Do we need to evaluate diastolic blood pressure in patients with suspected orthostatic hypotension?

Abstract

PurposeThe contribution of diastolic blood pressure measurement to the diagnosis of classical orthostatic hypotension is not known. We aimed to explore the prevalence of isolated systolic and diastolic orthostatic hypotension components in patients with syncope and orthostatic intolerance.MethodsA total of 1520 patients aged >15 years with suspected syncope and/or symptoms of orthostatic intolerance were investigated in a tertiary center using tilt-table testing and continuous non-invasive blood pressure monitoring. Classical orthostatic hypotension was defined as a decline in systolic blood pressure ≥20 mmHg and/or diastolic blood pressure ≥10 mmHg at 3 min of tilt test. The prevalence of upright systolic blood pressure <90 mmHg and its overlap with isolated diastolic orthostatic hypotension was also assessed.ResultsOne hundred eighty-six patients (12.2%) met current diagnostic criteria for classical orthostatic hypotension. Of these, 176 patients (94.6%) met the systolic criterion and 102 patients (54.8%) met the diastolic criterion. Ninety-two patients (49.5%) met both systolic and diastolic criteria, whereas ten patients (5.4%) met the diastolic criterion alone. Of these, three had systolic blood pressure <90 mmHg during tilt test and were diagnosed with orthostatic hypotension on the grounds of low standing blood pressure. Based on patient history and ancillary test results, causes of orthostatic intolerance and syncope other than orthostatic hypotension were present in the remaining seven patients.ConclusionsAn abnormal orthostatic fall in diastolic blood pressure without an abnormal fall in systolic blood pressure is rare among patients with syncope and orthostatic intolerance. Approximately 95% of patients with classical orthostatic hypotension can be identified by systolic criterion alone.

Noninvasive beat‐to‐beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages

“…Impaired short‐term HR and BP control as risk factors will not be considered in detail. For classification of the spectrum of abnormal BP responses, we will use the systolic BP cut‐off only, because (i) the absolute magnitude of changes in systolic BP is larger than that of diastolic BP and therefore easier to measure; (ii) an abnormal orthostatic fall in diastolic BP without an abnormal fall in systolic BP is rare amongst patients with syncope and orthostatic intolerance ; and (iii) an abnormal fall in diastolic BP with a minor or no fall in systolic BP will increase pulse pressure. Because the main determinants of brain blood flow are the absolute level of arterial pressure and the pulse pressure , an isolated fall in diastolic BP is not likely to induce significant hypoperfusion of the brain.…”

“…Classical orthostatic hypotension is defined here as a sustained systolic BP decline of ≥20 mmHg within 3 min of standing . FinAP measurement has the advantage of detecting a continuous/sustained BP fall matching the definition of orthostatic hypotension from 60 to 180 s of standing, that is a fall of ≥20 mmHg in systolic BP at 60 s standing that is sustained.…”

Clinical classification of orthostatic hypotensions

“…Of the 186 patients with OH, 176 (94.5%) met the systolic criterion and 102 (54.8%) met the diastolic criterion. As only ten (5.4%) solely met the diastolic criterion, they concluded that, when diagnosing OH in patients with syncope or orthostatic intolerance, measuring diastolic BP may be unnecessary [1]. Their findings ring true for the selected population they studied, as symptoms of cerebral ischemia correlate most closely with the rate and magnitude of the systolic BP drop.…”

Orthostatic hypotension in patients with late‐life depression: Prevalence and validation of a new screening tool

“…Orthostatic hypotension (OH) is a common age‐dependent cardiovascular autonomic dysfunction syndrome with prevalence rates estimated from 5% to 30% . OH is defined as a drop in systolic blood pressure of at least 20 mmHg and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing from a lying down position or with a head‐up tilt to at least 60° on a standard tilt table . OH is caused by orthostatic stress overwhelming the body's compensatory autonomic response .…”

“…1,2 OH is defined as a drop in systolic blood pressure of at least 20 mmHg and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing from a lying down position or with a head-up tilt to at least 60°on a standard tilt table. [3][4][5] OH is caused by orthostatic stress overwhelming the body's compensatory autonomic response. 6,7 Neurobiologically, it has been shown that this orthostatic stress could lead to cerebral hypo-perfusion 8,9 and subsequent formation of white matter hyperinsensities, 10,11 a well known finding in late life depression (LLD).…”