Diastolic Orthostatic Hypotension Research Articles

Older Age is a Risk Factor for Diastolic Orthostatic Hypotension

Older Age is a Risk Factor for Diastolic Orthostatic Hypotension

Orthostatic hypotension and mortality risk in geriatric outpatients: the impact of duration and magnitude of the blood pressure drop.

Orthostatic hypotension is a common condition associated with an increased mortality risk. This study investigates this association specifically in geriatric outpatients and additionally focuses on the duration and magnitude of orthostatic hypotension. In this observational prospective cohort study with geriatric outpatients from the Amsterdam Ageing cohort, we differentiated orthostatic hypotension in early orthostatic hypotension (EOH) and delayed/prolonged orthostatic hypotension (DPOH). The magnitude of drop in both SBP and DBP after either 1 or 3 min was quantified. Mortality data was obtained from the Dutch municipal register. Cox proportional hazard models were used to determine the association between orthostatic hypotension and mortality, adjusted for sex and age (model 1), additionally adjusted for orthostatic hypotension-inducing drugs + SBP (model 2) and the presence of cardiovascular disease and diabetes (model 3). Stratified analyses in patients with geriatric deficits were performed. We included 1240 patients (mean age 79.4 ± 6.9 years, 52.6% women). Prevalence of orthostatic hypotension was 443 (34.9%); 148 (11.9%) patients had EOH and 285 (23%) DPOH. DPOH was associated with a higher mortality risk [hazard ratio, 95% CI 1.69 (1.28-2.22)] whereas EOH was not associated with mortality risk. This association did not differ in patients with geriatric deficits. Furthermore, the magnitude of drop in both SBP and DBP was associated with a higher mortality risk. The presence of DPOH and the magnitude of both systolic and diastolic orthostatic hypotension are related to an increased mortality risk in geriatric outpatients. Whether the duration of orthostatic hypotension and magnitude of the drop in blood pressure is causally related to mortality risk or whether it is a sign of decreased resilience remains to be elucidated.

ORTHOSTATIC HYPOTENSION AND MORTALITY RISK IN GERIATRIC OUTPATIENTS: THE IMPACT OF DURATION AND MAGNITUDE OF THE BLOOD PRESSURE DROP

Objective: Orthostatic hypotension (OH) is a common condition associated with an increased mortality risk. This study investigates this association specifically in geriatric outpatients and additionally ocuses on the duration and magnitude of OH. Design and method: In this observational prospective cohort study with geriatric outpatients from the Amsterdam Ageing cohort, we differentiated OH in Early OH (EOH) and delayed/prolonged OH (DPOH). The magnitude of drop in both systolic and diastolic blood pressure (BP) after either 1 or 3 minutes was quantified. Mortality data was obtained from the Dutch municipal register. Cox proportional hazard models were used to determine the association between OH and mortality, adjusted for sex and age (model 1), additionally adjusted for OH-inducing drugs and SBP (model 2) and the presence of cardiovascular disease and diabetes (model 3). Stratified analyses in patients with geriatric deficits were performed. Results: We included 1240 patients (mean age 79.4 ± 6.9years, 52.6% females). Prevalence of OH was 443 (34.9%); 148 (11.9%) patients had EOH and 285 (23.0%) DPOH. DPOH was associated with a higher mortality risk (HR,95%CI: 1.69(1.28–2.22)) whereas EOH was not associated with mortality risk. This association did not differ in patients with geriatric deficits. Furthermore, the magnitude of drop in both systolic and diastolic BP was associated with a higher mortality risk (see figure for results of SBP). Conclusions: The presence of DPOH and the magnitude of both systolic and diastolic OH are related to an increased mortality risk in geriatric outpatients. Whether the duration of OH and magnitude of the drop in blood pressure is causally related to mortality risk or whether it is a sign of decreased resilience remains to be elucidated.

Clinical Epidemiology of Systolic and Diastolic Orthostatic Hypotension in Patients on Peritoneal Dialysis.

Blood pressure changes upon standing reflect a hemodynamic response, which depends on the baroreflex system and euvolemia. Dysautonomia and fluctuations in blood volume are hallmarks in kidney failure requiring replacement therapy. Orthostatic hypotension has been associated with mortality in hemodialysis patients, but neither this relationship nor the impact of changes in blood pressure has been tested in patients on peritoneal dialysis. We investigated both these relationships in a cohort of 137 PD patients. The response to orthostasis was assessed according to a standardized protocol. Twenty-five patients (18%) had systolic orthostatic hypotension, and 17 patients (12%) had diastolic hypotension. The magnitude of systolic and diastolic BP changes was inversely related to the value of the corresponding supine BP component (r = −0.16, p = 0.056 (systolic) and r = −0.25, p = 0.003 (diastolic), respectively). Orthostatic changes in diastolic, but not in systolic, BP were linearly related to the death risk (HR (1 mmHg reduction): 1.04, 95% CI 1.01–1.07, p = 0.006), and this was also true for CV death (HR: 1.08, 95% CI 1.03–1.12, p = 0.001). The strength of this association was not affected by further data adjustment (p ≤ 0.05). These findings suggest that independent of the formal diagnosis of orthostatic hypotension, even minor orthostatic reductions in diastolic BP bear an excess death risk in this population.

The Relationship between the Most Common Subtypes of Dementia and Orthostatic Hypotension in Older Adults

Background: It is crucial to evaluate the causes of morbidity and mortality in elderly patients with dementia, such as orthostatic hypotension (OH), which may affect their daily life activities, reduce the quality of life, and increase the caregiver burden. Objective: We aimed to investigate the relationship between OH and the most common subtypes of dementia in detail. Methods: A total of 268 older adults with dementia diagnosed with Alzheimer’s disease (AD), dementia with Lewy bodies (DLB), vascular dementia (VaD), and behavioral variant frontotemporal dementia (bvFTD), and 539 older adults without dementia were included in this prospective study. Comprehensive geriatric assessment including comorbidity, medication evaluation, and the head-up tilt test was also performed. Results: Of the participants, 13.8, 8.3, 6.4, and 4.8% had AD, DLB, bvFTD, and VaD, respectively. After adjusting for age, gender, the presence of comorbidities, and usage of OH-induced drugs; AD, DLB, and VaD were associated with OH (odds ratio [OR]: 2.23 confidence interval [CI] 95% 1.31–3.80; p = 0.003; OR: 3.68 CI 95% 1.98–6.83; p < 0.001, and OR: 3.56 CI 95% 1.46–8.69; p = 0.005, respectively). Furthermore, VaD was independently related to diastolic OH (OR: 4.19 CI 95% 1.66–10.57; p = 0.002), whereas AD and DLB were not. Conclusions: This study shows that elderly patients with DLB, AD, and VaD often have OH, a disabling autonomic dysfunction feature. Moreover, diastolic OH may play a role in the development of VaD. Therefore, considering potential complications of OH, it is essential to evaluate OH in the follow-up and management of those patients.

Associations of the systolic and diastolic components of orthostatic hypotension with markers of cardiovascular risk in older men: A cross-sectional analysis from The British Regional Heart Study.

The mechanisms underlying the association between orthostatic hypotension (OH) and cardiovascular disease are unclear. We investigated whether OH is associated with circulating cardiovascular risk markers. This was a cross‐sectional analysis of 3857 older, community‐dwelling men. “Consensus OH” was defined as a sitting‐to‐standing decrease in systolic blood pressure ≥20 mm Hg and/or diastolic blood pressure ≥10 mm Hg that occurred within three minutes of standing. Multiple generalized linear regression and logistic models were used to examine the association between cardiovascular risk markers and OH. Consensus OH was present in 20.2%, consisting of isolated systolic OH in 12.6%, isolated diastolic OH in 4.6%, and combined systolic and diastolic OH in 3.0%. Concentration of von Willebrand factor, a marker of endothelial dysfunction, was positively associated with isolated systolic OH (OR 1.35, 95% CI 1.05‐1.73) and combined systolic and diastolic OH (OR 2.27, 95% CI 1.35‐3.83); high circulating phosphate concentration, which may reflect vascular calcification, was associated with isolated diastolic OH (OR 1.53, 95% CI 1.04‐2.25) and combined systolic and diastolic OH (OR 2.12, 95% CI 1.31‐3.44), high‐sensitivity troponin T, a marker of myocardial injury, was positively associated with isolated diastolic OH (OR 1.69, 95% CI 1.07‐2.65) and N‐terminal pro‐brain natriuretic peptide, a marker of cardiac stress, was positively associated with combined systolic and diastolic OH (OR 2.14, 95% CI 1.14‐4.03). In conclusion, OH is associated with some cardiovascular risk markers implicated in endothelial dysfunction, vascular calcification, myocardial injury, and cardiac stress. Clinicians should consider assessing cardiovascular risk in patients with OH.

Systolic blood pressure postural changes variability is associated with greater dementia risk.

To determine whether orthostatic hypotension (OHYPO) and visit-to-visit blood pressure (BP) postural changes variability are associated with incident dementia. We studied 2,131 older adults from the Health, Aging, and Body Composition cohort study. Orthostatic BP was repeatedly assessed over a 5-year baseline period. OHYPO was defined as a fall ≥15 mm Hg in systolic or ≥7 mm Hg in diastolic BP after standing from a sitting position for one-third or more of the visits. Systolic OHYPO and diastolic OHYPO were also examined separately. BP postural changes variability over time was evaluated with several indicators, including SD and coefficient of variation (CV). Incident dementia was determined over 12 years after the baseline period by dementia medication use, ≥1.5 SD decline in Modified Mini-Mental State Examination score, or hospitalization records. Of 2,131 participants (mean age 73 years, 53% female, 39% Black), 309 (14.5%) had OHYPO, 192 (9.0%) had systolic OHYPO, 132 (6.2%) had diastolic OHYPO, and 462 (21.7%) developed dementia. After adjustment for demographics, seated systolic BP (SBP), antihypertensive drugs, cerebrovascular disease, diabetes mellitus, depressive symptoms, smoking, alcohol, body mass index, and presence of 1 or 2 APOE ε4 alleles, systolic OHYPO was associated with greater dementia risk (adjusted hazard ratio [HR] 1.37, 95% confidence interval [CI] 1.01-1.88), unlike diastolic OHYPO and OHYPO. SBP postural changes variability was also associated with higher dementia risk (highest tertile of variability [CV]: adjusted HR 1.35, 95% CI 1.06-1.71). Systolic OHYPO and visit-to-visit SBP postural changes variability were associated with greater dementia risk. Our findings raise the question of potential preventive interventions to control orthostatic SBP and its fluctuations.

White Matter Hyperintensities Mediate Impact of Dysautonomia on Cognition in Parkinson's Disease.

Patients with Parkinson's disease (PD) present with a broad spectrum of nonmotor features including autonomic disorders. More severe autonomic dysfunction in PD is associated with increased cognitive deficits. The presence of cerebral small-vessel disease, measured by T2-weighted magnetic resonance imaging white matter hyperintensity (WMH) burden, is also observed in patients with PD with faster cognitive decline. To investigate whether baseline orthostatic hypotension and autonomic dysfunction in early-stage PD affect later cognitive decline via mediation through cerebral small-vessel disease. De novo PD patients (N = 365) and age-matched controls (N = 174) with baseline T2-weighted/ fluid-attenuated inversion recovery scans were selected from the Parkinson's Progression Markers Initiative. WMHs were automatically segmented. Mediation analysis was used to assess whether WMH load mediates the effect of orthostatic hypotension and autonomic dysfunction (measured by Scales for Outcomes in Parkinson's Disease-Autonomic) on future cognitive decline (measured by Montreal Cognitive Assessment) in an average of 4 years of follow-up. Mediation analysis supported the existence of a full mediation of WMHs on the effect of diastolic orthostatic hypotension in patients with PD and future cognitive decline (average causal mediation effect: ab = -0.032, 95% confidence interval = -0.064 to -0.01, P = 0.01). There was also a partial mediation for overall autonomic dysfunction (ab = -0.027, 95% confidence interval = -0.054 to 0.00, P = 0.02). WMHs fully mediate the effect of diastolic orthostatic hypotension and partially mediate the effect of autonomic dysregulation on future cognitive decline in patients with PD. Our findings support the hypothesis that autonomic dysfunction in early clinical stages predisposes the brain to WMHs through dysregulation of the blood flow in the small vessels. This in turn increases the risk of future cognitive impairment in early PD.

Abstract 047: Mode of Orthostatic Hypotension Assessment and Dizziness in Older Adults

Background: Orthostatic hypotension (OH) is an important predictor of dizziness, falls, and death. However, there is substantial uncertainty regarding the most clinically meaningful way to assess OH. Methods: The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial (2015-2019), comparing the effect of vitamin D dose on fall risk in adults, 70 yrs or older. At baseline, seated blood pressure (BP) was measured after 5 minutes of rest. Then, after standing for 1 minute, a series of 3 BP measurements were performed, each separated by 30 seconds. Participants were asked about dizziness during the seated-to-standing protocol. OH was defined at 3 different times based on the consensus definition (a drop in systolic BP [SBP] of 20 or diastolic BP [DBP] of 10 mm Hg) and by its individual BP components. We used logistic regression to determine the association of OH definitions with dizziness. Results: Among 660 participants (mean age 76.4 ± 5.3 yrs, 44% women, 18% black), 52 (8%) reported dizziness and 19 (3%) had consensus OH. While all 3 assessments of consensus and systolic OH were associated with dizziness, associations based on average measurements were strongest (OR 6.8 [2.4, 19.6] and OR 11.7 [3.7, 36.7], respectively) ( Table ). Only diastolic OH measurements at or after 3 minutes were associated with dizziness. In contrast, the last measurement of postural change in SBP and none of DBP were associated with dizziness. Conclusions: OH based on an average of 3 SBP measurements between 1-5 minutes was the most strongly associated with dizziness, suggesting that precision is more important than timing. These findings are useful for the clinical assessment of dizziness.

Orthostatic hypotension among elderly patients in Italian internal medicine wards: an observational study.

Orthostatic hypotension (OH) is a multifactorial disorder, often asymptomatic. The prevalence of OH increases with age, ranging from 5 to 11% among middle-aged patients to 55% in the frail elderly depending on age and associated comorbidities. OH is often unrecognized or misdiagnosed and little is known about its prevalence in hospitalized elderly patients. Our aims were: (1) to determine the prevalence of OH in a cohort of elderly patients hospitalized in two internal medicine wards in Italy; (2) and to describe their characteristics and symptoms. During the 5 months from March 1, 2017 to July 31, 2017, the first 85 consecutive patients (65years or older) admitted in two internal medicine wards were enrolled. Patients were included in the study if they were able to get out of bed alone or with minor assistance, and able to stand up for at least 3 min. The study population comprised 85 patients with a mean age of 79.6 ( ± 7.2) years. OH was found in 64 (75.3%), occasional OH in 41 (48.2%), persistent OH in 23 (27.1%), and 21 (24.7%) patients had no OH. All patients had diastolic OH and 37 (57.8%) also systolic. Patients with persistent OH were oldest, with a higher percentage of renal failure. Twenty-six patients (40.6%) with OH reported symptoms. Dizziness was the most common symptom, especially after breakfast. No association was found between type of medications and risk of OH. Mortality risk was not statistically different between patients with or without OH 3 (p = 0.10) and 6 months after discharge (p = 0.18), but a trend was observed. We found that OH is very common in the patients admitted in the internal medicine wards, particularly diastolic OH. Close attention should be paid to OH and its symptoms, especially dizziness, in the oldest-old patients, and in patients with renal failure.

Malnutrition and Malnutrition Risk Can Be Associated with Systolic Orthostatic Hypotension in Older Adults.

Malnutrition and orthostatic hypotension(OH) are the two important geriatric syndromes, which have similar negative outcomes such as falls. The aim of the study is to detect whether there is any relation between malnutrition and OH. 862 geriatric patients, who had undergone comprehensive geriatric assessment (CGA),were included in the retrospective study. OH was identified as 20 and/or 10 mmHg dropped for systolic and/or diastolic blood pressures with the active standing test when patients got up from supine to standing position. Nutritional status was checked according to Mini Nutritional Assesment-Short Form(MNA-SF). The mean age of the patients was 74±8.05, and %66.3 of them were female. The prevalence of malnutrition, malnutrition-risk and OH were detected as 7.7%, 26.9 % and 21.2%, respectively. When OH, systolic OH, diastolic OH and control group were compared with CGA parameters and the effects of age and gender were removed, the frequency of falls and Timed-Up and Go Test were higher, activity daily living indexes and TINETTI-Balance scores were lower in systolic OH than without it (p<0.05).Systolic OH was more frequent in malnutrition-risk and malnutrition group than control group (p<0.002 and p<0.05, respectively). Diastolic OH was not associated with nutritional status (p>0.05).OH was only higher in malnutrition-risk group than robust (p<0.05). Our findings suggest that not only malnutrition but also malnutrition-risk may be associated with systolic OH, which leads to many negative outcomes in older adults. Because malnutrition/ malnutrition risk is preventable and reversible, nutritional status should be checked during the evaluation of OH patients.

Impact of variations in blood pressure with orthostatism on mortality: the HOMO study.

The aim of this study was to determine the impact of orthostatic hypotension (OH) and orthostatic hypertension (OHT) on all-cause mortality. A total of, 1176 adults from the community over 18 years of age were included in this ambispective study. The mean follow-up was 9.4 years. OH and OHT were defined as a decrease or an increase, respectively, in systolic blood pressure (BP) of at least 20 mmHg and/or diastolic BP of at least 10 mmHg from sitting to standing position at 1 and/or 3 min after standing. The impact of systolic or diastolic OH and systolic or diastolic OHT at 1 and 3 min after standing was also analyzed separately. In total, 135 individuals died during the follow-up. Neither OH [hazard ratio (HR) 1.23; 95% confidence interval (CI): 0.72-2.10] nor OHT (HR 0.90; 95% CI: 0.59-1.38) was associated with all-cause mortality in the adjusted models. In contrast, systolic OHT at 3 min (HR 2.31; 95% CI: 1.14-4.68) was independently associated with global mortality. Systolic OHT at 3 min is associated with all-cause mortality. The determination of this parameter could add valuable prognostic information during the routine examination of patients.

The relationship between orthostatic hypotension and the risk of myocardial infarction in the elderly

Objective To investigate the relationship between the systolic/diastolic orthostatic hypotension(OH-S/OH-D)and myocardial infarction(MI)in the elderly. Methods 200 subjects without myocardial infarction(MI)aged 60 years and over in our urban district were selected.The orthostatic and supine blood pressure and heart rate were measured in supine position after resting for more than 5 minutes and at 0 and 2 minutes after standing.All cases were divided into systolic orthostatic hypotension(OH-S)or diastolic orthostatic hypotension(OH-D)groups based on the results of orthostatic hypotension, and followed up by telephone with mean period of 325 days.The primary endpoint was MI occurrence for analyzing the correlation between OH-S/OH-D and MI incidence. Results The prevalence rate of OH in this cohort was 38%, with OH-S 20% and OH-D 18%.In the very elderly group(≥80 years)versus the elderly group, the occurrences of 0H and OH-S were(27%vs.21%, P=0.036; 22%vs.15%, P=0.020), respectively, while no significant difference was found in OH-D between the two groups.After 325 day follow-up, the prevalence of MI was significantly(P<0.05)higher in the OH-positive subjects than in the 0H-negative subjects, which result was the same as the prevalence of MI in OH-S or and OH-D group.After adjusting for age, supine blood pressure, creatinine and cerebrovascular history, logistic regression analysis showed that MI was correlated with OH(HR 15.72, 95%CI 3.29~74.23, P=0.002), OH-S(HR 8.552, 95%CI 2.51~30.21, P=0.004)and OH-D(HR 3.80, 95%CI 1.14~13.80, P=0.042). Compared with OH-D, OH-S had more significant correlation with MI. Conclusions Orthostatic hypotension, particularly systolic orthostatic hypotension, is common in elderly patients.The OH-S and OH-D have a significant correlation with MI. Key words: Hypotension, orthostatic; Myocardial infarction

Optimal diagnostic thresholds for diagnosis of orthostatic hypotension with a 'sit-to-stand test'.

This study aimed to identify optimal blood pressure cut-offs to diagnose orthostatic hypotension during a sit-to-stand manoeuvre. This was a cross-sectional study of patients and healthy controls from the Vanderbilt Autonomic Dysfunction Center. Blood pressure was measured while supine, seated and standing. Blood pressure changes were calculated from supine-to-standing and seated-to-standing. Orthostatic hypotension was diagnosed on the basis of a supine-to-standing SBP drop at least 20 mmHg or a DBP drop at least 10 mmHg. Receiver operator characteristic (ROC) curves identified optimal sit-to-stand cut-offs. Amongst the 831 individuals, more had systolic orthostatic hypotension [n = 354 (43%)] than diastolic orthostatic hypotension [n = 305 (37%)] during lying-to-standing. The ROC curves had good characteristics [SBP area under curve = 0.916 (95% confidence interval: 0.896-0.936), P < 0.001; DBP area under curve = 0.930 (95% confidence interval: 0.909-0.950), P < 0.001]. A sit-to stand SBP drop at least 15 mmHg had optimal test characteristics (sensitivity = 80.2%; specificity = 88.9%; positive predictive value = 84.2%; negative predictive value = 85.8%), as did a DBP drop at least 7 mmHg (sensitivity = 87.2%; specificity = 87.2%; positive predictive value = 80.1%; negative predictive value = 92.0%). A sit-to-stand manoeuvre with lower diagnostic cut-offs for orthostatic hypotension provides a simple screening test for orthostatic hypotension in situations wherein a supine-to-standing manoeuvre cannot be easily performed. Our analysis suggests that a SBP drop at least 15 mmHg or a DBP drop at least 7 mmHg best optimizes sensitivity and specificity of this sit-to-stand test.

Do we need to evaluate diastolic blood pressure in patients with suspected orthostatic hypotension?

PurposeThe contribution of diastolic blood pressure measurement to the diagnosis of classical orthostatic hypotension is not known. We aimed to explore the prevalence of isolated systolic and diastolic orthostatic hypotension components in patients with syncope and orthostatic intolerance.MethodsA total of 1520 patients aged >15 years with suspected syncope and/or symptoms of orthostatic intolerance were investigated in a tertiary center using tilt-table testing and continuous non-invasive blood pressure monitoring. Classical orthostatic hypotension was defined as a decline in systolic blood pressure ≥20 mmHg and/or diastolic blood pressure ≥10 mmHg at 3 min of tilt test. The prevalence of upright systolic blood pressure <90 mmHg and its overlap with isolated diastolic orthostatic hypotension was also assessed.ResultsOne hundred eighty-six patients (12.2%) met current diagnostic criteria for classical orthostatic hypotension. Of these, 176 patients (94.6%) met the systolic criterion and 102 patients (54.8%) met the diastolic criterion. Ninety-two patients (49.5%) met both systolic and diastolic criteria, whereas ten patients (5.4%) met the diastolic criterion alone. Of these, three had systolic blood pressure <90 mmHg during tilt test and were diagnosed with orthostatic hypotension on the grounds of low standing blood pressure. Based on patient history and ancillary test results, causes of orthostatic intolerance and syncope other than orthostatic hypotension were present in the remaining seven patients.ConclusionsAn abnormal orthostatic fall in diastolic blood pressure without an abnormal fall in systolic blood pressure is rare among patients with syncope and orthostatic intolerance. Approximately 95% of patients with classical orthostatic hypotension can be identified by systolic criterion alone.

OP.1D.01] DIASTOLIC ORTHOSTATIC HYPERTENSION PREDICTS A FAVORABLE CARDIOVASCULAR PROGNOSIS IN TYPE 2 DIABETES

Objective: The primary aim was to determine the prognostic impact of the diastolic and systolic orthostatic blood pressure responses in patients with type 2 diabetes. We also evaluated associations between different orthostatic blood pressure responses and markers of subclinical cardiovascular organ damage. Design and method: Office blood pressures were measured in the sitting and in the standing position in 749 patients with type 2 diabetes who participated in the CARDIPP study (Cardiovascular Risk factors in Patients with Diabetes – a Prospective study in Primary care). Diastolic orthostatic hypertension was defined as a rise of diastolic blood pressure of 10 mmHg or more, diastolic orthostatic hypotension was defined as a drop of diastolic blood pressure 10 mmHg or more, systolic orthostatic hypertension was defined as a rise of systolic blood pressure of 20 mmHg or more, and systolic orthostatic hypotension was defined as a drop of systolic blood pressure of 20 mmHg or more. Recruitment took place between the years 2005 – 2008. Patients were followed until any of the primary outcome events (cardiovascular death or hospitalization for either myocardial infarction or stroke) occurred or until December 31st, 2014. Measurements of aortic pulse wave velocity and carotid intima-media thickness were performed at base-line. Results: Diastolic orthostatic hypertension was found in 140 patients (18.7%) and was associated with significantly lower risk of cardiovascular events (crude hazard ratio compared with patients without diastolic orthostatic hypertension: 0.438, 95% C.I. 0.201 – 0.953, P = 0.037). The association remained statistically significant after adjustment for traditional cardiovascular risk factors. Diastolic orthostatic hypotension (n = 31) had no impact on the cardiovascular prognosis, but was associated with increased arterial stiffness and increased carotid intima-media thickness at base-line. Systolic orthostatic hypertension (n = 45) had no impact on the risk of cardiovascular events, but was associated with increased arterial stiffness at base-line. Systolic orthostatic hypotension (n = 24) had no impact on cardiovascular prognosis and was not associated with markers of cardiovascular organ damage. Conclusions: Diastolic orthostatic hypertension is common in patients with type 2 diabetes, and may be a novel marker for decreased cardiovascular risk in these patients.

Diastolic orthostatic hypertension and cardiovascular prognosis in type 2 diabetes: a prospective cohort study.

BackgroundIn patients with type 2 diabetes, the prognostic impact of an orthostatic rise in blood pressure is not known. Therefore, the aim of this study was to determine the prognostic implications of the diastolic orthostatic blood pressure response in a cohort of patients with type 2 diabetes. We also evaluated associations between different orthostatic blood pressure responses and markers of subclinical cardiovascular organ damage.MethodsOffice blood pressures were measured in the sitting and in the standing position in 749 patients with type 2 diabetes who participated in the CARDIPP study (Cardiovascular Risk factors in Patients with Diabetes—a Prospective study in Primary care). Diastolic orthostatic hypertension was defined as a rise of diastolic blood pressure ≥10 mmHg and diastolic orthostatic hypotension was defined as a drop of diastolic blood pressure ≥10 mmHg. Recruitment took place between the years 2005–2008, and patients were followed until any of the primary outcome events (cardiovascular death or hospitalization for either myocardial infarction or stroke) occurred or until December 31st, 2014. Measurements of aortic pulse wave velocity and of carotid intima-media thickness were performed at base-line.ResultsDiastolic orthostatic hypertension was found in 140 patients (18.7 %) and was associated with significantly lower risk of cardiovascular events (crude hazard ratio compared with patients with normal systolic and diastolic orthostatic blood pressure response: 0.450, 95 % C.I. 0.206–0.987, P = 0.046). Diastolic orthostatic hypotension was found in 31 patients (4.1 %) and was associated with higher values for aortic pulse wave velocity and carotid intima-media thickness, compared with patients with normal systolic and diastolic orthostatic blood pressure response.ConclusionsDiastolic orthostatic hypertension is common in patients with type 2 diabetes, and may be a novel marker for decreased cardiovascular risk in these patients.

PP.10.07

Objective: Orthostatic hypotension (OH) is a debilitating condition that is associated with decreased quality of life and increase all-cause mortality. There is insufficient information about OH in elderly Latinos. The aim of the present study was to determine the prevalence and risk factors for OH in community-dwelling elders from the Maracaibo Aging Study (MAS), Venezuela. Design and method: The MAS is a population-based study of community-dwelling individuals aged 55 years or older. The MAS included 2437 participants who underwent standardized assessments. Randomly selected, 887 subjects completed the OH protocol. OH was defined as a drop in systolic blood pressure (BP) of 20 mm Hg or more or a drop in diastolic BP of 10 mmHg after standing for 1, 3, or 5 minutes. Pulse pressure (PP) was the difference between systolic and diastolic BP. One-way ANOVA and χ2 tests were used for data analysis. Multivariate logistic regression model, adjusting for age, sex, smoking, obesity, hyperhomocysteinemia, heart rate (HR) and PP was performed to determine risk factors for OH. Results: The mean age of subjects was 66.6 yrs, and 62% were women. Hypertension was highly prevalent (80.3%), and one-third of the participants were obese. Prevalence of OH was 45% and doubled from 33% in the younger (55–64 y) group to 68.5% in the older (>75 y) group. The most common type was systolic OH (43%) compared with diastolic OH (26.5%) or combined systolic and diastolic (30.5%). All subjects with OH were hypertensive, 32% received treatment, and none of those treated had their BP controlled. Multivariate analysis revealed that, in the younger group, high HR (OR = 7.58 95% CI = 1.97 – 29.09) and PP (OR = 1.21, 95% CI = 1.16 – 1.26) were significantly associated with high risk of OH. Other confounders contributed to risk, including sex (OR = 0.20, 95% CI = 0.09 – 0.42) and smoking (OR = 0.44, 95% CI = 0.20 – 0.96). In the old group, only PP was associated with OH. Conclusions: Elderly participants of the MAS have a high prevalence of hypertension, and high rates OH. Male sex, high HR and high PP were risk factors for OH, while smoking was protective.

Orthostatic Hypotension and Mortality in Elderly Frail Patients: A Retrospective Cross-Sectional Study.

Orthostatic hypotension (OH) is a common problem in the elderly age group, and some studies have reported an association between OH and increased mortality. We evaluated possible associations between OH and mortality in a retrospective study of frail elderly patients who came for a comprehensive geriatric assessment.The study included all patients ≥65 years who were assessed in the outpatient Comprehensive Geriatric Assessment Unit. Data were collected from the computerized medical record, including blood pressure, sociodemographic data, lifestyle, falls, pulse rate, body mass index, functional and cognitive status, and comorbidity. Data on mortlaity were also collected.The study population consisted of 571 patients who underwent assessment over a 9-year study period. The mean age was 83.7 ± 6.1, 35.9% were males, and 183 (32.1%) were diagnosed with OH. Systolic OH (OHS) was more common than diastolic OH (25.2% vs 15.6%). In univariate analyses, OHS was associated with increased overall mortality. Over the follow-up period, 30.2% of the OHS patients died compared with 22.3% (P = 0.037), but in the Cox models there was no statistically significant associations between OHS and overall mortality. In contrast, age, burden of comorbidity, a low high-density lipoprotein level, and low creatinine clearance were independent predictors of increased overall mortality.In a population of frail elderly patients with a high burden of comorbidity, OH was not an independent risk factor for overall mortality.

Vitamin D deficiency is associated with orthostatic hypotension in oldest‐old women

Orthostatic hypotension, a condition that mostly affects 'oldest-old' (i.e. ≥80years) adults, is primarily explained by age-related dysfunction of blood pressure control. Vitamin D may contribute to blood pressure control. The aim of this study was to determine whether vitamin D deficiency is associated with orthostatic hypotension in oldest-old adults. Cross-sectional analysis at baseline of the EPIDOS study. Five French areas. A total of 329 community-dwelling oldest-old women (mean age 83.3±0.2years). Orthostatic hypotension was defined as a systolic blood pressure drop of ≥20mmHg and/or a diastolic blood pressure drop of ≥10mmHg within 3min of standing. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D (25OHD) concentration ≤10ngmL(-1) . Covariates included in the models were age, body mass index, diabetes mellitus, supine mean arterial pressure, number of drugs taken per day, use of antihypertensive or psychoactive drugs, cognition, quadriceps strength, current smoking, alcohol consumption, serum concentrations of parathyroid hormone, calcium and creatinine and season of testing. Diastolic orthostatic hypotension was observed more often among women with vitamin D deficiency (19.2%) compared to those without (10.0%; P=0.03). There was an inverse linear association between 25OHD concentration and change in diastolic blood pressure after 3min of standing (adjusted β=-0.07, P=0.046). Similarly, 25OHD deficiency was associated with orthostatic hypotension [adjusted odds ratio (OR) 3.36, P=0.004], specifically with diastolic orthostatic hypotension (adjusted OR 3.81, P=0.003). 25OHD deficiency was associated with orthostatic hypotension in oldest-old women, due to a greater drop in diastolic blood pressure on standing. This finding may lead to better understanding of the pathophysiology of falls in oldest-old adults with vitamin D deficiency.