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Orthostatic Hypotension at Different Times After Standing Erect in Elderly Adults
2015; Wiley; Volume: 63; Issue: 3 Linguagem: Inglês
10.1111/jgs.13324
ISSN1532-5415
AutoresAna Carolina R. Campos, Nathalia Aparecida de Almeida, André Luiz C. Ramos, Daniel França Vasconcelos, Marco Polo Dias Freitas, Maria Alice de Vilhena Toledo,
Tópico(s)Cardiovascular Health and Disease Prevention
ResumoJournal of the American Geriatrics SocietyVolume 63, Issue 3 p. 589-590 Letters to the EditorFree Access Orthostatic Hypotension at Different Times After Standing Erect in Elderly Adults Ana Carolina R. Campos MD, Ana Carolina R. Campos MD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorNathália A. de Almeida MD, Nathália A. de Almeida MD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorAndré L. Ramos, André L. Ramos Department of Statistics, Brasília University, Brasília, BrazilSearch for more papers by this authorDaniel F. Vasconcelos PhD, Daniel F. Vasconcelos PhD Department of Cardiology, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorMarco Polo Freitas PhD, Marco Polo Freitas PhD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorMaria Alice de V. Toledo PhD, Maria Alice de V. Toledo PhD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this author Ana Carolina R. Campos MD, Ana Carolina R. Campos MD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorNathália A. de Almeida MD, Nathália A. de Almeida MD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorAndré L. Ramos, André L. Ramos Department of Statistics, Brasília University, Brasília, BrazilSearch for more papers by this authorDaniel F. Vasconcelos PhD, Daniel F. Vasconcelos PhD Department of Cardiology, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorMarco Polo Freitas PhD, Marco Polo Freitas PhD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this authorMaria Alice de V. Toledo PhD, Maria Alice de V. Toledo PhD Geriatric Medical Center, University Hospital of Brasília, Brasília, BrazilSearch for more papers by this author First published: 04 March 2015 https://doi.org/10.1111/jgs.13324Citations: 9AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL To the Editor: Orthostatic hypotension (OH) is an important cause of morbidity and mortality in the elderly adults. The prevalence varies widely (5–33%).1, 2 One of the factors responsible for these discrepancies is the variation in the definition of OH.3, 4 Despite the importance and easy detection of OH, there is controversy in the literature regarding the time at which blood pressure (BP) should be measured after standing.5 The measurement is commonly taken 3 minutes after position change. Few studies have performed a comparative analysis of BP in the several minutes after standing. The aim of this study was to identify the prevalence of OH, regardless of its cause, at four points after standing in elderly adults in an outpatient setting. Table 1. Frequency of Orthostatic Hypotension Blood Pressure from Measured at Four Times Minutes After Standing n (%) P-Value 1 30 (33.7) <.001 3 22 (24.7) 5 18 (20.2) 10 19 (21.3) Methods Individuals followed up at the outpatient clinics of the Geriatric Medical Centre, University Hospital of Brasília, were consecutively and nonprobabilistically enrolled during 1 year. Inclusion criteria were aged 60 and older, undergoing outpatient treatment at the Geriatric Medical Centre, and providing informed consent. Exclusion criteria were inability to stand. After 5 minutes of rest, BP was measured in the supine position and 1, 3, 5, and 10 minutes after standing. BP was measured in the left arm using a mercury sphygmomanometer according to standards of the American Heart Association Council on High Blood Pressure.6 A drop in systolic blood pressure (SBP) of 20 mmHg or greater or of diastolic blood pressure (DBP) of 10 mmHg or greater, regardless of the time it occurred, was considered to indicate OH. Results One hundred eighty-one individuals, aged 60 to 96, were eligible for the study; 89 (49%) had OH at one or more times of measurement, 52 (58%) within 3 minutes and 37 (42%) after 3 minutes. Discussion There is a wide variation of data on the prevalence of OH, but there is a consensus that it increases with age.3-5 Different studies use different definitions of OH, which also contributes to the apparent variation in the prevalence of this condition. In addition, the same definition of OH is used in different ways in different studies. The time between measurements also varies. Some studies considered average blood pressure measured at different times. In others, a decrease only in SBP or only in DBP was considered for diagnosis.7 The definition most widely used for OH is based on the consensus of the American Autonomic Society and the American Academy of Neurology, published in 1996,8 but many individuals have symptoms of orthostatic intolerance with onset after 3 minutes from the variation of the position. Only a few studies have investigated OH since then.9, 10 Of the 89 individuals with OH in the study, 37 (42%) had a decrease in SBP or DBP only after 3 minutes. If the definition previously described had been considered, the prevalence of OH in this population would be 29%, as opposed to 49%. Measuring BP at different times after standing, before and after 3 minutes, increased the frequency of OH in this population (Table 1). Of the 30 participants who had OH in the first minute, 27 also had OH in the third minute. Only three patients had OH only in the first minute. Of the 37 patients with OH after the third minute, 18 (20%) had a decrease in BP evidenced in the fifth minute and 19 (21%) only in the tenth minute. The mean age of participants who had OH up to the third minute was 76.5, and that of participants who had OH after the first 3 minutes was 73.4 (P = .02). There is evidence that, if BP is measured for only up to 3 minutes, approximately half of the people would not be diagnosed with OH, which is a clinical condition associated with several other adverse conditions. Conclusion The current recommendations for diagnosing OH in older adults in a tertiary-care hospital are inadequate. Further longitudinal and multicenter studies should be conducted to evaluate the best time to measure BP in the standing position and the clinical relevance of late OH. Acknowledgments Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: ACRC: acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. NAA, ALR, DFV: analysis and interpretation of data. MPF: analysis and interpretation of data, review of manuscript. MAVT: study concept and design, analysis and interpretation of data, preparation and review of manuscript. Sponsor's Role: The study had no external funding sources or conflicts of interest. References 1Valbusa F, Labat C, Salvi P et al. Orthostatic hypotension in very old individuals living in nursing homes: The PARTAGE study. J Hypertens 2011; 30: 53– 60. 2Lipsitz LA. Orthostatic hypotension in the elderly. N Engl J Med 1989; 321: 952– 957. 3Tilvis RS, Hakala SM, Valvanne J et al. Postural hypotension and dizziness in a general aged population: A four-year follow-up of the Helsinki Aging Study. J Am Geriatr Soc 1996; 44: 809– 814. 4 The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology 1996; 46: 1470. 5Velseboer DC, Haan RJ, Wieling W et al. Prevalence of orthostatic hypotension in Parkinson's disease: A systematic review and meta-analysis. Parkinsonism Relat Disord 2011; 17: 724– 729. 6Pickering TG, Hall JE, Appel LJ et al. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: Blood pressure measurement in humans: A statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension 2005; 45: 142– 161. 7Low PA. Prevalence of orthostatic hypotension. Clin Auton Res 2008; 18: 8– 13. 8Fagard RH, Cort P. Orthostatic hypotension is a more robust predictor of cardiovascular events than nighttime reverse dipping in elderly. J Hypertens 2010; 56: 56– 61. 9Yu-Chien BS, Vyas MS, Hymen E et al. Gender differences in orthostatic hypotension. Am J Med Sci 2011; 342: 221– 225. 10Gibbons CH, Freeman R. Delayed orthostatic hypotension: A frequent cause of orthostatic intolerance. Neurology 2006; 67: 28. Citing Literature Volume63, Issue3March 2015Pages 589-590 ReferencesRelatedInformation
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