Review Article
Orthostatic hypotension: a common, serious and underrecognized problem in hospitalized patients

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Abstract

Orthostatic hypotension (OH) is strongly age-dependent, with a prevalence ranging from 5% to 11% in middle age to 30% or higher in the elderly. It is also closely associated with other common chronic diseases, including hypertension, congestive heart failure, diabetes mellitus, and Parkinson’s disease. Most studies of OH have been performed in population cohorts or elderly residents of extended care facilities, but in this review, we draw attention to a problem little studied to date: OH in hospitalized patients. The prevalence of OH in all hospitalized patients is not known because most studies have included only older individuals with multiple comorbid diseases, but in some settings as many as 60% of hospitalized adults have postural hypotension. Hospitalized patients are particularly vulnerable to the consequences of OH, particularly falls, because postural blood pressure (BP) regulation may be disturbed by many common acute illnesses as well as by bed rest and drug treatment. The temporal course of OH in hospitalized patients is uncertain, both because the reproducibility of OH is poor and because conditions affecting postural BP regulation may vary during hospitalization. Finally, OH during hospitalization often persists after discharge, where, in addition to creating an ongoing risk of falls and syncope, it is strongly associated with risk of incident cardiovascular complications, including myocardial infarction, heart failure, stroke, and all-cause mortality. Because OH is a common, easily diagnosable, remediable condition with important clinical implications, we encourage caregivers to monitor postural BP change in patients throughout hospitalization.

Introduction

Orthostatic hypotension (OH), usually defined by a drop in systolic blood pressure (SBP) of ≥20 mm Hg or in diastolic blood pressure (DBP) of ≥10 mm Hg within 3 minutes of standing,1, 2 is strongly age-dependent with a prevalence of 5% to 11% in the middle-aged adult population3, 4, 5, 6, 7 and 15% to 25% in individuals age 65 years and older.8, 9, 10, 11, 12, 13, 14, 15, 16 The highest prevalences are reported in elderly subjects with hypertension (15% to 30%), diabetes (15% to 25%), or Parkinson’s disease (∼50%).8 Because many individuals with OH are asymptomatic,6, 8, 17, 18 including some in whom the magnitude of the drop in BP is considerable,19 OH may not interfere with daily activities but still may increase the risk of falling, a major cause of morbidity and mortality.8, 20

In hospitalized patients, disorders and factors contributing to or aggravating OH are common and the most important, bed rest, practically universal (Table 1). Although there are only small studies in selected patient types, hospitalization appears to be associated with an extremely high prevalence of OH, and hospitalized patients are therefore vulnerable to falls and injury (Table 2).

In this review, we provide evidence that OH is sufficiently prevalent and clinically important enough that orthostatic blood pressure (BP) changes should be evaluated in all hospitalized patients routinely and repeatedly. We will focus on issues germane to hospitalization; more extensive discussions of the pathophysiology, treatment, and cardiovascular consequences of OH are available in several excellent recent reviews.8, 21, 22, 23, 24, 25

Section snippets

Normal Postural BP Regulation

The normal cardiovascular adjustments to orthostatic stress are well characterized.8, 21, 22 In brief, as healthy subjects change from recumbency to standing, 500 to 700 mL of blood pools into the lower extremities and in the splanchnic and pulmonary circulations.26, 27, 28 In addition, increased hydrostatic pressure in the lower extremities leads to translocation of fluid from the intravascular to interstitial space, which contracts plasma volume and causes hemoconcentration.26, 28 The

Failure of Normal Regulatory Responses

OH generally occurs when baroreflex-mediated autonomic and humoral responses are inadequate to maintain BP on standing, either because baroreflex function itself is impaired (eg, in the elderly),15, 23, 24 or because blood volume is insufficient to support ventricular filling. Disorders of baroreflex function may result from impaired function at any site in the reflex arc, including carotid sinus stretch receptors, the central nervous system connections, or efferent sympathetic nerve fibers and

Prevalence of OH in Hospitalized Patients

There are no comprehensive surveys of the prevalence of OH in hospitalized patients, but data derived from the Nationwide Inpatient Sample from 2004 suggest that it is at least of the order of 36 per 100,000 adult admissions (95% confidence interval (CI): 34–38).35 As has been shown in population studies, prevalence increases significantly with age, and in patients age 75 years or older the rate of hospitalization for OH is 233 per 100,000 (95% CI: 217–249).35 These are certainly very

Variability of Rates of OH during Hospitalization: The Need for Multiple Readings

Reproducibility of OH in population-based surveys of free-living elderly individuals is poor.44, 45, 46, 47 As with many quantitative disorders of cardiovascular regulation defined by thresholds (eg, hypertension), small variations in the measure of interest (postural BP change), arising from situational or technical factors may affect the reported prevalence of OH during serial measurements. However, even when care is taken to minimize sources of variability, reproducibility is low. In the

Diagnosing OH in Hospitalized Patients

There is no generally accepted methodology for determining postural BP change,77 and both active standing and passive head-up tilt-table approaches are employed: for routine use on a hospital unit, active standing should be sufficient. It is interesting that neither the consensus statement1 nor the American Heart Association guidelines on BP measurement78 specifically comment on whether the posture before active standing should be supine or seated; the European Federation of Neurological

Evaluation and Management of Newly Discovered OH

OH diagnosed in hospitalized patients not previously known to have the condition will usually have an obvious cause (eg, prolonged bed rest). In such cases, there is no need for immediate further investigation, but if OH persists, an evaluation plan should be recommended at discharge. For occasional patients in whom severe or symptomatic OH does not resolve during hospitalization, inpatient evaluation could be appropriate, but we stress that we do not recommend routinely delaying hospital

OH after Discharge from Hospital

How often OH encountered during hospitalization persists when patients transition to intermediate-care facilities or return to their usual living situation is not known, but the high prevalence of OH observed in nursing home residents and in population studies of elderly free-living individuals suggests that OH first encountered in the hospital will often remain a significant problem with important health implications after discharge. Surveys have documented a prevalence of OH of between 10%

Long-term Morbidity and Mortality from Cardiovascular Diseases and Stroke in Patients with OH

In addition to increasing the risk of falling, OH is an independent risk factor for morbidity and mortality from heart disease, stroke and cardiovascular and all-cause mortality (Table 3). The Malmö Preventive Project4 is the largest prospective study with the longest follow-up of the relationship of OH to total mortality, coronary events, and stroke. The study population was a Swedish urban middle-aged cohort (n = 33,346; 67.3% men; mean age, 45.7 years) in whom OH was assessed at baseline and

Conclusions

Although understudied, available evidence indicates that OH is a common problem in hospitalized patients. It has been our experience that postural BP change is infrequently assessed in hospitalized patients, usually only in those who complain of symptoms when sitting or standing after bed rest. Because OH is frequently asymptomatic or has only relatively nonspecific symptoms (eg, lightheadedness, weakness), which may be attributed to other conditions (eg, pain, medications), the only way to

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