Orthostatic Hyperreactivity and the Cardiovascular Risk in Juvenile and Middle-Age Hypertension

Abstract

Objective:The prognostic significance of orthostatic hypertension (BP) in young individuals is still controversial. This study aims to evaluate the association of hyperreactivity to standing with major adverse cardiovascular and renal events (MACE) in a cohort of young-to-middle-age subjects.Design and method:This investigation was performed in 1207 untreated stage 1 hypertensive subjects with a mean age of 33.1 ± 8.6 years. Supine and standing BPs were measured during two visits performed two weeks apart. At each visit, three supine BP measurements and three orthostatic measurements were taken at 1-minute intervals. The orthostatic BP response to standing was calculated as the average of the standing-lying BP differences obtained during the two visits. Hyperreactors to standing were defined people with a standing-supine systolic BP difference in the top decile (>6.5 mmHg). The mean difference in the whole group was -2.5 ± 7.3/4.6 ± 5.4 mmHg. In 630 participants 24 h urinary epinephrine was measured.Results:Hyperreactors to standing were more frequently smokers (p = 0.003) and coffee drinkers (p = 0.05), and had higher 24 h urinary epinephrine (118.4 ± 185.6 versus 77.0 ± 90.1 nmol/mol, p = 0.005). Hyperreactors also had a greater orthostatic response of diastolic BP (p < 0.001). Ambulatory hypertension evaluated with 24-hour recordings was more common in Hyperreactors than Normoreactors (90.8% versus 76.4%, p = 0.001). During a 17.2-year follow-up, 105 MACE were accrued. In multivariate Cox analysis adjusted for age, gender, parental history of cardiovascular disease, smoking, alcohol drinking, coffee use, physical activity habits, body mass index, office systolic and diastolic BP, postural diastolic BP change, office heart rate, serum glucose, and total cholesterol, Hyperreactors to standing had an almost doubled risk of MACE compared to Normoreactors with a hazard ratio of 1.97 (95%CI, 1.10–3.52). Hyperreactivity remained an independent predictor of MACE even when ambulatory BP data and incident hypertension during follow-up were included in the Cox model (hazard ratio: 1.94; 95%CI, 1.10–3.44).Conclusions:Our data indicate that in young-to-middle-age hypertensive subjects an exaggerated systolic BP response to standing is associated with sympatho-adrenergic hyperreactivity and is an independent predictor of MACE. Orthostatic BP assessment gives the advantage of simple acquisition and future guidelines should encourage measurement of BP on standing in young individuals.

Exaggerated blood pressure response to standing: a still underinvestigated issue

“…In the longitudinal analysis, for the hyperreactors to standing, the odds ratio was 2.45 [95% confidence interval (95% CI) 1.52-3.97, P < 0.001]. We concur that performing orthostatic BP testing in clinic is logistically simpler than ABPM, as suggested in our previously published flow-chart [7]. Ghazi et al [1] suggest that additional work is needed to characterize adults with OHT likely to have masked hypertension to enable earlier detection.…”

“…between-measurement interval [7]. The level of concordance was highest (Kappa coefficient, 0.51) when the 10 mmHg cutoff was used to define OHT and when a short time interval was considered (2 weeks).…”

Assessment and management of exaggerated blood pressure response to standing and orthostatic hypertension: consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability

“…The body and arm position are also crucial. From a pathophysiology point of view, BP response to standing may be more pronounced when compared to baseline supine instead of seated BP measurements [6,39]. Yet, in routine clinical practice, assessing BP change from seated to standing position is more feasible for screening.…”

Orthostatic blood pressure changes do not influence cognitive outcomes following intensive blood pressure control

“…Postural BP changes are common in patients with hypertension, including OH and OHT. OH results from an insufficient physiological response to the decreased venous return upon standing, whereas OHT results from overcompensation for the gravitational challenge [13,14]. There have been inconsistent findings about the association between orthostatic BP changes and cognitive dysfunction.…”

“…BP lowering has been reported to be associated with a lower risk of cognitive decline [11,12]. OH and OHT are not uncommon among hypertensive patients [13,14]. Individuals with significant orthostatic BP changes face an increased risk of falls and syncope [15], which raises concerns relating to aggravated cerebral hypoperfusion with intensive BP treatment in this population.…”