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Orthostatic hypotension elevates risk for CVD events
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In community-dwelling middle-aged adults, orthostatic hypotension was linked to elevated risk for CVD events and subclinical CVD, researchers reported.
“Despite the large number of systems involved, clinical algorithms often reduce orthostatic hypotension (OH) to either neurogenic or non-neurogenic OH, with non-neurogenic OH often implying dehydration. Because of this, treatments among adults without known neurological disease often focus on increasing blood pressure through higher sodium and fluid intake, discontinuing antihypertensive agents, and in some cases initiating mineralocorticoids. However, these interventions could be harmful in adults with orthostatic hypotension from cardiovascular disease,” Stephen P. Juraschek, MD, PhD,
instructor of medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, told Cardiology Today. “To address this question, we looked at whether OH identified in an ambulatory population was associated with undetected cardiovascular disease — carotid thickness, carotid plaque, high-sensitivity troponins (a marker of microischemia in the heart) and NT-proBNP (a marker of heart wall strain and future cardiovascular events, including heart failure, heart attacks, stroke and death). We hypothesized that OH would be commonly associated with cardiovascular disease, given the high prevalence of undetected cardiovascular disease among U.S. adults.”
The researchers analyzed 9,139 participants (mean age, 54 years; 57% women) from the ARIC prospective cohort study enrolled from 1987 to 1989, of whom 3% had OH, defined as decrease in systolic BP of at least 20% or diastolic BP of at least 10% from the supine to the standing position.
After a median of 26 years of follow-up, OH was associated with increased risk for the following:
MI (HR = 1.88; 95% CI, 1.44-2.46);
congestive HF (HR = 1.65; 95% CI, 1.34-2.04);
stroke (HR = 1.83; 95% CI, 1.35-2.48);
fatal CHD (HR = 2.77; 95% CI, 1.93-3.98);
any CHD (HR = 2; 95% CI, 1.64-2.44); and
all-cause mortality (HR = 1.68; 95% CI, 1.45-1.95).
According to the researchers, OH was also associated with carotid intimal thickness (beta = 0.05 mm; 95% CI, 0.04-0.07), carotid plaque (OR = 1.51; 95% CI, 1.18-1.93), detectable high-sensitivity troponin T (OR = 1.49; 95% CI, 1.16-1.93) and elevated NT-proBNP (OR = 1.92; 95% CI, 1.48-2.49).
“The fact that orthostatic hypotension was associated with all measures of CVD (both concurrent and future) presents strong evidence of a relationship between orthostatic hypotension and undetected cardiovascular disease,” Juraschek said in an interview. “Orthostatic hypotension detected in middle-aged adults should prompt consideration for latent cardiovascular disease. This is particularly important when considering treating OH with increased sodium/fluid intake, de-escalation/cessation of antihypertensive medications or starting mineralocorticoids (most severe cases). Orthostatic hypotension is often cited as a reason to stop or reduce blood pressure treatment. Our paper should incite caution to this seemingly intuitive clinical approach.” – by Erik Swain
For more information:
Stephen P. Juraschek, MD, PhD, can be reached at Section for Research, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center/Harvard Medical School, 330 Brookline Ave., CO-1309, Boston, MA 02215; email: sjurasch@bidmc.harvard.edu.
Disclosure s : Juraschek reports no relevant financial disclosures. Another author reports he is named on a patent application filed by Baylor College of Medicine and Roche related to biomarkers to improve prediction of HF risk.
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