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。     

Orthostatic hypotension,orthostatic intolerance and frailty: The Irish Longitudinal Study on Aging-TILDA

Because frailty may represent impaired response to physiological stress we explored the associations between frailty and orthostatic hypotension (OH), and orthostatic intolerance (OI). This study was based on a cross-sectional analysis of 5692 community dwelling adults aged 50 years and older included in wave 1 of the Irish Longitudinal Study on Aging. Frailty was assessed using both the phenotypic (FP) and frailty index (FI) models. OH was defined as a drop of ≥20 mmHg in systolic blood pressure or a drop of ≥10 mmHg diastolic pressure on standing from a seated position. OI was defined as reporting feeling dizzy, light headed or unsteady during this test. 346 (6.1%) participants had OH and 381 (6.7%) participants had OI. The prevalence OH in frail participants was 8.9%, compared to 5% in robust. Similarly the prevalence of OI was 14.3% in frail and 5.7% in robust participants. After adjustment for age and gender, OH was not significantly related to the FP (OR = 1.10 95% CI = 0.67, 1.81). Conversely OI was (OR = 1.80 95% CI = 1.13, 2.87), even after adjustment for age, gender, cardiovascular factors and mental health. In fully adjusted models OI remained related to slowness and low muscle strength and to higher FI scores. These data suggest OI symptoms in older adults may reflect various important underlying health deficits, indicative of increasing levels of frailty. Further assessment of frailty in patients experiencing OI is a potential opportunity for early intervention to delay functional decline.     

老年直立性低血压的检测和病因分析

目的检测老年人直立性低血压（ＯＨ）发生的状况及探讨其常见病因或诱因。方法对４８０例老年人进行卧位和直立位血压变化的检测,并对４１例服特拉唑嗪治疗前列腺增生病人不同时期血压进行监测。结果本组发病率１７１％。各年龄组ＯＨ发生率随增龄增高,６０～６９岁组、７０～７９岁组、≥８０岁组ＯＨ发生率分别为１１９％、１７６％、２９７％。糖尿病组、高血压组、糖尿病合并高血压组ＯＨ发生率分别为１８１％、１９１％、２２５％,显著高于健康老人组（Ｐ＜００５）。首剂服特拉唑嗪者ＯＨ发生率高达２６８％。结论ＯＨ的发生与年龄、高血压病、糖尿病及服用的药物相关。老年人ＯＨ发病率高,应对老年人常规进行ＯＨ的检查,并根据情况作出防护措施及指导药物的合理选择。     

Prevalence and associative factors of orthostatic hypotension in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study

BackgroundOrthostatic hypotension (OH) is commonly reported among older adults and is associated with an increased risk of mortality. This study aimed to describe the prevalence and investigate the possible associations between OH with sociodemographic variables, chronic medical conditions, health service utilisation, dementia and cognitive status among older adults residing in Singapore.MethodsData was collected from 2266 participants aged 60 years and older who participated in the Well-being of the Singapore Elderly (WiSE) study in 2013. Face-to-face interviews were conducted and data collected includes sociodemographic information, blood pressure measurements, medical history, health services utilisation, and cognitive status.ResultsThe prevalence of OH among older adults in Singapore was 7.8%. OH was highest in participants aged 85 years and above (OR: 2.33; 1.26–4.30; p = 0.007) compared to those aged 75–84 years (OR: 1.76; 1.08-2.85; p = 0.023). Participants with hypertension were more likely to have OH (OR: 3.03; 1.56–5.88, p = 0.001) than those without hypertension. Those with dementia were also more likely to have OH than those with normal cognitive status (p = 0.007).ConclusionsOlder age, hypertension, and dementia were independently associated with OH in the older adult population in Singapore. Interventions such as home safety assessment and preventive measures should be implemented to improve older adult’s functional capacity and quality of life to prevent injury.     

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 is associated with new-onset atrial fibrillation: Systemic review and meta-analysis

IntroductionOrthostatic 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.MethodsWe 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.ResultsFour 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).ConclusionsOH 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.     

Hypotension Unawareness in Profound Orthostatic Hypotension

Background

Clinicians depend on history given by the patients when considering the diagnosis of orthostatic hypotension.

Methods

Patients with a decrease in systolic blood pressure more than 60 mm Hg from baseline during a head-up tilt table test were included. They were classified according to their symptoms during the head-up tilt table test. Localization of the cause of orthostatic hypotension was sought in each of these groups.

Results

Eighty-eight (43%) patients had typical symptoms, 49 (24%) had atypical symptoms, and 68 (33%) were asymptomatic. The average decrease in systolic blood pressure was 88 mm Hg, 87.5 mm Hg, and 89.8 mm Hg in the typical, atypical, and asymptomatic groups, respectively (P = .81). Patients reported severe dizziness with a similar frequency as lower extremity discomfort. Backache and headache also were common atypical complaints. Patients with peripheral cause of dysautonomia were able to sustain the longest upright position during the head-up tilt table test (21 minutes, compared with central dysautonomia [15 minutes]) (P = .005). There was no correlation between the cause of dysautonomia and the occurrence of symptoms during the head-up tilt table test (P = .58).

Conclusion

A third of the patients with severe orthostatic hypotension are completely asymptomatic during the head-up tilt table test, and another quarter have atypical complaints that would not lead physicians toward the diagnosis of orthostatic hypotension. These findings suggest that they might not provide adequate information in diagnosing profound orthostatic hypotension in a subset of patients with this disorder.     

Orthostatic hypotension does not predict recurrent falling in a nursing home population

ObjectiveMost studies regard orthostatic hypotension (OH) as a causal factor for falls. However, the evidence is lacking for this assumption. We aimed to investigate the relationship between orthostatic hypotension and fall incidents in nursing home residents.MethodsA total of 249 patients was included in a prospective observational cohort study of nursing home residents. Falls were prospectively registered. Cox proportional hazard modelling and the conditional frailty model were used to analyse the relationship between OH and (recurrent) falling.ResultsAmong the 249 patients, 450 falls were recorded during follow-up and OH was present in 93 out of 249 patients. No significant associations were found between OH and the first fall incident (Hazard Ratio (HR) 1.01 (95% Confidence Interval (CI) 0.60–1.69) and recurrent falling (HR 1.21 (95%CI 0.65–2.24)).ConclusionsAlthough falling and OH were both highly prevalent in nursing home residents, no relationship between OH and falling was found.     

Orthostatic hypotension-related hospitalizations in the United States

Background

Orthostatic hypotension has been commonly described in elderly persons and is associated with an increased risk of falls, syncope, and cerebrovascular events. Nevertheless, the precise burden of this condition in the US is currently unknown.

Methods

We analyzed discharge data from the Nationwide Inpatient Sample to identify orthostatic hypotension-related hospitalizations and associated comorbidities after excluding acute causes of this condition. National hospitalization rates were estimated using US census population estimates, and the medical conditions most frequently associated with orthostatic hypotension were assessed.

Results

In 2004, there were an estimated 80,095 orthostatic hypotension-related hospitalizations, yielding an overall rate of 36 (95% confidence interval, 34 to 38) hospitalizations per 100,000 US adults. Orthostatic hypotension was the primary diagnosis in 35% of these hospitalizations. The number of orthostatic hypotension-related hospitalizations increased steadily with age, and patients aged 75 years or older had the highest annual hospitalization rate, 233 per 100,000 (95% confidence interval, 217 to 249). The median length of hospital stay was 3 days (IQR 2-6) and the overall in-hospital mortality was 0.9%. Caucasian males were most likely to be hospitalized with orthostatic hypotension. Syncope was the most common comorbid condition reported among orthostatic hypotension patients.

Conclusions

Orthostatic hypotension is a relatively common condition among hospitalized US elderly patients. In light of the progressive aging of the US population, the contribution of orthostatic hypotension to morbidity and mortality is likely to increase, and deserves further scrutiny.     

Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study

OBJECTIVES: To determine the prognostic role of orthostatic hypotension for cardiovascular disease (CVD) and all‐cause mortality in elderly people. DESIGN: Prospective study. SETTING: Community based. PARTICIPANTS: Five thousand sixty‐four subjects from the Rotterdam study aged 55 and older. MEASUREMENTS: Orthostatic hypotension was measured using a Dinamap automatic blood pressure recorder. Orthostatic hypotension is defined as a decline in systolic blood pressure of 20 mmHg or more or a decline in diastolic blood pressure of 10 mmHg or more from supine to standing position at any of three measurements taken 1, 2, and 3 minutes after standing. RESULTS: At baseline, 901 subjects had orthostatic hypotension. During follow‐up, 668 subjects had coronary heart disease (CHD) (mean follow‐up 6.0 ± 3.5 years), and 1,835 subjects died (mean follow‐up period 7.8 ± 3.8 years). Orthostatic hypotension increased the risk of CHD (hazard ratio (HR)=1.31, 95% confidence interval (CI)=1.08–1.57) and all‐cause mortality (HR=1.22, 95% CI=1.09–1.36), in models adjusted for age and sex. The risk was slightly lower after additional adjustment for cardiovascular risk factors. In analyses stratified for age, the HRs for all‐cause mortality were 1.80 (95% CI 1.25–2.60), 1.13 (0.89–1.42), and 1.27 (95% CI=1.11–1.44), in the first, second, and third tertile of age, respectively. CONCLUSION: Orthostatic hypotension increases the risk of CHD and all‐cause mortality in elderly people. The risk of CVD and mortality is strongest in younger and very old subjects.     

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.     

Orthostatic hypotension: From pathophysiology to clinical applications and therapeutic considerations

Orthostatic hypotension (OH), that is blood pressure fall when standing from the supine to the erect position, is a common cardiovascular disorder, highly prevalent in elderly and frail individuals and in patients with multiple comorbidities. Orthostatic hypotension is considered a manifestation of dysfunction of the autonomic nervous system, caused or facilitated by several neurological or non‐neurological diseases and conditions, while its clinical significance is increasingly recognized as a cause of impairment of quality of life and potentially of worse outcomes. Indeed, OH has been extensively studied and numerous prospective cohort studies support its association with adverse events, including coronary artery disease, heart failure, stroke, cognitive dysfunction, and, most importantly, mortality rates. Specific pharmacological and non‐pharmacological interventions have been established for the treatment of OH. However, randomized data evaluating the impact of therapeutic interventions on morbidity and mortality outcomes are lacking. Thus, despite that OH seems to have important prognostic implications indicated by several reported associations with adverse events, it remains unclear whether OH treatment could improve prognosis. In the present review, we discuss the clinical applications associated with ΟΗ by outlining the current perspectives on ΟΗ definition, diagnosis, pathophysiology, prognostic role, and treatment.     

Treatment of severe orthostatic hypotension with the somatostatin analogue octreotide

The long-acting somatostatin analogue octreotide was used in a patient with severe orthostatic hypotension resistant to conventional treatment. 0.4 ug/kg octreotide given subcutaneously abolished the postural drop in systolic blood pressure for about four hours and was more effective than a combination of fludrocortisone and pindolol.     

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 hypotension in the healthy elderly

Orthostatic hypotension (OH) is a common problem in elderly people causing several complications such as falls and fractures. In recent years, it was noticed that OH seems to have an association with cardiovascular risk factors including cerebrovascular events, higher nocturnal blood pressure levels, and arterial stiffness. In this study, we aimed to evaluate the prevalence of OH in our healthy elderly people and its association with blood pressures, left ventricular mass, plasma insulin, age, and autonomic tests including heart rate response (HRR) to valsalva maneuver, heart rate variation (HRV) during deep breathing, HRR to standing. A total of 61 subjects (35 male/26 female) were enrolled and completed the study. Nine out of 61 (14.7%) were found to have OH. When demographic features and study parameters were compared in both groups (subjects with OH: 9 and non-OH: 52), no difference in blood glucose, sodium, potassium, calcium, body mass index, systolic and diastolic blood pressures, HRR to valsalva maneuver, HRV during deep breathing, HRR to standing were found between the groups. While fasting plasma insulin level was significantly higher in non-OH group than those in OH group (p<0.05), left ventricular mass index was significantly higher in subjects with OH (p<0.05). In conclusion, OH is a prevalent condition in healthy elderly people and its relation with cardiovascular risk factors like increased left ventricular mass index and impaired blood pressure control need more studies to demonstrate such an association and responsible mechanisms.     

起搏后体位性低血压

观察7条狗起搏前后从卧位变为站位时的血流动力学变化。起搏后起立时平均动脉压平均下降28％,是正常时(13％)的二倍,并且恢复时间明显延长(P<0.01)。实验表明起搏前后狗的体位性低血压代偿机制不同,正常时起立时心输出量增加20％左右,心率平均增加24％,而每搏输出量在开始阶段常减少,有的在整个站立过程中减少。心率在提高心输出量,代偿体位性低血压中起着重要作用。起搏后由于心率固定不变,因而出现明显的体位性低血压。提高起搏频率可改善体位性低血压。     

Orthostatic Response before and after Nitroglycerin in Metoprolol- and Verapamil-Treated Angina Pectoris

ABSTRACT. The Orthostatic changes in heart rate (HR) and blood pressure (BP) were recorded in ten patients with stable angina pectoris before and after simultaneous sublingual nitroglycerin administration. All patients were examined three times: without other medication, during chronic metoprolol treatment, and during chronic verapamil treatment. Under control conditions, only minor changes were found in systolic BP following vertical tilting, while diastolic BP increased by approximately 10%. Nitroglycerin augmented these changes to some extent, while neither metoprolol nor verapamil caused significant changes. The Orthostatic HR increase was considerably augmented by nitroglycerin. Verapamil treatment did not influence this response, while metoprolol caused significant reductions. These findings seem to explain why some few patients have observed severe Orthostatic symptoms while taking nitroglycerin during treatment with β-adrenergic blocking agents.     

Orthostatic Syndromes Differ in Syncope Frequency

Background

There are conflicting opinions on whether postural tachycardia syndrome predisposes to syncope. We investigated this relationship by comparing the frequency of syncope in postural tachycardia syndrome and orthostatic hypotension.

Methods

We queried our autonomic laboratory database of 3700 patients. Orthostatic hypotension and postural tachycardia syndrome were defined in standard fashion, except that postural tachycardia syndrome required the presence of orthostatic symptoms and a further increase in heart rate beyond 10 minutes. Syncope was defined as an abrupt decrease in blood pressure and often, heart rate, requiring termination of the tilt study. Statistical analysis utilized Fisher's exact test and Student's t test, as appropriate.

Results

Of 810 patients referred for postural tachycardia syndrome, 185 met criteria while another 328 patients had orthostatic hypotension. Of the postural tachycardia syndrome patients, 38% had syncope on head-up tilt, compared with only 22% of those with orthostatic hypotension (P <.0001). In the postural tachycardia group, syncope on head-up tilt was associated with a clinical history of syncope in 90%, whereas absence of syncope on head-up tilt was associated with a clinical history of syncope in 30% (P <.0001). In contrast, syncope on head-up tilt did not bear any relationship to clinical history of syncope in the orthostatic hypotension group (41% vs 36%; P = .49).

Conclusion

Our results demonstrate that syncope (both tilt table and clinical) occurs far more commonly in patients who have postural tachycardia syndrome than in patients with orthostatic hypotension. These findings suggest that one should be clinically aware of the high risk of syncope in patients with postural tachycardia syndrome, and the low-pressure baroreceptor system that is implicated in postural tachycardia syndrome might confer more sensitivity to syncope than the high pressure system implicated in orthostatic hypotension.