Hypertension Treatment Effects on Orthostatic Hypotension and Its Relationship With Cardiovascular Disease

Juraschek, Stephen P.; Appel, Lawrence J.; Miller, Edgar R.; Mukamal, Kenneth J.; Lipsitz, Lewis A.

doi:10.1161/hypertensionaha.118.11337

Cited by 39 publications

(29 citation statements)

References 47 publications

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“…Data from the Irish Longitudinal Study on Ageing (TILDA) demonstrate that monotherapy with β-blockers is associated with an increased risk of OH during all phases of standing (OR 2.05, 95% CI 1.31–3.21 for initial OH; OR 3.36, 95% CI 1.87–6.03 for sustained hypotension) [ 18 ]. Similarly, an association between β-blockers and OH has also been described in nursing home residents [ 46 ] and in patients with chronic kidney disease [ 47 ]. A higher incidence of OH has been reported for mixed α- and β-blockers (e.g., carvedilol), particularly after the first dose [ 48 ].…”

Section: Antihypertensive Medications and Other Cardiovascular Drugs mentioning

confidence: 94%

“…The chronic use of ACE inhibitors (ACE-I) and angiotensin II receptor blockers does not seem to be associated with OH [ 18 , 46 , 47 ]. Conversely, a protective effect is reported by some studies [ 28 , 46 ], which may be attributed to improved vascular compliance and increased baroreceptor sensitivity deriving from the inhibition of the renin-angiotensin system [ 57 – 59 ].…”

Section: Antihypertensive Medications and Other Cardiovascular Drugs mentioning

confidence: 99%

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Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications

et al. 2020

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Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.

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Section: Antihypertensive Medications and Other Cardiovascular Drugs mentioning

confidence: 94%

Section: Antihypertensive Medications and Other Cardiovascular Drugs mentioning

confidence: 99%

Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications

et al. 2020

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“…All -cause and cardiovascular mortality There have been multiple studies 25,35,43,54,55,65,73,78,80,[82][83][84][85][86][87][88][89][90][91][92] as well as a meta -analysis 65 uniformly pointing to the increased mortality among patients in whom OH was detected, either by screening (population -based cohorts) or through characteristic symptoms confirmed by autonomic testing (TABLe 1). However, this issue has hitherto not been given sufficient priority in research activities.…”

Section: Cardiovascular Risk Factors and Circulatory Compli-mentioning

confidence: 99%

Orthostatic hypotension and cardiovascular risk

Fedorowski¹,

Ricci²,

Sutton³

2019

Kardiol Pol

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Orthostatic hypotension (OH) is a cardinal sign of cardiovascular (CV) autonomic dysfunction as a result of autonomic nervous system failure to control the postural hemodynamic homeostasis. The proportion of individuals with OH increases with aging and chronic conditions, such as neurodegenerative diseases, hypertension, heart failure, diabetes, renal dysfunction, autoimmune diseases, and cancer. In individuals over 70 years of age, more than 20% can be affected. It is now increasingly recognized that there is a direct relationship between OH and each step of the CV disease continuum, eventually leading to end-stage heart disease and CV death. In particular, prevalent OH is associated with cardiac functional and structural remodeling, left ventricular hypertrophy, elevated levels of circulating markers of inflammation, increased intima-media thickness, subclinical atherosclerosis, and thrombosis. Beyond subclinical changes, the presence of OH independently predicts coronary events, stroke, atrial fibrillation, heart failure, and CV mortality. Furthermore, OH is associated with syncope, falls, and fragility fractures, presenting hurdles to be overcome in the delivery of the best management of CV risk factors. Taken together, OH heralds disruption of global circulatory homeostasis and flags overt autonomic dysfunction. The presence of OH is also an independent risk factor for mortality and CV disease; however, until now, the importance of this highly prevalent disorder has been given insufficient attention by clinicians and other healthcare providers. Consequently, more studies are needed to find effective treatment for this troublesome condition and to identify preventive measures that could reduce the burden of CV risk in OH and autonomic dysfunction.

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“…No clear explanation exists for these anomalous effects but it seems possible that different hemodynamic subpopulations may experience different outcomes when HR is decreased. For example, if an individual with a blunted counter-regulatory SV or SVR response to HR-slowing is given a beta-blocker, there may be clinically significant signs of hypoperfusion or hypotension [44]. In this context, alterations in ventricular compliance and relaxation could reduce the impact of SV-HR counter-regulation and potentially imperil organ perfusion and functional responses.…”

Section: Discussionmentioning

confidence: 99%

Decoupling of Heart Rate and Blood Pressure: Hemodynamic Counter-regulatory Mechanisms and their Implications

Izzo¹,

Anwar²,

Elango³

et al. 2019

Artery Res

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To investigate the dynamic relationships among Heart Rate (HR) and systemic hemodynamics in everyday life, we performed 24-h ambulatory pulse wave analyses (Mobil-O-Graph) in individuals with normal and elevated BP (n = 116) and in a double-blinded cross-over study where HR was varied pharmacologically (n = 24). In the whole cohort and in the low [24-h mean Systolic BP (SBP) < 135 mmHg] and high (SBP ≥ 135 mmHg) groups, mean HR did not correlate with mean SBP but did correlate strongly and negatively with Stroke Volume Index (SVI) and Systemic Vascular Resistance Index (SVRI) over 24 h and during night-time and daytime periods (all p < 0.000). SVI varied by about 0.2 mL/m2 per bpm in both BP groups, while SVRI varied by about 0.03 and 0.01 mmHg.s.m2/mL per bpm in the high and low BP groups, respectively, p < 0.001). On stepwise multiple linear regression, there was greater sensitivity of SVI to HR in Blacks and younger individuals, and greater sensitivity of SVRI to HR with age in addition to higher SBP. In a crossover study (monotherapy for 1 month each with nebivolol or valsartan), BP was constant throughout, while SVI and SVRI varied inversely with HR as in the main cohort with similar intercepts and coefficients; the regression equations on either drug predicted the same SVI or SVRI at HR of 70 bpm. We conclude that the decoupling of BP from HR is facilitated by the continuous counter-regulation of SVI and SVRI against HR and that HR is the primary hemodynamic setpoint. These findings have implications for pathogenetic studies and imply that hemodynamic measurements should be corrected for HR.

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Hypertension Treatment Effects on Orthostatic Hypotension and Its Relationship With Cardiovascular Disease

Cited by 39 publications

References 47 publications

Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications

Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications

Orthostatic hypotension and cardiovascular risk

Decoupling of Heart Rate and Blood Pressure: Hemodynamic Counter-regulatory Mechanisms and their Implications

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