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Early orthostatic hypotension assessments superior

Contrary to existing recommendations to delay orthostatic hypotension measurements, assessments performed within the first minute of standing were most robustly associated with dizziness and individual long-term adverse outcomes and provide clinically useful information that may be missed with later measurements, according to findings published in JAMA Internal Medicine.

“Orthostatic hypotension is a common medical condition in older adults that is associated with higher risk of falls, coronary heart disease, stroke and death,” Stephen P. Juraschek, MD, PhD, from Johns Hopkins University, and colleagues wrote. “The determination of [orthostatic hypotension] is based on a consensus statement from the American Academy of Neurology, which has since been incorporated into international guidelines. This statement defines [orthostatic hypotension] by a postural reduction in systolic blood pressure of 20 mm Hg or greater or a diastolic blood pressure of 10 mm Hg or greater, measured 3 minutes after rising from a supine to standing position. However, the 3-minute time delay is often less practical in clinical settings owing to time constraints. It is unclear whether early measurements are as informative as later measurements.”

Juraschek and colleagues performed a prospective cohort study of 11,429 patients between the ages of 44 and 66 years (mean age, 54 years; 54% women; 26% black) to determine how effective early orthostatic hypotension measurements are vs. later measurements for assessing history of dizziness on standing and longitudinal adverse outcomes, including risk for fall, fracture, syncope, motor vehicle crashes and all-cause mortality. Participants were recruited from the Atherosclerosis Risk in Communities Study. The researchers measured orthostatic hypotension up to five times at 25-second intervals. Follow-up was conducted for a median of 23 years.

All participants had at least four orthostatic hypotension measurements after standing. Adjusted results indicated that the only measurement with increased odds for dizziness (OR = 1.49; 95% CI, 1.18-1.89) was the first measurement after standing (mean, 28 seconds; range, 21-62 seconds). The highest rates of fracture, syncope and death, at 18.9, 17 and 31.4 per 1,000 person-years, respectively, were also observed for this first measurement. There was a significant association between the initial measurement and the risk for fall (HR = 1.22; 95% CI, 1.03-1.44), fracture (HR = 1.16; 95% CI, 1.01-1.34), syncope (HR = 1.4; 95% CI, 1.2-1.63) and mortality (HR = 1.36; 95%CI, 1.23-1.51) after adjustment.

The highest rates of falls and motor vehicle crashes, at 13.2 and 2.5 per 1,000 person-years, respectively, were associated with the second measurement (mean, 53 seconds; range, 43-83 seconds). In addition, all long-term adverse outcomes were associated with the second measurement. There was no association and inconsistent associations between dizziness and individual longitudinal outcomes, respectively, and measurements obtained after one minute.

“Our study demonstrates that early assessments of [orthostatic hypotension] (within 1 minute) may be not only time-saving but also most clinically relevant and highly informative for long-term prognosis,” Juraschek and colleagues concluded. “While our data were derived from a relatively healthy community population, they imply that [orthostatic hypotension] measurement protocols might achieve their greatest prognostic value by including early poststanding BP measurement time points. These results represent compelling evidence for earlier time measurements in the assessment of [orthostatic hypotension] in middle-aged adults.”

In an invited commentary, Wolfgang Singer, MD, and Phillip A. Low, MD, both from the department of neurology at Mayo Clinic, wrote that these findings are “important and highly relevant.”

They noted that an important subgroup of patients have delayed [orthostatic hypotension], which would not be captured within the first three minutes of standing.

“Rather than abandoning the 3-minute orthostatic BP, we would advocate, however, the practice of obtaining 1- and 3-minute orthostatic BP in the routine clinical setting, and if otherwise unexplained abnormalities are seen, referring patients for formal autonomic testing that includes continuous beat-to-beat BP recordings during supine rest and orthostasis, along with other means to assess autonomic nervous system function more formally and systematically,” Singer and Low concluded. – by Alaina Tedesco

Disclosure: All authors report no relevant financial disclosures.