 2009; 54:1057-61. [PMID: 19738158 DOI: 10.1161/hypertensionaha.109.136853] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supine hypertension is difficult to manage in patients with pure autonomic failure (PAF), because treatment can worsen orthostatic hypotension. Supine hypertension in PAF has been associated with left ventricular hypertrophy, but end organ damage in the kidney has not been assessed. We reviewed hemodynamic and laboratory data of 64 male patients with PAF who were 69+/-11 (mean+/-SD) years old. Systolic blood pressure fell by 67+/-40 mm Hg within 10 minutes of standing, with an inappropriately low 13+/-11-bpm increase in heart rate. Plasma norepinephrine levels were below normal (0.62+/-0.32 nmol/L supine and 1.28+/-1.25 nmol/L standing). A control data set of 75 men (67+/-12 years) was obtained from a deidentified version of the Vanderbilt University Medical Center electronic medical chart database. Compared with controls, PAF patients had lower hemoglobin (8.3+/-0.9 versus 9.3+/-0.8 mmol/L; P<0.001), packed cell volume (0.40+/-0.04 versus 0.45+/-0.04; P<0.001), and red blood cell count (4.4+/-0.5 x 10(12) versus 5.0+/-0.5 x 10(12) cells/L; P<0.001). Serum creatinine and blood urea nitrogen levels were elevated in patients. Forty-eight percent of patients with PAF had supine hypertension (supine systolic blood pressure: > or = 150 mm Hg). Serum creatinine was higher in patients with supine hypertension (133+/-44 versus 106+/-27 micromol/L; P=0.021) and estimated glomerular filtration rate was lower (57+/-22 versus 70+/-20 mL/min per 1.73 m2; P=0.022) compared with patients who did not have supine hypertension. These findings may indicate that renal function is diminished in PAF in association with supine hypertension.
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Affiliation(s)
- Emily M Garland
- Autonomic Dysfunction Center, Vanderbilt University, Nashville, TN 37232-2195, USA.
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Ejaz AA, Kazory A, Heinig ME. 24-Hour Blood Pressure Monitoring in the Evaluation of Supine Hypertension and Orthostatic Hypotension. J Clin Hypertens (Greenwich) 2007; 9:952-5. [DOI: 10.1111/j.1524-6175.2007.07298.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Fisher AA, Davis MW. ALTERED BLOOD PRESSURE HOMEOSTASIS IN THE OLDEST OLD AND SURVIVAL. J Am Geriatr Soc 2007; 55:2102-3. [DOI: 10.1111/j.1532-5415.2007.01409.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kazory A, Heinig ME, Ejaz AA. Uncovering the hemodynamic profiles of patients with orthostatic hypotension. J Am Geriatr Soc 2007; 55:962-3. [PMID: 17537107 DOI: 10.1111/j.1532-5415.2007.01200.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ejaz AA, Sekhon IS, Munjal S. Characteristic findings on 24-h ambulatory blood pressure monitoring in a series of patients with Parkinson's disease. Eur J Intern Med 2006; 17:417-20. [PMID: 16962949 DOI: 10.1016/j.ejim.2006.02.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 01/30/2006] [Accepted: 02/20/2006] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with Parkinson's disease frequently present with orthostatic hypotension, prompting testing with 24-h ambulatory blood pressure monitoring (ABPM). The aim of our study was to identify characteristic patterns of blood pressure changes present on ABPM in a series of patients with Parkinson's disease. METHOD We retrospectively identified 13 patients with Parkinson's disease who had undergone ABPM for evaluation of symptomatic orthostatic hypotension. The ABPM tracings were analyzed for the presence or absence of reversal of circadian pattern, postprandial hypotension, noncompensatory heart rate variability, and average daytime and nocturnal blood pressure values. RESULTS Reversal of circadian rhythm was identified in 92.3%, postprandial hypotension in 100% and nocturnal hypertension in 100% of the cases. Some 61.5% of the patients exhibited daytime blood pressures in the prehypertensive range, and 23% had blood pressures in the stage 1 hypertension range per JNC 7 classification. CONCLUSION The characteristic findings on 24-h ABPM in this series of patients with Parkinson's disease were the presence of reversal of circadian rhythm (93%), postprandial hypotension (100%) and nocturnal hypertension (100%).
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Affiliation(s)
- A Ahsan Ejaz
- Division of Nephrology, Hypertension and Transplantation, University of Florida, P. O. Box 100224, Gainesville, FL 32610, USA
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Abstract
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20 mmHg or of diastolic blood pressure of at least 10 mmHg within 3 min of standing. It occurs in 30–50% of elderly individuals with disease and/or medication risk factors. It is uncommon in healthy elderly people. Most patients with orthostatic blood pressure changes do not have typical symptoms and therefore symptoms are not helpful in deciding who should be screened. Epidemiological data suggest that the presence of orthostatic hypotension is associated with syncope, falls, stroke and death. The treatment approach is not standardized, but a stepped-care algorithm is presented in this article, which is likely to be successful in many patients. Future studies need to focus on the potential benefits of screening and treating patients with this disorder, especially if they are asymptomatic.
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Affiliation(s)
- Scott L Mader
- Rehabilitation & LTC Division, Portland VA Medical Center, Portland, OR 97239, USA
- Oregon Health & Science University, 3181 S.W. Sam Jackson Park RoadPortland, OR 97239, USA
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Sahni M, Lowenthal DT, Meuleman J. A Clinical, Physiology and Pharmacology Evaluation of Orthostatic Hypotension in the Elderly. Int Urol Nephrol 2005; 37:669-74. [PMID: 16307360 DOI: 10.1007/s11255-005-7663-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Orthostatic hypotension is very common in the elderly. It increases morbidity and is an independant predictor of all cause mortality. It is defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing. Symptoms include light headedness, weakness, blurred vision, fatigue and lethargy and falls. Most patients have orthostatic hypotension due to non neurogenic causes. Drugs like antihypertensives and tricyclic antidepressants are very common causes of orthostatic hypotension. Diagnosis is based on the history and a thorough clinical examination. Based on the history and physical examination, further testing of the heart, kidneys and autonomic nervous system may be required in selected patients. Non pharmacological methods like slow position change, increased fluid and sodium intake, compression stockings and elevation of head of the bed are the key to management of orthostatic hypotension. After these methods, pharmacological treatment with fludrocortisone and midodrine should be tried. Other drugs like desmopresin acetate, xamoterol, erythropoetin and ocreotide can be used as second line agents in selected patients.
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Affiliation(s)
- Manish Sahni
- Malcolm Randall VA Medical Center, GRECC, 1601 SW Archer Road, Gainesville, Florida 32608, USA.
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Perspectives on the Treatment of Orthostatic Hypotension Associated With Hypertension. Int J Organ Transplant Med 2005. [DOI: 10.1016/s1561-5413(09)60181-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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