Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study

OBJECTIVES: To investigate the relationships between uncontrolled and controlled hypertension, orthostatic hypotension (OH), and falls in participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study (N=722, mean age 78.1). DESIGN: Prospective population‐based study. SETTING: Community. PARTICIPANTS: Seven hundred twenty‐two adults aged 70 and older living within a 5‐mile radius of the study headquarters at Hebrew Rehabilitation Center in Boston. MEASUREMENTS: Blood pressure (BP) was measured at baseline in the supine position and after 1 and 3 minutes of standing. Systolic OH (SOH) and diastolic OH at 1 and 3 minutes were defined as a 20‐mmHg decline in systolic BP and a 10‐mmHg decline in diastolic BP upon standing. Hypertension was defined as BP of 140/90 mmHg or greater or receiving antihypertensive medications (controlled if BP<140/90 mmHg and uncontrolled if ≥140/90 mmHg). Falls data were prospectively collected using monthly calendars. Fallers were defined as those with at least two falls within 1 year of follow‐up. RESULTS: OH was highest in participants with uncontrolled hypertension; SOH at 1 minute was 19% in participants with uncontrolled hypertension, 5% in those with controlled hypertension, and 2% in those without hypertension (P≤.001)). Participants with SOH at 1 minute and uncontrolled hypertension were at greater risk of falls (hazard ratio=2.5, 95% confidence interval=1.3–5.0) than those with uncontrolled hypertension without OH. OH by itself was not associated with falls. CONCLUSION: Older adults with uncontrolled hypertension and SOH at 1 minute are at greater risk for falling within 1 year. Hypertension control, with or without OH, is not associated with greater risk of falls in older community‐dwelling adults.     

Influence of orthostatic hypotension on mortality among patients discharged from an acute geriatric ward

BACKGROUND: Orthostatic hypotension (OH) is a common finding among older patients. The impact of OH on mortality is unknown. OBJECTIVE: To study the long-term effect of OH on total and cardiovascular mortality. PATIENTS AND METHODS: A total of 471 inpatients (227 males and 244 females), with a mean age of 81.5 years who were hospitalized in an acute geriatric ward between the years 1999 and 2000 were included in the study. Orthostatic tests were performed 3 times during the day on all patients near the time of discharge. Orthostatic hypotension was defined as a fall of at least 20 mmHg in systolic blood pressure (BP) and/or 10 mmHg in diastolic BP upon assuming an upright posture at least twice during the day. Patients were followed until August 31, 2004. Mortality data were taken from death certificates. RESULTS: One hundred and sixty-one patients (34.2%) experienced OH at least twice. Orthostatic hypotension had no effect on all cause and cause specific mortality. Over a follow-up of 3.47+/-1.87 years 249 patients (52.8%) had died 83 of whom (33.3%) had OH. Age-adjusted mortality rates in those with and without OH were 13.4 and 15.7 per 100 person-years, respectively. Cox proportional hazards model analysis demonstrated that male gender, age, diabetes mellitus, and congestive heart failure increased and high body mass index decreased total mortality. CONCLUSIONS: Orthostatic hypotension is relatively common in elderly patients discharged from acute geriatric wards, but has no impact on vascular and nonvascular mortality.     

Influencing factors and hemodynamic study of initial and sustained orthostatic hypotension in middle‐aged and elderly patients

Orthostatic hypotension (OH) is a common autonomic disorder. This study aimed to investigate the influencing factors and hemodynamic mechanisms of initial and sustained OH in middle‐aged and elderly patients. The authors analyzed the clinical characteristics and hemodynamic variables of patients aged ≥ 50 years according to the various forms of OH, diagnosed by an active orthostatic test using the CNAP monitor. The study included 473 participants; 119 (25.2%) patients had initial (54, 45.4%) or sustained (65, 54.6%) OH. Age, comorbidities, or medications did not differ significantly between the initial OH and non‐OH groups. Sustained OH was associated with age and diabetes (p = .003 and p = .015, respectively). Hemodynamic analysis revealed higher cardiac output (CO) in the sustained OH group within 15 s than in the non‐OH and initial OH groups (both p < .001); no difference in CO was observed between the initial OH and non‐OH groups. The systemic vascular resistance (SVR) in both initial OH and sustained OH groups within 15 s was lower than that in the non‐OH group (both p < .001). No differences in SVR at 3 min were observed between the initial OH and non‐OH groups. The SVR at 3 min in the sustained OH group was significantly lower than in non‐OH and initial OH groups (both p < .001). Age and diabetes emerged as the independent risk factors associated with sustained OH. Initial OH is associated with a mismatch of increase in CO and decrease in SVR. Sustained OH is mainly associated with sustained inadequate adjustment in SVR.     

Arterial stiffness in elderly patients with normotension and hypertension in Brazil

Data on arterial stiffness in older populations, according to blood pressure (BP) levels, are scarce in Brazil. The objective of this study was to establish reference values for core measures of arterial stiffness, including carotid‐femoral pulse wave velocity (cf‐PWV) and aortic augmentation index (AIx), in a cohort of older individuals with normotension (NT) and hypertension. Cross‐sectional analysis was performed with applanation tonometry data from 1192 patients aged 60 years or older. The authors classified patients according to their BP levels as having NT, controlled hypertension (CH), and uncontrolled hypertension (UH). The cf‐PWV values were 9.11 ± 0.16 m/s (NT), 9.12 ± 0.18 m/s (CH), and 9.42 ± 2.2 m/s (UH) (P < 0.005; UH vs NT and CH). The AIx was 33.3% for the entire cohort and similar across all groups. The cf‐PWV increased with age but reached a ceiling at 75 years. Compared with men, women had a higher AIx but similar cf‐PWV levels. In conclusion, the markers of arterial stiffness were similar among individuals with NT/CH and higher among individuals with UH.     

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.     

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.     

Effect of time standing up on orthostatic blood pressure change in the elderly: The J-SHIPP Study

Background:   Orthostatic dysregulation of blood pressure (BP) has been shown to be associated with an increased incidence of future cardiovascular disease, stroke and even mortality. To make a meaningful assessment of this association, we evaluated the effect of time elapsed after standing on any change in orthostatic BP.
Methods:   This study concerns 237 community-dwelling elderly people free from any history or symptoms of cardiovascular disease and not on medication. Basal BP was determined by averaging two determinations of supine BP measured with an automatic oscillometric BP recorder after resting for more than 10 min. Orthostatic change in BP was determined at 1 min and 3 min intervals after standing up.
Results:   The orthostatic change in systolic BP (ΔSBP) had a Gaussian distribution with a pivot at 1.2 ± 14 mmHg. The prevalence of subjects showing more than a 10% decrease in SBP at the 1-min interval was 14.3% (34 subjects). At the 3-min interval, 11 of them showed ΔSBP within ± 10%. However, another 17 subjects (7.2%) were newly diagnosed as having orthostatic hypotensive disorder. Similarly, 17.3% (41 cases) of subjects showed more than a 10% increase in ΔSBP at the 1-min interval. Among them, 22 (9.3%) subjects showed ΔSBP within ± 10% at the 3-min interval. However, another 20 (8.4%) subjects were newly diagnosed as having orthostatic hypertensive disorder.
Conclusion:   These results suggests that orthostatic dysregulation of BP could be evaluated by measuring at 1-min interval. However, if abnormal variation of BP was not observed, repeated measurement at 3 min would be necessary.     

老年高血压患者体位性低血压的相关因素分析和干预措施

目的探讨老年高血压患者体位性低血压(orthostatic hypotension,OH)的相关因素,并提出合理的干预措施以降低OH的发生率。方法选取2016年9月至2018年6月在新华医院老年医学科诊治的老年高血压患者217例,OH组57例,非OH组(NOH组)160例。比较两组的基线资料、降压药物使用情况、基础疾病情况。危险因素的筛选采用Logistics多因素回归分析。结果Logistics多因素回归分析结果显示年龄(OR=1.335,95%CI:1.125~1.584,P=0.002)、α受体阻断药(OR=1.582,95%CI:1.239~2.020,P=0.000)、降压药物≥3种(OR=1.452,95%CI:1.169~1.804,P=0.018)、心房颤动(OR=1.362,95%CI:1.206~1.538,P=0.008)和合并疾病≥2种(OR=1.485,95%CI:1.241~1.777,P=0.001)是OH的独立危险因素。结论老年高血压患者OH的发生率与高龄、α受体阻断药、心房颤动、合并多种疾病以及联合应用≥3种降压药物有关,必须对这些因素加以有针对性的干预,以降低OH发生率。     

Altered platelet alpha 2 adrenoreceptors in orthostatic hypotension

Alpha 2 adrenergic agonists have been used to raise blood pressure in patients with idiopathic orthostatic hypotension (IOH). In an attempt to define the mechanism of action of these agents, radioligand binding of [3H]clonidine, an alpha 2 agonist, and of [3H]yohimbine, an alpha 2 antagonist, to human platelet membranes from a patient with IOH was performed to determine the maximum number (Bmax) and dissociation constant (KD) for this receptor. There was a marked decrease in receptor number in this patient when compared to normal subjects. In normal volunteers the specific binding of [3H]clonidine yielded a mean Bmax of 33 +/- 2 fmol/mg protein and a KD of 5.5 +/- 0.6 nM, while for the patient the Bmax was 20 fmol/mg protein and the KD was 7.4 nM. For [3H]yohimbine binding in normals, the Bmax was 165 +/- 12 fmol/mg protein and the KD was 4.0 +/- 0.5 nM, whereas for the patient the Bmax was 65 fmol/mg protein and the KD was 12.0 nM. Alpha 2 adrenergic agonists such as clonidine decrease blood pressure by stimulating central presynaptic alpha 2 sites, and thus inhibiting sympathetic activity. There are also alpha 2 adrenergic receptor sites postsynaptically on vascular smooth muscle. The presence of this receptor postsynaptically in a patient with a reduction of the presynaptic inhibitory sites could account for clonidine's pressor activity in patients with IOH. Further study of both alpha 2-adrenergic receptors in patients with IOH may be important in developing an understanding of central and peripheral mechanisms in the control of blood pressure.     

Arterial stiffness index: A new evaluation for arterial stiffness in elderly patients with essential hypertension

Background: Arterial stiffness is one of the predictors of cardiovascular event. Arterial stiffness is commonly measured by pulse wave velocity between the carotid and femoral arteries. Recently the arterial stiffness index which is measured by computerized oscillometry at the upper arm was developed. As this procedure is a convenient means of measuring pulse wave velocity, we considered it suitable to evaluate arterial stiffness in elderly patients. We evaluated this arterial stiffness index and compared it with other methods of evaluating arterial stiffness in hypertensive patients, including the elderly. Methods: Forty‐two patients with essential hypertension, including 26 subjects over 60 years old were enrolled. We evaluated the arterial stiffness index by computerized oscillometry, and also evaluated arterial stiffness between the carotid‐femoral artery and the brachial‐tibial artery, the second derivative of photoplethysmogram, the forearm vasodilator response to reactive hyperemia by strain‐gauge plethysmography. Results: Arterial stiffness index was positively correlated with pulse wave velocity between the carotid‐femoral artery (P < 0.0001; r = 0.579), the heart‐carotid artery (r = 0.454) and right brachial‐tibial artery (r = 0.549). It was also correlated with b/a (r = 0.474) and d/a (r = 0.568) by a second derivative of photoplethysmogram, but not correlated with a reactive vasodilator response. In elderly patients, arterial stiffness index was also correlated with carotid‐femoral pulse wave velocity (P < 0.05; r = 0.456) but not correlated with a vasodilator response to reactive hyperemia. Conclusion: These data suggest that arterial stiffness index is correlated to common pulse wave velocity between the carotid and femoral arteries, so this index might be useful to evaluate arterial stiffness in hypertensive patients including the elderly.     

体位性低血压的两种分型

体位性低血压是老年人中常见的体征,也是心脑血管疾病和跌倒的独立危险因素,并增加全因死亡率。目前在研究体位性低血压时,越来越多采用连续无创血压测量设备,且常结合直立倾斜试验,并根据血流动力学参数进行分型。本综述将重点介绍公认的两种分型,即形态学分型及生理学分型。     

Systolic orthostatic hypotension is related to lowered cognitive function: Findings from the Maine‐Syracuse Longitudinal Study

The aim of the present study was to examine the relationship between orthostatic changes in blood pressure (BP) and cognition, with consideration given to cardiovascular risk factors and lifestyle variables. The cross‐sectional analysis included 961 community‐dwelling participants of the Maine‐Syracuse Longitudinal Study, for whom BP clinic measures (five sitting, five recumbent, and five standing) were obtained. Eighteen percent of participants had orthostatic hypotension (fall in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg upon standing) and 6% had orthostatic hypertension (rise in systolic BP ≥20 mm Hg). Orthostatic hypotension and hypertension defined using traditional criteria were unrelated to cognition with covariate adjustment. However, an examination of systolic and diastolic BP change independently revealed that participants with systolic orthostatic hypotension had poorer global cognition, verbal memory, and scanning and tracking scores than those with normal systolic BP change. The authors conclude that systolic orthostatic hypotension is significantly associated with reduced cognitive function.     

Arterial stiffness is increased in healthy subjects with a positive family history of hypertension

Abstract

A positive family history of hypertension is a risk factor for cardiovascular diseases. We investigated the value of pulse wave velocity (PWV) in healthy subjects with a positive family history of hypertension. 255 healthy subjects (M/F: 75/180) were divided into two groups according to without (group 1) or with (group 2) a positive family history of hypertension. Carotid-femoral pulse wave velocity (CF-PWV) was measured by Complior apparatus. Our results showed that CF-PWV was significantly higher in group 2 than in group 1 (7.90?±?1.31 versus 7.32?±?1.15?m/s, p?<?0.001). High-density lipoprotein cholesterol (HDL-C) was significantly higher in group 1 than in group 2. Multiple linear regressions showed that age, family history, GLU, and MAP were independent influencing factors of CF-PWV in the entire study group. Our present study showed PWV is significantly higher in healthy subjects with a positive family history of hypertension. Family history might play an important role in this process.     

Atherosclerosis of the carotid bulb is associated with the severity of orthostatic hypotension in non-diabetic adult patients: a cross-sectional study

Background: The carotid bulb has a high density of baroreceptors that play an important role in maintaining blood pressure. We hypothesized that atherosclerosis of the carotid bulb would reflect the severity of orthostatic hypotension more accurately than would atherosclerosis of other carotid artery segments.

Methods: This cross-sectional study included 198 non-diabetic adults. We measured the cardio-vascular ankle index as an index of arterial stiffness, intima-media thickness in each carotid artery segment (internal carotid artery, carotid bulb, distal and proximal portions, respectively, of the common carotid artery) as a measure of atherosclerosis, and heart rate variability as a measure of cardiac autonomic function. The sit-to-stand test was used to assess severity of orthostatic hypotension.

Results: Intima-media thickness of the carotid bulb was correlated with orthostatic systolic blood pressure change (r = ?0.218, p = 0.002), cardio-ankle vascular index (r = 0.365, p < 0.001) and heart rate variability parameters. Multivariate regression analysis revealed that among all of the segments, only intima-media thickness of the carotid bulb was an independent predictor of orthostatic systolic blood pressure change (p = 0.022).

Conclusion: Atherosclerosis of the carotid bulb was associated with severity of orthostatic hypotension, arterial stiffening and cardiac autonomic dysfunction than that of other carotid artery segments.