Clinical implications of delayed orthostatic hypotension

Abstract

Objective: To define the long-term outcome of delayed orthostatic hypotension (OH).Hypothesis: Delayed OH is an early and milder form of OH that progresses over time. Methods:We reviewed the medical records of 230 previously reported patients who completed autonomic testing at our center from January 1, 2002, through December 31, 2003. All available information on clinical diagnosis, mortality, medication use, and autonomic testing were extracted and included in the reported outcomes. Standard criteria were used to define OH and delayed OH.Results: Forty-eight individuals with delayed OH, 42 individuals with OH, and 75 controls had complete follow-up data. Fifty-four percent of individuals with delayed OH progressed to OH. Thirty-one percent of individuals with delayed OH developed an a-synucleinopathy. The 10-year mortality rate in individuals with delayed OH was 29%, in individuals with baseline OH was 64%, and in controls was 9%. The 10-year mortality of individuals who progressed to OH was 50%. Progression to OH was associated with developing an a-synucleinopathy, baseline diabetes, and abnormal baseline autonomic test results.Conclusion: Delayed OH frequently progresses to OH with a high associated mortality. Orthostatic hypotension (OH) is a reduction in systolic blood pressure (BP) of at least 20 mm Hg or diastolic BP of at least 10 mm Hg within 3 minutes of standing, or a similar fall in BP within 3 minutes of upright tilt-table testing to at least 60°. However, the duration of time necessary to detect a fall in BP that is clinically meaningful may extend beyond 3 minutes. Over 20 years ago, Streeten and Anderson 1 introduced the concept of delayed OH (DOH)-a BP fall on standing or upright tilt-table testing that occurred after the 3-minute cutoff. We extended those findings in a report documenting that DOH occurred with the same frequency as OH in a population of individuals referred for autonomic testing.2 In addition, DOH was associated with both parasympathetic and sympathetic adrenergic dysfunction, although of less severity than in those individuals with a fall in BP within 3 minutes of standing or tilt-table testing.DOH is now widely recognized among specialists as a potential cause of orthostatic intolerance and is included in a recent consensus statement on disorders of orthostatic intolerance. However, despite several cross-sectional studies of individuals with DOH, there are no longitudinal data available.1,2,4 Further, it is not known whether DOH is an early presentation of OH, or whether it is a more benign or nonprogressive form of orthostatic intolerance.We hypothesized that DOH was an early and milder form of OH. We therefore expected that DOH would progress to OH over time, would be associated with similar underlying disease mechanisms, and would have similar long-term complications. In order to investigate these hypotheses, we reviewed the medical records of all individuals reported in our original DOH study. 2 Here, we present the 10-year follow-up data of the groups described ...

Orthostatic hypotension: pathophysiology, assessment, treatment and the paradox of supine hypertension

“…78 Proof of concept studies suggest a role for ABPM in OH, and this should be further explored in RCT. Management often poses difficult challenges, with a limited evidence base to guide therapy.…”

The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension

“…Some individuals may develop delayed OH later than 3 min of standing, which can be identified with prolonged standing blood pressures, or prolonged tilt table testing (HUT) [34, 38]. …”

Effects of orthostatic hypotension on cognition in Parkinson disease

“…Furthermore, as delayed OH is common in patients with PD and other a-synucleinopathies, clinicians should also be mindful of this manifestation of autonomic failure in those individuals who show a normal hemodynamic response within the first 3 minutes of standing. 34,35 A multiphasic cognitive profile, if detected as part of a comprehensive assessment across postural changes, would be instructive for providers and would reveal otherwise unrecognized targets for intervention. For instance, impairments in verbal fluency, already noted in PD, could make it increasingly difficult to communicate effectively, particularly in the setting of already reduced nonverbal expression caused by declining motor functions.…”