Diagnosing orthostatic hypotension: a narrative review of the evidence

Frith, James

doi:10.1093/bmb/ldv025

Cited by 29 publications

(19 citation statements)

References 48 publications

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“…observer) which are likely to further effect the repeatability of measurements. Previous studies have noted that orthostatic BP measurements have relatively poor reproducibility [29][30], with the reproducibility thought to be higher in those with neurogenic OH [31]. Others have also noted low levels of agreement in OH definitions (kappa 0.17-0.32) based on active stands performed at the same time on different days [32], suggesting that at least in this relatively healthy population, OH can be transient for a numbers of people.…”

Section: Discussionmentioning

confidence: 99%

Reliability of orthostatic beat-to-beat blood pressure tests: implications for population and clinical studies

Finucane

Kenny

2017

Clin Auton Res

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ObjectiveTo assess the test-retest reliability of orthostatic beat-to-beat blood pressure responses to active standing and related clinical definitions of orthostatic hypotension. MethodsA random sample of community dwelling older adults from the pan-European Survey of Health, Ageing and Retirement in Europe, Ireland underwent a health assessment which mimicked that of the Irish Longitudinal Study on Ageing. An active stand test was performed using continuous blood pressure measurements. Participants attended a repeat assessment 4-12 weeks after the initial measurement. A mixed-effects regression model estimated the reliability and minimum detectable change while controlling for fixed observer and time of day effects. ResultsA total of 125 individuals underwent repeat assessment (mean age 66.2±7.5;55.6% women).Mean time between visits was 84.3±23.3 days. There was no significant mean difference in heart rate or blood pressure recovery variables between the first and repeat assessments.Minimum detectable change was noted for changes from resting values in systolic blood pressure(26.4mmHg) and diastolic blood pressure(13.7mmHg) at 110 seconds and for changes in heart rate(10.9bpm) from resting values at 30 seconds after standing. Intra-class correlation values ranged from 0.47 for nadir values to 0.80 for heart rate and systolic blood pressure values measured 110 seconds after standing. ConclusionContinuous orthostatic beat-to-beat blood pressure and related clinical definitions show moderate reliability and substantial natural variation over a 4-12 week period.Understanding variation in measures is essential for study design or estimating the effects of orthostatic hypotension, while clinically it can be used when evaluating longer term treatment effects.

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Section: Discussionmentioning

confidence: 99%

Reliability of orthostatic beat-to-beat blood pressure tests: implications for population and clinical studies

Finucane

Kenny

2017

Clin Auton Res

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“…Subgroup 2 performed postural changes A, D (supine to stand at preferred speed), E (head up tilt, i.e., tilting from supine position to 70-degree tilt in 15 s without use of leg muscles) and F (1-min squat, i.e., an isometric leg exercise test increasing BP). Postural changes A-E were preceded by a 5-min resting period [to reach steady state of BP regulation (Frith, 2015)] and followed by a 3-min standing period.…”

Section: Protocolmentioning

confidence: 99%

“…Sensitivity for the diagnosis of OH is higher for continuous BP measurement than for intermittent BP measurements after standing up, and continuous BP measurement has shown to be stronger associated with physical performance (Pasma et al, 2014;de Bruïne et al, 2018). However, clinical orthostatic BP measurements do not account for many of the symptoms and falls patients experience at home, due to the time varying and posture-and movement dependent nature of orthostatic BP drop, resulting in a poor reproducibility of the OH diagnosis (Frith, 2015). Furthermore, the baroreflex (i.e., change in interval between heart beats as a response to BP changes) and cerebral autoregulation (CAR, i.e., regulation of cerebral blood flow during BP changes) are mechanisms that potentially attenuate the clinical consequences of OH and are therefore essential to understand the relationship between OH and clinical outcome (James and Potter, 1999;Mehagnoul-Schipper et al, 2000;Saint Martin et al, 2013;Tarumi et al, 2014;Ziegler, 2018).…”

Section: Introductionmentioning

confidence: 99%

Multimodal Monitoring of Cardiovascular Responses to Postural Changes

et al. 2020

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Background: In the poorly understood relationship between orthostatic hypotension and falls, next to blood pressure (BP), baroreflex sensitivity (BRS) and cerebral autoregulation (CAR) may be key measures. The posture-and movement dependency of orthostatic hypotension requires continuous and unobtrusive monitoring. This may be possible using simultaneous photoplethysmography (PPG), electrocardiography (ECG), and near-infrared spectroscopy (NIRS) signal recordings, from which pulse wave velocity (PWV; potentially useful for BP estimation), BRS and CAR can be derived. The PPG, NIRS and PWV signal correlation with BP and BRS/CAR reliability and validity need to be addressed. Methods: In 34 healthy adults (mean age 25 years, inter quartile range 22-45; 10 female), wrist and finger PPG, ECG, bifrontal NIRS (oxygenated and deoxygenated hemoglobin) and continuous BP were recorded during sit to stand and supine to stand movements. Sixteen participants performed slow and rapid supine to stand movements; eighteen other participants performed a 1-min squat movement. Pulse wave velocity (PWV) was defined as the inverse of the ECG R-peak to PPG pulse delay; PPG, NIRS and PWV signal correlation with BP as their Pearson correlations with mean arterial pressure (MAP) within 30 s after the postural changes; BRS as inter beat interval drop divided by systolic BP (SBP) drop during the postural changes; CAR as oxygenated hemoglobin drop divided by MAP drop. BRS and CAR were separately computed using measured and estimated (linear regression) BP. BRS/CAR reliability was defined by the intra class correlation between repeats of the same postural change; validity as the Pearson correlation between BRS/CAR values based on measured and estimated BP. Results: The highest correlation with MAP was found for finger PPG and oxygenated hemoglobin, ranging from 0.75-0.79 (sit to stand), 0.66-0.88 (supine to stand), and 0.82-0.94 (1-min squat). BRS and CAR reliability was highest during the different supine

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“…For routine assessment of orthostatic circulatory adjustments, intermittent BP measurement with a sphygmomanometer and monitoring of the heart rate (HR) are adequate. Serial BP and HR measurements in the supine position and after 2–3 min of standing provide a general assessment of the circulatory response to standing . However, such intermittent BP measurement is not appropriate for evaluation of conditions in which there are sudden transient changes in the circulation, such as the rapid changes that occur during standing, which can only be evaluated with continuous arterial BP measurement .…”

Section: Introductionmentioning

confidence: 99%

Noninvasive beat‐to‐beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages

et al. 2017

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Over the past 30 years, noninvasive beat-to-beat blood pressure (BP) monitoring has provided great insight into cardiovascular autonomic regulation during standing. Although traditional sphygmomanometric measurement of BP may be sufficient for detection of sustained orthostatic hypotension, it fails to capture the complexity of the underlying dynamic BP and heart rate responses. With the emerging use of noninvasive beat-to-beat BP monitoring for the assessment of orthostatic BP control in clinical and population studies, various definitions for abnormal orthostatic BP patterns have been used. Here, age-related changes in cardiovascular control in healthy subjects will be reviewed to define the spectrum of the most important abnormal orthostatic BP patterns within the first 180 s of standing. Abnormal orthostatic BP responses can be defined as initial orthostatic hypotension (a transient systolic BP fall of >40 mmHg within 15 s of standing), delayed BP recovery (an inability of systolic BP to recover to a value of >20 mmHg below baseline at 30 s after standing) and sustained orthostatic hypotension (a sustained decline in systolic BP of ≥20 mmHg occurring 60-180 s after standing). In the evaluation of patients with light-headedness, pre(syncope), (unexplained) falls or suspected autonomic dysfunction, it is essential to distinguish between normal cardiovascular autonomic regulation and these abnormal orthostatic BP responses. The prevalence, clinical relevance and underlying pathophysiological mechanisms of these patterns differ significantly across the lifespan. Initial orthostatic hypotension is important for identifying causes of syncope in younger adults, whereas delayed BP recovery and sustained orthostatic hypotension are essential for evaluating the risk of falls in older adults.

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Diagnosing orthostatic hypotension: a narrative review of the evidence

Abstract: Establishing the long-term clinical outcomes for transient drops in BP detected on continuous, non-invasive monitoring. Evaluating the different patterns of BP drop to aid diagnosis and direct treatment.

Cited by 29 publications

References 48 publications

Reliability of orthostatic beat-to-beat blood pressure tests: implications for population and clinical studies

Reliability of orthostatic beat-to-beat blood pressure tests: implications for population and clinical studies

Multimodal Monitoring of Cardiovascular Responses to Postural Changes

Noninvasive beat‐to‐beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages

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