Prognostic value of postural hypotension in hospitalized patients with heart failure.

Although postural hypotension (PH) is reportedly associated with mortality in the general population, the prognostic value for heart failure is unclear. This was a post-hoc analysis of FRAGILE-HF, a prospective multicenter observational study focusing on frailty in elderly patients with heart failure. Overall, 730 patients aged ≥ 65 years who were hospitalized with heart failure were enrolled. PH was defined by evaluating seated PH, and was defined as a fall of ≥ 20 mmHg in systolic and/or ≥ 10 mmHg in diastolic blood pressure within 3 min after transition from a supine to sitting position. The study endpoints were all-cause death and heart failure readmission at 1 year. Predictive variables for the presence of PH were also evaluated. PH was observed in 160 patients (21.9%). Patients with PH were more likely than those without PH to be male with a New York Heart Association classification of III/IV. Logistic regression analysis showed that male sex, severe heart failure symptoms, and lack of administration of angiotensin-converting enzyme inhibitors were independently associated with PH. PH was not associated with 1-year mortality, but was associated with a lower incidence of readmission after discharge after adjustment for other covariates. In conclusion, PH was associated with reduced risk of heart failure readmission but not with 1-year mortality in older patients with heart failure.

Morbidity and mortality in orthostatic hypotension.

This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as neurogenic OH (nOH); these two conditions have distinct pathophysiologies and affect different patient populations. The prevalence of OH in the elderly varies depending on the study population. In community dwellers, OH prevalence is estimated at 16%, whereas in institutionalized patients, it may be as high as 60%. The prevalence of OH increases exponentially with age, particularly in those 75 years and older. Multiple epidemiological studies have identified OH as a risk factor for all-cause mortality and cardiovascular disease including heart failure and stroke. Real-world data from administrative databases found polypharmacy, multiple co-morbid conditions, and high health-care utilization as common characteristics in OH patients. A comprehensive evaluation of medications associated with OH is discussed with particular emphasis on the use of anti-hypertensive therapy from two large clinical trials on high-intensive versus standard blood pressure management. Finally, we also review the epidemiology of nOH based on the underlying neurodegenerative disorder (either Parkinson's disease or multiple system atrophy), and the presence of co-morbid conditions such as hypertension and cognitive impairment.

Delayed orthostatic hypotension.

Delayed orthostatic hypotension is a fall in blood pressure beyond 3 min of standing or upright tilt table testing. The prevalence, clinical features and pathophysiology are reviewed. To date, there is little data to support a standardized or recommended treatment. However, the 10-year mortality rates of individuals with delayed orthostatic hypotension are approximately 50%. Despite the fact that delayed orthostatic hypotension carries the same symptoms, risks and high mortality rate as classical orthostatic hypotension, but is under-recognized. The frequency with which delayed orthostatic hypotension develops into classical orthostatic hypotension, the high associated mortality rates and risk of development of the neurodegenerative disorders classified as alpha-synucleinopathies underscores the need for further study of this condition.

The impact of supine hypertension on target organ damage and survival in patients with synucleinopathies and neurogenic orthostatic hypotension.

INTRODUCTION: In addition to neurogenic orthostatic hypotension (nOH), patients with synucleinopathies frequently have hypertension when supine. The long-term consequences of both abnormalities are difficult to disentangle. We aimed to determine if supine hypertension is associated with target organ damage and worse survival in patients with nOH. METHODS: Patients with nOH due to multiple system atrophy (MSA), Parkinson disease (PD), or pure autonomic failure (PAF) were classified into those with or without supine hypertension (systolic BP of at least 140 mmHg or diastolic BP of at least 90 mmHg). Organ damage was assessed by measuring cerebral white matter hyperintensities (WMH), left ventricular hypertrophy (LVH), and renal function. We prospectively followed patients for 30 months (range: 12-66 months) and recorded incident cardiovascular events and all-cause mortality. RESULTS: Fifty-seven patients (35 with probable MSA, 14 with PD and 8 with PAF) completed all evaluations. In addition to nOH (average fall 35 ± 21/17 ± 14 mmHg, systolic/diastolic, mean ± SD), 38 patients (67%) had supine hypertension (systolic BP > 140 mmHg). Compared to those without hypertension, patients with hypertension had higher blood urea nitrogen levels (P = 0.005), lower estimated glomerular filtration rate (P = 0.008), higher prevalence of LVH (P = 0.040), and higher WMH volume (P = 0.019). Longitudinal follow-up of patients for over 2 years (27.1 ± 14.5 months) showed that supine hypertension was independently associated with earlier incidence of cardiovascular events and death (HR = 0.25; P = 0.039). CONCLUSIONS: Supine hypertension in patients with nOH was associated with an increased risk for target organ damage, cardiovascular events, and premature death. Defining management strategies and safe blood pressure ranges in patients with nOH remains an important research question.

Delayed versus classic orthostatic hypotension: clinical and prognostic implications.

Purpose: Orthostatic hypotension (OH) is a common disorder, especially among hospitalised patients. Classic OH is defined as occurring 3 or less minutes of orthostatic stress, and delayed OH as occurring after 3 min of stress. We aimed to compare clinical characteristics and prognosis between inpatients with classic vs. delayed OH.Methods: We performed a retrospective analysis of data from 358 inpatients, aged ≥60 years, who were evaluated for the occurrence of OH at the initial phase of ambulation in four previous prospective studies in our department. Demographic, clinical and prognostic data were compared between patients with (n = 191) vs. without (n = 167) OH, classic (n = 138) vs. delayed (n = 53) OH and seated (n = 115) vs. standing (n = 76) OH.Results: Demographic characteristics, duration of bed rest, the main reasons for admission and the use of offending medications were comparable between the delayed and classic OH groups. Mean maximal postural diastolic (p < .001) and systolic (p = .063) blood pressure falls were higher among patients with classic v. delayed OH. No statistically significant difference between the patients with classic and delayed OH were observed in the occurrence of OH-related symptoms (62.3 vs. 69.8%, p = .42). During a median follow-up of 5.5 years, no statistically significant differences in survival were observed between patients with vs. without OH (p = .14), classic vs. delayed OH (p = .68) and seated vs. standing OH (p = .067). On multivariate analysis, these variables remained not significantly associated with decreased survival.Conclusions: Among inpatients, delayed OH is associated with a lesser magnitude of orthostatic blood pressure fall than classic OH. However, rates of symptomatic OH and long-term mortality were comparable between the groups. Thus, among hospitalised patients, delayed OH should be considered as posing the same severity as classic OH.

Clinical Relevance of Orthostatic Hypotension in Patients with Atrial Fibrillation and Suspected Transient Ischemic Attack.

INTRODUCTION: Orthostatic hypotension (OH) and atrial fibrillation (AF) are both regarded as independent risk factors for transient ischemic attack (TIA). However, the clinical implication of OH in the presence of AF is unclear. This study investigates, for the first time, the association between blood pressure (BP), OH and mortality in a cohort of patients with AF and TIA symptoms. AIM: To investigate the incidence of the association between OH, AF and TIA. METHODS: This retrospective observational study utilised the Leicester one-stop transient TIA clinic patient database to consider the initial systolic and diastolic BP of 688 patients with a diagnosis of AF. The primary outcome was time until death. Covariant measures included status of AF diagnosis (known or new AF), cardiovascular risk factors, and primary clinic diagnosis [cerebrovascular (CV) versus non-cerebrovascular (non-CV)]. Statistical models adjusted for sex, age, previous AF diagnosis. RESULTS: Mortality rate was higher in the over 85 age group [191.5 deaths per 1000 person years (py) (95% CI 154.0-238.1)] and lower in the aged 75 and younger age group [40.0 deaths per 1000 py (95% CI 27.0-59.2)] compared to intermediate groups. A 10 mmHg increase in supine diastolic BP was associated with a significant reduction in the hazard of mortality for patients suspected of TIA with AF [adjusted HR 0.79 (95% CI 0.68-0.92), p < 0.001]. The mortality rate for patients with OH was 119.0 deaths per 1000 py compared with a rate of 98.0 for patients without OH (rate ratio 1.2, p = 0.275). CONCLUSION: Higher diastolic BP may be a marker for reduced mortality risk in patients with a previous AF diagnosis and non-CV diagnosis. Lower diastolic BP and the presence of AF pertain to a higher mortality risk. This study raises the importance of opportunistic screening for both OH and AF in patients presenting to TIA clinic.

Orthostatic hypotension among elderly patients in Italian internal medicine wards: an observational study.

Orthostatic hypotension (OH) is a multifactorial disorder, often asymptomatic. The prevalence of OH increases with age, ranging from 5 to 11% among middle-aged patients to 55% in the frail elderly depending on age and associated comorbidities. OH is often unrecognized or misdiagnosed and little is known about its prevalence in hospitalized elderly patients. Our aims were: (1) to determine the prevalence of OH in a cohort of elderly patients hospitalized in two internal medicine wards in Italy; (2) and to describe their characteristics and symptoms. During the 5 months from March 1, 2017 to July 31, 2017, the first 85 consecutive patients (65 years or older) admitted in two internal medicine wards were enrolled. Patients were included in the study if they were able to get out of bed alone or with minor assistance, and able to stand up for at least 3 min. The study population comprised 85 patients with a mean age of 79.6 ( ± 7.2) years. OH was found in 64 (75.3%), occasional OH in 41 (48.2%), persistent OH in 23 (27.1%), and 21 (24.7%) patients had no OH. All patients had diastolic OH and 37 (57.8%) also systolic. Patients with persistent OH were oldest, with a higher percentage of renal failure. Twenty-six patients (40.6%) with OH reported symptoms. Dizziness was the most common symptom, especially after breakfast. No association was found between type of medications and risk of OH. Mortality risk was not statistically different between patients with or without OH 3 (p = 0.10) and 6 months after discharge (p = 0.18), but a trend was observed. We found that OH is very common in the patients admitted in the internal medicine wards, particularly diastolic OH. Close attention should be paid to OH and its symptoms, especially dizziness, in the oldest-old patients, and in patients with renal failure.

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

BACKGROUND: Orthostatic hypotension (OH) has been independently associated with increased risk of stroke and other cardiovascular events. We sought to investigate the relationship between OH at follow-up and recurrent stroke risk in SPS3 (Secondary Prevention of Small Subcortical Strokes) trial patient cohort. This is a retrospective cohort analysis. METHODS: We included all SPS3 trial participants with blood pressure measurements in both sitting and standing position per protocol at baseline, with at least 1 follow-up visit to establish the relationship between OH at follow-up and recurrent stroke risk (primary outcome). Secondary outcomes included major vascular events, myocardial infarction, all-cause mortality, and, ischemic and hemorrhagic stroke subtypes. Participants were classified as having OH at baseline and at each follow-up visit based on a systolic BP decline ≥20 mm Hg or a diastolic BP decline ≥10 mm Hg on position change from sitting to standing. We used Cox proportional hazards regression modeling to compare the risk of outcomes among those with and without OH. RESULTS: A total of 2275 patients were included with a mean follow up time 3.2 years (standard deviation = 1.6 years). 39% (881/2275) had OH at some point during their follow-up. Of these, 41% (366/881) had orthostatic symptoms accompanying the BP drop. In a fully adjusted model, those with OH had a 1.8 times higher risk of recurrent stroke than those without OH (95% confidence interval: 1.1-3.0). The risk of ischemic stroke, major vascular events, and all-cause mortality was similarly elevated among the OH group. CONCLUSION: OH was associated with increased recurrent stroke risk, vascular events, and all-cause death in this large cohort of lacunar stroke patients. Whether minimizing OH in the management of poststroke hypertension in patients with lacunar stroke reduces recurrent stroke risk deserves further study.

Relationships between orthostatic hypotension, frailty, falling and mortality in elderly care home residents.

BACKGROUND: Orthostatic hypotension (OH; profound falls in blood pressure when upright) is a common deficit that increases in incidence with age, and may be associated with falling risk. Deficit accumulation results in frailty, regarded as enhanced vulnerability to adverse outcomes. We aimed to evaluate the relationships between OH, frailty, falling and mortality in elderly care home residents. METHODS: From the Minimum Data Set (MDS) document, a frailty index (FI-MDS) was generated from a list of 58 deficits, ranging from 0 (no deficits) to 1.0 (58 deficits). OH was evaluated from beat-to-beat blood pressure and heart rate (finger plethysmography) collected during a 15-min supine-seated orthostatic stress test. Retrospective and prospective falling rates (falls/year) were extracted from facility falls incident reports. All-cause 3-year mortality was determined. Data are reported as mean ± standard error. RESULTS: Data were obtained from 116 older adults (aged 84.2 ± 0.9 years; 44% males) living in two long term care facilities. The mean FI-MDS was 0.36 ± 0.01; FI-MDS was correlated with age (r = 0.277; p = 0.003). Those who were frail (FI ≥ 0.27) had larger Initial (- 17.8 ± 4.2 vs - 6.1 ± 3.3 mmHg, p = 0.03) and Consensus (- 22.7 ± 4.3 vs - 11.5 ± 3.3 mmHg, p = 0.04) orthostatic reductions in systolic arterial pressure. Frail individuals had higher prospective and retrospective falling rates and higher 3-year mortality. Receiver operating characteristic curves evaluated the ability of FI-MDS alone to predict prospective falls (sensitivity 72%, specificity 36%), Consensus OH (sensitivity 68%, specificity 60%) and 3-year mortality (sensitivity 77%, specificity 49%). Kaplan Meier survival analyses showed significantly higher 3-year mortality in those who were frail compared to the non-frail (p = 0.005). CONCLUSIONS: Frailty can be captured using a frailty index based on MDS data in elderly individuals living in long term care, and is related to susceptibility to orthostatic hypotension, falling risk and 3-year mortality. Use of the MDS to generate a frailty index may represent a simple and convenient risk assessment tool for older adults living in long term care. Older adults who are both frail and have impaired orthostatic blood pressure control have a particularly high risk of falling and should receive tailored management to mitigate this risk.

Association of Orthostatic Hypotension Timing With Clinical Events in Adults With Diabetes and Hypertension: Results From the ACCORD Trial.

OBJECTIVE: To determine the effects of orthostatic hypotension (OH) measurement timing on its associations with dizziness, falls, fractures, cardiovascular disease (CVD), and mortality. METHODS: We analyzed OH measurements from the Action to Control Cardiovascular Risk in Diabetes BP trial, which evaluated two blood pressure (BP) goals (systolic BP [SBP] < 120 mm Hg vs. SBP < 140 mm Hg) and incident CVD among adults with diabetes and hypertension. Seated BP was measured after 5 minutes of rest at baseline and follow-up visits (12 months, 48 months, and exit). Standing BP was measured 3 consecutive times (M1-M3) after standing, starting at 1 minute with each measurement separated by 1 minute. Consensus OH was defined as a drop in SBP ≥ 20 mm Hg or diastolic BP (DBP) ≥ 10 mm Hg. Participants were asked about orthostatic dizziness, recent falls, and recent fractures, and underwent surveillance for CVD events and all-cause mortality. RESULTS: There were 4,268 participants with OH assessments over 8,450 visits (mean age 62.6 years [SD = 6.6]; 46.6% female; 22.3% black). Although all measures of consensus OH were significantly associated with dizziness, none were associated with falls, and only M2 (~3 minutes) was significantly associated with fractures. No measurements were associated with CVD events, but later measurements were significantly associated with mortality. BP treatment goal did not increase risk of OH regardless of timing. Associations were not consistently improved by the mean or minimum of M1-M3. CONCLUSION: In this population of adults with hypertension and diabetes, neither single time nor set of measurements were clearly superior with regard to outcomes. These findings support the use of a flexibly timed, single measurement to assess OH in clinical practice. CLINICAL TRIALS REGISTRATION: Trial Number NCT00000620.

Impact of orthostatic hypotension and antihypertensive drug treatment on total and cardiovascular mortality in a very elderly community-dwelling population.

OBJECTIVE: The aim of this study was to examine the relationship between orthostatic hypotension, cardiovascular drug intake and mortality in a very elderly community-dwelling population (>80 years of age). METHODS: In 2013-2014, 224 (71 M, 31.7%) 80-year-old individuals from one primary care practice were invited to participate. Basic clinical information was gathered and blood pressure (BP) measurements were performed while sitting and after 1 and 3 min in the standing position on 209 patients. The individuals were followed till December 2016. RESULTS: Orthostatic hypotension was present, depending on applied definition, in 34.5% of the individuals at 1 min, 38.3% at 3 min; 44.9% on either 1 or 3 min, and 27.8% individuals in both measurements. Sixty-nine (30.8%) individuals died during the follow-up. Presence of orthostatic hypotension, irrespective of definition, did not have any significant association with the mortality risk in all groups. Intensive hypertension treatment (more than two drugs versus none) was associated with longer survival. In a multivariate logistic regression analysis, only age and presence of coronary heart disease/congestive heart failure had a negative predictive value on mortality. In both treated and untreated individuals, presence of orthostatic hypotension was not linked to mortality. CONCLUSION: Although orthostatic hypotension is very common among the very elderly, its presence is not related to increased risk of death (all-cause/cardiovascular). Intensively treated elderly patients had significantly longer survival time than untreated individuals.

Interest of Combined Blood Pressure Measurements in Very Old Frail Subjects: The PARTAGE Study.

BACKGROUND: Several clinical studies have shown that blood pressure (BP) measurements in very old frail individuals are of limited interest due to the fact that several age-related alterations and geriatric syndromes may modify BP. We studied in persons over 80-year old living in nursing homes the combined effects of 3 BP patterns on total mortality and major cardiovascular (CV) events: (i) low pulse pressure amplification (L-PPA) between carotid and brachial artery, (ii) systolic BP (SBP) <130 mm Hg (L-SBP), under >1 antihypertensive drugs, and (iii) changes in SBP between supine and upright position of >20 mm Hg in both directions (hypotension/hypertension, orthostatic SBP [O-SBP]). METHODS: This analysis was performed in subjects of the PARTAGE study presenting all these 3 measurements (n = 883). The combined effects of L-PPA, L-SBP, and O-SBP were studied during the 2 years followed-up period. RESULTS: After adjusting for age, sex, and history of CV events, all 3 BP patterns were independent determinants of major CV events (L-PPA, (P = 0.023); L-SBP, (P = 0.050); O-SBP, (P = 0.015)), whereas L-PPA (P = 0.012) and L-SBP (P = 0.006) were also independent determinants of total mortality. Compared with the subjects without any BP pattern, the presence of 2 or 3 BP patterns was associated with an increase in total mortality and major CV events greater than 2 and 2.5 times, respectively. CONCLUSIONS: In very old frail subjects, there is a particular interest for using different BP measurement approaches, than in younger populations, in order to evaluate the risks related to the BP levels. CLINICAL TRIALS REGISTRATION: Trial Number: NCT00901355 (Clinical Trials.gov).

Orthostatic Hypotension and Risk of Clinical and Subclinical Cardiovascular Disease in Middle-Aged Adults.

BACKGROUND: Although orthostatic hypotension (OH) is a well-recognized manifestation of neuropathy and hypovolemia, its contribution to cardiovascular disease (CVD) risk is controversial. METHODS AND RESULTS: Participants with OH, defined as a decrease in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, were identified during the first visit of the ARIC (Atherosclerosis Risk in Communities) Study (1987-1989) within 2 minutes of standing. All participants were followed up for the development of myocardial infarction, heart failure, stroke, fatal coronary heart disease (CHD), any CHD (combination of silent, nonfatal, and fatal CHD or cardiac procedures), and all-cause mortality. Participants were assessed for carotid intimal thickness and plaque during the first visit. Detectable high-sensitivity troponin T (≥5 ng/L) and elevated NT-proBNP (N-terminal pro-B-type natriuretic peptide; ≥100 pg/mL) were determined in blood collected during the second visit (1990-1992). All associations were adjusted for known CVD risk factors. In 9139 participants (57% women; 23% black; mean age, 54±5.7 years), 3% had OH. During follow-up (median, 26 years), OH was associated with myocardial infarction (hazard ratio [HR], 1.88; 95% confidence interval [CI], 1.44-2.46), congestive heart failure (HR, 1.65; 95% CI, 1.34-2.04), stroke (HR, 1.83; 95% CI, 1.35-2.48), fatal CHD (HR, 2.77; 95% CI, 1.93-3.98), any CHD (HR, 2.00; 95% CI, 1.64-2.44), and all-cause mortality (HR, 1.68; 95% CI, 1.45-1.95). OH was also associated with carotid intimal thickness (ß, 0.05 mm; 95% CI, 0.04-0.07 mm), carotid plaque (odds ratio, 1.51; 95% CI, 1.18-1.93), detectable high-sensitivity troponin T (odds ratio, 1.49; 95% CI, 1.16-1.93), and elevated NT-proBNP (odds ratio, 1.92; 95% CI, 1.48-2.49). CONCLUSIONS: OH identified in community-dwelling middle-aged adults was associated with future CVD events and subclinical CVD. Further research is necessary to establish a causal role for OH in the pathogenesis of CVD.

Orthostatic hypotension and overall mortality in 1050 older patients of the outpatient comprehensive geriatric assessment unit.

AIM: Orthostatic hypotension is a common problem in individuals aged ≥65 years. Its association with mortality is not clear. The aim of the present study was to evaluate associations between orthostatic hypotension and overall mortality in a sample of individuals aged ≥65 years who were seen at the Outpatient Comprehensive Geriatric Assessment Unit, Clalit Health Services, Beer-Sheva, Israel. METHODS: Individuals who were evaluated in the Outpatient Comprehensive Geriatric Assessment Unit between January 2005 and December 2015, and who had data on orthostatic hypotension were included in the study. The database included sociodemographic characteristics, body mass index, functional and cognitive state, geriatric syndromes reached over the course of the assessment, and comorbidity. Data on mortality were also collected. RESULTS: The study sample included 1050 people, of whom 626 underwent comprehensive geriatric assessment and 424 underwent geriatric consultation. The mean age was 77.3 ± 5.4 years and 35.7% were men. Orthostatic hypotension was diagnosed in 294 patients (28.0%). In univariate analysis, orthostatic hypotension was associated with overall mortality only in patients aged 65-75 years (HR 1.5, 95% CI 1.07-2.2), but in the multivariate model this association disappeared. CONCLUSIONS: In older frail patients, orthostatic hypotension was not an independent risk factor for overall mortality. Geriatr Gerontol Int 2018; 18: 1009-1017.

Association of History of Dizziness and Long-term Adverse Outcomes With Early vs Later Orthostatic Hypotension Assessment Times in Middle-aged Adults.

Importance: Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. It is not known whether measurements performed immediately after standing predict adverse events as strongly as measurements performed closer to 3 minutes. Objective: To compare early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes. Design, Setting, and Participants: This was a prospective cohort study of middle-aged (range, 44-66 years) participants in the Atherosclerosis Risk in Communities Study (1987-1989). Exposures: Orthostatic hypotension, defined as a drop in blood pressure (BP) (systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg) from the supine to standing position, was measured up to 5 times at 25-second intervals. Main Outcomes and Measures: We determined the association of each of the 5 OH measurements with history of dizziness on standing (logistic regression) and risk of fall, fracture, syncope, motor vehicle crashes, and all-cause mortality (Cox regression) over a median of 23 years of follow-up (through December 31, 2013). Results: In 11 429 participants (mean age, 54 years; 6220 [54%] were women; 2934 [26%] were black) with at least 4 OH measurements after standing, after adjustment OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds; range, 21-62 seconds) was the only measurement associated with higher odds of dizziness (odds ratio [OR], 1.49; 95% CI, 1.18-1.89). Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1000 person-years. Measurement 2 was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1000 person-years. Furthermore, after adjustment measurement 1 was significantly associated with risk of fall (hazard ratio [HR], 1.22; 95% CI, 1.03-1.44), fracture (HR, 1.16; 95% CI, 1.01-1.34), syncope (HR, 1.40; 95% CI, 1.20-1.63), and mortality (HR, 1.36; 95% CI, 1.23-1.51). Measurement 2 (mean [SD], 53 [7.5] seconds; range, 43-83 seconds) was associated with all long-term outcomes, including motor vehicle crashes (HR, 1.43; 95% CI, 1.04-1.96). Measurements obtained after 1 minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes. Conclusions and Relevance: In contrast with prevailing recommendations, OH measurements performed within 1 minute of standing were the most strongly related to dizziness and individual adverse outcomes, suggesting that OH be assessed within 1 minute of standing.

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

OBJECTIVE: The aim of this study was to determine the impact of orthostatic hypotension (OH) and orthostatic hypertension (OHT) on all-cause mortality. PATIENTS AND METHODS: A total of, 1176 adults from the community over 18 years of age were included in this ambispective study. The mean follow-up was 9.4 years. OH and OHT were defined as a decrease or an increase, respectively, in systolic blood pressure (BP) of at least 20 mmHg and/or diastolic BP of at least 10 mmHg from sitting to standing position at 1 and/or 3 min after standing. The impact of systolic or diastolic OH and systolic or diastolic OHT at 1 and 3 min after standing was also analyzed separately. RESULTS: In total, 135 individuals died during the follow-up. Neither OH [hazard ratio (HR) 1.23; 95% confidence interval (CI): 0.72-2.10] nor OHT (HR 0.90; 95% CI: 0.59-1.38) was associated with all-cause mortality in the adjusted models. In contrast, systolic OHT at 3 min (HR 2.31; 95% CI: 1.14-4.68) was independently associated with global mortality. CONCLUSION: Systolic OHT at 3 min is associated with all-cause mortality. The determination of this parameter could add valuable prognostic information during the routine examination of patients.

Prevalence of orthostatic hypertension in the very elderly and its relationship to all-cause mortality.

OBJECTIVE: To investigate the association with mortality of orthostatic hypertension (OHYPER) amongst the oldest old. METHODS: Two waves of community-dwelling residents born in 1920-1921 were examined at age of 85 (n = 1004) and 90 (n = 437). OHYPER, orthostatic hypotension (OHYPO), or orthostatic normotension (ONORMO) were so classified when difference of standing-sitting SBP either increased or decreased by at least 20 mmHg or not. RESULTS: Prevalence of OHYPO, ONORMO, and OHYPER was 5% (n = 48), 91% (n = 915), and 4% (n = 41) at age 85, and 9% (n = 39), 88% (n = 385), and 3% (n = 13) at age 90. There was a tendency for fewer men among OHYPER, and significantly more participants with financial hardship, higher weight, loneliness, and anemia (P < 0.05 for all) among the 85-year-olds, fewer with poor self-rated health, and more with anemia among the 90-year-olds. Sitting blood pressure was 157 ±â€Š22/75 ±â€Š11, 147 ±â€Š21/74 ±â€Š11, and 140 ±â€Š16/74 ±â€Š10 mmHg among OHYPO, ONORMO, and OHYPER at age 85 (P < 0.0001), and 166 ±â€Š28/75 ±â€Š10, 145 ±â€Š23/69 ±â€Š11, and 138 ±â€Š23/74 ±â€Š9 mmHg at age 90 (P < 0.0001). Ten-year survival were 27, 30, and 27%, respectively, at age 85 (log-rank P = 0.34). Five-year survival were 57, 67, and 55%, respectively, at age 90 (log-rank P = 0.14). In an adjusted Cox proportional hazards ratio model, OHYPER at age 85 was not associated with mortality (hazards ratio = 0.95, 95% confidence interval 0.65-1.39). The few OHYPER among 90-year-olds precluded modeling. CONCLUSION: OHYPER is quite uncommon among community-dwelling 85 and 90-year-olds and is not associated with increased mortality.

Speed of Heart Rate Recovery in Response to Orthostatic Challenge.

RATIONALE: Speed of heart rate recovery (HRR) may serve as an important biomarker of aging and mortality. OBJECTIVE: To examine whether the speed of HRR after an orthostatic maneuver (ie, active stand from supine position) predicts mortality. METHODS AND RESULTS: A longitudinal cohort study involving a nationally representative sample of community-dwelling older individuals aged ≥50 years. A total of 4475 participants completed an active stand at baseline as part of a detailed clinic-based cardiovascular assessment. Beat-to-beat heart rate and blood pressure responses to standing were measured during a 2-minute window using a finometer and binned in 10-s intervals. We modeled HRR to the stand by age group, cardiovascular disease burden, and mortality status using a random effects model. Mortality status during a mean follow-up duration of 4.3 years served as the primary end point (n=138). Speed of HRR in the immediate 20 s after standing was a strong predictor of mortality. A 1-bpm slower HRR between 10 and 20 s after standing increased the hazard of mortality by 6% controlling for established risk factors. A clear dose-response relationship was evident. Sixty-nine participants in the slowest HRR quartile died during the observation period compared with 14 participants in the fastest HRR quartile. Participants in the slowest recovery quartile were 2.3× more likely to die compared with those in the fastest recovery quartile. CONCLUSIONS: Speed of orthostatic HRR predicts mortality and may aid clinical decision making. Attenuated orthostatic HRR may reflect dysregulation of the parasympathetic branch of the autonomic nervous system.

The duration of the orthostatic blood pressure drop is predictive of death.

BACKGROUND: Orthostatic hypotension (OH) affects 6% of community-dwelling older people. This increases to 60% when non-invasive, continuous blood pressure (BP) monitoring is used, due to identification of transient drops in BP which recover rapidly. AIM: To determine the clinical relevance of these transient orthostatic BP drops. DESIGN: Five-year clinical observational study. METHODS: One hundred three consecutive new patients attending a Falls and Syncope Clinic in the UK from 1 February 2009 underwent continuous BP monitoring during an active stand. BP profiles were analysed to quantify all reductions in BP, measuring the duration of any drop below diagnostic criteria. Five-year follow-up data were extracted from hospital clinical records to assess clinical outcomes. RESULTS: Systolic BP (sBP) dropped ≥20 mmHg in 76 (74%) individuals, with 65 (63%) having ≥10 mmHg drop in diastolic BP. However, only 22 (21%) cases were diagnosed clinically with OH. A sustained reduction in BP (≥30 s) had a sensitivity of 0.91 and specificity of 0.88 for a clinical diagnosis of OH, being more accurate than absolute BP reduction alone. A sustained reduction in sBP was associated with greater use of vasopressors (36%,P0.001) and an independent, significantly greater risk of death (45% at 5 years,P0.009). CONCLUSION: An orthostatic reduction in sBP lasting ≥30 s improves accuracy of diagnosis. Moreover, given the significant adverse outcomes with a sustained reduction, clinicians should consider this when diagnosing and treating patients, as transient OH does not appear to be clinically significant.

Orthostatic hypotension in diabetic patients-10-year follow-up study.

INTRODUCTION: Cardiovascular autonomic neuropathy in diabetics is a common but often underestimated and underdiagnosed complication of diabetes mellitus. One of the most clinical apparent forms of cardiovascular autonomic neuropathy is orthostatic hypotension. OBJECTIVES: To retrospectively assess the association of the orthostatic hypotension (OH) with macrovascular and microvascular complications of diabetes mellitus and to determine its effect on mortality. DESIGN AND METHODS: We retrospectively analyzed 187 patients with diabetes mellitus (60 patients with diabetes type 1 and 127 patients with diabetes type 2). Patients were divided into groups according to presence or absence of OH and type of diabetes. Association of OH with macrovascular and microvascular complications was evaluated and the effect of OH on 10-year all-cause mortality was also assessed. RESULTS: OH was present in 31.7% of patients with diabetes type 1 (DM1) and in 32.3% of patients with diabetes type 2 (DM2). OH was positively associated with the prevalence of myocardial infarction in DM1 (OR=10.67) and with prevalence of stroke in DM2 (OR=3.33). There was also a strong association of OH and the prevalence of peripheral artery disease in both DM1 (OR=14.18) and DM2 (OR=3.26). Patients with both types of diabetes and OH had significantly higher prevalence of nephropathy (DM1 OR=8.68, DM2 OR=3.24), retinopathy (DM1 OR=8.09, DM2 OR=4.08) and peripheral neuropathy (DM1 OR=17.14, DM2 OR=7.51) Overall 10year mortality rate was higher in diabetic patients with OH. CONCLUSIONS: Presence of OH in diabetics is associated with higher prevalence of macrovascular and microvascular complications of diabetes mellitus and also with higher 10-year mortality.