Insights into the clinical management of the syndrome of supine hypertension – orthostatic hypotension (SH-OH): The Irish Longitudinal Study on Ageing (TILDA)

Orthostatic hypotension (OH) often co-exists with hypertension. As increasing age affects baroreflex sensitivity, it loses its ability to reduce blood pressure when lying down. Therefore, supine hypertension may be an important indicator of baroreflex function. This study examines (i) the association between OH and future falls in community-dwelling older adults and (ii) if these associations persist in those with co-existing OH and baseline hypertension, measured supine and seated. Data from 1500 community-dwelling adults aged ≥65 years from The Irish Longitudinal Study on Ageing (TILDA) were used. Continuous beat-to-beat blood pressure was measured using digital photoplethysmography during an active stand procedure with OH defined as a drop in systolic blood pressure (SBP) ≥20 mmHg and/or ≥10 mm Hg in diastolic blood pressure (DBP) within 3 minutes of standing. OH at 40 seconds (OH40) was used as a marker of impaired early stabilisation and OH sustained over the second minute (sustained OH) was used to indicate a more persistent deficit, similar to traditional OH definitions. Seated and supine hypertension were defined as SBP ≥140 mm Hg or DBP ≥90 mm Hg. Modified Poisson models were used to estimate relative risk of falls (recurrent, injurious, unexplained) and syncope occurring over four year follow-up. OH40 was independently associated with recurrent (RR = 1.30, 95% CI = 1.02,1.65), injurious (RR = 1.43, 95% CI = 1.13,1.79) and unexplained falls (RR = 1.55, 95% CI = 1.13,2.13). Sustained OH was associated with injurious (RR = 1.55, 95% CI = 1.18,2.05) and unexplained falls (RR = 1.63, 95% CI = 1.06,2.50). OH and co-existing hypertension was associated with all falls outcomes but effect sizes were consistently larger with seated versus supine hypertension. OH, particularly when co-existing with hypertension, was independently associated with increased risk of future falls. Stronger effect sizes were observed with seated versus supine hypertension. This supports previous findings and highlights the importance of assessing orthostatic blood pressure behaviour in older adults at risk of falls and with hypertension. Observed associations may reflect underlying comorbidities, reduced cerebral perfusion or presence of white matter hyperintensities.

Download Full-text

Supine Hypertension Is Associated With an Impaired Cerebral Oxygenation Response to Orthostasis: Finding From The Irish Longitudinal Study on Ageing

Hypertension ◽

10.1161/hypertensionaha.121.17111 ◽

2021 ◽

Author(s):

Louise Newman ◽

John D. O’Connor ◽

Roman Romero-Ortuno ◽

Richard B. Reilly ◽

Rose Anne Kenny

Keyword(s):

Longitudinal Study ◽

Orthostatic Hypotension ◽

Sex Education ◽

Cerebral Autoregulation ◽

Near Infrared ◽

Cerebral Oxygenation ◽

Vascular System ◽

Organ Damage ◽

Antihypertensive Medications ◽

Supine Hypertension

The cerebrovascular effects of supine hypertension (SH) are still poorly understood. With aging and atherosclerosis of the vascular system, it is not uncommon for SH and non-neurogenic orthostatic hypotension to co-occur. Given evidence for end organ damage and more extreme cerebral dysfunction in those with SH-orthostatic hypotension, we hypothesized that SH would be associated with impaired cerebral autoregulation. The aim of this study was to characterize the cerebrovascular response to orthostasis. Near-infrared spectroscopy was used to quantify the cerebrovascular response. We analyzed data from Wave 3 of TILDA (The Irish Longitudinal Study on Ageing; n=2750). Cerebral oxygenation and blood pressure (BP) were monitored continuously during an active stand. Responses were modeled using multilevel mixed-effects models and adjusted for important covariates such as age, sex, education, antihypertensive medications, and comorbidities. Forty-nine percent of the sample had SH. Those with SH demonstrated an impaired BP response and a slower recovery of BP after standing, graded by severity of SH. The cerebral oxygenation response was similar for both groups, but when standardized to mean arterial BP, the response was impaired in those with SH. A deficit of −0.83% (95% CI, −0.93 to −0.74) remained after 3 minutes of standing. Our study determined that cerebral oxygenation and cerebral autoregulation are impaired in those with SH. In older patients, consideration should be given to measuring SH and screening for orthostatic hypotension. Therapeutic studies are needed to better understand the relationship between cerebral oxygenation, medications, supine BP, and orthostatic hypotension.

Download Full-text

Unobtrusive Detection of Simulated Orthostatic Hypotension and Supine Hypertension Using Ballistocardiogram and Electrocardiogram of Healthy Adults

IEEE Journal of Translational Engineering in Health and Medicine ◽

10.1109/jtehm.2018.2864738 ◽

2018 ◽

Vol 6 ◽

pp. 1-13 ◽

Cited By ~ 2

Author(s):

Isaac S. Chang ◽

Narges Armanfard ◽

Abdul Q. Javaid ◽

Jennifer Boger ◽

Alex Mihailidis

Keyword(s):

Orthostatic Hypotension ◽

Healthy Adults ◽

Supine Hypertension

Download Full-text

Is Baseline Orthostatic Hypotension Associated With a Decline in Global Cognitive Performance at 4‐Year Follow‐Up? Data From TILDA (The Irish Longitudinal Study on Ageing)

Journal of the American Heart Association ◽

10.1161/jaha.118.008976 ◽

2018 ◽

Vol 7 (19) ◽

Cited By ~ 16

Author(s):

Triona McNicholas ◽

Katy Tobin ◽

Daniel Carey ◽

Susan O'Callaghan ◽

Rose Anne Kenny

Keyword(s):

Longitudinal Study ◽

Orthostatic Hypotension ◽

Cognitive Performance

Download Full-text

603 CHALLENGES IN THE MANAGEMENT OF SEVERE ORTHOSTATIC HYPOTENSION ASSOCIATED WITH SUPINE HYPERTENSION IN A PATIENT WITH AUTONOMIC DYSFUNCTION ON BACKGROUND OF NASOPHARYNGEAL CARCINOMA AND TYPE II DIABETES MELLITUS

Age and Ageing ◽

10.1093/ageing/afab119.16 ◽

2021 ◽

Vol 50 (Supplement_2) ◽

pp. ii14-ii18

Author(s):

Q M N Rachel ◽

K Mamun ◽

M H Nguyen

Keyword(s):

Blood Pressure ◽

Nasopharyngeal Carcinoma ◽

Orthostatic Hypotension ◽

Carotid Sinus ◽

Blood Pressure Monitoring ◽

Pharmacological Interventions ◽

Supine Hypertension ◽

Neck Irradiation ◽

Baroreflex Failure

Abstract Introduction Combined chemotherapy and radiotherapy increases long term survival in patients with nasopharyngeal carcinoma. However, radiotherapy of the carotid sinus or brain stem can evolve labile hypertension and orthostatic intolerance from chronic baroreflex failure. Diabetes would also cause this neuropathy. Management of patients with Supine hypertension-Orthostatic hypotension can be very challenging. Methods A case report was done on a 71-year-old man with metastatic nasopharyngeal carcinoma status post radiation therapy who was admitted with severe supine hypertension-orthostatic hypotension. Patient was managed with both non-pharmacological and pharmacological methods, and monitored for postural symptoms, complications of severe supine hypertension—which has been linked to left ventricular hypertrophy and kidney dysfunction, and placed on 24 hour ambulatory blood pressure monitoring to aid in management so as to prevent hypertension induced organ damage. Results This review outlines the pathophysiology of Supine hypertension-Orthostatic hypotension, treatment complications and potential management strategies recommendations for this group of patients. It revealed the benefit of having a 24 hour ambulatory blood pressure monitoring, which provides insight on the timing and magnitude of an individual’s blood pressure fluctuations throughout the day so as to further guide management. Conclusion Chronic baroreflex failure is a late sequela of neck irradiation for naso-pharyngeal carcinoma due to accelerated atherosclerosis in the region of the carotid sinus baroreceptor. Treatment goal is achieved with adequate control of pre-syncopal symptoms and prevention of long term complications. Non-pharmacological interventions remain the first line of therapy, followed by pharmacological interventions as necessary. Nonetheless, management of blood pressure in these elderly patients with baroreflex dysfunction remains challenging and should be individualized. Moving forward, a prospective study on the incidence of late onset, iatrogenic baroreflex failure as a late complication of neck irradiation and its particular relationship to carotid arterial rigidity should be conducted to increase awareness, timely diagnosis and management of the condition among physicians.

Download Full-text

Standing and Supine Blood Pressure Outcomes Associated With Droxidopa and Midodrine in Patients With Neurogenic Orthostatic Hypotension: A Bayesian Meta-analysis and Mixed Treatment Comparison of Randomized Trials

Annals of Pharmacotherapy ◽

10.1177/1060028018786954 ◽

2018 ◽

Vol 52 (12) ◽

pp. 1182-1194 ◽

Cited By ~ 7

Author(s):

Jack J. Chen ◽

Yi Han ◽

Jonathan Tang ◽

Ivan Portillo ◽

Robert A. Hauser ◽

...

Keyword(s):

Blood Pressure ◽

Orthostatic Hypotension ◽

Fixed Effects ◽

Randomized Trials ◽

Meta Analysis ◽

Mixed Treatment Comparison ◽

Neurogenic Orthostatic Hypotension ◽

Supine Hypertension ◽

Treatment Comparison ◽

Mixed Treatment

Background: The comparative effects of droxidopa and midodrine on standing systolic blood pressure (sSBP) and risk of supine hypertension in patients with neurogenic orthostatic hypotension (NOH) are unknown. Objective: To perform a Bayesian mixed-treatment comparison meta-analysis of droxidopa and midodrine in the treatment of NOH. Methods: The PubMed, CENTRAL, and EMBASE databases were searched up to November 16, 2016. Study selection consisted of randomized trials comparing droxidopa or midodrine with placebo and reporting on changes in sSBP and supine hypertension events. Data were pooled to perform a comparison among interventions in a Bayesian fixed-effects model using vague priors and Markov chain Monte Carlo simulation with Gibbs sampling, calculating pooled mean changes in sSBP and risk ratios (RRs) for supine hypertension with associated 95% credible intervals (CrIs). Results: Six studies (4 administering droxidopa and 2 administering midodrine) enrolling a total of 783 patients were included for analysis. The mean change from baseline in sSBP was significantly greater for both drugs when compared with placebo (droxidopa 6.2 mm Hg [95% CrI = 2.4-10] and midodrine 17 mm Hg [95% CrI = 11.4-23]). Comparative analysis revealed a significant credible difference between droxidopa and midodrine. The RR for supine hypertension was significantly greater for midodrine, but not droxidopa, when compared with placebo (droxidopa RR = 1.4 [95% CrI = 0.7-2.7] and midodrine RR = 5.1 [95% CrI = 1.6-24]). Conclusion and Relevance: In patients with NOH, both droxidopa and midodrine significantly increase sSBP, the latter to a greater extent. However, midodrine, but not droxidopa, significantly increases risk of supine hypertension.

Download Full-text