TIA, stroke and orthostatic hypotension: a disease spectrum related to ageing vasculature?

AIMS: We sought to identify the determinants of orthostatic hypotension (OH) among patients referred to the transient ischaemic attack (TIA) clinic. METHODS: We conducted a retrospective analysis of prospectively collected data on patients who attended the TIA clinic in a UK hospital between January 2006 and September 2009. Each patient had their supine and standing or sitting blood pressure measured. Logistic regression was used to estimate the univariate and multivariate odds of OH for the subgroups of patients based on their diagnosis. A 10% significance level for the univariate analysis was used to identify variables in the multivariate model. RESULTS: A total of 3222 patients were studied of whom 1131 had a TIA, 665 a stroke and 1426 had other diagnoses. The prevalence of either systolic or diastolic OH in the TIA, stroke and patients with other diagnoses was similar being 22% (n = 251), 24% (n = 162) and 20% (n = 292), respectively. Multivariate analyses showed age, prior history of TIA, and diabetes were independently significantly associated with systolic OH alone or diastolic OH alone or either systolic or diastolic OH [ORs 1.03 (1.02-1.05); 1.56 (1.05-2.31); 1.65 (1.10-2.47), respectively]. Among the patients with the diagnosis of stroke, peripheral vascular disease (PVD) was significantly associated with increased odds of OH (3.56, 1.53-8.31), whereas male gender had a significantly lower odds of OH (0.61, 0.42-0.88). In patients with other diagnoses, age (1.04, 1.02-1.05) and diabetes (1.47, 1.04-2.09) were associated with OH, whereas male gender was (0.76, 0.58-1.00) not associated with OH. CONCLUSION: Orthostatic hypotension is prevalent among patients presenting to TIA clinic. Previous history of vascular disease (prior TIA/stroke/PVD) appears to be a significant associate of OH in this patient population.

A systematic review of the pharmacological management of orthostatic hypotension.

OBJECTIVES: The 'short' and 'long-term' benefits of pharmacological interventions to treat orthostatic hypotension (OH) remain unclear. The aim was to systematically examine the published literature on the effectiveness of different drug regimens for the treatment of OH. DESIGN: Systematic review. SETTING: MEDLINE (1950-Week 7, 2011), EMBASE (1980-Week 7, 2011), CINAHL (1981-Week 7, 2011) databases and hand-searching of bibliographies were used to identify suitable papers. PARTICIPANTS: Studies selected were those, which investigated drug treatment of OH in a single- or double-blind randomised controlled trial (RCT) in humans over 18 years of age. MEASUREMENTS: Data were extracted from suitable full-text articles by three investigators independently. RESULTS: The 13 trials met the criteria for systematic review amongst which was considerable variation in the size of postural blood pressure (BP) change with active treatment. However, there was evidence that commonly used drugs midodrine or fludrocortisone therapy did increase standing or head-up-tilt (HUT) systolic blood pressure in certain patient groups. CONCLUSION: The evidence that pharmacological therapy is of benefit for the treatment of OH is limited by the lack of good quality clinical trial evidence. Further well-designed RCTs of pharmacological treatment of OH investigating the impact on postural symptoms as well as actual BP changes are needed.

High mortality of older patients admitted to hospital from care homes and insight into potential interventions to reduce hospital admissions from care homes: the Norfolk experience.

There is a high mortality rate in patients admitted to hospitals acutely from care homes. In a retrospective case analysis study of 3772 older people admitted to the Department of Medicine for the Elderly between January and June 2005, 340 (9.0%) were from care homes, and 93 (27.3%) of the residents died during the index admission. Nearly 40% of these deaths occurred within 24h of admission indicating a high level of less appropriate admissions. Investigating eight nursing homes which admitted the highest number of patients from one primary care trust revealed that the most cited reasons for admission were the lack of advance care plans, access to General Practitioners (GPs) out of hours, as well as general access to palliative care and specialist nurses, and poor communication between patient, relatives, GPs, hospitals and care home staff. Our findings provide some useful insight into the factors that need to be addressed to avoid unnecessary or inappropriate admissions from care homes for better end of life care in aging societies.