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The clinical assessment of orthostatic hypotension

Published online by Cambridge University Press:  20 July 2010

Karl R Davis*
Affiliation:
University Hospital of Wales, Cardiff, UK
*
Address for correspondence: Dr Karl Davis, c/o C7 Office, University Hospital of Wales, Heath Park, Cardiff CF14 4XW. Email: [email protected]

Summary

Orthostatic hypotension is a common condition seen in up to one-third of community-dwelling and two-thirds of hospitalized older people. It is part of a spectrum of abnormal cardiovascular responses to postural challenge and is associated with syncope, dizziness, falls, volume depletion, drug side-effects and an increased mortality. This article discusses the current classification of orthostatic hypotension and related conditions, and the clinical importance of the control of the cardiovascular response to orthostasis. These are considered with particular reference to the measurement of postural cardiovascular responses in the routine clinical setting. By improving understanding of the methods that are used for assessment of postural changes in blood pressure, clinicians should have greater confidence in the reliability of measurement and in their interpretation.

Type
Clinical geriatrics section
Copyright
Copyright © Cambridge University Press 2010

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References

1Fedorowski, A, Stavenow, L, Hedblad, B, Berglund, G, Nilsson, PM, Melander, O.Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project). Eur Heart J 2010; 31: 8591.CrossRefGoogle ScholarPubMed
2Alli, C, Avanzini, F, Bettelli, G et al. Prevalence and variability of orthostatic hypotension in the elderly. Results of the ‘Italian study on blood pressure in the elderly (SPAA)’. Eur Heart J 1992; 13: 178–82.CrossRefGoogle Scholar
3Räihä, I, Luutonen, S, Piha, J, Seppänen, A, Toikka, T, Sourander, L.Predisposing factors, and prognostic importance of postural hypotension. Arch Intern Med 1995; 155: 930–35.CrossRefGoogle ScholarPubMed
4Luukinen, H, Koski, K, Laippala, P, Kivela, SL.Prognosis of diastolic and systolic orthostatic hypotension in older persons. Arch Int Med 1999; 159: 273–80.CrossRefGoogle ScholarPubMed
5Vloet, LC, Pel-Little, RE, Jansen, PA, Jansen, RW.High prevalence of postprandial and orthostatic hypotension among geriatric patients admitted to Dutch hospitals. J Gerontol A Biol Sci Med Sci 2005; 60: 1271–77.CrossRefGoogle ScholarPubMed
6Weiss, A, Grossman, E, Beloosesky, Y, Grinblat, J.Orthostatic hypotension in acute geriatric wards: is it a consistent finding? Arch Intern Med 2002; 162: 2369–74.CrossRefGoogle Scholar
7Gorelik, O, Fishlev, G, Litvinov, V, Almoznino-Sarafian, D, Alon, I, Shteinshnaider, M, Chachashvily, S, Modai, D, Cohen, N.First morning standing up may be risky in acutely ill older inpatients. Blood Pressure 2005; 14: 139–43.CrossRefGoogle ScholarPubMed
8Belmin, J, Abderrhamane, M, Medjahed, S, Sibony-Prat, J, Bruhat, A, Bojic, N, Marquet, T.Variability of blood pressure response to orthostatism and reproducibility of the diagnosis of orthostatic hypotension in elderly subjects. J Gerontol A Biol Sci Med Sci 2000; 55: M66771.CrossRefGoogle ScholarPubMed
9Shin, C, Abbott, RD, Lee, H, Kim, J, Kimm, K.Prevalence and correlates of orthostatic hypotension in middle-aged men and women in Korea: the Korean Health and Genome Study. J Hum Hypertens 2004; 18: 717–23CrossRefGoogle ScholarPubMed
10Mathias, CJ, Bannister, R.Investigations of Autonomic Disorders in Autonomic Failure, ed. Bannister, R, Mathias, CJ, 3rd edn.New York: Oxford University Press, 1992; pp. 255–90.Google Scholar
11Rutan, GH, Hermanson, B, Bild, DE, Kittner, SJ, LaBaw, F, Tell, GS.Orthostatic hypotension in older adults: the cardiovascular health study. Hypertension 1992; 19: 508–19.CrossRefGoogle ScholarPubMed
12Masaki, KH, Schatz, IJ, Burchfiel, CM, Sharp, DS, Chiu, D, Foley, D, Curb, JD.Orthostatic hypotension predicts mortality in elderly men: the Honolulu Heart Program. Circulation 1998; 98: 2290–95.CrossRefGoogle ScholarPubMed
13Luukinen, H, Airaksinen, KE.Orthostatic hypotension predicts vascular death in older diabetic patients. Diabetes Res Clin Pract 2005; 67: 163–66.CrossRefGoogle ScholarPubMed
14Tilvis, RS, Hakala, SM, Valvanne, J, Erkinjuntti, T.Postural hypotension and dizziness in a general aged population: a four-year follow-up of the Helsinki Aging Study. J Am Geriatr Soc 1996; 44: 809–14.CrossRefGoogle Scholar
15Sasaki, O, Nakahama, H, Nakamura, S, Yoshihara, F, Inenaga, T, Yoshii, M, Kohno, S, Kawano, Y.Orthostatic hypotension at the introductory phase of haemodialysis predicts all-cause mortality. Nephrol Dial Transplant 2005; 20: 377–81.CrossRefGoogle ScholarPubMed
16NICE. Clinical Guideline 21 Falls: The Assessment and Prevention of Falls in Older People. London: NICE, 2004 (also available from: http://www.nice.org.uk/CG021NICEguideline).Google Scholar
17NICE. Clinical Guideline 34 Hypertension: Management of hypertension in adults in primary care (partial update) London: NICE, 2006 (also available from: http://www.nice.org.uk/CG034NICEguideline).Google Scholar
18NICE. Clinical Guideline 35 Parkinson's Disease: National clinical guideline for diagnosis and management in primary and secondary care. Lavenham Press Ltd, Sudbury, 2006 (also available from: http://www.nice.org.uk/CG035NICEguideline).Google Scholar
19Moya, A, Sutton, R, Ammirati, F et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30: 2631–71.Google ScholarPubMed
20Ewing, DJ, Clarke, BF.Diagnosis and management of autonomic neuropathy. Br Med J 1983; 285: 916–18.CrossRefGoogle Scholar
21Ooi, WL, Barrett, S, Hossain, M, Kelley-Gagnon, M, Lipsitz, LA.Patterns of orthostatic blood pressure change and their clinical correlates in a frail, elderly population. JAMA 1997; 277: 1299–304.CrossRefGoogle Scholar
22Ward, C, Kenny, R.Reproducibility of orthostatic hypotension in symptomatic elderly. Am J Med 1996; 100: 418–22.CrossRefGoogle ScholarPubMed
23Ward, C, Kenny, RA.The reproducibility of orthostatic hypotension in the elderly presenting with postural symptoms. Age Ageing 1994; 23: 19.CrossRefGoogle Scholar
24Cooke, J, Carew, S, O'Connor, M, Costelloe, A, Sheehy, T, Lyons, D.Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension. Q J Med 2009; 102: 335–39.CrossRefGoogle Scholar
25McKay, DW, Campbell, NRC, Parab, LS, Chockalingam, A, Fodor, JG.Clinical assessment of blood pressure. J Hum Hypertens 1990; 4: 639–45.Google ScholarPubMed
26Jacob, G, Costa, F, Shannon, JR, Robertson, RM, Wathen, M, Stein, M, Biaggioni, I, Ertl, A, Black, B, Robertson, D.The neuropathic postural tachycardia syndrome. N Engl J Med 2000; 343: 1008–14.CrossRefGoogle ScholarPubMed
27Gibbons, CH, Freeman, R.Delayed orthostatic hypotension: a frequent cause of orthostatic intolerance. Neurology 2006; 67: 2832.CrossRefGoogle ScholarPubMed
28Streeten, DH, Anderson, GHJ.Delayed orthostatic intolerance. Arch Intern Med 1992; 152: 1066–72.CrossRefGoogle ScholarPubMed
29Smit, AA, Halliwill, JR, Low, PA, Wieling, W.Pathophysiological basis of orthostatic hypotension in autonomic failure. J Physiol 1999; 519: 110.CrossRefGoogle ScholarPubMed
30Low, PA (ed). Clinical Autonomic Disorders; Evaluation and Management. Little Brown Company, Boston, 1993.Google Scholar
31Mathias, CJ, Bannister, R (eds). Autonomic Failure: A Textbook of Clinical Disorders of the Autonomic System, 4th edn. Oxford University Press, New York, 1999.Google Scholar
32Grubb, BP.Neurocardiogenic syncope and related disorders of orthostatic intolerance. Circulation 2005; 111: 29973006.CrossRefGoogle ScholarPubMed
33van Lieshout, JJ, Wieling, W, Karemaker, JM, Secher, NH.Syncope, cerebral perfusion, and oxygenation. J Appl Physiol 2003; 94: 833–48.CrossRefGoogle ScholarPubMed
34Ewing, DJ, Campbell, I, Murray, A, Neilson, JMM, Clarke, B.Immediate heart-rate response to standing: simple test for autonomic neuropathy in diabetes. Br Med J 1978; 1: 145–47.CrossRefGoogle ScholarPubMed
35Task Force on Heart Rate Variability of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability: Standards of Measurement, Physiological Interpretation, and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 1996; 17: 354–81.CrossRefGoogle Scholar
36Millet, C, Custaud, MA, Maillet, A, Allevard, AM, Duvareille, M, Gauquelin-Koch, G, Gharib, C, Fortrat, JO.Endocrine responses to 7 days of head-down bed rest and orthostatic tests in men and women. Clin Physiol 2001; 21: 172–83.CrossRefGoogle ScholarPubMed
37Mathias, CJ.Orthostatic hypotension: Causes, mechanisms, and influencing factors. Neurology 1995; 45 supplement 5: S611.Google ScholarPubMed
38Akashi, YJ, Springer, J, Lainscak, M, Anker, SD.Atrial natriuretic peptide and related peptides. Clin Chem Lab Med 2007; 45: 1259–67.CrossRefGoogle ScholarPubMed
39Gupta, D, Nair, M. Neurogenic orthostatic hypotension: chasing ‘the fall’. Post Med J 2008; 84: 614.CrossRefGoogle ScholarPubMed
40Mathias, CJ.Autonomic diseases: clinical features and laboratory evaluation. J Neurol Neurosurg Psychiatry 2003; 74 suppl III: 3141.CrossRefGoogle ScholarPubMed
41Jacob, G, Shannon, JR, Black, B, Biaggioni, I, Mosqueda-Garcia, R, Robertson, RM, Robertson, D.Effects of volume loading and pressor agents in idiopathic orthostatic tachycardia. Circulation 1997; 96: 575–80.CrossRefGoogle ScholarPubMed
42AAS/AAN. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Consensus Statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology 1996; 46: 1470–71.CrossRefGoogle Scholar
43Kaufmann, H.Consensus Statement on the definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. Clin Auton Res 1996; 6: 125–26.Google ScholarPubMed
44Atkins, D, Hanusa, B, Sefcik, T, Kapoor, W.Syncope and orthostatic hypotension. Am J Med 1991; 91: 179–85.CrossRefGoogle ScholarPubMed
45Carey, BJ, Potter, JF.Cardiovascular causes of falls. Age Ageing 2001; 30 suppl 4: 1924.CrossRefGoogle ScholarPubMed
46Weiss, A, Chagnac, A, Beloosesky, Y, Weinstein, T, Grinblat, J, Grossman, E. Orthostatic hypotension in the elderly: are the diagnostic criteria adequate? J Hum Hypertens 2004; 18: 301–5.CrossRefGoogle ScholarPubMed
47Brignole, M, Alboni, P, Benditt, DG et al. Guidelines on Management (diagnosis and treatment) of Syncope – Update 2004. Europace 2004; 6: 467537 (also available at: http://www.escardio.org/NR/rdonlyres/C63F3582-4C38-401A-96D3-2933ECA984C8/0/syncopeFullEuropace04_500Kb.pdf).Google ScholarPubMed
48Carlson, JE.Assessment of orthostatic blood pressure. Southern Med J 1999; 92: 167–73.CrossRefGoogle ScholarPubMed
49Caine, SE, Alsop, K, MacMahon, M.Overlooking orthostatic hypotension with routine blood-pressure equipment. Lancet 1998; 352: 458.CrossRefGoogle ScholarPubMed
50Eigenbrodt, ML, Rose, KM, Couper, DJ, Arnett, DK, Smith, R, Jones, D.Orthostatic hypotension as a risk factor for stroke: The Atherosclerosis Risk in Communities (ARIC) Study, 19871996. Stroke 2000; 31: 2307–13.CrossRefGoogle ScholarPubMed
51Arbogast, SD, Alshekhlee, A, Hussain, Z, McNeeley, K, Chelimsky, TC.Hypotension unawareness in profound orthostatic hypotension. Am J Med 2009; 122: 574–80.CrossRefGoogle ScholarPubMed
52Lahrmann, H, Cortelli, P, Hilz, M, Mathias, CJ, Struhal, W, Tassinari, M.EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol 2006; 13: 1066–77.CrossRefGoogle ScholarPubMed
53Gibbons, CH, Freeman, R.Orthostatic dyspnea: a neglected symptom of orthostatic hypotension. Clin Autonom Res 2005; 15: 4044.CrossRefGoogle ScholarPubMed
54Shibao, C, Gamboa, A, Diedrich, A, Biaggioni, I.Management of hypertension in the setting of autonomic failure: a pathophysiological approach. Hypertension 2005; 45: 469–76.CrossRefGoogle ScholarPubMed
55Naschitz, JE, Slobodin, G, Elias, N, Rosner, I.The patient with supine hypertension and orthostatic hypotension: a clinical dilemma. Postgrad Med J 2006; 82: 246–53.CrossRefGoogle ScholarPubMed
56WAG. National Service Framework for older people in Wales. WAG, Cardiff, 2006 (also available at: http://www.wales.nhs.uk/sites3/home.cfm?orgid=439).Google Scholar
57Kenny, RA (ed). Syncope in the Older Patient, 1st edn.Chapman & Hall, London, 1996.Google Scholar
58Williams, B, Poulter, NR, Brown, MJ, Davis, M, McInnes, GT, Potter, JF, Sever, PS, McG, Thom S; British Hypertension Society. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004 – BHS IV. J Hum Hypertens 2004; 18: 139–85.CrossRefGoogle ScholarPubMed
59Chobanian, AV, Bakris, GL, Black, HR et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289: 2560–72.CrossRefGoogle ScholarPubMed
60Lance, R, Link, ME, Padua, M, Clavell, LE, Johnson, G, Knebel, A.Comparison of different methods of obtaining orthostatic vital signs. Clin Nurs Res 2000; 9: 479–91.CrossRefGoogle ScholarPubMed
61Macrae, AD, Bulpitt, CJ.Assessment of postural hypotension in elderly patients. Age Ageing 1989; 18: 110–12.CrossRefGoogle ScholarPubMed
62Gorny, DA.Arterial blood pressure measurement technique. AACN Clinical Issues 1993; 4: 6680.CrossRefGoogle ScholarPubMed
63McAlister, FA, Straus, SE.Measurement of blood pressure: an evidence based review. Br Med J 2001; 322: 908–11.CrossRefGoogle ScholarPubMed
64Netea, RT, Smits, P, Lenders, J, Thien, T.Does it matter whether blood pressure measurements are taken with subjects sitting or supine? J Hypertens 1998; 16: 263–68.CrossRefGoogle ScholarPubMed
65Fisher, AA, Davis, MW, Srikusalanukul, W, Budge, MM.Postprandial hypotension predicts all-cause mortality in older, low-level care residents. J Am Ger Soc 2005; 53: 1313–20.CrossRefGoogle ScholarPubMed
66Puisieux, F, Boumbar, Y, Bulckaen, H, Bonnin, E, Houssin, F, Dewailly, P.Intraindividual variability in orthostatic blood pressure changes among older adults: the influence of meals. J Am Geriatr Soc 1999; 47: 1332–36.CrossRefGoogle ScholarPubMed
67Irvin, DJ, White, M.The importance of accurately assessing orthostatic hypotension. Geriatric Nursing 2004; 25: 99101.CrossRefGoogle ScholarPubMed
68Gabbett, TJ, Gass, GC.Reliability of orthostatic responses in healthy men aged between 65 and 75 years. Exp Physiol 2005; 90: 587–92.CrossRefGoogle ScholarPubMed
69Vloet, LC, Smits, R, Frederiks, CM, Hoefnagels, WH, Jansen, RW.Evaluation of skills and knowledge on orthostatic blood pressure measurements in elderly patients. Age Ageing 2002; 31: 211–16.CrossRefGoogle ScholarPubMed
70Van Der Velde, N, Van Den Meiracker, AH, Stricker, BH, Van Der Cammen, TJ.Measuring orthostatic hypotension with the Finometer device: is a blood pressure drop of one heartbeat clinically relevant? Blood Pressure Monitoring 2007; 12: 167–71.CrossRefGoogle ScholarPubMed
71Cheshire, WP, Phillips, LH.Delayed orthostatic hypotension: is it worth the wait? Neurology 2006; 67: 89.CrossRefGoogle ScholarPubMed
72Jones, DA, Huwez, F.Don't forget standing blood pressure. Br Med J 2008: 336: 344.CrossRefGoogle ScholarPubMed
73Rubenstein, LZ, Robbins, A, Josephson, KR, Schulman, BL, Osterweil, D.The value of assessing falls in an elderly population: A randomized clinical trial. Ann Intern Med 1990; 113: 308–16.CrossRefGoogle Scholar