Orthostatic blood pressure control in Marfan's syndrome

A 33-year old male patient, with Marfan's syndrome, reportedsymptoms of orthostatic intolerance and fatigue as a longstandingproblem. Orthostatic cardiovascular examination showed poororthostatic tolerance, with a rise in heart rate and a fallin arterial blood pressure and cerebral blood flow velocity.Self-discovered physical counterpressure manoeuvers improvedsymptoms, related to a substantial increase in arterial pressureand cerebral perfusion. When orthostatic complaints are reportedby patients with Marfan's syndrome, physical counterpressuremanoeuvers should be advised to reduce symptoms of posturalhypotension.     

Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly

OBJECTIVEs: We investigated the prognostic significance of orthostatic hypotension on the risk of myocardial infarction (MI) amongst the elderly. DESIGN: Prospective population-based study. SETTING: Home-dwelling population. SUBJECTS: Orthostatic testing was performed between 8 a.m. and 2 p.m., irrespective of having had meals, on 792 persons, representing 82% of all home-dwelling persons aged > or =70 years living in five municipalities around the city of Oulu. MAIN OUTCOME MEASURES: Occurrence of cases of MI were recorded during mean 3.58 (SD 1.09) years follow-up period, from national mortality statistics and local hospital discharge registers. RESULTS: Ninety cases of MI, of which 40 were fatal after initial hospitalization, occurred during the follow-up period. Orthostatic diastolic blood pressure (BP) drop 1 min after standing up was associated with subsequent MI, but systolic BP reactions had no predictive value. According to the Cox regression model, the strongest predictor of the occurrence of subsequent MI was found in regard to > or =8 mmHg drop in diastolic BP 1 min after standing up; adjusted for history of MI, diabetes mellitus, chest pain, use of calcium antagonist, beta-blocker, nitrate and diuretic medication, hazard ratio of MI being 2.00 (1.11-3.59). CONCLUSIONS: Orthostatic testing offers a novel means to assess the risk of MI amongst elderly persons. Diastolic BP drop immediately after standing up identifies elderly subjects at a high risk of subsequent MI.     

Orthostatic hypotension: pathophysiology,assessment, treatment and the paradox of supine hypertension

Both hypertension and orthostatic hypotension (OH) are strongly age‐associated and are common management problems in older people. However, unlike hypertension, management of OH has unique challenges with few well‐established treatments. Not infrequently, they both coexist, further compounding the management. This review provides comprehensive information on OH, including pathophysiology, diagnostic workup and treatment, with a view to provide a practical guide to its management. Special references are made to patients with supine hypertension and postprandial hypotension and older hypertensive patients.     

Orthostatic hypertension: From pathophysiology to clinical applications and therapeutic considerations

Orthostatic hypertension (OHT), that is, sustained increase in blood pressure after standing, is an increasingly recognized cardiovascular disorder having been examined in much fewer studies compared with orthostatic hypotension (OH). However, in both OHT and OH, dysfunction of the autonomous nervous system is considered to be the primary pathophysiological disturbance, while significant associations with essential hypertension have been observed. Although in many studies OHT has been related to subclinical or clinical target organ damage, there is also evidence denying such an association. Because OHT is defined variably across different studies, the comparison of relevant outcomes is at least problematic. Since evidence about OHT treatment is exclusively based on limited non‐randomized studies, no specific recommendations have been developed. Therefore, both the prognostic role and the clinical significance of OHT remain largely undefined. The aim of the present review is to summarize the available evidence regarding the definition, diagnosis, pathophysiology, prognostic role and treatment of OHT and highlight potential clinical implications of this underestimated condition.     

Orthostatic hypotension and long‐term incidence of atrial fibrillation: the malmö preventive project

Abstract. Fedorowski A, Hedblad B, Engström G, Gustav Smith J, Melander O (Department of Clinical Sciences, Lund University, Malmö; and Skåne University Hospital, Malmö, Sweden). Orthostatic hypotension and long‐term incidence of atrial fibrillation: the Malmö Preventive Project. J Intern Med 2010; 268 : 383–389. Objectives. Orthostatic hypotension (OH), a common manifestation of autonomic dysfunction, has been identified as an independent risk factor for all‐cause mortality and incident cardiovascular disease. However, the role of OH in the development of atrial fibrillation has not been studied. Design. We investigated the incidence of atrial fibrillation in relation to baseline presence of OH according to international consensus criteria in the Swedish population‐based prospective cohort of the Malmö Preventive Project. The study sample consisted of 33 346 individuals (67.3% men; mean age, 45.6 ± 7.4 years; range, 26–61 years). The association between OH and incidence of atrial fibrillation during follow‐up was assessed using the Kaplan–Meier method and multivariable Cox proportional hazard models, taking into account conventional risk factors for atrial fibrillation. Results. At baseline, 1987 participants (6.1%) met the diagnostic criteria for OH. Over a follow‐up period of approximately 24 years, 2312 individuals (3.0 events/1000 person‐years) were diagnosed with new‐onset atrial fibrillation. Of these, 196 had OH at baseline (4.6 events/1000 person‐years amongst all OH‐positive individuals). In a multivariable Cox regression analysis, OH predicted incidence of atrial fibrillation independently of other risk factors (hazard ratio [HR]: 1.30; 95% confidence interval [CI]: 1.05–1.61; P = 0.016), and this association was significant in hypertensive (HR: 1.44; 95%CI: 1.10–1.88; P = 0.008), but not in normotensive participants (HR: 1.10; 95%CI: 0.77–1.58; P = 0.60). Conclusions. The presence of OH predicts the incidence of atrial fibrillation in middle‐aged hypertensive individuals, independently of conventional risk factors. Further studies of the association of autonomic dysfunction and OH with atrial fibrillation are needed.     

Anti-LGI1 Encephalitis Developing Immunoglobulin Responsive Orthostatic Hypotension after Remission

Anti-leucine-rich glioma-inactivated 1 (LGI1) antibody is associated with limbic encephalitis. We herein report a patient with anti-LGI1 encephalitis who developed severe orthostatic hypotension (OH) responsive to immunoglobulin therapy five years after developing symptoms of encephalitis. A 71-year-old man presented with amnesia caused by limbic encephalitis. The symptoms of encephalitis improved partially without any immunotherapy. Five years later, he developed severe OH, and anti-LGI1 antibody was positive. The catecholamine dynamics indicated that the central autonomic nervous system was the lesion of his OH. Intravenous immunoglobulin therapy improved the OH. This case suggests that anti-LGI1 antibody can be associated with severe OH.     

Relationship Between Arterial Blood Pressure Disturbances and Alpha Adrenoceptor Density

To investigate the influence of blood pressure disturbances on human platelet alpha2-adrenoceptor density, we studied 7 normotensive Parkinsonians with orthostatic hypotension and 23 mild essential hypertensive patients. Plasma catecholamine levels were measured by HPLC and alpha2-adrenoceptor number and affinity determined by [3H]-yohimbine binding. Alpha-adrenergic reactivity was investigated by blood pressure response to noradrenaline infusion in Parkinsonians and by adrenaline-induced platelet aggregation in hypertensive patients. In Parkinsonians with orthostatic hypotension, in comparison with Parkinsonians without orthostatic hypotension and normotensive control subjects age and sex matched, noradrenaline plasma levels were significantly lower (62 ±11, 195 ±14 and 219 ±13 pg. ml^?1 respectively, p < 0.05), platelet alpha2—adrenoceptor     

动态血压监测对老年体位性低血压评价的探讨

目的探讨动态血压监测（ABPM）技术对老年体位性低血压的评价价值。方法对152例门诊老年人进行卧位及立位3min血压测量,根据血压变化将患者分为体位性低血压组及非体位性血压组。对所有患者进行动态血压监测,计算并比较两组全天、白天以及夜间的平均血压、平均脉压、血压负荷、血压变异系数、动态动脉硬化指数以及24h血压昼夜节律。结果体位性低血压组的夜间平均收缩压、夜间平均舒张压、夜间收缩压负荷、夜间舒张压负荷、全天收缩压变异系数均高于非体位性低血压组,血压昼夜节律以反杓型为主。结论动态血压监测在老年体位性低血压的用药指导中有着重要的临床作用;老年体位性低血压存在夜间高血压、卧位高血压、收缩压波动范围大、血压昼夜节律异常的特点,上述特征均可造成重要靶器官的损伤。     

Relationship between systolic time intervals and arterial blood pressure

It has been suggested that systolic time intervals (STI) can be used to monitor the cardiac effects of antihypertensive treatments and also to evaluate hypertensive patients. STI changes observed in hypertensives have been ascribed to myocardial disease, although they could be due to the existence of a relationship between STI and blood pressure. A group of 37 subjects (18 normotensives and 19 hypertensives) with no signs of heart failure and left ventricular dysfunction were studied to examine the relationship of STI to blood pressure. Pacing with an external battery pulse generator was performed at the rate of 95 beats/min in order to eliminate differences in heart rate. STI were measured from good quality high speed (100 mm/s) recordings and the average value of 10 consecutive cardiac cycles was used for statistical analysis. Normal subjects showed significantly lower values of pre-ejection period (PEP), electromechanical systole (QS2), and pre-ejection period/left ventricular ejection time ratio (PEP/LVET). Moreover, a significant inverse relationship between diastolic pressure and LVET and significant direct relationships between diastolic pressure and PEP, systolic pressure and PEP, diastolic pressure and PEP/LVET, and between systolic pressure and PEP/LVET were demonstrated. We suggest to consider the relation of STI to blood pressure to provide regression equations to best appreciate and use STI.     

Impaired orthostatic blood pressure stabilization and reduced hemoglobin in chronic kidney disease

Impaired orthostatic blood pressure (BP) stabilization is prevalent in patients with chronic kidney disease (CKD) and is associated with adverse outcomes. We aimed to test the hypothesis that reduced hemoglobin is an important contributor to orthostatic intolerance in CKD in the present study. This study included 262 patients with non‐dialysis‐dependent CKD. Seated and standing BP was measured, and orthostatic BP reduction was calculated for both systolic BP (∆ SBP) and diastolic BP (∆ DBP). The association between orthostatic BP reduction and hemoglobin was determined by multiple linear regression models. We also performed mediation analysis to test to what extent the effect of renal dysfunction on impaired orthostatic BP stabilization can be explained by reduced hemoglobin. The mean age of the patients was 57.7 (±14.5) years, and 61.5% were male. Both ∆ SBP and ∆ DBP correlated negatively with estimated glomerular filtration rate (eGFR). With adjustment for age and sex, hemoglobin level was negatively associated with ∆ SBP (β = −1.4, SE = 0.4, P < .001) and ∆ DBP (β = −0.6, SE = 0.2, P = .009). The associations remained significant with further adjustment for additional covariates. When eGFR was introduced as a covariate, it did not eliminate the significance (both P < .05). The associations remained essentially unchanged in a sensitivity analysis excluding those with concurrent erythropoietin use. Mediation analysis demonstrated that reduced hemoglobin accounted for 35.4% (P = .004) of the effect of eGFR on ∆ SBP and 47.7% (P = .032) on ∆ DBP. Our study suggests that reduced hemoglobin is a potentially important contributor to the development of orthostatic hypotension in CKD.     

Continuous noninvasive orthostatic blood pressure measurements and their relationship with orthostatic intolerance, falls, and frailty in older people

OBJECTIVES: To identify morphological orthostatic blood pressure (BP) phenotypes in older people and assess their correlation with orthostatic intolerance (OI), falls, and frailty and to compare the discriminatory performance of a morphological classification with two established orthostatic hypotension (OH) definitions: consensus (COH) and initial (IOH). DESIGN: Cross‐sectional. SETTING: Geriatric research clinic. PARTICIPANTS: Four hundred forty‐two participants (mean age 72, 72% female) without dementia or risk factors for autonomic neuropathy. MEASUREMENTS: Active lying‐to‐standing test monitored using a continuous noninvasive BP monitor. For the morphological classification, four orthostatic systolic BP variables were extracted (delta (baseline – nadir) and maximum percentage of baseline recovered by 30 seconds and 1 and 2 minutes) using the 5‐second averages method and entered in K‐means cluster analysis (three clusters). Main outcomes were OI, falls (≥1 in past 6 months), and frailty (modified Fried criteria). RESULTS: The morphological clusters were small drop, fast overrecovery (n=112); medium drop, slow recovery (n=238); and large drop, nonrecovery (n=92). Their characterization revealed an increasing OI gradient (17.9%, 27.5%, and 44.6% respectively, P<.001) but no significant gradients in falls or frailty. The COH definition failed to reveal clinical differences between COH+ (n=416) and COH? (n=26) participants. The IOH definition resulted in a clinically meaningful separation between IOH+ (n=85) and IOH? (n=357) subgroups, as assessed according to OI (100% vs 11.5%, P<.001), falls (24.7% vs 10.4%, P<.001), and frailty (14.1% vs 5.4%, P=.005). CONCLUSION: It is recommended that the IOH definition be applied when taking continuous noninvasive orthostatic BP measurements in older people.     

Prevalence and variability of orthostatic hypotension in the elderly. Results of the 'Italian study on blood pressure in the elderly (SPAA)'. The 'Gruppo di Studio Sulla Pressione Arteriosa nell'Anziano'.

The prevalence of orthostatic hypotension (OH) in an elderly outpatient population was assessed according to the most common criteria given in the literature. Short-term OH variability and relationships between OH and its known risk factors were also analysed. A sample of 3858 elderly outpatients aged 65 years or more was randomly recruited by 444 Italian general practitioners. The patients' blood pressure (BP) and heart rate were recorded in both lying and standing positions at two visits 7 days apart. Three definitions were used for the identification of OH: (1) a decrease in systolic BP greater than 20 mmHg (SOH); (2) a decrease in both systolic (greater than 20 mmHg) and diastolic (greater than 10 mmHg) BP (SDOH); (3) any decrease in systolic BP associated with symptoms (SyOH). Prevalence figures for SOH were 13.8% at the first and 12.6% at the second visit, and respectively 5.3 and 4.8% for SDOH, 14.1 and 11.8% for SyOH. All the criteria were met by less than 2% of subjects at each visit. The diagnosis of OH was confirmed at both visits in 36.3% of cases for SOH, in 25.7% for SDOH, and in 43.9% for SyOH. Each different OH definition identifies a population subgroup characterized by different sets of risk-factors. The presence and prevalence of OH is difficult to define because different people may be identified by the currently accepted criteria or by the same criterion over a short time.     

Sustained blood pressure control and coronary heart disease,stroke, heart failure,and mortality: An observational analysis of ALLHAT

Achieving blood pressure (BP) control is associated with lower cardiovascular disease (CVD) risk, but less is known about CVD risk associated with sustained BP control over time. This observational analysis of the Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was restricted to participants with four to seven visits with systolic BP (SBP) measurements during a 22‐month period (n = 24 309). The authors categorized participants as having sustained BP control (SBP < 140 mm Hg) at 100%, 75% to <100%, 50% to <75%, and <50% of visits during this period. Outcomes included fatal coronary heart disease (CHD)/nonfatal myocardial infarction (MI), stroke, heart failure (HF), a composite CVD outcome (fatal CHD/nonfatal MI, stroke, or HF), and mortality. Hazard ratios (HRs) for the association of category of sustained BP control for each outcome were obtained using proportional hazards models. SBP control was present among 20.0% of participants at 100%, 16.4% at 75% to less than 100%, 27.0% at 50% to less than 75%, and 36.6% at less than 50% of visits. Compared to those with SBP control at 100% visits, adjusted HR (95% CI) among those with SBP control at <50% of visits was 1.16 (0.93‐1.44) for fatal CHD/nonfatal MI, 1.71 (1.26‐2.32) for stroke, 1.63 (1.30‐2.06) for HF, 1.39 (1.20‐1.62) for the composite CVD outcome, and 1.14 (0.99‐1.30) for mortality. Sustained SBP control may be beneficial for preventing stroke, HF, and CVD outcomes in adults taking antihypertensive medication.     

Blood pressure measurement and blood pressure control in Veterans Affairs medical centers

The Veterans Affairs (VA) medical centers provide care for millions of Veterans at high risk of cardiovascular disease and accurate BP measurement in this population is vital for optimal BP control. Few studies have examined terminal digit preference (TDP), a marker of BP measurement bias, clinician perceptions of BP measurement, and BP control in VA medical centers. This mixed methods study examined BP measurements from Veterans aged 18 to 85 years with hypertension and a primary care visit within 8 VA medical centers. TDP for all clinic BP measurements was examined using a goodness of fit test assuming 10% frequency for each digit. Interviews were also conducted with clinicians from 3 VA medical centers to assess perceptions of BP measurement. The mean age of the 98,433 Veterans (93% male) was 68.5 years (SD 12.7). BP was controlled (<140/90 mmHg) in 76.5% and control rates ranged from 72.2% to 81.0% across the 8 VA medical centers. Frequency of terminal digits 0 through 9 differed significantly from 10% for both SBP and DBP within each center (P < .001) but level of TDP differed by center. The highest BP control rates were noted in centers with highest TDP for digits 0 and 8 for both SBP and DBP. Clinicians reported use of semi-automated oscillometric devices for clinic BP measurement, but elevated BP readings were often confirmed by auscultatory methods. Significant TDP exists for BP measurement in VA medical centers, which reflects continued use of auscultatory methods.     

Environment and the ageing lung*

Abstract A brief review of changes in the morphology, physiology and defence mechanism in the ageing lung is presented. During the ageing process, the lung is also affected by environmental insults, which can be exogenous or endogenous. Exogenous factors include infection, climate, air pollution and mechanical injuries, whereas endogenous environments are certain system diseases (e.g. diabetes mellitus and thromboembolism) as well as infectious diseases (e.g. tuberculosis).     

The structural arteriolar changes in diabetes mellitus and essential hypertension: The relative contribution of ageing and high blood pressure

AIM: To evaluate the relative contribution of blood pressure, non-insulindependent diabetes mellitus and ageing on arteriolar structuralchanges in essential hypertension and diabetes mellitus. POPULATION AND METHODS: One hundred subjects, 25 with hypertension (A), 25 with hypertensionand diabetes (B), 25 with diabetes (C) and 25 healthy subjects(D). Blood pressure average values, obtained with non-invasivemonitoring, and minimal vascular resistance, calculated withstrain-gauge plethysmography, were statistically correlated.Multiple regression analysis was performed to assess the contributionof blood pressure and age. RESULTS: Minimal vascular resistance was higher in A, B and C than inD, and higher in B than in A and C. The coefficient of bloodpressure in the multiple regression analysis was significantfor all the parameters in A and B but not in C and D; that ofage was significant only in A and only for the average valuesof mean and diastolic blood pressure. CONCLUSION: Hypertension and diabetes show arteriolar structural changesof similar gravity. Age does play a role in hypertension buta smaller one than that played by blood pressure. In hypertensionand diabetes the lack of significance of the contribution ofage to the correlation between minimal vascular resistance andpressure could be ascribed to other neurohumoral factors. Thesefactors play a much more important role in diabetes, where neitherblood pressure nor age show any correlation with high vascularresistance.     

老年高血压患者的血压控制现状及影响因素分析

目的分析老年高血压患者的血压控制现状及影响因素,指导老年高血压患者的综合防治。方法回顾性分析老年高血压患者2593例,依据血压控制情况分为血压控制正常组(853例)和高血压组(1740例)。所有患者均进行了超声心动图检查,测定左心室二尖瓣舒张早期血流峰值(E)和舒张晚期血流峰值(A)比值(E/A)及LVEF等指标。结果2 593例老年高血压患者服药率和血压控制率分别为94.4%、32.9%。6种常用的降压药物中应用较多的是利尿剂、钙离子拮抗剂、血管紧张素Ⅱ受体拮抗剂和血管紧张素转换酶抑制剂。1988例(76.7%)合并有吸烟史、血脂异常、高血压家族史、肥胖等危险因素。超声心动图检查心脏收缩功能异常率17.2%、E/A比值异常率27.6%。单因素及多因素logistic回归分析,血压控制正常组和高血压组动脉粥样硬化、冠心病、体重指数、TC、HDL-C和左心室后壁等6项指标差异有统计学意义。结论老年高血压患者血压的控制并未有随着服药数量的增加而改善。应该对合并的危险因素及临床情况、生化指标及心脏的结构和功能异常等进行综合防治。