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1.
High Blood Press Cardiovasc Prev ; 27(1): 93-101, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32048202

RESUMO

INTRODUCTION: Orthostatic hypotension (OH) and atrial fibrillation (AF) are both regarded as independent risk factors for transient ischemic attack (TIA). However, the clinical implication of OH in the presence of AF is unclear. This study investigates, for the first time, the association between blood pressure (BP), OH and mortality in a cohort of patients with AF and TIA symptoms. AIM: To investigate the incidence of the association between OH, AF and TIA. METHODS: This retrospective observational study utilised the Leicester one-stop transient TIA clinic patient database to consider the initial systolic and diastolic BP of 688 patients with a diagnosis of AF. The primary outcome was time until death. Covariant measures included status of AF diagnosis (known or new AF), cardiovascular risk factors, and primary clinic diagnosis [cerebrovascular (CV) versus non-cerebrovascular (non-CV)]. Statistical models adjusted for sex, age, previous AF diagnosis. RESULTS: Mortality rate was higher in the over 85 age group [191.5 deaths per 1000 person years (py) (95% CI 154.0-238.1)] and lower in the aged 75 and younger age group [40.0 deaths per 1000 py (95% CI 27.0-59.2)] compared to intermediate groups. A 10 mmHg increase in supine diastolic BP was associated with a significant reduction in the hazard of mortality for patients suspected of TIA with AF [adjusted HR 0.79 (95% CI 0.68-0.92), p < 0.001]. The mortality rate for patients with OH was 119.0 deaths per 1000 py compared with a rate of 98.0 for patients without OH (rate ratio 1.2, p = 0.275). CONCLUSION: Higher diastolic BP may be a marker for reduced mortality risk in patients with a previous AF diagnosis and non-CV diagnosis. Lower diastolic BP and the presence of AF pertain to a higher mortality risk. This study raises the importance of opportunistic screening for both OH and AF in patients presenting to TIA clinic.


Assuntos
Fibrilação Atrial/epidemiologia , Hipotensão Ortostática/epidemiologia , Ataque Isquêmico Transitório/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Pressão Sanguínea , Inglaterra/epidemiologia , Feminino , Frequência Cardíaca , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/mortalidade , Hipotensão Ortostática/fisiopatologia , Incidência , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/mortalidade , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Estudos Retrospectivos , Fatores de Risco
2.
Hypertension ; 74(4): 1033-1040, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31476905

RESUMO

Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Hipotensão Ortostática/epidemiologia , Síncope/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anlodipino/uso terapêutico , Atenolol/uso terapêutico , Clortalidona/uso terapêutico , Feminino , Humanos , Incidência , Masculino , Medicare , Resultado do Tratamento , Estados Unidos
3.
Hypertension ; 74(3): 639-644, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31327261

RESUMO

There has been much interest in investigating vitamin D status with orthostatic hypotension. However, studies have been small, inconsistent, and with a lack of standardization. The aim of this study was to investigate the association with vitamin D status in a large, nationally representative older adult population using a traceable standard of measurement and an accurate assessment of beat-to-beat blood pressure (BP). This study used participants aged >50 years from The Irish Longitudinal Study on Ageing. Impaired stabilization of BP on standing was defined as a sustained drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP up to 40 seconds post stand (impaired stabilization of BP on standing). We also analyzed participants who sustained a drop of ≥20 mm Hg systolic BP or ≥10 mm Hg diastolic BP throughout the 110 seconds stand (OH110). Vitamin D was categorized into sufficient (≥50 nmol/L), insufficient (30-50 nmol/L), and deficient (<30 nmol/L) status. After exclusion criteria 4209 participants were included. Those with deficiency were more likely to be smokers, take antihypertensive medications and had higher levels of cardiovascular disorders compared with those with sufficient status. In a univariate logistic regression those with deficient (odds ratio, 1.18; 95% CI, 0.86-1.61; P=0.303) or insufficient (odds ratio, 1.13; 95% CI, 0.91; P=0.272) status were no more likely to have evidence of impaired stabilization of BP on standing on active stand compared with sufficiency. Similar findings were found for OH110: deficient (odds ratio, 0.85; 95% CI, 0.52-1.40; P=0.528) or insufficient (odds ratio, 0.86; 95% CI, 0.61-1.21; P=0.384) versus sufficiency. In conclusion, vitamin D is not significantly associated with orthostatic hypotension in older adults.


Assuntos
Avaliação Geriátrica/métodos , Hipotensão Ortostática/diagnóstico , Deficiência de Vitamina D/diagnóstico , Vitamina D/sangue , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Estudos de Coortes , Feminino , Hospitais Universitários , Humanos , Hipotensão Ortostática/epidemiologia , Vida Independente , Irlanda , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Sensibilidade e Especificidade , Deficiência de Vitamina D/epidemiologia
4.
Aten. prim. (Barc., Ed. impr.) ; 51(5): 294-299, mayo 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-180878

RESUMO

Objetivo: Estimar la prevalencia de la hipotensión ortostática (HO) en pacientes de 80 o más años de edad que demandan consulta en una unidad de atención primaria. Relacionar la HO con las enfermedades más prevalentes y los fármacos más consumidos. Diseño: Transversal observacional. Localización: Unidad de atención primaria, Santiago de Compostela. Participantes: Se reclutaron 81 pacientes de 80 o más años representativos de una unidad de atención primaria. Se excluyeron 10 pacientes. Mediciones principales: Se realizó la medición de la presión arterial en decúbito y posteriormente en bipedestación en el instante siguiente a la incorporación y tras 3 min. Se revisaron en la historia clínica electrónica los diagnósticos y los tratamientos activos mediante una entrevista al paciente y cuidador. Resultados: En un 26,76% de los pacientes se produjo un descenso mayor o igual de 20 mmHg en la presión arterial sistólica y/o 10 mmHg en la presión arterial diastólica, en el instante siguiente al cambio postural. El descenso se mantuvo tras 3min de la incorporación de decúbito a bipedestación en el 16,90% de los pacientes. Ningún paciente estaba diagnosticado de HO. La mayor razón de prevalencia se dio con la diabetes mellitus (1,6; p = 0,412), no habiendo diferencias para la hipertensión arterial (p = 0,881). La HO se relacionó de forma estadísticamente significativa con la toma de bloqueadores de sistema renina-angiotensina-aldosterona (OR: 8,174; IC95%: 1,182-56,536; p = 0,033) y benzodiacepinas (OR: 5,938; IC95%: 1,242-28,397; p = 0,026). Conclusión: La HO tuvo una prevalencia del 16,90% en los pacientes de edad avanzada que acudieron a consulta. Debe tenerse en cuenta su relación con algunos fármacos (bloqueadores de sistema renina-angiotensina-aldosterona y benzodiacepinas)


Objective: To estimate the prevalence of orthostatic hypotension (OH) in patients 80 years old and over attending a primary care unit. To relate OH to the most prevalent pathologies and to the most used drugs. Design: Transversal observational study. Location: Primary care unit, Santiago de Compostela. Participants: Eighty one patients 80 years old or over representative of a primary care unit were recruited. Ten patients were excluded. Main measurements: Blood pressure was measured in decubitus and later in erect position first immediately after standing and then after 3 minutes. Diagnoses and active treatments were reviewed in the electronic clinical history and through an interview with the patient and caregiver. Results: In 26.76% of patients the systolic blood pressure fell by 20 mmHg or more and/or the diastolic blood pressure fell by 10 mmHg in the instant following the postural shift. In 16.90% of patients the drop persisted after 3 minutes of standing from decubitus position. None of the patients was diagnosed with OH. The highest prevalence ratio was observed for diabetes mellitus (1.6; P=.412), not existing differences for arterial hypertension (P=.881). OH related in a statistically meaningful way to the use of renin angiotensin aldosterone system inhibitors (OR: 8.174, CI95%: 1.182-56.536); P=.033] and benzodiazepines (OR: 5.938, CI95%: 1.242-28.397; P=.026)]. Conclusion: OH had a prevalence of 16.90% among the elderly patients who had a consultation. Its connection with some drugs (renin angiotensin aldosterone system inhibitors and benzodiazepines) must be considered


Assuntos
Humanos , Masculino , Feminino , Idoso de 80 Anos ou mais , Hipotensão Ortostática/epidemiologia , Atenção Primária à Saúde/estatística & dados numéricos , Determinação da Pressão Arterial/métodos , Estudos Transversais , Registros Eletrônicos de Saúde/estatística & dados numéricos , Benzodiazepinas/uso terapêutico , Saúde do Idoso
5.
Medicina (Kaunas) ; 55(4)2019 Apr 20.
Artigo em Inglês | MEDLINE | ID: mdl-31009994

RESUMO

Background and objective: Orthostatic hypotension (OH) is a decrease in systolic blood pressure (BP) of 20 mm Hg and in diastolic BP of 10 mm Hg when changing the position from lying to standing. Arterial hypertension (AH), comorbidities and polypharmacy contribute to its development. The aim was to assess the presence of OH and its predictors in asymptomatic chronic kidney disease (CKD) patients. Material and methods: 45 CKD patients with estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73 m2 (CKD+) were examined for signs of OH and its predictors. The results were compared with the control group of 22 patients with eGFR > 60 mL/min/1.73 m2 (CKD-). Asymptomatic patients without ischemic heart disease and previous stroke were qualified. Total blood count, serum creatinine, eGFR, urea, phosphates, calcium, albumins, parathyroid hormone, uric acid, C reactive protein, N-terminal pro b-type natriuretic peptide, lipid profile, and urine protein to creatinine ratio were assessed. Simultaneously, patients underwent echocardiography. To detect OH, a modified Schellong test was performed. Results: OH was diagnosed in 17 out of 45 CKD+ patients (average age 69.12 ± 13.2) and in 8 out of 22 CKD- patients (average age 60.50 ± 14.99). The CKD+ group demonstrated significant differences on average values of systolic and diastolic BP between OH+ and OH- patients, lower when standing. In the eGFR range of 30-60 mL/min/1.73 m2 correlation was revealed between OH and ß-blockers (p = 0.04), in the entire CKD+ group between ß-blockers combined with diuretics (p = 0.007) and ACE-I (p = 0.033). Logistic regression test revealed that chronic heart failure (CHF, OR = 15.31), treatment with ß-blockers (OR = 13.86) were significant factors influencing the presence of OH. Conclusions: Predictors of OH in CKD may include: CHF, treatment with ß-blockers, combined with ACE-I and diuretics.


Assuntos
Doenças Assintomáticas/epidemiologia , Hipotensão Ortostática/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Doença Crônica , Comorbidade , Diuréticos/efeitos adversos , Quimioterapia Combinada , Feminino , Insuficiência Cardíaca/complicações , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Estatísticas não Paramétricas
6.
J Am Heart Assoc ; 7(19): e008976, 2018 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-30371298

RESUMO

Background It is postulated that orthostatic hypotension ( OH ), a reduction in blood pressure (≥20/10 mm Hg) within 3 minutes of standing, may increase cognitive decline because of cerebral hypoperfusion. This study assesses the impact of OH on global cognition at 4-year follow-up, and the impact of age and hypertension on this association. Methods and Results Data from waves 1 and 3 of TILDA (The Irish Longitudinal Study on Ageing) were used. Baseline blood pressure response to active stand was assessed using beat-to-beat blood pressure monitoring. Two measures of OH were used-at 40 seconds ( OH 40) and 110 seconds ( OH 110). Global cognition was measured using the Montreal Cognitive Assessment. Mixed-effects Poisson regression assessed whether baseline OH was associated with a decline in global cognition at 4-year follow-up. The analysis was repeated, stratifying by age (age 50-64 years and age ≥65 years), and including an interaction between OH and hypertension. Baseline OH 110 was associated with an increased error rate in Montreal Cognitive Assessment at follow-up (incident rate ratio 1.17, P=0.028). On stratification by age, the association persists in ages 50 to 64 years (incident rate ratio 1.25, P=0.048), but not ages ≥65 years. Including an interaction with hypertension found those with co-existent OH 110 and hypertension (incident rate ratio 1.27, P=0.011), or OH 40 and hypertension (incident rate ratio 1.18, P=0.017), showed an increased error rate; however, those with isolated OH 110, OH 40, or isolated hypertension did not. Conclusions OH is associated with a decline in global cognition at 4-year follow-up, and this association is dependent on age and co-existent hypertension.


Assuntos
Envelhecimento/fisiologia , Pressão Sanguínea/fisiologia , Cognição/fisiologia , Disfunção Cognitiva/etiologia , Hipotensão Ortostática/complicações , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/fisiopatologia , Feminino , Seguimentos , Humanos , Hipotensão Ortostática/epidemiologia , Hipotensão Ortostática/fisiopatologia , Incidência , Irlanda/epidemiologia , Masculino , Pessoa de Meia-Idade , Postura/fisiologia , Prognóstico , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo
7.
Am J Hypertens ; 31(12): 1278-1285, 2018 11 13.
Artigo em Inglês | MEDLINE | ID: mdl-30239598

RESUMO

BACKGROUND: The aim of this study is to clarify associations between orthostatic blood pressure (BP) change, as well as possible physiological factors, and day-to-day home BP variability, a promising risk factor for cardiovascular outcomes. METHODS: Study participants were 6,465 community residents (age 58.3 years). Home BP was measured every morning and evening for 7 days. Orthostatic BP was calculated as the maximum difference between BP measured while sitting and remeasured after 1 and 3 minutes standing. RESULTS: Frequency of individuals who showed orthostatic BP decline was as follows: systolic BP (SBP) change ≥-20 mm Hg: 2.6%, ≥-10 mm Hg: 14.1%. These subgroups showed larger home SBP variability (average real variability: 11.3 ± 5.3, 8.7 ± 3.9 mm Hg) when compared with orthostatic normotensives (7.6 ± 3.7 mm Hg) (all P < 0.001). Multiple linear regression analysis adjusted for major covariates, including seated BP, identified orthostatic BP drop as an independent determinant for morning BP variability (≥-20 mm Hg: ß = 0.037, P = 0.003; ≥-10 mm Hg: ß = 0.026, P = 0.036) but not for evening BP variability. Carotid hypertrophy was significantly associated with home BP variability (morning: ß = 0.052, P = 0.001; evening: ß = 0.065, P < 0.001) and showed a U-shaped association with orthostatic BP change. Plasma B-type natriuretic peptide level, a previously suggested factor for BP variability, did not show significant association with morning and evening BP variability. CONCLUSION: Orthostatic BP decline was significantly associated with morning BP variability. Large artery atherosclerosis was a common risk factor.


Assuntos
Pressão Sanguínea , Ritmo Circadiano , Hipotensão Ortostática/fisiopatologia , Postura , Adulto , Idoso , Aterosclerose/epidemiologia , Aterosclerose/fisiopatologia , Biomarcadores/sangue , Monitorização Ambulatorial da Pressão Arterial , Estudos Transversais , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Valor Preditivo dos Testes , Fatores de Risco , Fatores de Tempo
8.
BMC Neurol ; 18(1): 125, 2018 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-30144800

RESUMO

BACKGROUND: Neurogenic orthostatic hypotension (nOH) results from impaired vasoconstriction due to dysfunction of the autonomic nervous system and is commonly associated with Parkinson disease (PD), multiple system atrophy (MSA), and pure autonomic failure. nOH can increase the risk of falls due to symptoms that include postural lightheadedness or dizziness, presyncope, and syncope. The purpose of this study was to obtain information from patients and caregivers regarding the symptoms and burden of nOH to expand on limited knowledge regarding the impact of nOH on quality of life. METHODS: This author-designed survey included questions regarding nOH (e.g., frequency and impact of symptoms, management) and was conducted online by Harris Poll via distribution to individuals who agreed to participate in Harris Poll online surveys or who were members of relevant disease advocacy organizations. Eligible patients were aged ≥ 18 years with PD, MSA, or pure autonomic failure and ≥ 1 of the following: orthostatic hypotension (OH), nOH, low blood pressure upon standing, or OH/nOH symptoms. Eligible caregivers cared for such patients but were not necessarily linked to any patient participant. RESULTS: Survey responses were received from 363 patients and 128 caregivers. PD was the most frequent underlying disorder (90% of patients; 88% of individuals managed by the caregivers). Despite meeting survey diagnosis criteria, a formal diagnosis of OH or nOH was reported by only 36% of patients and 16% of caregivers. The most frequent symptoms of nOH were dizziness or lightheadedness, fatigue when standing, and difficulty walking. A negative impact on patient quality of life caused by nOH symptoms was reported by 59% of patients and 75% of caregivers. Most respondents (≥87%) reported that nOH symptoms adversely affected patients' ability to perform everyday activities (most frequently physical activity/exercise, housework, and traveling). Falls (≥1) in the previous year due to nOH symptoms were reported by 57% of patients and 80% of caregivers. CONCLUSIONS: These survey results support the premise that nOH symptoms have a substantial negative impact on patient function and quality of life. The relatively low rates of formal nOH/OH diagnosis suggest the need for heightened awareness regarding the condition and its symptom burden.


Assuntos
Cuidadores/estatística & dados numéricos , Hipotensão Ortostática , Adulto , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Hipotensão Ortostática/etiologia , Hipotensão Ortostática/fisiopatologia , Doença de Parkinson/complicações , Qualidade de Vida
9.
J Neuropathol Exp Neurol ; 77(10): 942-949, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-30137426

RESUMO

This study aimed to investigate phosphorylated α-synuclein (p-syn) in autonomic skin nerves of Parkinson disease (PD) patients with and without orthostatic hypotension (OH). We studied 28 PD patients with normal corrected Mini-Mental State Examination including 14 patients with neurogenic OH (PD + OH) and 14 matched patients did not complain of OH (PD - OH); 7 of whom were re-evaluated over a follow-up period (4 ± 2 years). Skin biopsy was performed in proximal and distal sites. PD + OH patients showed a higher p-syn deposition than PD - OH, with widespread autonomic cholinergic and adrenergic skin nerve involvement. Over the follow-up period, PD - OH patients showed an increase in motor dysfunction scores without autonomic symptoms and a slight increase of skin p-syn deposition but still lower than PD + OH, mainly restricted to adrenergic fibers of skin vessels (SV). In summary, PD + OH patients showed a wide involvement of p-syn deposits in autonomic cholinergic and adrenergic skin nerves compared with PD - OH, and PD - OH patients showed a lower load of skin p-syn restricted to adrenergic fibers of SV still persisting over the follow-up period. The data supported a different pathogenesis between PD + OH and PD - OH and may help to identify a specific diagnostic trait for PD + OH.


Assuntos
Hipotensão Ortostática/metabolismo , Doença de Parkinson/metabolismo , Pele/inervação , Pele/metabolismo , alfa-Sinucleína/metabolismo , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/metabolismo , Feminino , Seguimentos , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Masculino , Pessoa de Meia-Idade , Fibras Nervosas/metabolismo , Doença de Parkinson/diagnóstico , Doença de Parkinson/epidemiologia , Fosforilação/fisiologia
10.
Ann Pharmacother ; 52(12): 1182-1194, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29972032

RESUMO

BACKGROUND: The comparative effects of droxidopa and midodrine on standing systolic blood pressure (sSBP) and risk of supine hypertension in patients with neurogenic orthostatic hypotension (NOH) are unknown. OBJECTIVE: To perform a Bayesian mixed-treatment comparison meta-analysis of droxidopa and midodrine in the treatment of NOH. METHODS: The PubMed, CENTRAL, and EMBASE databases were searched up to November 16, 2016. Study selection consisted of randomized trials comparing droxidopa or midodrine with placebo and reporting on changes in sSBP and supine hypertension events. Data were pooled to perform a comparison among interventions in a Bayesian fixed-effects model using vague priors and Markov chain Monte Carlo simulation with Gibbs sampling, calculating pooled mean changes in sSBP and risk ratios (RRs) for supine hypertension with associated 95% credible intervals (CrIs). RESULTS: Six studies (4 administering droxidopa and 2 administering midodrine) enrolling a total of 783 patients were included for analysis. The mean change from baseline in sSBP was significantly greater for both drugs when compared with placebo (droxidopa 6.2 mm Hg [95% CrI = 2.4-10] and midodrine 17 mm Hg [95% CrI = 11.4-23]). Comparative analysis revealed a significant credible difference between droxidopa and midodrine. The RR for supine hypertension was significantly greater for midodrine, but not droxidopa, when compared with placebo (droxidopa RR = 1.4 [95% CrI = 0.7-2.7] and midodrine RR = 5.1 [95% CrI = 1.6-24]). Conclusion and Relevance: In patients with NOH, both droxidopa and midodrine significantly increase sSBP, the latter to a greater extent. However, midodrine, but not droxidopa, significantly increases risk of supine hypertension.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Droxidopa/uso terapêutico , Hipotensão Ortostática/tratamento farmacológico , Midodrina/uso terapêutico , Posição Ortostática , Decúbito Dorsal , Antiparkinsonianos/efeitos adversos , Antiparkinsonianos/uso terapêutico , Teorema de Bayes , Pressão Sanguínea/fisiologia , Droxidopa/efeitos adversos , Humanos , Hipertensão/induzido quimicamente , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Hipotensão Ortostática/epidemiologia , Hipotensão Ortostática/fisiopatologia , Midodrina/efeitos adversos , Meta-Análise em Rede , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Decúbito Dorsal/fisiologia , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vasoconstritores/uso terapêutico
11.
Am J Hypertens ; 31(12): 1255-1259, 2018 11 13.
Artigo em Inglês | MEDLINE | ID: mdl-29982276

RESUMO

Orthostatic hypotension (OH) is an important and common medical problem, particularly in the frail elderly with multiple comorbidities and polypharmacy. OH is an independent risk factor for falls and overall mortality. Hypertension is among the most common comorbidities associated with OH, and its presence complicates the management of these patients because treatment of one can worsen the other. However, there is evidence that uncontrolled hypertension worsens OH so that both should be managed. The limited data available suggest that angiotensin receptor blockers and calcium channel blockers are preferable antihypertensives for these patients. Patients with isolated supine hypertension can be treated with bedtime doses of short-acting antihypertensives. Treatment of OH in the hypertensive patients should focus foremost on the removal of drugs that can worsen OH, including ones that are easily overlooked, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol. OH and postprandial hypotension can be prevented with abdominal binders and acarbose, respectively, without the need to increase baseline blood pressure. Upright blood pressure can be improved by harnessing residual sympathetic tone with atomoxetine, which blocks norepinephrine reuptake in nerve terminals, and pyridostigmine, which facilitates cholinergic neurotransmission in autonomic ganglia. Oral water bolus acutely but transiently increases blood pressure in autonomic failure patients. If traditional pressor agents are needed, midodrine and droxidopa can be used, administered at the lowest dose and frequency that improves symptoms. Management of OH in the hypertensive patient is challenging, but a management strategy based on understanding the underlying pathophysiology can be effective in most patients.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Hipertensão/tratamento farmacológico , Hipotensão Ortostática/tratamento farmacológico , Postura , Anti-Hipertensivos/efeitos adversos , Tomada de Decisão Clínica , Comorbidade , Humanos , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Hipotensão Ortostática/epidemiologia , Hipotensão Ortostática/fisiopatologia , Fatores de Risco , Resultado do Tratamento
12.
Parkinsonism Relat Disord ; 56: 82-87, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30057156

RESUMO

INTRODUCTION: We sought to evaluate if the presence of abnormal circadian loss of nocturnal blood pressure dipping (reverse dipping) is associated with cardiovascular dysautonomia, a major source of morbidity in Parkinson disease. METHODS: Consecutive Parkinson disease patients were enrolled in this cross-sectional study between January 2015 and June 2017. All subjects underwent same-day autonomic testing and 24-h ambulatory blood pressure monitoring. Cardiovascular dysautonomia was defined by the presence of at least one moderate or severe cardiovagal and adrenergic test abnormality. RESULTS: We recruited 114 PD patients (79 males; mean age 64 ±â€¯10 years; disease duration 6 ±â€¯4 years). Cardiovascular dysautonomia was present in 32% (36/114). The blood pressure patterns were normal dipping in 28.9% (n = 33), extreme dipping in 6.1% (n = 7), reduced dipping in 32.5% (n = 37), and reverse dipping in 32.5% (n = 37). Reverse dipping was disproportionately prevalent in subjects with cardiovascular dysautonomia (69% vs 15%, p < 0.001). The diagnostic accuracy of reverse dipping in discriminating cardiovascular dysautonomia (AUC 0.791, specificity 84%, sensitivity 69%) was higher than that of bedside blood pressure ascertainment of neurogenic orthostatic hypotension (0.681, 66%, 69%) and supine hypertension (0.641, 78%, 50%). CONCLUSIONS: Reverse nocturnal blood pressure dipping is a marker of cardiovascular dysautonomia in Parkinson disease, which can be screened for with ease and affordability using ambulatory blood pressure monitoring.


Assuntos
Pressão Sanguínea/fisiologia , Hipertensão/fisiopatologia , Hipotensão Ortostática/fisiopatologia , Doença de Parkinson/fisiopatologia , Disautonomias Primárias/fisiopatologia , Idoso , Ritmo Circadiano/fisiologia , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/diagnóstico , Doença de Parkinson/epidemiologia , Disautonomias Primárias/diagnóstico , Disautonomias Primárias/epidemiologia
13.
Niger J Clin Pract ; 21(7): 932-938, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29984728

RESUMO

Background: Chronic kidney disease (CKD) is a global public health problem with increasing incidence and mortality in Africa. Autonomic dysfunction (AD) has been implicated as a major contributor to the disease morbidity and mortality, but little is known about the predictors of this dysfunction in African populations. Understanding the predictors of this condition is necessary for early detection and management of CKDs. Objectives: This study was designed to determine the predictors of AD in CKD patients in Nigeria. Materials and Methods: It was a cross-sectional study of CKD patients at University of Nigeria Teaching Hospital, Enugu, Nigeria. The CKD patients with AD were compared with those without AD and a normal control group. Autonomic function was assessed through noninvasive cardiovascular tests: measurement of resting tachycardia, orthostatic hypotension, heart rate response (HRR) to standing, HRR to Valsalva maneuvre, and HRR to respiration. Data on symptoms of CKD and AD were obtained using a validated questionnaire. Results: The mean age of the CKD patients was 41.3 ± 1.5 (range: 21-69) years. Early hospital presentation is associated with significantly less risk of the development of AD (P < 0.001). Dizziness, nocturnal diarrhea, and impotence are the major markers/predictors of AD in CKD patients (P < 0.05). Conclusion: AD is common among predialysis CKD patients in Nigeria, and best predicted by the presence of postural dizziness, nocturnal diarrhea, and impotence in men. Physicians should, therefore, be on the lookout for these features for prompt and adequate management of cases.


Assuntos
Doenças do Sistema Nervoso Autônomo/epidemiologia , Hipotensão Ortostática/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Hospitais de Ensino , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Nigéria/epidemiologia , Manobra de Valsalva
14.
Int J Geriatr Psychiatry ; 33(10): 1397-1402, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30043432

RESUMO

OBJECTIVES: The objective of this study was to assess the prevalence of orthostatic hypotension (OH) in a sample of late life depression (LLD) patients and to determine the validity of a standardized questionnaire, the Orthostatic Hypotension Questionnaire (OHQ). Secondarily, we wished to assess variables associated with OH. METHODS: We conducted a cross-sectional study on 82 consecutive geriatric outpatients presenting with LLD. OH was defined as a fall in systolic blood pressure of greater than 20 mm Hg and/or 10 mm Hg on diastolic blood pressure on an orthostatic stress test from sitting to standing. Logistic regressions were used to identify factors associated with OH. RESULTS: The prevalence of OH as measured on the orthostatic stress test and on the OHQ was 28% and 57%, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the OHQ were 69.6% (95% CI 47%-87%), 47.5% (95%CI 34%-61%), 0.54 (95% CI: 0.43-0.64), 34% (95%CI 21%-49%), and 80% (95%CI 63%-92%), respectively. Females were more likely to have OH (OR: 3.96, 95%CI 1.06-14.89, P = .041), and those married or in a common-law relationship were less likely to have OH (OR: 0.25, 95% CI 0.08-0.72, P = .011). CONCLUSIONS: OH is common in patients with LLD conferring them a risk of gait instability and falls. Females had a higher risk of having OH while participants who were married or in a common-law relationship were less likely to have OH. Although the OHQ is a quick to administer paper-based screening test, it did not show adequate diagnostic accuracy in patients with LLD seen in a routine psychiatry clinic.


Assuntos
Transtorno Depressivo/fisiopatologia , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Programas de Rastreamento/métodos , Acidentes por Quedas/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea , Canadá/epidemiologia , Estudos Transversais , Feminino , Avaliação Geriátrica/métodos , Humanos , Modelos Logísticos , Masculino , Programas de Rastreamento/normas , Valor Preditivo dos Testes , Prevalência , Sensibilidade e Especificidade , Inquéritos e Questionários/normas
15.
Neurology ; 91(8): e759-e768, 2018 08 21.
Artigo em Inglês | MEDLINE | ID: mdl-30045960

RESUMO

OBJECTIVE: To examine associations of orthostatic hypotension (OH) with dementia and long-term cognitive decline and to update previously published results in the same cohort for stroke with an additional 16 years of follow-up. METHODS: We analyzed data from 11,709 participants without a history of coronary heart disease or stroke who attended the baseline examination (1987-1989) of the prospective Atherosclerosis Risk in Communities (ARIC) study. OH was defined as a drop in systolic blood pressure (BP) of at least 20 mm Hg or a drop in diastolic BP of at least 10 mm Hg on standing. Dementia was ascertained via examination, contact with participants or their proxy, or medical record surveillance. Ischemic stroke was ascertained via cohort surveillance of hospitalizations, cohort follow-up, and linkage with registries. Both outcomes were adjudicated. Cognitive function was ascertained via 3 neuropsychological tests administered in 1990 to 1992 and 1996 to 1998 and a full battery of tests in 2011 to 2013. Scores were summarized and reported as SDs. We used adjusted Cox regression and linear mixed models. RESULTS: Over ≈25 years, 1,068 participants developed dementia and 842 had an ischemic stroke. Compared to persons without OH at baseline, those with OH had a higher risk of dementia (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.20-1.97) and ischemic stroke (HR 2.08, 95% CI 1.65-2.62). Persons with OH had greater, although nonsignificant, cognitive decline over 20 years (SD 0.09, 95% CI -0.02 to 0.21). CONCLUSIONS: OH assessed in midlife was independently associated with incident dementia and ischemic stroke. Additional studies are needed to elucidate potential mechanisms for these associations and possible applications for prevention.


Assuntos
Transtornos Cognitivos/etiologia , Demência/complicações , Demência/epidemiologia , Hipotensão Ortostática/epidemiologia , Acidente Vascular Cerebral/etiologia , Arteriosclerose/epidemiologia , Pressão Sanguínea/fisiologia , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Características de Residência
16.
Eur Heart J ; 39(33): 3135-3143, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-30052878

RESUMO

Aims: Systematically reviewing the literature found orthostatic hypotension (OH) to be associated with an increased risk of incident dementia but limited data were available in those at highest risk, the hypertensive oldest-old. Our aim was to analyse the relationship between OH and incident cognitive decline or dementia in this group and to synthesize the evidence base overall. Method and results: Participants aged ≥80 years, with hypertension, were from the Hypertension in the Very Elderly Trial (HYVET) cohort. Orthostatic hypotension was defined as a fall of ≥15 mmHg in systolic and or ≥7 mmHg in diastolic pressure after 2 min standing from a sitting position. Subclinical orthostatic hypotension with symptoms (SOH) was defined as a fall

Assuntos
Disfunção Cognitiva/etiologia , Hipertensão/psicologia , Hipotensão Ortostática/psicologia , Idoso de 80 Anos ou mais , Pressão Sanguínea/fisiologia , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/fisiopatologia , Estudos de Coortes , Demência/epidemiologia , Demência/etiologia , Demência/fisiopatologia , Humanos , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Hipotensão Ortostática/epidemiologia , Hipotensão Ortostática/fisiopatologia , Fatores de Risco , Sensibilidade e Especificidade
17.
Parkinsonism Relat Disord ; 54: 68-73, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29728329

RESUMO

OBJECTIVE: The purpose of our study was to explore the factors associated with the survival of multiple system atrophy (MSA) patients and to produce a prognostic nomogram to predict survival in an individual MSA patient. METHODS: 220 probable MSA patients were included from 2009 to 2013. Disease severity was measured by the Unified Multiple System Atrophy Rating Scale (UMSARS). The univariate and multivariable Cox regression analyses were used to identify factors associated with survival in MSA patients. A nomogram model predicting the probability of survival was formulated based on the results of the multivariate Cox analysis. The results were validated using bootstrap resampling and a prospective study on 80 patients included from January 2014 to August 2015 at the same institution. RESULTS: Median survival from symptom onset to death was 6.4 years (95%CI = 6.1-6.7). The multivariate Cox survival model suggested that autonomic onset, higher UMSARS score, frequent falls, orthostatic hypotension(OH) and shorter diagnostic delay were associated with poor survival. The nomogram model for the multivariate Cox survival model had a concordance index of 0.677 in primary cohort, which showed a concordance index of 0.721 in validation cohort. CONCLUSION: Autonomic onset, higher UMSARS score, frequent falls, OH and shorter diagnostic delay at baseline were independent markers for poor survival in MSA. The prognostic nomogram model created by the significant independent factors for longer survival provided an effective way to predict the probability of longer survival in an individual MSA patient.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Diagnóstico Tardio , Hipotensão Ortostática/epidemiologia , Modelos Estatísticos , Atrofia de Múltiplos Sistemas/mortalidade , Índice de Gravidade de Doença , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nomogramas , Prognóstico , Análise de Sobrevida , Fatores de Tempo
18.
J Am Heart Assoc ; 7(10)2018 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-29735525

RESUMO

BACKGROUND: Although orthostatic hypotension (OH) is a well-recognized manifestation of neuropathy and hypovolemia, its contribution to cardiovascular disease (CVD) risk is controversial. METHODS AND RESULTS: Participants with OH, defined as a decrease in blood pressure (systolic ≥20 mm Hg or diastolic ≥10 mm Hg) from the supine to standing position, were identified during the first visit of the ARIC (Atherosclerosis Risk in Communities) Study (1987-1989) within 2 minutes of standing. All participants were followed up for the development of myocardial infarction, heart failure, stroke, fatal coronary heart disease (CHD), any CHD (combination of silent, nonfatal, and fatal CHD or cardiac procedures), and all-cause mortality. Participants were assessed for carotid intimal thickness and plaque during the first visit. Detectable high-sensitivity troponin T (≥5 ng/L) and elevated NT-proBNP (N-terminal pro-B-type natriuretic peptide; ≥100 pg/mL) were determined in blood collected during the second visit (1990-1992). All associations were adjusted for known CVD risk factors. In 9139 participants (57% women; 23% black; mean age, 54±5.7 years), 3% had OH. During follow-up (median, 26 years), OH was associated with myocardial infarction (hazard ratio [HR], 1.88; 95% confidence interval [CI], 1.44-2.46), congestive heart failure (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, 2.00; 95% CI, 1.64-2.44), and all-cause mortality (HR, 1.68; 95% CI, 1.45-1.95). OH was also associated with carotid intimal thickness (ß, 0.05 mm; 95% CI, 0.04-0.07 mm), carotid plaque (odds ratio, 1.51; 95% CI, 1.18-1.93), detectable high-sensitivity troponin T (odds ratio, 1.49; 95% CI, 1.16-1.93), and elevated NT-proBNP (odds ratio, 1.92; 95% CI, 1.48-2.49). CONCLUSIONS: OH identified in community-dwelling middle-aged adults was associated with future CVD events and subclinical CVD. Further research is necessary to establish a causal role for OH in the pathogenesis of CVD.


Assuntos
Pressão Sanguínea , Doenças Cardiovasculares/epidemiologia , Hipotensão Ortostática/epidemiologia , Postura , Doenças Assintomáticas , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/fisiopatologia , Feminino , Humanos , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/mortalidade , Hipotensão Ortostática/fisiopatologia , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
19.
Clin Transl Sci ; 11(4): 387-396, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29637739

RESUMO

RP5063 is a multimodal dopamine (D)-serotonin (5-HT) stabilizer with a high affinity for D2/3/4 and 5-HT1A/2A/2B/7 receptors and moderate affinity for the serotonin transporter. Single-dose (10 and 15 mg fasting, 15 mg fed) safety in healthy volunteers and multiple-dose (10, 20, 50, and 100 mg fed, 10 days) safety and pharmacodynamics in patients with stable schizophrenia were defined in two phase I studies. In the single-dose study, 32 treatment-emergent adverse events (TEAEs) were observed. Orthostatic hypotension (n = 6), nausea (n = 5), and dizziness (n = 4) were the most common. One serious adverse event (SAE), seen in a patient who should not have been in the study due to a history of seizures, involved brief seizure-like symptoms. In the multiple-dose study, 75 TEAEs were reported. Akathisia (n = 20) and somnolence (n = 14) were the most frequent. No clinically significant changes were seen in glucose or prolactin levels, lipid profiles, weight, or electrocardiographic recordings. In both studies, all TEAEs resolved and none led to withdrawal from the study or death. A pharmacodynamic evaluation reflected significant improvements with RP5063 (P < 0.05) over placebo in an analysis of patients with a baseline Positive and Negative Syndrome Scale (PANSS) score ≥50 for positive subscale scores. Improvements of the Trail Making A and Trail Making B test results were observed for patients treated in the 50 mg dose group for days 5, 10, and 16. These findings indicate that RP5063 is well-tolerated up to 100 mg and displays promising preliminary clinical behavioral and cognition activity signals in patients with stable disease over a 10-day period.


Assuntos
Antipsicóticos/efeitos adversos , Compostos Orgânicos/efeitos adversos , Esquizofrenia/tratamento farmacológico , Adulto , Antipsicóticos/administração & dosagem , Tontura/induzido quimicamente , Tontura/epidemiologia , Relação Dose-Resposta a Droga , Método Duplo-Cego , Voluntários Saudáveis , Humanos , Hipotensão Ortostática/induzido quimicamente , Hipotensão Ortostática/epidemiologia , Masculino , Náusea/induzido quimicamente , Náusea/epidemiologia , Compostos Orgânicos/administração & dosagem , Psicometria , Esquizofrenia/diagnóstico , Convulsões/induzido quimicamente , Convulsões/epidemiologia , Resultado do Tratamento , Adulto Jovem
20.
Hypertension ; 71(5): 946-954, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29632103

RESUMO

There is an established cross-sectional association between orthostatic hypotension (OH) and late-life depression. The aim of this observational study was to clarify the longitudinal association between baseline symptomatic OH (sOH-30) and incident depression in a sample of >3000 older people without baseline depression (mean age: 62 years at baseline). This study was embedded within the Irish Longitudinal Study on Ageing using data from waves 1 to 3, collected between 2009 and 2014. At 2- and 4-year follow-up, a score ≥9 on the 8-item Center for Epidemiological Studies Depression Scale was used to define incident depression. sOH-30 was defined as a drop in systolic blood pressure ≥20 mm Hg or diastolic blood pressure ≥10 mm Hg at 30 seconds post-standing in conjunction with orthostatic symptoms, such as dizziness, using beat-to-beat measurements. Almost one fifth (proportion, 18%; 95% confidence interval [CI], 16-20) of the study sample had sOH-30. One tenth (proportion, 10%; 95% CI, 9-12) had incident depression. Participants with incident depression were twice as likely to have sOH-30 at baseline compared with those without incident depression (linear regression, 13% [95% CI, 8-19] versus 7% [95% CI, 6-8]). Weighted logistic regression models demonstrated that sOH-30 predicted incident depression with an odds ratio of 1.90 (95% CI, 1.15-3.15) after controlling for covariates, including subthreshold depression, hypotension, cognitive impairment, and antidepressant use. Asymptomatic OH at 30 seconds and initial OH did not predict depression. This study demonstrates that sOH-30 predicts incident depression in a population-representative sample of older people and may, therefore, represent a potentially modifiable risk factor for late-life depression.


Assuntos
Depressão/diagnóstico , Depressão/epidemiologia , Hipotensão Ortostática/diagnóstico , Hipotensão Ortostática/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Determinação da Pressão Arterial/métodos , Estudos de Coortes , Comorbidade , Feminino , Avaliação Geriátrica , Humanos , Vida Independente , Modelos Lineares , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Prognóstico , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo
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