Diagnosing orthostatic hypotension with continuous and interval blood pressure measurement devices.

Orthostatic hypotension (OH) is defined as a drop in systolic blood pressure (SBP) of ≥20 mm Hg and/or a drop in diastolic blood pressure (DBP) of ≥10 mm Hg within 3 min of standing. The international guidelines recommend ideally diagnosing OH with a continuous blood pressure (BP) measurement device, although in daily practice interval BP measurement devices are used more often. We aimed to investigate the difference in observed prevalence of OH between an interval and a continuous BP measurement device. A total of 104 patients with a mean age of 69 years were included. The prevalence of OH was 35.6% (95% CI: 26.4-44.8) with the interval BP measurement and 45.2% (95% CI: 35.6-54.8) with the continuous BP measurement device (P = .121). Lin's coefficient of concordance ranged from 0.47 to 0.59 for the drop in systolic blood pressure and from 0.33 to 0.42 for the drop in diastolic blood pressure. The positive proportion of agreement in diagnosis of OH between the interval and continuous measure was 59.5% and the negative proportion of agreement was 72.5%. Although the prevalence of OH was not significantly different between the continuous and the interval BP measurement devices using a similar amount of measurement, the concordance between interval and continuous measure is low resulting in low positive and negative proportions of agreement in the diagnosis of OH. We conclude that continuous BP measurement cannot be substituted by an interval BP measurement to diagnose OH.

Standing orthostatic blood pressure measurements cannot be replaced by sitting measurements.

As many elderly patients are not able to stand for several minutes, sitting orthostatic blood pressure (BP) measurements are sometimes used as an alternative. We aimed to investigate the difference in BP response and orthostatic hypotension (OH) prevalence between the standard postural change to the sitting and the standing position in a cross-sectional observational study. BP was measured with a continuous BP measurement device during two postural changes, from supine to the sitting and from supine to the standing position. Linear mixed models were used to investigate the differences in changes (Δ) of systolic BP (SBP) and diastolic BP (DBP) between the two postural changes. The prevalence and the positive and negative proportions of agreement of OH were calculated of the two postural changes. One hundred and four patients with a mean age of 69 years were included. ΔSBP was significantly larger in the standing position compared with the sitting between 0 and 44 s. ΔDBP was significantly larger in the sitting position compared with the standing 75-224 s after postural change. The prevalence of OH was 66.3% (95% confidence interval (CI) 57.2, 75.4) in the standing position and 67.3% (95% CI 58.3, 76.3) in the sitting position. The positive proportion of agreement was 74.8% and the negative proportion of agreement was 49.3%. A clear difference was seen in BP response between the two postural changes. Although no significant difference in prevalence of OH was observed, the positive and negative proportion of agreement of the prevalence of OH were poor to moderate, which indicates a different outcome between both postural changes.

Patient Activation in Type 2 Diabetes: Does It Differ between Men and Women?

Background. Aim was to investigate whether the degree of patient activation of patients with type 2 diabetes (T2D) is different between men and women. Furthermore, we investigated which factors are associated with patient activation in men and women. Methods. This cross-sectional study included 1615 patients with T2D from general practices. Patient activation was measured with the Patient Activation Measure (PAM) questionnaire. Multivariate linear regression analyses were used to investigate the association between gender and patient activation. Stratified analyses according to gender were performed to investigate which factors are associated with patient activation. Results. No association between gender and PAM score was found after adjustment for all selected confounders (p = 0.094). In men, lower age (p = 0.001), a higher WHO-5 score (p < 0.001), and a lower BMI (p = 0.013) were associated with a higher PAM score. In women, a higher WHO-5 score (p < 0.017) and the absence of macrovascular complications (p < 0.031) were associated with a higher PAM score. Conclusion. There is no difference in the degree of patient activation of men and women with T2D. Age, well-being, and BMI were found to be associated with patient activation in men, whereas well-being and macrovascular complications were found to be associated with patient activation in women.

Within-Sulfonylurea-Class Evaluation of Time to Intensification with Insulin (ZODIAC-43).

BACKGROUND: Previous studies have shown that many within-class differences exist between sulfonylureas (SUs), however, whether differences exist regarding the time it takes between initiating an SU and the need to intensify treatment with insulin is unclear. The aim of this study was investigate the relationships between the three frequently used sulphonylureas, prescribed as dual therapy next to metformin, and the time needed to treatment intensification with either insulin or oral triple therapy in patients with type 2 diabetes mellitus. METHODS: Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) is a prospective observational cohort study set in primary care in the Netherlands. Annually collected data on diabetes medication and clinical variables within ZODIAC are used to evaluate the primary outcome, time to insulin and secondary outcome, time to either insulin or triple oral therapy. For statistical analysis a time-dependent cox proportional hazard model was used. RESULTS: 3507 patients were included in the analysis, with a mean age of 61 (SD 11.4) and a median HbA1c of 6.8% [IQR 6.4-7.4] (50.8 mmol/mol [IQR 46.4-57.4]).The hazard ratio (HR) for the primary endpoint was 1.10 (95% CI 0.78-1.54) for metformin/glimepiride and 0.93 (95% CI 0.67-1.30) for metformin/tolbutamide with metformin/gliclazide as reference group. The HR for the secondary outcome was 1.04 (95% CI 0.78-1.40) and 0.85 (95% CI 0.64-1.13), respectively. CONCLUSION: In this large Dutch primary care cohort, new users of neither gliclazide, glimepiride nor tolbutamide as dual therapy with metformin, resulted in differences in the time needed for further treatment intensification.

Orthostatic changes in blood pressure and mortality in a nursing home population.

OBJECTIVE: Hypertension, orthostatic hypotension and orthostatic hypertension (OHT) are highly prevalent in old age. The associations in the very elderly and frail patients between blood pressure, and especially orthostatic changes in blood pressure, and mortality are unclear. We aimed to investigate the relationships between orthostatic changes in blood pressure, blood pressure and mortality in nursing home residents. DESIGN AND METHODS: A prospective observational cohort study. Cox proportional hazard modelling was used to investigate the relation between orthostatic hypotension, OHT, the various blood pressure variables and mortality with adjustment for confounders. In the case of significant associations in the models, risk prediction capabilities were assessed with Harrell's C statistics and the proportion of explained variance (R). RESULTS: Two hundred and ninety patients with a mean age of 80.8 (SD 9.9) years participated in this study. The overall mortality risk increased by 17% [95% confidence interval (CI): 2-34%] for every 10-mmHg increase in DBP. Adding DBP did not change Harrell's C values and increased R with 0.03 or less. Only in patients at the psychogeriatric department, orthostatic hypotension was associated with an increased all-cause mortality risk [hazard ratio (HR) 1.71 (95% CI: 1.08-2.71%)]. The HR of OHT in this patient group was 0.61 (95% CI: 0.32-1.19%). CONCLUSION: DBP was related to all-cause mortality in a nursing home population. Orthostatic hypotension was related to all-cause mortality in the most frail group of nursing home patients. The predictive capabilities of both DBP and orthostatic hypotension are rather small with respect to mortality. A beneficial effect of OHT could not be excluded on the basis of the width of the CI.