Orthostatic Hypotension Due to Autonomic Disorders in the Hypertension Clinic

Mansoor, George A.

doi:10.1016/j.amjhyper.2005.09.019

Cited by 22 publications

(25 citation statements)

References 58 publications

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“…The prevalence of OH in our study was relatively low (10.3%) as compared to our previous report and the report by Fagard et al 13,16 This can attributed to the fact that the prevalence of OH increases with age 17 and our subjects were relatively young. Despite the low rate of OH, we were able to demonstrate a higher prevalence of reverse-dipping in patients with OH.…”

Section: Orthostatic Hypotension Ambulatory Blood Pressure Monitoringcontrasting

confidence: 51%

Orthostatic Hypotension Is Associated With Nocturnal Change in Systolic Blood Pressure

Voichanski

Grossman

Leibowitz

et al. 2012

American Journal of Hypertension

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159original contributions nature publishing group Ambulatory blood pressure monitoring (ABPM) in normotensive and hypertensive subjects demonstrates a dipping blood pressure (BP) circadian pattern with a 10% decrease in BP readings at night. Some patients demonstrate a decrease of less than 10% (nondipping) or even an increase in BP at night (reverse-dipping). 1 A nondipping pattern is observed in elderly, diabetics, patients with sleep apnea syndrome, patients with metabolic syndrome, in patients with several forms of secondary hypertension and is associated with increased cardiovascular (CV) morbidity and mortality. 2-4 Orthostatic hypotension (OH) is defined as a decline of at least 20 mm Hg in systolic BP, and/or 10 mm Hg in diastolic BP, when changing from the recumbent to an upright position. 5 The incidence of OH increases with age and is common in individuals with peripheral neuropathy and autonomic failure.The association between OH and CV morbidity and mortality is controversial. 6-9 Weiss et al. failed to show increased mortality in elderly patients with OH, 9 whereas several other studies have shown that OH is associated with CV morbidity and mortality. 6-8 Many patients with autonomic failure have both OH and a nondipping BP pattern. 10 Circadian patterns of BP have not been well studied among individuals with OH. Moreover, there is little data relating postural BP changes to nocturnal BP changes. We hypothesized that the changes in BP during upright posture may contribute to the circadian pattern of BP. Therefore, we designed this prospective study to evaluate whether OH is associated with an abnormal dipping BP pattern, and whether nocturnal changes in BP levels are related to postural BP changes. MethodsThis was a prospective study that included 185 consecutive hypertensive patients, who were referred for 24-h ABPM at the Chaim Sheba Medical Center's hypertension unit either to confirm the diagnosis of hypertension before treatment, or to assess BP control. Participants were included in the study if they were able to lie down for 5 min and stand up for 3 min without any external support. Patients with sleep apnea di agnosed in a sleep laboratory, and patients with documentedThe first two authors contributed equally to this study and are co-first authors of this manuscript.

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Section: Orthostatic Hypotension Ambulatory Blood Pressure Monitoringcontrasting

confidence: 51%

Orthostatic Hypotension Is Associated With Nocturnal Change in Systolic Blood Pressure

Voichanski

Grossman

Leibowitz

et al. 2012

American Journal of Hypertension

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“…7,19,21 It has also been shown that there is an inverse relationship between orthostatic systolic BP change and the asleep-awake BP ratio, with more pronounced orthostatic systolic BP reduction in reverse dippers. 22,23 Because of its known association with a worse prognosis, 23,24 orthostatic hypotension may have contributed to the worse outcome of reverse dippers. The fact that these potential mechanisms contributing to the worse prognosis of reverse dippers have not been assessed is a limitation of the current meta-analysis.…”

Section: Discussionmentioning

confidence: 99%

Night–day blood pressure ratio and dipping pattern as predictors of death and cardiovascular events in hypertension

et al. 2009

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Our objective was to assess the prognostic significance of the night-time dipping pattern and the night-day blood pressure (BP) ratio for mortality and cardiovascular events in hypertensive patients without major cardiovascular disease at baseline. We performed a meta-analysis on individual data of 3468 patients from four prospective studies performed in Europe. Age of the subjects averaged 61±13 years; 45% were men and 61% were under antihypertensive treatment at the time of ambulatory BP monitoring. The night-day BP ratio and 24-h BP averaged, respectively, 0.907±0.085/ 0.866±0.095 and 138.1±16.4/82.3±11.0 mm Hg. Total follow-up time amounted to 23 164 patient-years. We used multivariable Cox regression analysis to assess the outcome of reverse dippers, non-dippers and extreme dippers vs dippers, and to assess the hazard ratios associated with 1 standard deviation higher night-day BP ratio. In comparison with dippers, and with adjustment for confounders and 24-h BP, the incidence of cardiovascular events was worse in reverse dippers (Pp0.05), whereas mortality was lower in extreme dippers (Pp0.01); outcome was similar in non-dippers and dippers. The systolic night-day BP ratio independently predicted all-cause mortality and cardiovascular events (Pp0.001), which persisted after additional adjustment for 24-h BP (Pp0.05); appropriate interaction terms indicated that the results were similar in men and women, in younger and older patients and in treated and untreated patients. In conclusion, the dipping pattern and the night-day BP ratio significantly and independently predict mortality and cardiovascular events in hypertensive patients without history of major cardiovascular disease, even after adjustment for 24-h BP.

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“…Although these authors observed prevalences of 6% 12 and 5%, 6,7,9 respectively, the prevalence amounted to 19% in our study when we used a similar definition of OH, confirming the higher prevalence of OH in the elderly. 21,22 In the populationbased studies, OH was independently associated with all-cause mortality, 9,12 cardiovascular mortality, 9 and CHD, 7,12 but this was only the case for stroke in one study. 6 Most studies reported on older subjects, [1][2][3][4][5]8,10,11 and the results have not always been consistent.…”

Section: Discussionmentioning

confidence: 99%

“…1,11 Furthermore, some studies reported separately on systolic and diastolic OH, 2,3,5,8 but most studies accepted OH if either of the 2 was present. The prevalence of both OH and reverse dipping increases with age, 21,22 and the 2 phenomena may be interrelated, because a lower BP in the upright position may contribute to a lower ABP during the day than during the night. 23,24 However, no study has addressed the relative prognostic importance of OH and reverse dipping.…”

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confidence: 99%

Orthostatic Hypotension Is a More Robust Predictor of Cardiovascular Events Than Nighttime Reverse Dipping in Elderly

2010

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Abstract-Aims of the study were to assess in an elderly population the prevalences of orthostatic hypotension at different times after standing and of nighttime reverse dipping on ambulatory blood pressure monitoring, as well as their interrelationships and relative prognostic power for incident cardiovascular events. The study population consisted of 374 patients (225 women), aged 70.2Ϯ8.5 years, registered in 1 primary care practice and without major cardiovascular events or other comorbidities at baseline. They experienced 76 first cardiovascular events (death, myocardial infarction, or stroke) during 3406 years of follow-up. Systolic/diastolic orthostatic hypotension, defined as a decrease of systolic/diastolic blood pressure of Ն20/Ն10 mm Hg, was present in 24.0%/13.3% of the patients immediately after standing, and in, respectively, 18.1%/10.5% and 12.4%/11.6% after 1 and 2 minutes, whereas systolic/diastolic reverse dipping occurred in 14.4%/9.5%. Orthostatic hypotension was 2 to 3 times more prevalent in reverse dippers than in dippers (PՅ0.01). Systolic orthostatic hypotension was a significant and independent predictor of cardiovascular events, which was stronger during recovery than immediately after standing; in Cox regression analysis, the adjusted hazard ratio amounted to 2.38 (PϽ0.01) after 2 minutes. The independent predictive power of diastolic orthostatic hypotension was only significant soon after standing (PϽ0.05). Systolic and diastolic reverse dipping carried prognostic significance in univariable analyses (PϽ0.001) but not after adjustment for confounders, including 24-hour blood pressure. We conclude that orthostatic hypotension contributes to the phenomenon of reverse dipping but is a more robust predictor of cardiovascular events than reverse dipping in the elderly of the current study. (Hypertension. 2010;56:56-61.)Key Words: ambulatory blood pressure monitoring Ⅲ cardiovascular events Ⅲ orthostatic hypotension Ⅲ prevalence Ⅲ prognosis Ⅲ reverse dipping A number of studies have assessed the prognostic significance of orthostatic hypotension (OH) 1-12 or reverse dipping on ambulatory blood pressure (BP; ABP) monitoring (ABPM). [13][14][15][16][17][18][19] Daytime ABP is usually higher than nighttime ABP, and the reverse diurnal pattern is independently associated with a higher incidence of cardiovascular events 16,18,19 and mortality 13,15,16,18,19 in most but not all studies. 14,17 Also, OH carries a worse prognosis for all-cause 4,9,11,12 and cardiovascular mortality, 5,9 coronary heart disease (CHD), 7,8,11,12 stroke, 6 or an aggregate of cardiovascular events, 12 although not all of the studies agree with regard to mortality 1-3,10 or stroke. 11,12 OH has been defined as a reduction of systolic BP of Ն20 mm Hg or of diastolic BP of Ն10 mm Hg within 3 minutes of standing, 20 but this definition has been applied differently in the various prognostic studies. Some authors have reported on single BP measurements at different time intervals after standing, [2][3][4][5]8,12 whereas others...

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Orthostatic Hypotension Due to Autonomic Disorders in the Hypertension Clinic

Cited by 22 publications

References 58 publications

Orthostatic Hypotension Is Associated With Nocturnal Change in Systolic Blood Pressure

Orthostatic Hypotension Is Associated With Nocturnal Change in Systolic Blood Pressure

Night–day blood pressure ratio and dipping pattern as predictors of death and cardiovascular events in hypertension

Orthostatic Hypotension Is a More Robust Predictor of Cardiovascular Events Than Nighttime Reverse Dipping in Elderly

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