Orthostatic hypertension

Last updated
Orthostatic hypertension
Other namesPostural hypertension
Specialty Neurology, cardiology

Orthostatic hypertension is a medical condition consisting of a sudden and abrupt increase in blood pressure (BP) when a person stands up. [1] Orthostatic hypertension is diagnosed by a rise in systolic BP of 20 mmHg or more when standing. Orthostatic diastolic hypertension is a condition in which the diastolic BP raises to 98 mmHg or over in response to standing, [2] [3] [4] but this definition currently lacks clear medical consensus, so is subject to change. Orthostatic hypertension involving the systolic BP is known as systolic orthostatic hypertension.

Contents

High diastolic blood pressure measured while standing in a person who stood up shortly after waking up. High diastolic blood pressure measurement of a person who stood up after waking up.jpg
High diastolic blood pressure measured while standing in a person who stood up shortly after waking up.

When it affects an individual's ability to remain upright, orthostatic hypertension is considered as a form of orthostatic intolerance. The body's inability to regulate blood pressure can be a type of dysautonomia.

Baroreflex and autonomic pathways normally ensure that blood pressure is maintained despite various stimuli, including postural change. The precise mechanism of orthostatic hypertension remains unclear, but alpha-adrenergic activity may be the predominant pathophysiologic mechanism of orthostatic hypertension in elderly hypertensive patients. [5] Other mechanisms are proposed for other groups with this disorder. [1]

A prevalence of 1.1% was found in a large population study. [6] The risk of orthostatic hypertension has been found to increase with age, with it being found in 16.3% of older hypertensive patients. [7]

Causes

The causes of this condition are not well understood, but research suggests that it may be caused by a combination of hemodynamic and neurohumoral factors. [8]

Some studies have found that orthostatic hypertension may be caused by increased vascular resistance, possibly due to excess plasma shifts or increased blood viscosity. Other studies have suggested that it may be caused by a reduction in cardiac preload, or an increase in venous pooling. [8]

Research suggests that it may be caused by an overshoot in neurohumoral adjustments to standing. Some studies have found that patients with orthostatic hypertension have normal levels of venous plasma norepinephrine, but that these levels increase excessively upon standing. [9] [10] However, other studies have not found elevated levels of norepinephrine in patients with orthostatic hypertension compared to hypertensive controls. [11] These findings suggest that the causes of orthostatic hypertension may be multifactorial and more research is needed to fully understand the underlying mechanisms. [8]

Signs and symptoms

Connections to other disorders

Risks

Diagnosis

The condition can be assessed by a tilt table test.

Treatments

Currently, no treatments are officially recommended for orthostatic hypertension, as it is still little known and has various causes. Hence, treatment for those with this disorder is trial and error. Some treatments which have been successfully used for this condition are medications doxazosin, [22] carvedilol, [23] captopril, and propranolol hydrochloride. Treatment of coexisting conditions, e.g., hypovolemia, also is used. Some specialists in severe cases give saline intravenously for hypovolemia, which, if it is the cause, brings the orthostatic hypertension down to a safe level. Pressure garments over the pelvis and the lower extremities may be used as part of treatment, due to the blood pooling issue occurring in many with the disorder. [12]

Epidemiology

The prevalence of this condition has been studied in various populations. In a study conducted in 1922, it was found that 4.2% of 2000 apparently healthy aviators aged 18 to 42 years had an increase in diastolic blood pressure from below 90 mmHg while in the supine position to above 90 mmHg in the upright posture. [24]

Study which defined orthostatic hypertension as a sustained increase in systolic blood pressure of at least 20 mmHg and/or diastolic blood pressure of at least 10 mmHg within 3 minutes of standing, have reported a prevalence rate of orthostatic hypertension ranging from 5% to 30%. This range is generally consistent with the prevalence of orthostatic hypotension. [8]

See also

Related Research Articles

<span class="mw-page-title-main">Blood pressure</span> Pressure exerted by circulating blood upon the walls of arteries

Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" refers to the pressure in a brachial artery, where it is most commonly measured. Blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure in the cardiac cycle. It is measured in millimeters of mercury (mmHg) above the surrounding atmospheric pressure, or in kilopascals (kPa). The difference between the systolic and diastolic pressures is known as pulse pressure, while the average pressure during a cardiac cycle is known as mean arterial pressure.

<span class="mw-page-title-main">Hypertension</span> Long-term high blood pressure in the arteries

Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia. Hypertension is a major cause of premature death worldwide.

Orthostatic hypotension, also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when standing up or sitting down. Primary orthostatic hypotension is also often referred to as neurogenic orthostatic hypotension. The drop in blood pressure may be sudden, within 3 minutes or gradual. It is defined as a fall in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg after 3 minutes of standing. It occurs predominantly by delayed constriction of the lower body blood vessels, which is normally required to maintain adequate blood pressure when changing the position to standing. As a result, blood pools in the blood vessels of the legs for a longer period, and less is returned to the heart, thereby leading to a reduced cardiac output and inadequate blood flow to the brain.

<span class="mw-page-title-main">Hypotension</span> Abnormally low blood pressure

Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is indicated by two numbers, the systolic blood pressure and the diastolic blood pressure, which are the maximum and minimum blood pressures within the cardiac cycle, respectively. A systolic blood pressure of less than 90 millimeters of mercury (mmHg) or diastolic of less than 60 mmHg is generally considered to be hypotension. Different numbers apply to children. However, in practice, blood pressure is considered too low only if noticeable symptoms are present.

<span class="mw-page-title-main">Pulse pressure</span> Difference between systolic and diastolic blood pressure

Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. Healthy pulse pressure is around 40 mmHg. A pulse pressure that is consistently 60 mmHg or greater is likely to be associated with disease, and a pulse pressure of 50 mmHg or more increases the risk of cardiovascular disease. Pulse pressure is considered low if it is less than 25% of the systolic. A very low pulse pressure can be a symptom of disorders such as congestive heart failure.

<span class="mw-page-title-main">Indapamide</span> Thiazide-like diuretic drug

Indapamide is a thiazide-like diuretic drug used in the treatment of hypertension, as well as decompensated heart failure. Combination preparations with perindopril are available. The thiazide-like diuretics reduce risk of major cardiovascular events and heart failure in hypertensive patients compared with hydrochlorothiazide with a comparable incidence of adverse events. Both thiazide diuretics and thiazide-like diuretics are effective in reducing risk of stroke. Both drug classes appear to have comparable rates of adverse effects as other antihypertensives such as angiotensin II receptor blockers and dihydropyridine calcium channel blockers and lesser prevalence of side-effects when compared to ACE-inhibitors and non-dihydropyridine calcium channel blockers.

Essential hypertension is a form of hypertension without an identifiable physiologic cause. It is the most common type affecting 85% of those with high blood pressure. The remaining 15% is accounted for by various causes of secondary hypertension. Essential hypertension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. Hypertension can increase the risk of cerebral, cardiac, and renal events.

<span class="mw-page-title-main">Mean arterial pressure</span> Average blood pressure in an individual during a single cardiac cycle

In medicine, the mean arterial pressure (MAP) is an average calculated blood pressure in an individual during a single cardiac cycle. Although methods of estimating MAP vary, a common calculation is to take one-third of the pulse pressure, and add that amount to the diastolic pressure. A normal MAP is about 90 mmHg.

<span class="mw-page-title-main">Postural orthostatic tachycardia syndrome</span> Abnormally high heart rate when standing

Postural orthostatic tachycardia syndrome (POTS) is a condition characterized by an abnormally large increase in heart rate upon sitting up or standing. POTS is a disorder of the autonomic nervous system that can lead the individual to experience a variety of symptoms. Symptoms may include lightheadedness, brain fog, blurred vision, weakness, fatigue, headaches, heart palpitations, exercise intolerance, nausea, diminished concentration, tremulousness (shaking), syncope (fainting), coldness or pain in the extremities, numbness or tingling in the extremities, chest pain, and shortness of breath. Other conditions associated with POTS include migraine headaches, Ehlers–Danlos syndrome, asthma, autoimmune disease, vasovagal syncope and mast cell activation syndrome. POTS symptoms may be treated with lifestyle changes such as increasing fluid, electrolyte, and salt intake, wearing compression stockings, gentler and slow postural changes, avoiding prolonged bedrest, medication, and physical therapy.

<span class="mw-page-title-main">Hypertensive emergency</span> Very high blood pressure and signs of organ damage

A hypertensive emergency is very high blood pressure with potentially life-threatening symptoms and signs of acute damage to one or more organ systems. It is different from a hypertensive urgency by this additional evidence for impending irreversible hypertension-mediated organ damage (HMOD). Blood pressure is often above 200/120 mmHg, however there are no universally accepted cutoff values.

Severely elevated blood pressure is referred to as a hypertensive crisis, due to the high risk of complications. People with blood pressures in this range may have no symptoms, but are more likely to report headaches and dizziness than the general population. Other symptoms accompanying a hypertensive crisis may include visual deterioration due to retinopathy, breathlessness due to heart failure, or a general feeling of malaise due to kidney failure.

Hypertensive encephalopathy (HE) is general brain dysfunction due to significantly high blood pressure. Symptoms may include headache, vomiting, trouble with balance, and confusion. Onset is generally sudden. Complications can include seizures, posterior reversible encephalopathy syndrome, and bleeding in the back of the eye.

The Dietary Approaches to Stop Hypertension or the DASH diet is a diet to control hypertension promoted by the U.S.-based National Heart, Lung, and Blood Institute, part of the National Institutes of Health (NIH), an agency of the United States Department of Health and Human Services. The DASH diet is rich in fruits, vegetables, whole grains, and low-fat dairy foods. It includes meat, fish, poultry, nuts, and beans, and is limited in sugar-sweetened foods and beverages, red meat, and added fats. In addition to its effect on blood pressure, it is designed to be a well-balanced approach to eating for the general public. DASH is recommended by the United States Department of Agriculture (USDA) as a healthy eating plan. The DASH diet is one of three healthy diets recommended in the 2015–20 U.S. Dietary Guidelines, which also include the Mediterranean diet and a vegetarian diet. The American Heart Association (AHA) considers the DASH diet "specific and well-documented across age, sex and ethnically diverse groups."

<span class="mw-page-title-main">Ambulatory blood pressure</span> Technique for measuring blood pressure over regular intervals

Ambulatory blood pressure, as opposed to office blood pressure, is the blood pressure over the course of the full 24-hour sleep-wake cycle. Ambulatory blood pressure monitoring (ABPM) measures blood pressure at regular intervals throughout the day and night. It avoids the white coat hypertension effect in which a patient's blood pressure is elevated during the examination process due to nervousness and anxiety caused by being in a clinical setting. ABPM can also detect the reverse condition, masked hypertension, where the patient has normal blood pressure during the examination but uncontrolled blood pressure outside the clinical setting, masking a high 24-hour average blood pressure. Out-of-office measurements are highly recommended as an adjunct to office measurements by almost all hypertension organizations.

In medicine, systolic hypertension is defined as an elevated systolic blood pressure (SBP). If the systolic blood pressure is elevated (>140) with a normal (<90) diastolic blood pressure (DBP), it is called isolated systolic hypertension. Eighty percent of people with systolic hypertension are over the age of 65 years old. Isolated systolic hypertension is a specific type of widened pulse pressure.

Prehypertension, also known as high normal blood pressure and borderline hypertensive (BH), is a medical classification for cases where a person's blood pressure is elevated above optimal or normal, but not to the level considered hypertension. Prehypertension is now referred to as "elevated blood pressure" by the American College of Cardiology (ACC) and the American Heart Association (AHA). The ACC/AHA define elevated blood pressure as readings with a systolic pressure from 120 to 129 mm Hg and a diastolic pressure under 80 mm Hg, Readings greater than or equal to 130/80 mm Hg are considered hypertension by ACC/AHA and if greater than or equal to 140/90 mm Hg by ESC/ESH. and the European Society of Hypertension defines "high normal blood pressure" as readings with a systolic pressure from 130 to 139 mm Hg and a diastolic pressure 85-89 mm Hg.

Orthostatic syncope refers to syncope resulting from a postural decrease in blood pressure, termed orthostatic hypotension.

<span class="mw-page-title-main">Heart failure with preserved ejection fraction</span> Medical condition

Heart failure with preserved ejection fraction (HFpEF) is a form of heart failure in which the ejection fraction – the percentage of the volume of blood ejected from the left ventricle with each heartbeat divided by the volume of blood when the left ventricle is maximally filled – is normal, defined as greater than 50%; this may be measured by echocardiography or cardiac catheterization. Approximately half of people with heart failure have preserved ejection fraction, while the other half have a reduction in ejection fraction, called heart failure with reduced ejection fraction (HFrEF).

Hypertensive disease of pregnancy, also known as maternal hypertensive disorder, is a group of high blood pressure disorders that include preeclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, and chronic hypertension.

The Systolic Blood Pressure Intervention Trial (SPRINT) is a multi-center clinical trial that was performed from 2010 to 2015, and published in November 2015.

References

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  2. ↑ Bell, David S. (May 2000). "Orthostatic Intolerance (OI) Test Results". Lyndonville News. 2 (3).
  3. ↑ Streeten, D.H.P. (1987). Orthostatic Disorders of the Circulation. New York: Plenum Medical. p. 116. ISBN   978-1-4684-8962-0.
  4. ↑ Jordan, Jens; Biaggioni, Italo; Kotsis, Vasilios; Nilsson, Peter; Grassi, Guido; Fedorowski, Artur; Kario, Kazuomi (February 2023). "Consensus statement on the definition of orthostatic hypertension endorsed by the American Autonomic Society and the Japanese Society of Hypertension". Hypertension Research. 46 (2): 291–294. doi:10.1038/s41440-022-01074-0. ISSN   1348-4214. PMC   9899687 .
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  7. 1 2 Fan XH, Sun K, Zhou XL, Zhang HM, Wu HY, Hui RT (January 2011). "[Association of orthostatic hypertension and hypotension with target organ damage in middle and old-aged hypertensive patients]". Zhonghua Yi Xue Za Zhi. 91 (4): 220–224. PMID   21418863.
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  11. ↑ Vriz, O.; Soon, G.; Lu, H.; Weder, A. B.; Canali, C.; Palatini, P. (May 1997). "Does orthostatic testing have any role in the evaluation of the young subject with mild hypertension?: an insight from the HARVEST study". American Journal of Hypertension. 10 (5 Pt 1): 546–551. doi: 10.1016/s0895-7061(96)00489-x . ISSN   0895-7061. PMID   9160766.
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  13. ↑ Streeten DH, Anderson GH, Richardson R, Thomas FD (March 1988). "Abnormal orthostatic changes in blood pressure and heart rate in subjects with intact sympathetic nervous function: evidence for excessive venous pooling". The Journal of Laboratory and Clinical Medicine. 111 (3): 326–335. PMID   3343547.
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  17. ↑ Takada Y, Shimizu H, Kazatani Y, Azechi H, Hiwada K, Kokubu T (January 1984). "Orthostatic hypertension with nephroptosis and aortitis disease". Archives of Internal Medicine. 144 (1): 152–154. doi:10.1001/archinte.144.1.152. PMID   6362595.
  18. ↑ Miranda CL, Henderson MC, Wang JL, Nakaue HS, Buhler DR (October 1986). "Induction of acute renal porphyria in Japanese quail by Aroclor 1254". Biochemical Pharmacology. 35 (20): 3637–3639. doi:10.1016/0006-2952(86)90637-4. PMID   3094542.
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  20. ↑ Yatsuya H, Folsom AR, Alonso A, Gottesman RF, Rose KM (February 2011). "Postural changes in blood pressure and incidence of ischemic stroke subtypes: the ARIC study". Hypertension. 57 (2): 167–173. doi:10.1161/HYPERTENSIONAHA.110.161844. PMC   3214760 . PMID   21199999.
  21. ↑ Kostis, W.J., Sargsyan, D., Mekkaoui, C. et al. Association of orthostatic hypertension with mortality in the Systolic Hypertension in the Elderly Program. J Hum Hypertens 33, 735–740 (2019). doi : 10.1038/s41371-019-0180-4
  22. ↑ Hoshide S, Parati G, Matsui Y, Shibazaki S, Eguchi K, Kario K (January 2012). "Orthostatic hypertension: home blood pressure monitoring for detection and assessment of treatment with doxazosin". Hypertension Research. 35 (1): 100–106. doi: 10.1038/hr.2011.156 . PMID   21918522.
  23. ↑ Moriguchi A, Nakagami H, Kotani N, Higaki J, Ogihara T (March 2000). "Contribution of cardiovascular hypersensitivity to orthostatic hypertension and the extreme dipper phenomenon". Hypertension Research. 23 (2): 119–123. doi: 10.1291/hypres.23.119 . PMID   10770258.
  24. ↑ Schneider, Edward C.; Truesdell, Dorothy (1922-08-01). "A statistical study of the pulse rate and the arterial blood pressures in recumbency, standing, and after a standard exercise". American Journal of Physiology. Legacy Content. 61 (3): 429–474. doi:10.1152/ajplegacy.1922.61.3.429. ISSN   0002-9513.

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