Orthostatic Blood Pressure Recovery Research Articles

Relationship between sarcopenia and orthostatic blood pressure recovery in older falls clinic attendees

Key Summary PointsAimTo determine the association between sarcopenia and orthostatic blood pressure (BP) recovery in falls clinic attendees aged 50 years or older.FindingsSarcopenia had a significantly slower rate of BP recovery (both systolic and diastolic) during the 10–20 s period after standing, independent of confounders.MessageSarcopenia had a modest but significant attenuating effect on early orthostatic haemodynamics.

Differential Associations Between Two Markers of Probable Sarcopenia and Continuous Orthostatic Hemodynamics in The Irish Longitudinal Study on Ageing.

Sarcopenia and orthostatic hypotension are growing age-related health burdens associated with adverse outcomes, including falls. Despite a possible pathophysiological link, the association between the 2 disorders is not well elucidated. We sought to investigate this relationship in The Irish Longitudinal Study on Ageing (TILDA). Data from 2 858 participants at wave 3 of TILDA were analyzed. Probable sarcopenia was defined as per the European Working Group on Sarcopenia in Older People revised definition cutoffs (hand grip strength [HGS] <27 kg in men, <16 kg in women, and/or 5-chair stand test [5CST] time >15 seconds). Participants underwent an active stand orthostatic test with continuous blood pressure (BP) monitoring. Multilevel mixed-effects models, controlling for possible confounders, were used to assess the effect of probable sarcopenia by HGS and 5CST criteria on the change in BP after standing. HGS- and 5CST-defined probable sarcopenia were independently associated with an attenuated BP recovery at 10-20 seconds poststand (systolic BP: β -0.54, p < .001; β -0.25, p < .001). On average, those meeting HGS probable sarcopenia criteria had a significantly lower BP at 20, 30, and 40 seconds (differences in systolic BP: -5.01 mmHg, -3.68 mmHg, -2.32 mmHg, p < .05 for all). Those meeting 5CST probable sarcopenia criteria had a significant difference in systolic BP at 20 seconds (-1.94 mmHg, p = .002) but not at 30 or 40 seconds. Probable sarcopenia had a significant association with delayed orthostatic BP recovery, with HGS-defined probable sarcopenia having a stronger association than 5CST-defined probable sarcopenia. Results support a modest but significant pathophysiological link between probable sarcopenia and orthostatic hypotension.

Orthostatic blood pressure recovery in older males using alpha-blockers for lower urinary tract symptoms, an explorative study in a urology outpatient clinic.

Alpha-blockers have been associated with orthostatic hypotension (OH). We aimed to assess the prevalence of OH measured with beat-to-beat blood pressure monitoring in older male outpatients who used alpha-blockers for lower urinary tract symptoms (LUTS). In addition, we investigated associations of OH with duration of alpha-blocker use, concomitant medication use and comorbidity. Cross-sectional explorative study in a urology outpatient clinic. Older white males ≥65 years using alpha-blockers for LUTS were included. Blood pressure responses to standing up from supine were recorded using a validated beat-to-beat blood pressure device (Finapres). Prevalence rates were derived from the beat-to-beat data to include OH measured between 60-110 s (OH), impaired recovery OH at 40 s (OH[40]), initial OH (IOH) and normal orthostatic response. Subgroups were defined based on duration of alpha-blocker use, polypharmacy, and Charlson comorbidity index (CCI), to obtain relative risks. Sixty-five patients were included. Median age was 75 years (range 65-92). The prevalence of OH was 7.7% (n=5). The prevalence of OH(40) was 16.9% (n=11) and of IOH 38.5% (n=25). Thirty-six patients (55.4%) had a normal orthostatic response. The relative risk of OH for the subgroup using 10 medications (n=13) was 6.0 (95%CI 1.1-32.3). For the subgroup with multimorbidity (CCI ≥3, n=11) this was 7.4 (95%CI 1.4-39.0). Recent initiation of alpha-blocker use (<3 months) did not increase OH risk (RR 0.6 [95%CI 0.1-5.1]). The overall prevalence of OH was low and comparable to age-matched population prevalence, suggesting that the relative contribution of alpha-blockers to OH was small. However, OH risk significantly increased in patients with multimorbidity or polypharmacy. For these patients, the benefits of starting alpha-blockers for LUTS should be weighed against the increased risk of OH.

Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness : Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN).

An expert committee was formed to reach consensus on the use of Tilt Table Testing (TTT) in the diagnosis of disorders that may cause transient loss of consciousness (TLOC) and to outline when other provocative cardiovascular autonomic tests are needed. While TTT adds to history taking, it cannot be a substitute for it. An abnormal TTT result is most meaningful if the provoked event is recognised by patients or eyewitnesses as similar to spontaneous ones. The minimum requirements to perform TTT are a tilt table, a continuous beat-to-beat blood pressure monitor, at least one ECG lead, protocols for the indications stated below and trained staff. This basic equipment lends itself to perform (1) additional provocation tests, such as the active standing test carotid sinus massage and autonomic function tests; (2) additional measurements, such as video, EEG, transcranial Doppler, NIRS, end-tidal CO2 or neuro-endocrine tests; (3) tailor-made provocation procedures in those with a specific and consistent trigger of TLOC. TTT and other provocative cardiovascular autonomic tests are indicated if the initial evaluation does not yield a definite or highly likely diagnosis, but raises a suspicion of (1) reflex syncope, (2) the three forms of orthostatic hypotension (OH), i.e. initial, classic and delayed OH, as well as delayed orthostatic blood pressure recovery, (3) postural orthostatic tachycardia syndrome or (4) psychogenic pseudosyncope. A therapeutic indication for TTT is to teach patients with reflex syncope and OH to recognise hypotensive symptoms and to perform physical counter manoeuvres.

Metformin may adversely affect orthostatic blood pressure recovery in patients with type 2 diabetes: substudy from the placebo-controlled Copenhagen Insulin and Metformin Therapy (CIMT) trial

BackgroundMetformin has been shown to have both neuroprotective and neurodegenerative effects. The aim of this study was to investigate the effect of metformin in combination with insulin on cardiovascular autonomic neuropathy (CAN) and distal peripheral neuropathy (DPN) in individuals with type 2 diabetes (T2DM).MethodsThe study is a sub-study of the CIMT trial, a randomized placebo-controlled trial with a 2 × 3 factorial design, where 412 patients with T2DM were randomized to 18 months of metformin or placebo in addition to open-labelled insulin. Outcomes were measures of CAN: Changes in heart rate response to deep breathing (beat-to-beat), orthostatic blood pressure (OBP) and heart rate and vibration detection threshold (VDT) as a marker DPN. Serum levels of vitamin B12 and methyl malonic acid (MMA) were analysed.ResultsAfter 18 months early drop in OBP (30 s after standing) was increased in the metformin group compared to placebo: systolic blood pressure drop increased by 3.4 mmHg (95% CI 0.6; 6.2, p = 0.02) and diastolic blood pressure drop increased by 1.3 mmHg (95% CI 0.3; 2.6, p = 0.045) compared to placebo. Beat-to-beat variation decreased in the metformin group by 1.1 beats per minute (95% CI − 2.4; 0.2, p = 0.10). Metformin treatment did not affect VDT group difference − 0.33 V (95% CI − 1.99; 1.33, p = 0.39) or other outcomes. Changes in B12, MMA and HbA1c did not confound the associations.ConclusionsEighteen months of metformin treatment in combination with insulin compared with insulin alone increased early drop in OBP indicating an adverse effect of metformin on CAN independent of vitamin B12, MMA HbA1c.Trial registration The protocol was approved by the Regional Committee on Biomedical Research Ethics (H–D-2007-112), the Danish Medicines Agency and registered with ClinicalTrials.gov (NCT00657943).

Orthostatic blood pressure recovery associates with physical performance, frailty and number of falls in geriatric outpatients.

Objective:Blood pressure (BP) recovery after orthostatic hypotension might be important to prevent cerebral hypoperfusion episodes in older adults, and be related to better clinical outcome. The objective was to study the relationship between BP recovery and clinical outcome, that is physical and cognitive performance, frailty and falls, in geriatric outpatients.Methods:One hundred and sixty-eight geriatric outpatients underwent continuous (beat-to-beat) BP measurements during standing up, and a comprehensive geriatric assessment, including assessment of physical performance (chair stand test), cognitive performance (Mini Mental State Examination), frailty (Fried criteria) and falls in the previous year. BP recovery was evaluated at 15–30, 30–60, 60–120 and 120–180 s after standing up and defined as mean SBP and DBP in the respective time intervals minus baseline BP. Associations with clinical outcome were assessed using linear (physical and cognitive performance and frailty) and logistic (falls) regression, adjusting for age, sex, baseline BP and initial BP drop.Results:SBP recovery was associated with frailty (30–60 s interval; β = 0.013, P = 0.02) and falls (30–60 s interval; odds ratio = 1.024, P = 0.02). DBP recovery was associated with physical performance (30–60 s interval; β = 0.215, P = 0.01), frailty (30–60 s interval; β = 0.028, P = 0.02) and falls (30–60 s interval; odds ratio = 1.039, P = 0.04). Neither SBP nor DBP recovery was associated with cognitive performance.Conclusion:DBP recovery was particularly associated with clinical outcome in geriatric outpatients, suggesting BP recovery to be of clinical interest.

Orthostatic Blood Pressure Recovery Is Associated With the Rate of Cognitive Decline and Mortality in Clinical Alzheimer’s Disease

BackgroundImpaired recovery of blood pressure (BP) after standing has been shown to be related to cognitive function and mortality in people without dementia, but its role in people with Alzheimer’s disease (AD) is unknown. The aim of this study was to investigate the association of the orthostatic BP response with cognitive decline and mortality in AD.MethodsIn this post hoc analysis of a randomized controlled trial (Nilvad), we measured the beat-to-beat response of BP upon active standing in mild-to-moderate AD. This included the initial drop (nadir within 40 seconds) and recovery after 1 minute, both expressed relative to resting values. We examined the relationship between a small or large initial drop (median split) and unimpaired (≥100%) or impaired recovery (<100%) with 1.5-year change in Alzheimer’s Disease Assessment—cognitive subscale (ADAS-cog) scores and all-cause mortality.ResultsWe included 55 participants (age 73.1 ± 6.2 years). Impaired BP recovery was associated with higher increases in ADAS-cog scores (systolic: β [95% confidence interval] = 5.6 [0.4–10.8], p = .035; diastolic: 7.6 [2.3–13.0], p = .006). During a median follow-up time of 49 months, 20 participants died. Impaired BP recovery was associated with increased mortality (systolic: HR [95% confidence interval] = 2.9 [1.1–7.8], p = .039; diastolic: HR [95% confidence interval] = 5.5 [1.9–16.1], p = .002). The initial BP drop was not associated with any outcome. Results were adjusted for age, sex, and intervention group.ConclusionsFailure to fully recover BP after 1 minute of standing is associated with cognitive decline and mortality in AD. As such, BP recovery can be regarded as an easily obtained marker of progression rate of AD.

Hemodynamic Mechanisms Underlying Initial Orthostatic Hypotension, Delayed Recovery and Orthostatic Hypotension

ObjectivesContinuous noninvasive blood pressure (BP) measurement enables us to observe rapid changes in BP and to study underlying hemodynamic mechanisms. This study aimed to gain insight into the pathophysiological mechanisms underlying short-term orthostatic BP recovery patterns in a real-world clinical setting with (pre)syncope patients. Setting and ParticipantsIn a prospective cohort study, the active lying-to-standing test was performed in suspected (pre)syncope patients in the emergency department with continuous noninvasive finger arterial BP measurement. MeasuresChanges in systolic BP, cardiac output (CO), and systemic vascular resistance (SVR) were studied in normal BP recovery, initial orthostatic hypotension, delayed BP recovery, and sustained orthostatic hypotension. ResultsIn normal recovery (n = 47), ΔBP at nadir was −24 (23) mmHg, with a CO change of +10 (21%) and SVR of −23 (21%). In initial orthostatic hypotension (n = 7) ΔBP at nadir was −49 (17) mmHg and CO and SVR change was −5 (46%) and −29 (58%), respectively. Delayed recovery (n = 12) differed significantly from normal recovery 30 seconds after standing, with a ΔBP of −32 (19) vs 1 (16) mmHg, respectively. Delayed recovery was associated with a significant difference in SVR changes compared to normal recovery, −17 (26%) vs +4 (20%), respectively. There was no difference in CO changes. In sustained orthostatic hypotension (n = 16), ΔBP at 180 seconds after standing was −39 (21) mmHg, with changes in CO of −16 (31%) and SVR of −9 (20%). Conclusions/ImplicationsHemodynamic patterns following active standing are heterogeneous and differ across orthostatic BP recovery patterns, suggesting that volume status, medication use, and autonomic dysfunction should all be taken into account when evaluating these patients. Moreover, results suggest that a delayed BP recovery is associated with an impaired increase in SVR in a significant proportion of individuals, implying that physicians treating older adults with hypertension should consider the possible negative effect of intensive hypertension treatment on initial orthostatic blood pressure control.

Orthostatic blood pressure recovery patterns in suspected syncope in the emergency department

IntroductionOrthostasis is a frequent trigger for (pre)syncope but some forms of orthostatic (pre)syncope have a worse prognosis than others. Routine assessment of orthostatic BP in the ED can detect classic...

Impaired Orthostatic Blood Pressure Recovery Is Associated with Unexplained and Injurious Falls.

Cardiovascular disorders are recognized as important modifiable risk factors for falls. However, the association between falls and orthostatic hypotension (OH) remains ambivalent, particularly because of poor measurement methods of previous studies. The goal was to determine for the first time to what extent OH (and variants) are risk factors for incident falls, unexplained falls (UF), injurious falls (IF) and syncope using dynamic blood pressure (BP) measurements in a population study. Nationally representative longitudinal cohort study-The Irish Longitudinal Study on Ageing (TILDA)-wave 1 (2009-2011) with 2-year follow-up at wave 2 (2012-2013). Community-dwelling adults. Four thousand one hundred twenty-seven participants were randomly sampled from the population of older adults aged ≥50 years resident in Ireland. Continuous BP recordings measured during active stands were analyzed. OH and variants (initial OH and impaired orthostatic BP stabilization OH(40)) were defined using dynamic BP measurements. Associations with the number of falls, UF, IF, and syncope reported 2 years later were assessed using negative binomial and modified Poisson regression as appropriate. Participants had a mean age of 61.5 (8.2) years (54.2% female). OH(40) was associated with increased relative risk of UF (RR: 1.52 95% CI: 1.03-2.26). OH was associated with all-cause falls (IRR: 1.40 95% CI: 1.01-1.96), UF(RR: 1.81 95% CI: 1.06-3.09), and IF(RR: 1.58 95% CI: 1.12-2.24). IOH was not associated with any outcome. With the exception of initial orthostatic hypotension, beat-to-beat measures of impaired orthostatic BP recovery (delayed recovery OH (40) or sustained orthostatic hypotension OH) are independent risk factors for future falls, unexplained falls, and injurious falls.

Impaired orthostatic blood pressure recovery and cognitive performance at two-year follow up in older adults: The Irish Longitudinal Study on Ageing.

BackgroundProspective investigations of the association between impaired orthostatic blood pressure (BP) regulation and cognitive decline in older adults are limited, and findings to-date have been mixed. The aim of this study was to determine whether impaired recovery of orthostatic BP was associated with change in cognitive function over a 2-year period, in a population based sample of community dwelling older adults.MethodsData from the first two waves of the Irish Longitudinal Study on Ageing were analysed. Orthostatic BP was measured during a lying to standing orthostatic stress protocol at wave 1 using beat-to-beat digital plethysmography, and impaired recovery of BP at 40 s post stand was investigated. Cognitive function was assessed at wave 1 and wave 2 (2 years later) using the Mini-Mental State Exam (MMSE), verbal fluency and word recall tasks.ResultsAfter adjustment for measured, potential confounders, and multiple imputation for missing data, the change in the number of errors between waves on the MMSE was 10 % higher [IRR (95 % CI) = 1.10 (0.96, 1.26)] in those with impaired recovery at 40 s. However, this was not statistically significant (p = 0.17). Impaired BP recovery was not associated with change in performance on any of the other cognitive measures.ConclusionsThere was no clear evidence for an association between impaired recovery of orthostatic BP and change in cognition over a 2-year period in this nationally representative cohort of older adults. Longer follow-up and more detailed cognitive testing would be advantageous to further investigate the relationship between orthostatic BP and cognitive decline.Electronic supplementary materialThe online version of this article (doi:10.1007/s10286-016-0340-3) contains supplementary material, which is available to authorized users.

Stressful life events and orthostatic blood pressure recovery in older adults.

The majority of the literature on stress and blood pressure (BP) concerns the increased risk of cardiovascular morbidity and mortality from high BP. Because the sympathetic nervous system is critical to the maintenance of orthostatic BP, it was hypothesized that older adults who have experienced more stressful life events (SLEs) would be more likely to show impaired recovery of BP in response to orthostatic stress. A total of 3,765 participants (Mage = 61.6 years, SD = 8.2; 54% female) from the first wave of The Irish Longitudinal Study on Ageing (TILDA) were included in the current analysis. Exposure to lifetime SLEs was ascertained by self-completion questionnaire, and beat-to-beat orthostatic BP measurement was carried out. Individuals who failed to recover at least 95% of their baseline BP by 60 s post stand were characterized as having impaired orthostatic BP recovery. An independent, dose-response relationship between the number of SLEs reported and the odds of impaired systolic BP recovery was observed after adjustment for covariates (1 event: odds ratio [OR] = 1.19, 95% confidence interval [CI] [0.98, 1.45], p = .078; 2 events: OR = 1.33, 95% CI [1.03, 1.73], p = .031; 3 or more events: OR = 1.56, 95% CI [1.12, 1.73], p = .009). This relationship was not evident for diastolic BP recovery. The reporting of a higher number of SLEs is associated with greater risk of impaired systolic BP recovery from orthostatic stress. Potential clinical implications include an increased risk of cerebral hypoperfusion, which predisposes older adults to falls, faints, and changes in cognitive status.

Supplemental Material for Stressful Life Events and Orthostatic Blood Pressure Recovery in Older Adults

Supplemental Material for Stressful Life Events and Orthostatic Blood Pressure Recovery in Older Adults