Standing Blood Pressure Research Articles

Orthostatic blood pressure changes and incident atrial fibrillation in patients with hypertension: Insights from the SPRINT trial

Abstract Background Exaggerated orthostatic changes in systolic blood pressure (SBP) were associated with adverse cardiovascular events. However, the predictive role of SBP hyperactivity to standing on incident atrial fibrillation (AF) is unclear. Purpose We aim to assess the association between orthostatic SBP changes and incident AF. Methods We performed a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial), a randomized controlled trial comparing intensive (<120 mm Hg) and standard (<140 mm Hg) SBP interventions in participants with hypertension. Participants with standing SBP <110 mm Hg were not eligible for randomization according to the SPRINT protocol. Participants without AF who had seated and standing SBP measurements at baseline and available baseline or follow-up ECG were included in this analysis. Orthostatic SBP changes were defined as standing SBP minus seated SBP. Patients were grouped into tertiles of orthostatic SBP changes. AF was ascertained from the standard 12-lead ECG obtained at baseline, year 2, year 4, a close-out visit, and any visit when suspected of serious adverse events. We used Cox proportional regression models and restricted spline curves to assess the association of orthostatic SBP changes with incident AF. Results Among 8,455 participants included in this analysis, 327 incident AF cases occurred during follow-up. The restricted spline curve depicted a U-shaped relationship between orthostatic SBP changes and incident AF in the unadjusted model (P for nonlinearity = 0.012) (Figure 1). After adjusting for age, female, race, smoking, alcohol use, history of cardiovascular disease, history of chronic kidney disease, and body mass index, a SBP increase ≥ 6 mm Hg to standing was independently associated with a 43% higher risk of incident AF (HR: 1.43; 95% CI: 1.07-1.90; P = 0.014) compared to nonsignificant orthostatic SBP changes (>-4 mm Hg to <6 mm Hg). A SBP decrease ≥ 4 mm Hg to standing showed a nonsignificant higher risk of developing AF compared to SBP changes of >-4 mm Hg to <6 mm Hg (Figure 2). In subgroup analysis, the results presented a similar tendency to the main result. Sensitivity analyses also generated consistent results while additionally adjusting for seated and standing blood pressure or heart rate. Conclusion In this post hoc analysis of the SPRINT trial, exaggerated SBP increase to standing independently predicts incident AF.Figure 1Figure 2

Electroencephalogram of Normotensive Individuals During Sitting and Standing Blood Pressure Measurement Positions

Electroencephalogram of Normotensive Individuals During Sitting and Standing Blood Pressure Measurement Positions

Audit of Geriatric Emergency Medicine-Unit staff compliance in providing care in line with the Age Friendly Health Systems Conceptual Framework

Abstract Background The Geriatric Emergency Medicine Unit (GEMU) in University Hospital Limerick (UHL) is in the Emergency Department for the assessment of those over the age of 75. The unit is staffed by a multi-disciplinary team with specialist skills in older person’s care. The aim of this audit was to determine assessment and documentation compliance with the Age Friendly Health Systems conceptual framework for older persons who present to GEMU. Methods A retrospective documentation review took place from patients who attended GEMU between January-March 2023. Medical record numbers were selected at random from the Health and Social Care Professionals (HSCP) team data management system with individual patient records subsequently retrieved from the Therefore Emergency Medicine (EM) patient management system. Patient records were reviewed by SW, which included Nursing, EM Doctors documentation and HSCP documentation. Results 15 charts were reviewed. Compliance varied across all areas from 0-100%. Compliance was greatest in the domains of the EWS score, mobility assessments, falls history and 4AT. Hydration and the documentation of ‘What Matters’/patient care preference were both 0%. Otherwise, compliance broadly was >50%. The first re-audit of 15 charts took place from December 2023-January 2024. Improvements were noted across all assessments, with 100% compliance additionally achieved in CFS, cognitive status, co-morbidities and nutritional intake. A second re-audit of 15 charts took place from March-April 2024, with further improvements seen in terms of lying and standing blood pressures and polypharmacy assessments. Conclusion Results demonstrate the continued improvements made amongst the team in adhering to the Age Friendly Health Systems Framework. Efforts are ongoing to focus specifically on the care preference component, with structured QIPs in place and a view to re-auditing in Q4 2024.

Atomoxetine on neurogenic orthostatic hypotension: a randomized, double-blind, placebo-controlled crossover trial.

We previously reported that single doses of the norepinephrine transporter inhibitor, atomoxetine, increased standing blood pressure (BP) and ameliorated symptoms in patients with neurogenic orthostatic hypotension (nOH). We aimed to evaluate the effect of atomoxetine over four weeks in patients with nOH. A randomized, double-blind, placebo-controlled crossover clinical trial between July 2016 and May 2021 was carried out with an initial open-label, single-dose phase (10 or 18mg atomoxetine), followed by a 1-week wash-out, and a subsequent double-blind 4-week treatment sequence (period 1: atomoxetine followed by placebo) or vice versa (period 2). The trial included a 2-week wash-out period. The primary endpoint was symptoms of nOH as measured by the orthostatic hypotension questionnaire (OHQ) assessed at 2 weeks. A total of 68 patients were screened, 40 were randomized, and 37 completed the study. We found no differences in the OHQ composite score between atomoxetine and placebo at 2 weeks (-0.3 ± 1.7 versus -0.4 ± 1.5; P = 0.806) and 4 weeks (-0.6 ± 2.4 versus -0.5 ± 1.6; P = 0.251). There were no differences either in the OHSA scores at 2 weeks (3 ± 1.9 versus 4 ± 2.1; P = 0.062) and at 4 weeks (3 ± 2.2 versus 3 ± 2.0; P = 1.000) or in the OH daily activity scores (OHDAS) at 2 weeks (4 ± 3.0 versus 5 ± 3.1, P = 0.102) and 4 weeks (4 ± 3.0 versus 4 ± 2.7, P = 0.095). Atomoxetine was well-tolerated. While previous evidence suggested that acute doses of atomoxetine might be efficacious in treating nOH; results of this clinical trial indicated that it was not superior to placebo to ameliorate symptoms of nOH. ClinicalTrials.gov; NCT02316821.

Associations of Hypertension and Orthostatic Hypotension with Subclinical Cardiovascular Disease

Abstract Background Orthostatic hypotension is associated with cardiovascular disease. It remains unclear if low standing blood pressure or high seated blood pressure is responsible for this association. We compared associations of orthostatic hypotension and hypertension with high-sensitivity cardiac troponin I and N-terminal pro-B-type natriuretic peptide. Methods We performed a secondary analysis of the Study to Understand Fall Reduction and Vitamin D in You (STURDY), a randomized controlled trial funded by the National Institute on Aging, between July 2015 and May 2019. Participants were community-dwelling adults, 70 years or older. Blood tests for high-sensitivity cardiac troponin I and N-terminal pro-B-type natriuretic peptide were drawn at visits concurrent with blood pressure measurements. Secondary analysis occurred in 2023. We determined associations between blood pressure phenotypes and cardiac biomarkers. Results Of 674 participants (mean age 76.5 ± 5.4 years, 43% female, 17.2% Black race), 29.1% had prior cardiovascular disease. Participants with seated hypertension had 10.1% greater high-sensitivity cardiac troponin I (95% CI = 3.8, 16.9) and 11.0% greater N-terminal pro-B-type natriuretic peptide (4.0, 18.6) than those without seated hypertension. Participants with standing hypertension had 8.6% (2.7, 14.9) greater high-sensitivity cardiac troponin I and 11.8% greater N-terminal pro-B-type natriuretic peptide (5.1, 18.9) than those without standing hypertension. Hypotensive phenotypes were not associated with either biomarker. Conclusions Both seated and standing hypertension were associated with greater high-sensitivity cardiac troponin I and N-terminal pro-B-type natriuretic peptide, but hypotensive phenotypes were not. Hypoperfusion may not be the principal mechanism behind subclinical cardiac injury among older adults with orthostatic hypotension.

Orthostatic Hypotension: a clinical marker for the body-first subtype of patients with Parkinson’s Disease

Our study aimed to investigate the clinical characteristics of PD patients stratified by OH status before and after levodopa challenge to explore the hypothesis that OH might serve as a clinical marker for the body-first subtype of PD. Supine and standing blood pressure were measured in a large cross-sectional cohort of PD patients at the OFF status before and after levodopa challenge test (LCT). Based on OH status, patients were divided into three groups: spontaneous OH (SOH), only levodopa-induced OH (LOH) and non-OH (NOH). Clinical characteristics and associated factors were compared among the groups. A total of 928 patients with a mean age of 62.4 years and average disease duration of 7.9 years were included. There were 224 (24.1%) patients with SOH, 321 (34.6%) with LOH, and 383 (41.3%) with NOH. Compared to NOH, both SOH and LOH were associated with older age, motor fluctuations, and probable rapid eye movement sleep behavior disorder (pRBD). In addition, OH was more associated with cardiovascular and digestive dysfunction, disease severity and worse quality of life. Results of the current study suggest that PD patients developed OH which is more likely to comorbid with RBD, severe autonomic dysfunction and motor fluctuations, consistent with the body-first subtype of PD.

EP3 - Reducing general surgical inpatient falls: an allied health professionals’ perspective

Abstract Aims Understand the current view of inpatient falls on a general surgical ward from allied health professionals. Identifies ways to reduce inpatient falls in general surgery. Methods Staff from two acute surgical wards were surveyed in December 2023. Seven questions used Likert scales (1-to-5, 1=Not preventable at all/significantly reduces the risks of falls/not confident at all/unimportant 5= Entirely preventable /significantly increases the risks of falls/very confident/important). One question focused on recent fall involvement. Modal values were taken. Data was inputted using Google Docs and analysed in Microsoft Excel. Results 13 responded (5 nurses, 4 health care support workers, 4 sisters). 7/13 had been involved in a fall in the last six months. Staff felt that the current post-inpatient fall proforma slightly reduces further falls risk. Factors that staff felt significantly increases the risks of falls were reduced mobility, delirium, falls history and impaired cognition. Factors that staff felt significantly reduces the risk of falls were, identifying patients at risk of falls, measuring lying and standing blood pressure, identifying the level of supervision for patient mobilisation, therapy assessment, initiating geriatric/falls review of high-risk falls patients, medication review, education of patients on avoiding falls and early senior clinician involvement in falls. Most staff felt mostly confident (4) knowing how to reduce the risk of falls and managing falls. Conclusions Most staff are comfortable managing falls. The falls proforma needs further development incorporating areas identified in this study to help reduce inpatient falls.

2326 Improving recording and documentation of lying standing blood pressure In patients > 65 admitted with/At high risk of fall(s)

Abstract Introduction The World Falls Guideline 2022 recommends that measurement of lying-standing blood pressure (LSBP) is an integral part of the multifactorial falls assessment (1). Pre-intervention less than half of eligible patients had a LSBP recorded and documented. The aim was to improve the recording and documentation of LSBP for adults aged 65 and over admitted with a fall or at high risk for falls. Method All patients aged 65 and over admitted with fall or identified as at high risk for falls to a care of the elderly ward were included over the period of 15th September 2023-15th November 2023. Royal College of Physicians (RCP) guidance (2017) for standard measurement of LSBP was used2. Data was collected on electronic spreadsheets from electronic observation charts. Two plan do study act (PDSA) cycles were conducted. Firstly, ward posters demonstrated how to record and document LSBP. Secondly ward-based one-to-one teaching interventions using RCP LSBP lanyard flashcards (2) were conducted. Results Following cycle one, 50% of eligible patients had LSBP documented. Following cycle two, 80% of eligible patients had LSBP documented. Following two PDSA cycles, there was a 37.1% increase in the average number of eligible patients who had LSBP correctly recorded and documented. Conclusion(s) Interventions of aide memoirs and education for nursing and medical staff improved the recording and documentation of LSBP. Indications and correct measurement guidance for LSBP should be included in future ward staff induction information and departmental teaching sessions. References 1) Montero-Odasso, M, Van der Velde N, Martin FC et al. The Task Force on Global Guidelines for Falls in Older Adults, World guidelines for falls prevention and management for older adults: a global initiative, Age and Ageing, Volume 51, Issue 9, September 2022. 2) Measurement of lying and standing blood pressure: A brief guide for clinical staff. 2017. https://www.rcplondon.ac.uk/projects/outputs/measurement-lying-and-standing-blood-pressure-brief-guide-clinical-staff.

Norepinephrine Reuptake Inhibition, an Emergent Treatment for Neurogenic Orthostatic Hypotension.

The NET (norepinephrine transporter) is situated in the prejunctional plasma membrane of noradrenergic neurons. It is responsible for >90% of the norepinephrine uptake that is released in the autonomic neuroeffector junction. Inhibitors of this cell membrane transporter, known as norepinephrine reuptake inhibitors (NRIs), are commercially available for the treatment of depression and attention deficit hyperactivity disorder. These agents increase norepinephrine levels, potentiating its action in preganglionic and postganglionic adrenergic neurons, the latter through activation of α-1 adrenoreceptors. Previous studies found that patients with neurogenic orthostatic hypotension can improve standing blood pressure and reduce symptoms of neurogenic orthostatic hypotension after a single administration of the selective NRI atomoxetine. This effect was primarily observed in patients with impaired central autonomic pathways with otherwise normal postganglionic sympathetic fibers, known as multiple system atrophy. Likewise, patients with normal or high norepinephrine levels may benefit from NRIs. The long-term efficacy of NRIs for the treatment of neurogenic orthostatic hypotension-related symptoms is currently under investigation. In summary, an in-depth understanding of the pathophysiology of neurogenic orthostatic hypotension resulted in the discovery of a new therapeutic pathway targeted by NRI.

Carbon Dioxide as a Novel Blood Pressure Therapy for Neurogenic Orthostatic Hypotension

BACKGROUND: On standing, people with neurogenic orthostatic hypotension (nOH) experience plummeting blood pressure (>20/10mmHg), crippling symptoms, and syncope. Current blood pressure therapies lack effcacy and have serious side effects. In healthy people, increased inspired CO2 increases blood pressure. This raises the tantalizing possibility that increased inspired CO2 may effectively treat nOH patients. OBJECTIVE: We aimed to understand if increased inspired CO2 can increase standing blood pressure in nOH. METHODS: Seventeen patients with nOH (F=5; 71±8 years) completed three randomized sit-to-stand tests with inspired CO2 maintained 0mmHg (0CO2), +5mmHg (+5CO2) or +10mmHg (+10CO2) relative to baseline. Respiratory and hemodynamics (blood pressure, heart rate, stroke volume, cardiac output, systemic vascular resistance) were continuously measured. Data are reported as mean ± SD. The change (stand-sit) in respiratory and hemodynamics between 0mmHg, +5mmHg and +10mmHg were compared using a repeated measures ANOVA with a Bonferroni correction. RESULTS: Inspired CO2 caused a dose-dependent increase in standing blood pressure (0CO2:-43±25mmHg; +5CO2:-22±26mmHg; +10CO2:-4±30mmHg; p<0.001). Blood pressure changes were predominantly facilitated by increased stroke volume (0CO2:-10±10mL; +5CO2:-5±10mL; +10CO2:0.1±10mL;p<0.001) and cardiac output (0CO2:-0.2±0.6L/min; +5CO2:0.2±0.5L/min; +10CO2:0.7±0.5L/min; p<0.001) as neither the changes in heart rate (p=0.2) nor systemic vascular resistance (p=0.6) were different across CO2 conditions. Breathing CO2 decreased the percentage of time that standing systolic blood pressure dropped ≥20mmHg (0CO2:75±35%; +5CO2:48±38%; +10CO2:32±37%; p<0.001) and fewer patients met the blood pressure criteria for orthostatic hypotension (p=0.02). CONCLUSION: Our data indicates increased inspired CO2 can increase standing blood pressure in nOH patients by increasing stroke volume and cardiac output. CO2 may offer a novel pressor therapy for patients with nOH. This work was supported by a University of Calgary Seed Funding (S.R.R). J.R.B is supported by a Canadian Institutes of Health Research (CIHR) Fellowship, a Libin Cardiovascular Institute Post-Doctoral Fellowship in Women’s Cardiovascular Health, the Natural Sciences and Engineering Research Council of Canada (NSERC) Brain CREATE Program, and a Canadian Cardiovascular Society Fellowship. S.I.R. is supported by the NSERC Brain CREATE Program, an Alberta Graduate Excellence Scholarship, and an Alberta Strategy for Patient Oriented SUPPORT Unit scholarship. A.V.I is supported by a CIHR Fellowship and an Achievers in Medical Science Postdoctoral Fellowship. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Quality improvement project to improve the recording and documentation of lying- standing blood pressure in patients >65y admitted with a fall or at high risk for falls

Quality improvement project to improve the recording and documentation of lying- standing blood pressure in patients >65y admitted with a fall or at high risk for falls

Brain white matter changes and their associations with non-motor dysfunction in orthostatic hypotension in α-synucleinopathy: A NODDI study.

The specific non-motor symptoms associated with α-synucleinopathies, including orthostatic hypotension (OH), cognitive impairment, and emotional abnormalities, have been a subject of ongoing controversy over the mechanisms underlying the development of a vicious cycle among them. The distinct structural alterations in white matter (WM) in patients with α-synucleinopathies experiencing OH, alongside their association with other non-motor symptoms, remain unexplored. This study employs axial diffusivity and density imaging (NODDI) to investigate WM damage specific to α-synucleinopathies with concurrent OH, delivering fresh evidence to supplement our understanding of the pathogenic mechanisms and pathological rationales behind the occurrence of a spectrum of non-motor functional impairments in α-synucleinopathies. This study recruited 49 individuals diagnosed with α-synucleinopathies, stratified into an α-OH group (n = 24) and an α-NOH group (without OH, n = 25). Additionally, 17 healthy controls were included for supine and standing blood pressure data collection, as well as neuropsychological assessments. Magnetic resonance imaging (MRI) was utilized for the calculation of NODDI parameters, and tract-based spatial statistics (TBSS) were employed to explore differential clusters. The fibers covered by these clusters were defined as regions of interest (ROI) for the extraction of NODDI parameter values and the analysis of their correlation with neuropsychological scores. The TBSS analysis unveiled specific cerebral regions exhibiting disparities within the α-OH group as compared to both the α-NOH group and the healthy controls. These differences were evident in clusters that indicated a decrease in the acquisition of the neurite density index (NDI), a reduction in the orientation dispersion index (ODI), and an increase in the isotropic volume fraction (FISO) (p < 0.05). The extracted values from these ROIs demonstrated significant correlations with clinically assessed differences in supine and standing blood pressure, overall cognitive scores, and anxiety-depression ratings (p < 0.05). Patients with α-synucleinopathies experiencing OH exhibit distinctive patterns of microstructural damage in the WM as revealed by the NODDI model, and there is a correlation with the onset and progression of non-motor functional impairments.

1770 Assessment of lying and standing blood pressure; an audit leading to an improved clinical effectiveness and quality improvement

Abstract Introduction Assessment of lying and standing blood pressure is commonly undertaken in geriatric medicine to make a diagnosis of orthostatic or postural hypotension. We carried out the audit to review the clinical practice and assess its adherence to the Royal College of Physicians (RCP) guidance on how to accurately measure the lying and standing blood pressure (Falls and Fragility Fracture Audit Programme). Method It was a prospective audit. The first audit cycle was conducted in July 2020 and the second cycle in April 2021 Results During the first data collection, the practice was reviewed in 69 patients. 35 were female (age range 63-92 years) and 34 male (age range 72-95 years). The lying and standing blood pressures were measured in 27 patients. Only 4 were performed as per the RCP guidance. 34 team members (including doctors, nurses, healthcare assistants, etc.) were randomly surveyed on how to correctly measure lying and standing blood pressure. None were aware of the RCP guidance in this context. We delivered local presentations of the results of the audit and RCP guidance flyers were displayed on the bulletin boards in the department. During the second cycle, the practice was reviewed in 58 patients. 30 were female (aged 67-94 years) and 28 male (aged 68-96 years). The lying and standing blood pressures were measured in 32 patients, of which 20 were recorded according to the RCP guidance. There was an increase of adherence to the guidance from 14.8% to 62.5% after undertaking the aforementioned interventions. Conclusions Following dissemination of the RCP guidance on how to accurately measure the lying and standing blood pressures, we witnessed an improvement in the practice suggestive of an improved clinical effectiveness. Robustly evaluating a service followed by education of the staff can lead to enhanced clinical care and quality improvement.

2031 Lying and standing blood pressure and ECG for the falling patient

Abstract Introduction Many elderly patients admitted to hospital have presented following a fall. Causes for falls are often complex and multifactorial, but causes such as postural hypotension and cardiac arrhythmias are easily diagnosed with lying and standing blood pressure (LSBP) and ECG respectively. Therefore, these investigations should be offered as a minimum to any elderly patient after a fall. We aim to review and improve the number of patients receiving LSBP and ECG after presenting to the Acute Frailty Unit (AFU) with a fall. Methods Falls admissions were reviewed over two four-week periods, before and after intervention. We gathered information on whether patients had LSBP and ECG, and whether these were reviewed and documented by a doctor or specialist nurse. Patients who could not stand for LSBP were not included. Interventions included teaching for all staff on AFU about LSBP and ECGs, posters about investigations after falls, flash cards on how and when to perform LSBPs and a daily tick-box to complete at handover confirming investigations had been reviewed. Results During the first four weeks, 31 patients were identified who presented with falls. 31 (100%) had LSBP recorded and 25 (81%) of these had documentation that it had been reviewed by doctor or specialist nurse. 26 (84%) received an ECG and 24 (92%) of these had a documented review. After intervention, 42 patients were identified. 40 (95%) had LSBP recorded, 42 (100%) of these were reviewed. 42 (100%) of patients had an ECG and 36 (100%) of these were reviewed. Conclusion Multiple simple interventions including education, visual prompts and procedural changes can improve practice and help to ensure that minimum investigations are achieved for all frail patients presenting with falls. These interventions could be applied to other common presentations on the AFU and may be an appropriate next step.

1805 The importance of ongoing awareness and education for Lying and Standing blood pressure (LSBP) during hospital admissions

Abstract Introduction Inpatient falls remain a huge problem in hospital, causing significant injuries to patients and are an avoidable cost to the NHS. Therefore, the National Audit of Inpatient Falls (2015-2017) set out key recommendations for management of falls, including the measurement of LSBP within 3 days of hospital admission. Method Our project was conducted in a major acute teaching hospital in North West London across three geriatric wards. Our aim was to improve the measurement of LSBP and correct documentation across the wards in line with the NAIF guidelines. We excluded patients unable to mobilise to standing with support, patients too unwell or unable to follow instructions and actively dying patients. Prior to any intervention, we found that only 24% of patients had LSBP performed within three days of admission. We focused our intervention in raising education and awareness across our staff. We arranged weekly reminders during MDT meetings, created posters and organised twice monthly teaching sessions, including one to one, on how to document correctly electronically. Results After one month of intervention, 73% of patients had LSBP as part of the ward round plan and almost half of patients had it correctly recorded on our system. After 4 months, we reaudited our project and found that only 32% of patients had LSBP appropriately recorded. This significant decrease can be explained by the changeover of junior doctors and emphasises the need of a more sustainable change. Conclusion Our goal is making LSBP part of a routine preadmission checklist when appropriate. We are currently working on making changes to our electronic patient record (EPR) to facilitate documentation to members of staff. This includes a new falls assessment tool and the newly incorporation of Smartzone feature on EPR. This will allow staff to put non-critical jobs in the workflow showing a less intrusive alert until completed.

163 Examining the appropriateness of tilt-testing within a community integrated care hub for older persons services

Abstract Background Tilt-testing has been widely used in acute hospitals for more than 20 years in Ireland. Its use in community settings has been promoted in recent years with the development of the National Integrated Care Programme for Older Persons (NICPOP). In our integrated care hub our focus lies in the assessment of falls and frailty. We propose to examine if the current rational for performing tilt-testing has showed a diagnostic yield. Methods We retrospectively reviewed all tilt reports in the ambulatory care hub from November 2021 to May 2023. We examined the rationale for ordering the test, the number of patients who received a diagnosis of Orthostatic Hypotension (OH) and treatment that was commenced. Results 59 tilt reports were examined between the 18 month period. The average age of the patients were 83 (range 68–93). The male to female ratio was 1:1.3. All patients had an indicator for testing. The 5 indicators that emerged were falls, syncope, orthostatic intolerance, lying and standing blood pressure drop and dizziness. 11/59 (19%) patients had one indicator, 18/59 (31%) patients had two indicators, 15/59 (25%) patients had three indicators and 15/59 (25%) patients had four indicators for performing a tilt. OH was diagnosed in 36/59 (61%) patients of whom 9/36 (25%) had symptomatic OH during both HUT and AS, 8/36 (22%) had symptoms during HUT alone, 6/36 (17%) had symptoms during AS and 9/36 (25%) were asymptomatic throughout testing. 4/36 (11%) had no documentation regarding their symptoms during tilting. De-prescribing was performed in 16/36 (44%) patients and Midodrine was commenced in 18/36 (50%) patients with fludrocortisone being started on 2/36 (6%) patients. Conclusion We demonstrated a high yield from the tilt-test investigations and in combination with Ambulatory BP monitoring had a significant number of medications de-prescribed. The greater preponderance of more than one indicator for tilt-testing was greater than what we perceived.

252 An audit of the inpatient course of patients with Parkinson’s Disease in a level four hospital in 2019

Abstract Background Studies show that patients with Parkinson’s Disease (PD) are more often admitted to acute hospitals and have increased Length-of-Stay (LoS) compared to age-matched controls associated with higher morbidity and mortality. This review was undertaken as the outcomes of patients with PD have not been evaluated in this level 4 hospital. Previous work locally has shown a lack of knowledge regarding the inpatient management of PD. Methods Data was collected from a retrospective chart review (115 admissions coded with PD in 2019). 10 patients were selected from medical, surgical, and orthopaedic admissions respectively (36 admissions). Charts were reviewed recording demographics, LoS, Emergency Department (ED) management, complications, outcomes, and readmission rates. Data was collected, stored, and analysed using Microsoft Excel. Results Median age of patients was 80 years. 44% were female. Median length of stay was 15.5 days. PD was documented in 97% of patients in ED, of whom 11% of patients received their PD medications in ED. 78% of patients had a history of falls, but only 20% had lying and standing blood pressure recorded. 38% had delirium as an inpatient. 42% of patients were made nil by mouth (NPO) during their stay, 87% of these secondary to peri-procedural fasting. Medications were held in 71% of procedures. Only 69% of discharge summaries were readily available. 6 patients (20%) were readmitted within 3 months. Conclusion This review highlights several areas for improvement in the management of inpatients with PD in a level four hospital. Initial interventions include education sessions for healthcare staff and review of ED pathways. PD medication management will also be reviewed. Accessible electric discharge summaries are also a key area for improvement. We aim to assess patients with PD experience of their inpatient journey as the next step in our quality improvement project. We will reaudit in 6 months.

Abstract P158: Associations Of Orthostatic Hypotension And Resting Hypertension With Biomarkers Of Subclinical Cardiovascular Disease

Background: Orthostatic hypotension (OH) is associated with cardiovascular disease (CVD), but mechanisms for this relationship are unclear. Objective: To determine associations between orthostatic, seated, or standing hypotension with two biomarkers of subclinical injury—high sensitivity cardiac troponin I (hs-cTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP)—relative to orthostatic, seated, or standing hypertension (HTN). Methods: We performed a secondary analysis of the Study to Understand Fall Reduction and Vitamin D in You (STURDY) using standardized seated and standing blood pressure (BP) assessments. We defined OH as a drop in systolic BP (SBP) ≥20 or diastolic BP (DBP) ≥10 mm Hg upon standing; seated or standing hypotension as BP ≤105/≤65 mm Hg; orthostatic HTN as an increase in BP ≥20/≥10 mm Hg upon standing; and seated or standing HTN as BP ≥140/≥90 mm Hg. Associations between BP phenotypes and serum Hs-cTnI and NT-proBNP were determined using mixed-effects Tobit models. Results: Of 673 participants (mean age 76.5 ± 5.4 years; 43% female; 17% Black), 63% had prior CVD. Those with seated HTN had a 10.2% greater hs-cTnI ( P = 0.001) and 11.0% greater NT-proBNP ( P = 0.002) than those without seated HTN ( Table) . Participants with standing HTN had an 8.6% ( P = 0.004) greater hs-cTnI and 11.8% greater NT-proBNP ( P = 0.0005) than those without standing HTN. No hypotensive phenotypes were associated with biomarkers. Conclusions: Both seated and standing HTN are associated with greater hs-cTnI and NT-proBNP, but hypotensive phenotypes were not. Hypoperfusion may not be a major contributor to subclinical cardiac injury among older adults with OH.

Association of Supine Hypertension Versus Standing Hypotension With Adverse Events Among Middle-Aged Adults.

Management of orthostatic hypotension (OH) prioritizes prevention of standing hypotension, sometimes at the expense of supine hypertension. It is unclear whether supine hypertension is associated with adverse outcomes relative to standing hypotension. To compare the long-term clinical consequences of supine hypertension and standing hypotension among middle-aged adults with and without OH. The ARIC study (Atherosclerosis Risk in Communities) measured supine and standing blood pressure (BP) in adults aged 45 to 64 years, without neurogenic OH, between 1987 and 1989. We defined OH as a positional drop in systolic BP ≥20 mm Hg or diastolic BP ≥10 mm Hg, supine hypertension as supine BP≥140/≥90 mm Hg, and standing hypotension as standing BP≤105/≤65 mm Hg. Participants were followed for >30 years. We used Cox regression models to examine associations with cardiovascular disease events, all-cause mortality, falls, and syncope. Of 12 489 participants (55% female, 26% Black, mean age 54 years, SD 6), 4.4% had OH. Among those without OH (N=11 943), 19% had supine hypertension and 21% had standing hypotension, while among those with OH (N=546), 58% had supine hypertension and 38% had standing hypotension. Associations with outcomes did not differ by OH status (P-interactions >0.25). Supine hypertension was associated with heart failure (hazard ratio, 1.83 [95% CI, 1.68-1.99]), falls (hazard ratio, 1.12 [95% CI, 1.02-1.22]), and all-cause mortality (hazard ratio, 1.45 [95% CI, 1.37-1.54]), while standing hypotension was only significantly associated with mortality (hazard ratio, 1.06 [95% CI, 1.00-1.14]). Supine hypertension was associated with higher risk of adverse events than standing hypotension, regardless of OH status. This challenges conventional OH management, which prioritizes standing hypotension over supine hypertension.

What Is the Relevance of Low Standing Blood Pressure?

What Is the Relevance of Low Standing Blood Pressure?