Supine Diastolic Blood Pressure Research Articles

Cholinesterase Inhibitors Modulate Autonomic Function in Patients with Alzheimer´s Disease and Mixed Dementia

Cholinesterase inhibitors (ChEIs), the mainstay treatment for dementia, have systemic actions that can affect cardiovascular and autonomic nervous system (ANS). Thirty-nine patients with Alzheimer´s disease or mixed dementia underwent a comprehensive clinical evaluation, prior to and during ChEIs therapy, including orthostatic challenge, electrocardiogram (EKG) and heart rate variability (HRV) spectral analysis through Holter recordings. ChEIs therapy determined a decrease in supine diastolic blood pressure (BP) and in both diastolic and systolic BP in orthostatic position (79.8 ± 9.0 vs. 76.4 ± 9.3 mmHg, p=0.012; 79.9 ± 11.6 vs. 75.3 ± 9.9, p=0.005 and 144.6 ± 25.8 vs. 137.6 ± 21.1, p=0.020, respectively). Spectral analysis revealed no difference on static HRV components, but, during orthostatic challenge, an increase in LF/HF ratio (2.2±2.4 vs. 4.6±5.9, p=0.011) and a reduction in HF component emerged (1604.3 ± 5610.1 vs. 266.1 ± 525.5, p=0.010). ChEIs showed no influence on EKG parameters or on the occurrence of orthostatic hypotension. Treatment with ChEIs was associated with functional improvement of the ANS behavior and to a decrease in supine DBP and in both orthostatic SBP and DBP.

ASSA13-10-23 Influencing Factors of Orthostatic Hypotension in Hospitalised Patients of Cardiology

Objectives The aim is to determine the influencing factors of orthostatic hypotension (OH) in inpatients of cardiology. Methods A total of 200 patients hospitalised in cardiology of Peking University People’s Hospital from July 2012 to August 2012 were included. The orthostatic blood pressures were measured in supine position after resting for more than 5 minutes and at 0 min, 1 min, 2 min and 3 min after standing. OH was defined as fall in systolic BP below 20 mmHg and/or diastolic BP below 10 mmHg of baseline within 3 min in upright position. Subjects were divided into OH positive and OH negative group. Compare the baseline data, comorbidities and treatment medication differences of OH group with non-OH group, and analyse the influencing factors of OH. Results The prevalence of OH in subjects was 24%. Both the supine systolic and diastolic blood pressure were higher in OH positive group than OH negative group ( P = 0.001). The prevalence of diabetes (31.3% vs . 10.5%, P = 0.001) and stroke (27.1% vs . 9.9%, P = 0.003) was higher in OH positive group than OH negative group. The proportion of application of α receptor blockers (12.5% vs. 2.6%, P = 0.014), psychotropic drugs (16.7% vs. 5.3%, P = 0.011), Hypoglycemic drugs (27.1% vs. 10.5%, P = 0.005) and antiplatelet drugs (68.8% vs. 52%, P = 0.041) were higher in OH positive group than OH negative group. Logistic regression found that the risk of OH was related to diabetes (OR = 3.84, 95% CI 1.63∼9.043), stroke (OR = 3.469, 95% CI 1.409∼8.542),application of α receptor blockers (OR = 5.537, 95% CI 1.354∼22.643) and psychotropic drugs (OR = 3.292, 95% CI 1.035∼10.471). Conclusions OH was very common in hospitalised patients. Diabetes mellitus, stroke, and the application of α receptor blockers and psychotropic drugs may increase the risk of OH.

Abstract TP369: Blood Pressure Dynamics During Long Sitting Position In Acute Ischemic Stroke Patients: Prevalence Of Orthostatic Hypotension.

Background and Purpose: Long sitting positioning (LSP) using head of bed elevation is an important part of early rehabilitation and mobilization for patients with acute ischemic stroke. However, little is known about orthostatic hypotension (OH) during LSP, which is potential risk factor for ischemic stroke recurrence. This study aimed to investigate the prevalence of OH during LSP and its related factors. Methods: Patients with acute ischemic stroke were enrolled in this study (n=246, male: 68.1%, mean age 74.7y). Ten-minutes LSP by 70-degree head of bead elevation with successive blood pressure (BP) measurement was conducted a week after their stroke. BP was measured for three times on un-affected arm: pre-measurement in supine position, 1 and 10 minutes after beginning of LSP. OH was defined as ≥20 mmHg fall in systolic BP (SBP) and/ or ≥10 mmHg fall in diastolic BP (DBP) from pre-measurement in supine position. Potential related factors such as demographics, comorbidities, stroke severity, baseline BP were investigated by multivariate logistic analysis. Results: The overall prevalence of OH were 15.0% (n=37) at 1 minute and 20.3% (n=50) at 10 minutes after beginning of LSP. Patients with OH at 1 minute were more likely to have higher supine DBP (p=0.034), and patients with OH at 10 minutes were more likely to have higher supine SBP (p=0.004) and DBP (p<0.001). In multivariate logistic analysis showed that older age (OR [95%CI], 1.05[1.01-1.09]), male gender (3.15[1.19-8.33]) and higher supine DBP (1.03[1.00-1.06]) were independently associated with the OH at 1 minute after LSP. Similarly, older age (1.05[1.01-1.08]) and higher supine DBP (1.05[1.03-1.08]) were independently associated with OH at 10minutes after LSP. Conclusions: The OH prevalence at 1 minute after beginning of LSP was similar to previous studies which defined OH as hypotension in upright position. However, the prevalence rose remarkably at 10 minutes after LSP, while temporary hemodynamic instability would recover within one minute in healthy adults. These results implicated that impaired activity of the autonomic nervous system in acute ischemic stroke patients was associated with defect in hemodynamics regulation, especially in the patients with older age and/or higher supine BP.

RISKS FOR PERIPHERAL ARTERIAL DISEASE IN THE ELDERLY WITH TYPE 2 DIABETES MELLITUS : Their Correlation with High Sensitivity C-reactive Protein and Ankle-Brachial Index

The Indonesian elderly population has been projected to increase up to about four-fold inthree decades (1990-2020). As a consequence of this population trend, the increased prevalence ofdegenerative diseases would be inevitable; this would include the prevalence of peripheral arterialdisease.This study aims to identify the correlation of diverse risk factors, either traditional or nontraditional,with the ankle-brachial index scores, and the correlation of novel non-traditional riskfactor, e.i. high sensitive C-reactive protein with the prevalence of perioheral arterial disease in theelderly, age 60-80 years old, with type 2 diabetes mellitus.Among the 146 elderly patients with type 2 diabetes mellitus, and based on measurement ofthe ABI score, approximately 30.9% of them had PAD. Some traditional and non-traditional riskfactors having a significant correlation with the ankle-brachial index score, were age (r = -0.396, p <0.001 for right ABI; r = -0.509, p < 0.001 for left ABI), supine systolic blood pressure (r= -0.268, p =0.012 for right ABI; r = -0.267, p = 0.013 for left ABI), 2-hour post-prandial blood glucose (r= -0.252, p = 0.018 for right ABI), and hsCRP (r = -0.280, p = 0.011 for right ABI; r = -0.402, p <0.001 for left ABI); whereas other risk factors like obesity based on waist circumference and BMI,non-supine systolic blood pressure, fasting blood glucose, HbA1C, duration of diabetes, plasma lipidsdid not show statistically significant different odd ratios. After linear regression test for risk factorshaving significant correlations with ABI, age and hsCRP were found to influence the ABI scores.Based on a case-control study, risk factors which, to some extent, had statistically significant valuesas risk factors, include older age (? 70 years old; OR = 7.737 [CI = 2.515-23.805]; p < 0.001),relatively high supine diastolic blood pressure (? 90 mmHg; OR = 6.882 [CI = 0.789-60.060]; p =0.048), and high concentration of hsCRP (> 3 mg/L; OR = 4.420 [CI = 1.287-15.181]; p = 0.013).Among these statistically significant risk factors, after logistic regression test analysis, only the age ofthe patient appeared to have significant influence on the prevalence of PAD.In conclusion, this study demonstrates a negative correlation between hsCRP and ABI score;and high levels of hsCRP appeared to be a risk factor for PAD. The age of the patient, however,appeared to be the strongest risk factor for PAD.

Garlic for the prevention of cardiovascular morbidity and mortality in hypertensive patients

Garlic is widely used by patients for its blood pressure lowering effects. A meta-analysis published in 2008 concluded that garlic consumption lowers blood pressure in hypertensive and normotensive patients. Therefore, it is important to review the currently available evidence to determine whether garlic may also have a beneficial role in the reduction of cardiovascular events and mortality rates in patients with hypertension. To determine whether the use of garlic as monotherapy, in hypertensive patients, lowers the risk of cardiovascular morbidity and mortality compared to placebo. A systematic search for trials was conducted in the Cochrane Hypertension Group Specialised Register, CENTRAL, MEDLINE, EMBASE, AGRICOLA, AMED, and CINAHL up to November 2011. A hand search of reference lists of identified reviews was conducted. Experts in the area were also contacted to identify trials not found in the electronic search. Clinicaltrials.gov was searched for ongoing trials. Randomized, placebo-controlled trials of any garlic preparation versus placebo for the treatment of hypertension were included. Two reviewers independently extracted data and assessed trial quality using the risk of bias tool. Data synthesis and analysis was performed using RevMan 5. The search identified two randomized controlled trials for inclusion. One trial included 47 hypertensive patients and showed that garlic significantly reduces mean supine systolic blood pressure by 12 mmHg (95% CI 0.56 to 23.44 mmHg, p=0.04) and mean supine diastolic blood pressure by 9 mmHg (95% CI 2.49 to 15.51 mmHg, p=0.007) versus placebo. The authors state that garlic was "free from side effects" and that no serious side effects were reported. There were 3 cases "where a slight smell of garlic was noted."The second trial could not be meta-analysed as they did not report the number of people randomized to each treatment group. They did report that 200 mg of garlic powder given three times daily, in addition to hydrochlorothiazide-triamterene baseline therapy, produced a mean reduction of systolic blood pressure by 10-11 mmHg and of diastolic blood pressure by 6-8 mmHg versus placebo.Neither trial reported clinical outcomes and insufficient data was provided on adverse events. There is insufficient evidence to determine if garlic provides a therapeutic advantage versus placebo in terms of reducing the risk of mortality and cardiovascular morbidity in patients diagnosed with hypertension. There is also insufficient evidence to determine the difference in withdrawals due to adverse events between patients treated with garlic or placebo.Based on 2 trials in 87 hypertensive patients, it appears that garlic reduces mean supine systolic and diastolic blood pressure by approximately 10-12 mmHg and 6-9 mmHg, respectively, over and above the effect of placebo but the confidence intervals for these effect estimates are not precise and this difference in blood pressure reduction falls within the known variability in blood pressure measurements. This makes it difficult to determine the true impact of garlic on lowering blood pressure.

Sympathetic neural and hemodynamic responses to upright tilt in elderly African Americans versus Caucasians

It has been demonstrated that neural control of blood pressure (BP) is different in young African Americans (AA) and Caucasians (CAU). Whether this is also true in elderly people is unclear. We tested the hypothesis that elderly AA have enhanced sympathetic neural responses during orthostasis compared with elderly CAU. Muscle sympathetic nerve activity (MSNA), BP, and heart rate (HR) were recorded continuously, cardiac output (Qc, C2H2 rebreathing), stroke volume (SV=Qc/HR) and total peripheral resistance (TPR=mean BP/Qc) were measured intermittently supine and during 5‐min 60‐degree upright tilt in 10 AA [6 M, 4F; 65±4 (SD) yrs] and 15 CAU (9M, 6 F; 67±4 yrs). AA and CAU had similar supine (44±10 vs 42±8 bursts/min) and upright MSNA burst frequency (59±11 vs 60±11 bursts/min; P=0.98 for race, <0.01 for posture, 0.58 for interaction). However, upright total MSNA was smaller in AA than CAU (162±39 vs 248±126%; P<0.01). Systolic BP, HR, Qc and SV were not different between groups in the supine position and during upright tilt. Supine diastolic BP was similar between groups (66±7 vs 65±8 mmHg; P=0.76), but upright diastolic BP was greater in AA than CAU (80±10 vs 71±8 mmHg; P=0.02). TPR did not differ between AA and CAU in both supine (1536±295 vs 1741±401 dyn·s·cm−5) and upright postures (2490±555 vs 2522±886 dyn·s·cm−5; P=0.47 for race, <0.01 for posture, 0.71 for interaction). These results suggest that elderly African Americans have a blunted sympathetic neural responsiveness but enhanced blood pressure reactivity during orthostasis compared with elderly Caucasians, which may be attributable to an augmented sympathetic vascular transduction.Supported by NIH R01 HL091078.

Influence of Body Positions on Blood Pressure Measurements in Hypertensive Patients

To study the effects of body positions on blood pressure (BP) measurements in hypertensive patients and possible influencing factors. Using a standard mercury sphygmomanometer (CBP) and ambulatory blood pressure monitoring (ABP), standing, sitting and supine BP measurements were carried out in turn in 334 hospitalized hypertensive patients after they kept each of the above body positions for 2 hours. During the testing, BP was taken by ABP every 15 minutes and by CBP at the end of each posture period. Systolic blood pressure (SBP) measured by ABP was similar among all 3 positions. However, diastolic blood pressure (DBP) measured by ABP was significantly lower in supine position compared to standing and sitting positions (P<0.05). SBP measured by CBP was higher in supine position compared to standing and sitting positions (P<0.05), but DBP was lower in supine position than standing and sitting positions (P<0.05). Except supine DBP, BP measured by ABP was significantly higher than CBP measurements in standing, sitting and supine positions (P<0.05). Multivariate regression analysis showed that the duration of hypertension, gender and fasting plasma glucose (FPG) were independent factors of SBP variation (P<0.05), while age and cholesterol were independent predictors for DBP variation (P<0.05). Body positions contribute to variations of BP measurements in hypertensive patients. Hypertension duration, gender and FBG affect SBP variations while age and cholesterol affect DBP variations.

Influence of the neurological level of spinal cord injury on cardiovascular outcomes in humans: a meta-analysis

Although motor and sensory deficits following spinal cord injury (SCI) are well known, there are still contrasting reports on how SCI affects baseline cardiovascular (CV) parameters and other autonomic functions. Meta-analysis is performed. To examine the effect of injury level on supine and seated CV function in individuals with SCI. A total of 98 studies representing 1968 individuals were retrieved for analysis. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were abstracted from the studies and compared between four groups according to the neurological lesion level, cervical (C) SCI (C4-C8), high-thoracic (HT) SCI (T1-T6), low-thoracic lumbar (LTL) SCI (below T6) and able-bodied (AB) controls. In the supine position, SBP, DBP and HR were lower in C compared with HT, LTL and AB (all P<0.04). In the seated position, SBP and DBP were significantly lower in C compared with LTL and AB (all P<0.003) and HR was significantly lower in C compared with LTL only (P=0.01). A final finding was that C exhibited a lower resting SBP in the seated compared with the supine position (P<0.001). Individuals with SCI exhibit a lesion-dependent impairment in resting CV function, whereby those with the highest injury had the greatest degree of CV dysfunction. A further finding was that individuals with a C injury exhibited a lower resting SBP in the seated vs supine position. Thus, clinicians and researchers should consider lesion level and body position when measuring and interpreting CV parameters in individuals with SCI.

Effects of a home‐based exercise program on metabolic risk factors and fitness in long‐term survivors of childhood acute lymphoblastic leukemia

Long-term survivors of childhood acute lymphoblastic leukemia (ALL) have increased risk of cardiovascular disease (CVD). The prevalence of insulin resistance and other cardiometabolic risk factors is increased in ALL survivors, and insufficient physical activity (PA) and low cardiopulmonary fitness are common. The purpose of this study was to evaluate the effects of a simple, inexpensive home-based exercise program on cardiometabolic risk factors and fitness in long-term ALL survivors. Seventeen 16- to 30-year-old survivors of childhood ALL (age at diagnosis ≤16 years) were recruited to a 16-week home-based exercise program. Peak oxygen uptake (VO(2 peak)), muscle strength, and metabolic risk factors were studied before and after the exercise program. Fasting plasma insulin (P = 0.01), HOMA-IR (homeostasis model assessment, insulin resistance) (P = 0.002), waist circumference (P = 0.003), waist-to-hip ratio (P = 0.002), fat percent (P = 0.04), and supine diastolic blood pressure (P = 0.03) decreased during the program, while weight and body mass index remained unchanged. VO(2 peak) and maximal work load (W/kg) improved by 5% (P = 0.01 and P = 0.02, respectively) during the exercise program. The results of the Sit-Up test, Back extensor test, and Full Squatting test improved as well (P = 0.01, P = 0.002, and P = 0.0004, respectively). A simple home-based exercise program was effective in improving cardiometabolic risk factor status and fitness in young adult survivors of childhood ALL. Simple exercise programs should be recommended to this population with increased risk of CVD to improve metabolic risk factor status and fitness.

The effect of oral alpha-lipoic acid in overweight/obese individuals on brachial-ankle pulse wave velocity and supine blood pressure: a randomized, crossover, double-blind, placebo-controlled trial

To investigate the effect of oral alpha-lipoic acid (ALA) supplement on brachial-ankle pulse wave velocity (baPWV), supine systolic blood pressure (SBP) and diastolic blood pressure (DBP) in overweight/obese individuals. An 8-week double-blind, randomized, placebo-controlled and cross-over trial with a 4-week washout between cross-over periods. Sixty-three males and 40 females aged 22 - 57 years old who met the inclusion criteria as (1) Han ethnicity; (2) 20 - 60 years old; (3) BMI ≥ 25 kg/m(2) and having at least one of the following risk factors: borderline hypertension (130 mm Hg ≤ SBP < 140 mm Hg and/or 85 mm Hg ≤ supine DBP< 90 mm Hg), dyslipidemia (fasting total cholesterol ≥ 5.2 mmol/L or HDL-C < 1.04 mmol/L), or impaired fasting glucose (6.1 mmol/L ≤ fasting glucose < 7.0 mmol/L); (4) Not on any antioxidant vitamin supplement. They were randomly assigned to Group 1 or Group 2 in a 1:1 ratio balanced for gender. Group 1 received 8 weeks ALA (1200 mg/day) followed by 4-week washout period and followed by another 8 weeks placebo; while Group 2 received 8 weeks placebo (1200 mg/day) followed by 4-week washout period, and followed by ALA treatment for 8 weeks. BaPWV and supine blood pressure were measured at the beginning of 1(st) phase and 2(nd) phase and at the endpoint of the whole trial. Mixed effect linear regression model was performed to compare the change of baPWV and supine blood pressure between ALA group and placebo group. BaPWV decreased -33.03 cm/s ± 130.70 cm/s for ALA group and increased 5.66 cm/s ± 139.89 cm/s for placebo group, supine systolic blood pressure decreased -4.09 mm Hg ± 9.18 mm Hg for ALA group and -2.32 mm Hg ± 8.16 mm Hg for placebo group. Supine diastolic blood pressure decreased -1.29 mm Hg ± 6.55 mm Hg for ALA group and -0.48 mm Hg ± 6.63 mm Hg for placebo group. These three mix-effect models did not show significant effect of ALA treatment after adjustment on baseline values, sex, age, treatment sequence or period. The current trial did not provide evidence that oral intake of ALA for 8 weeks had significant effects on lowering baPWV, supine systolic blood pressure or supine diastolic blood pressure.

Orthostatic tolerance is difficult to predict in recurrent syncope patients

We tested the hypothesis that detailed anthropometric and hemodynamic measurements predict orthostatic tolerance in neurally mediated syncope patients. In addition, we tested whether orthostatic tolerance is related to syncope frequency in real life. Earlier studies in patients with neurally mediated syncope suggested that orthostatic heart rate and blood pressure responses predict the tilt table responses with high sensitivity and specificity. We analyzed data from 157 consecutive patients (n=100 exploratory cohort, n=57 confirmatory cohort) with recurrent syncope in whom orthostatic tolerance was quantified as the time to (pre)syncope during head-up tilt testing combined with lower body negative pressure. We measured heart rate, brachial blood pressure, cardiac stroke volume, heart rate and blood pressure variability, and spontaneous baroreflex sensitivity supine and early during head-up tilt. The orthostatic heart rate increase showed the strongest correlation with orthostatic tolerance. The best multivariate model including age, supine diastolic blood pressure, supine blood pressure variability, as well as tilt-induced changes in diastolic blood pressure and heart rate explained no more that 40% of the variability in orthostatic tolerance. The model failed to predict orthostatic tolerance in the confirmatory cohort. Frequency or number of free-living syncopal episodes were only weakly related to orthostatic tolerance. In patients with neurally mediated syncope, orthostatic tolerance in the clinical laboratory is difficult to predict with a wide range of anthropometric and cardiovascular measurements and correlates poorly with syncope occurrence in real life.

Nebivolol in Obese and Non‐Obese Hypertensive Patients

Use of beta-blockers in hypertensive obese patients remains controversial because of concerns about potential influences on weight, lipids, and glucose metabolism. The authors examined a pooled analysis of 3 multicenter randomized placebo-controlled trials. Patients were randomized to placebo or an increasing dose of nebivolol for 12 weeks. Primary outcome was the mean baseline to end point change in trough mean sitting diastolic blood pressure (SiDBP). Secondary outcomes were baseline to end point changes in trough sitting systolic blood pressure (SiSBP); trough standing and peak supine diastolic blood pressure and systolic blood pressure. Nebivolol reduced SiDBP significantly compared with placebo at all doses > or =2.5 mg in obese and non-obese patients. Reductions in SiSBP with nebivolol were higher than controls at all studied doses > or =5 mg in non-obese and > or =2.5 mg in obese patients. These findings and nebivolol's neutral effects on lipid and carbohydrate metabolism suggest that it is one option for blood pressure control in the moderately obese population.

Seating-Induced Postural Hypotension Is Common in Older Patients with Decompensated Heart Failure and May Be Prevented by Lower Limb Compression Bandaging

Background: Postural hypotension induced by transition from supine to sitting position and measures for its prevention in heart failure has not been investigated. Objective: Our purpose was to evaluate the prevalence of postural hypotension and associated clinical manifestations as well as the contribution of various risk factors for postural hypotension on transition from lying to sitting in older patients with decompensated heart failure, and to study the eventual preventive effect of leg bandaging. Methods: Seating-induced postural hypotension (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic blood pressure fall) was assessed on the first study day in 108 patients aged ≥60 years, hospitalized for acutely decompensated heart failure. On the next day, in patients manifesting postural hypotension, compression bandages were applied along both legs before seating. Blood pressure, heart rate, O₂ saturation, and the occurrence of dizziness or palpitations were recorded prior to and 1, 3 and 5 min following seating. Results: Postural hypotension occurred in 49.1% of patients. Dizziness and/or palpitations manifested in 25%. Diastolic (36.1%) versus systolic (23.1%) postural hypotension prevailed (p = 0.05). On univariate analysis, postural hypotension was associated with female sex (p = 0.03), more severe heart failure (p = 0.05), longer bedrest (p = 0.04), higher supine systolic (p = 0.01) or diastolic (p = 0.002) blood pressure, nonischemic heart failure (p = 0.002), and not using nitrates (p = 0.01). On multivariate analysis, longer bedrest (OR = 1.58, 95% CI = 1.13–2.2, p < 0.001), higher supine diastolic blood pressure (OR = 1.33, 95% CI = 1.1–1.61, p = 0.001), and nonischemic heart failure (OR = 3.48, 95% CI = 1.4–8.63, p = 0.009) were the most predictive of postural hypotension. Compression bandages prevented postural hypotension in 21 of 49 patients and decreased the degree of postural blood pressure fall (p < 0.001). Conclusion: Seating-induced postural hypotension is common among older inpatients with decompensated heart failure, especially with longer bedrest, higher supine diastolic blood pressure and non-ischemic etiology. Leg compression bandaging may be useful for the prevention of postural hypotension in these patients.

Pooled analysis of the safety and tolerability of desvenlafaxine Succinate compared with placebo in the treatment of major depressive disorder

Objective:To characterize the safety and tolerability of desvenlafaxine succinate (DVS) in patients with major depressive disorder (MDD).Methods:Pooled data from 7 double-blind, placebo-controlled studies were analyzed. Adult outpatients with DSM-IV MDD received DVS or placebo for 8 weeks. Four studies employed flexible dosing of DVS (100-200mg/d [1 study]; 200-400mg/d [3 studies]); 3 studies evaluated fixed doses (100/200/400mg/d [1 study]; 200/400mg/d [2 studies]). Vital signs and treatment-emergent adverse events (TEAEs) were evaluated. In the fixed-dose subset of studies, dose-related effects were analyzed.Results:The overall safety population consisted of 2014 patients (DVS: n=1211; placebo: n=803); 60% were women. Adverse events were responsible for discontinuations in 4% of placebo-treated patients and 15% of DVS-treated patients. Discontinuation rates increased with dose (10% with 100mg/d to 17% with 400mg/d) in the subset of fixed-dose studies. TEAEs were consistent with the serotonin-norepinephrine reuptake inhibitor (SNRI) class. Nausea was generally mild to moderate with a median duration less than or = to 6 days; the incidence decreased to placebo-like rates after week 1. With all doses of DVS, small but statistically significant changes in mean blood pressure were observed. Mean changes in pulse rate and the proportion of potentially clinically important increases in sustained elevations in supine diastolic blood pressure were higher for patients receiving 200/400mg/d than among placebo-treated subjects; values for these parameters with the 100mg/d dose did not differ from placebo.Conclusions:DVS treatment exhibited a safety and tolerability profile that was generally consistent with the SNRI class.

The hemodynamic and neurohumoral phenotype of postural tachycardia syndrome

Previous studies of patients with postural tachycardia syndrome (POTS) have been hampered by relatively small cohorts, failure to control medications and diet, and inconsistent testing procedures. The Vanderbilt Autonomic Dysfunction Center Database provided results of posture studies performed in 165 patients and 66 normal controls after dietary and medication restrictions. All posture studies were performed after an overnight fast and > or =30 minutes of supine rest. In both the supine and standing positions, heart rate (HR) and plasma concentrations of norepinephrine (NE), epinephrine, and dopamine were higher in patients with POTS compared with the healthy controls. Supine diastolic blood pressure (BP) was also elevated in POTS, whereas supine plasma l-3,4-dihydroxyphenyalanine was reduced. In an analysis of patient subgroups with either an upright plasma NE > or = 3.54 nM (high NE) or an upright plasma NE < 3.54 nM (normal NE), HR and BP were greater in the patient subgroup with high NE. In addition to these significant differences in hemodynamic and catechol measurements, we demonstrated that supine and standing plasma aldosterone and the aldosterone/renin ratio were decreased in patients with POTS. Plasma renin activity (PRA) tended to be higher in patients, and standing HR for those in the highest PRA quartile was significantly greater than for those in the lowest PRA quartile. Our results from larger cohorts of patients and controls than previously studied confirm published findings and contribute additional evidence of sympathetic activation in postural tachycardia syndrome (POTS). Abnormalities in the renin-angiotensin-aldosterone system may also contribute to the POTS phenotype.

Predicting outcomes on head-up tilt based on orthostatic hypotension patterns

To assess the frequency of different orthostatic hypotension (OH) patterns in patients having supine hypertension with OH ('SHOH') versus patients with OH and normal supine blood pressure ('OH alone'); and to relate OH patterns with outcomes on head-up tilt. Consecutive patients with nonspecific dizziness were studied with a 10-min supine, 30-min head-up tilt test. Supine hypertension was diagnosed when supine systolic blood pressure (SBP) was at least 140 mmHg and/or supine diastolic blood pressure was at least 90 mmHg. OH was defined as SBP reduction of at least 20 mmHg within 3 min of tilt. OH patterns were identified corresponding to SBP time-curves during the initial 5 min of tilt: progressive, sustained and transient patterns. Among 400 patients tested, 31 had 'SHOH' and 39 had 'OH alone'. Frequencies of OH patterns were similar in both groups. The progressive OH pattern predicted symptomatic hypotension, leading to early tilt termination in all 'SHOH' and 88% of 'OH alone' patients. In comparison, tilt was early terminated in 33-48% of patients with sustained OH, transient OH and without OH. Early tilt termination was unrelated to age, gender, magnitude of supine SBP, pulse pressure and nadir SBP within 5 min tilt. Five minutes of postural challenge permitted assessing OH patterns. Outcome on protracted tilt was related to OH patterns, the worse outcome being likened to progressive OH, both in patients with 'SHOH' and in patients with 'OH alone'. Future studies will show whether OH patterns may serve as guidance for blood pressure therapy in selected patients.

Assessment of orthostatic hypotension in the emergency room

The study sought to determine the duration of standing needed to detect most cases of orthostatic hypotension (OH) in the emergency room (ER) and to correlate OH with symptoms, hospitalization and survival. Patients attending a tertiary‐center ER within a 2‐month period underwent orthostatic tests after 1, 3 and 5 min of standing. OH was defined as a drop of ⩾20 mmHg in systolic pressure or ⩾10 mmHg in diastolic pressure on assuming an upright posture. Of the 814 patients tested (402 men, mean age 56.6±19.9 years), 206 (25.3%) had OH, detected in most cases (83.5%) after 3 min of standing. OH was associated with significantly higher supine systolic (p = 0.013) and diastolic (p = 0.004) blood pressure, symptoms of syncope (r = 0.11, p<0.001) or dizziness (r = 0.14, p<0.0001) and risk of hospitalization (50.9% vs 22.9%, p<0.0001). Crude mortality was similar between patients with and without OH (13.8% vs 8.7%, p = 0.06). However, on age‐adjusted analysis, patients older than 75 years with OH had significantly increased mortality (p = 0.04). In conclusion, 3 min of standing is apparently sufficient for the diagnosis of most cases of OH. Considering the high rate of OH and its predictive value for hospitalization, it should be routinely assessed in all ER patients.

E.02.01 Psychopharmaca in the management of the consequences of disasters

This article reviews the cardiovascular effects of antidepressants drugs. Tricyclic antidepressants (TCAs) have the most significant cardiovascular side effects of any of the antidepressant agents. TCA side effects may be particularly burdensome or even life-threatening in patients with preexisting cardiovascular disease. Orthostatic hypotension is the most common cardiovascular side effect, and conduction disturbances and ventricular arrhythmias are the most life-threatening ones. TCAs' quinidine-like effects account for these conduction and rhythm disturbances. Monoamine oxidase inhibitors (MAOIs) commonly induce orthostatic hypotension. Hypertensive crises and the serotonin syndrome are the most serious problems associated with MAOI administration. MAOIs require dietary and concomitant drug restrictions to minimize adverse effects. Rarely, spontaneous severe hypertension may occur during MAOI administration. Bupropion administration may increase patients' blood pressure, particularly in those with preexisting hypertension. Trazodone may provoke ventricular arrhythmias. Nefazodone and the selective serotonin reuptake inhibitors (SSRIs) may contribute to drug-drug interactions that have significant cardiovascular adverse effects as a part of those interactions. Also, concomitant administration of SSRIs and MAOIs may produce the serotonin syndrome and vasomotor instability. Venlafaxine may increase supine diastolic blood pressure. According to the manufacturer, subjects taking this agent require blood pressure monitoring. Considering what we know about all antidepressants, periodic blood pressure assessment should be a routine part of the practice of psychiatry.

Nonspecific dizziness: frequency of supine hypertension associated with hypotensive reactions on head-up tilt

The clinical syndrome of supine hypertension associated with orthostatic hypotension (OH) in given individuals is recognized by specialists, but is underdiagnosed in the community. The objective of this study was to assess supine hypertension associated with hypotensive reactions on head-up tilt (SH-HRT) among patients evaluated for nonspecific dizziness. Consecutive patients with nonspecific dizziness were studied with a 10-min supine 30-min head-up tilt test. Supine hypertension (SH) was diagnosed when supine systolic blood pressure (SBP) was > or = 140 mmHg and/or supine diastolic blood pressure (DBP) was > or = 90 mmHg. Hypotensive reactions on tilt (HRT) were diagnosed when SBP decreased by > or = 30 mmHg on tilt and/or DBP decreased by > or = 15 mmHg. Of 430 patients tested, 42 (9.8%) had SH-HRT. The median age was 67 years; 37 had a pretest diagnosis of hypertension, with treatment. The median supine BP was 162/90 mmHg; the median nadir BP on tilt was 118/78 mmHg. Four SH-HRT patterns were recognized: (I) SH with typical neurogenic OH (n = 6), (II) SH with vasovagal reaction on tilt (n = 4), (III) SH with sustained HRT (n = 28), and (IV) SH with mixed orthostatic-vasovagal reaction on tilt (n = 4). Dizziness on tilt occurred in 25% of patients category III (SH with sustained HRT), while appearing universally in other SH-HRT patterns. In conclusion, nonspecific dizziness may be the chief complaint in patients with SH-HRT, a disorder often unrecognized by clinicians. Different patterns of SH-HRT on HUTT may reflect different aberrations in cardiovascular homeostasis and may require differentiated management strategies.

Randomized Trial of Sertraline Versus Venlafaxine XR in Major Depression

The comparative efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) was recently debated. Meta-analyses, based mainly on fluoxetine comparator data, suggest that the SNRI venlafaxine has superior efficacy to SSRIs in treatment of major depression. To compare quality of life (QOL), efficacy, safety, and tolerability associated with sertraline and venlafaxine extended release (XR) for treatment of DSM-IV major depression. This was an 8-week, double-blind, randomized study of sertraline (50-150 mg/day) versus venlafaxine XR (75-225 mg/day), followed by a 2-week taper period. Subjects were recruited from 7 sites in Turkey and 6 sites in Australia between October 2002 and July 2003. The primary outcome measure was the Quality of Life Enjoyment and Satisfaction Questionnaire. Secondary outcome measures included measures of depression (including response and remission), anxiety, pain, safety (e.g., blood pressure), and tolerability (e.g., discontinuation symptoms). A total of 163 subjects received study treatment (women, 69%; mean age, 37.0 [SD = 12.9] years). No significant differences in QOL or efficacy were noted between treatments on the primary or secondary endpoints for the total study population or the anxious depression and severe depression subgroups. A priori analyses of symptoms associated with treatment discontinuation demonstrated no difference between treatment groups. However, in post hoc analyses, sertraline was associated with less burden of moderate to severe discontinuation symptoms. Venlafaxine XR was associated with a relative increase in mean blood pressure (supine diastolic blood pressure, -4.4 mm Hg difference at week 8/last observation carried forward). Sertraline and venlafaxine XR demonstrated comparable effects on QOL and efficacy in treatment of major depression, although sertraline may be associated with a lower symptom burden during treatment discontinuation and a reduced risk of blood pressure increase.