Differences in age-independent effects of blood pressure on baroreflex sensitivity between normal and hypertensive subjects

Influence of aging and other cardiovascular risk factors on baroreflex sensitivity

OBJECTIVES

To examine the influence of known cardiovascular risk factors (cholesterol, blood glucose levels, arterial pressures, heart rate, and aging) on baroreflex sensitivity.

DESIGN

An observational epidemiological study.

SETTING

Geriatric Division at the Policlinico Umberto Primo, University of Rome La Sapienza.

PARTICIPANTS

Two hundred three subjects whose ages ranged from 9 to 94 years, apparently healthy and free of detectable clinical evidence of atherosclerosis.

MEASUREMENTS

All subjects underwent determination of baroreflex sensitivity by phenylephrine infusion (BSphe), and by a noninvasive method derived from spectral analysis of R-R interval and arterial pressure variabilities (alpha index).

RESULTS

The population, subdivided into tertiles for each variable studied, had lower BSphe values and lower alpha indexes as a function of age, plasma low-density lipoprotein (LDL) cholesterol, and systolic blood pressure. The alpha index was significantly lower in both groups with elevated LDL cholesterol levels than in those with lower levels (II and III vs I tertile, P <.001), whereas BSphe differed significantly only in the two groups who had extreme levels of LDL (I vs III tertile, P <.001). Multiple regression analysis identified a negative association of the alpha index with age (P <.001), heart rate (P <.01), area under the glucose-response curve (P <.001), and LDL cholesterol (P <.01), but of BSphe only with age (P <.001) and heart rate (P <.01).

CONCLUSION

These findings indicate that some risk factors for coronary heart disease adversely influence baroreflex sensitivity.

Variability of blood pressure response to orthostatism and reproducibility of the diagnosis of orthostatic hypotension in elderly subjects

BACKGROUND

Orthostatic hypotension (OH) is a major problem in the elderly population. Its diagnosis is based on measurement of the blood pressure (BP) response to orthostatism (BPRO). This study investigates the within-day and day-to-day variability of the BPRO and the reproducibility of the diagnosis of OH in this population.

METHODS

BP was measured in the supine position and after 1 and 2 minutes of orthostatism in 53 consecutive elderly patients (43 women and 10 men aged 83.7 +/- 9.5 years) of an intermediate care geriatric ward. BPRO was assessed 4 times on the same day (8-9 AM, 10-11 AM, 1-2 PM, and 5-6 PM) and twice more on another day of the same week (8-9 AM and 1-2 PM).

RESULTS

There were significant within-day differences between the four orthostatic changes in systolic BP (OCs, supine minus standing systolic BP) after 1 minute or 2 minutes (p < .05). Day-to-day differences between the OCs measured at the same times were not significant. OH defined as an OCs of 20 mm Hg or more at 1 or 2 minutes of orthostatism, was found in ten cases (19%) in the initial set of measurements on the first day. A cumulative diagnosis of OH after the six BPRO tests was found in 23 cases (43%). The reproducibility of the diagnosis of OH was mild or poor (all kappa values were below 0.47).

CONCLUSIONS

BPRO exhibits significant within-day variability in elderly patients. Within-day and day-to-day reproducibility of the diagnosis of OH, based on conventional criteria, were found to be poor.

Cardiovascular, autonomic, and plasma catecholamine responses in unilateral and bilateral carotid artery stenosis

OBJECTIVE

To determine impairment of baroreceptor afferent activity, which may affect cardiovascular autonomic function in patients with unilateral and bilateral carotid artery stenosis. Comparison was made with normal subjects and hypertensive patients.

METHODS

A series of cardiovascular autonomic function tests along with plasma noradrenaline (norepinephrine) measurements were performed in 46 patients with carotid artery stenosis (CAS); 23 had unilateral and 23 had bilateral stenosis. Comparison was made with 21 hypertensive patients (with a similar degree of raised blood pressure), and 27 normal subjects.

RESULTS

Over a third of patients with unilateral and bilateral CAS had postural hypotension. Heart rate did not rise appropriately in CAS despite the postural fall in blood pressure. Pressor responses in CAS were preserved. Heart rate responses to respiratory stimuli were attenuated. Plasma noradrenaline concentrations rose normally during head up tilt.

CONCLUSION

A substantial proportion with CAS had postural hypotension and attenuated heart rate responses. This was not due to sympathetic vasoconstrictor or cardiac parasympathetic failure, thus suggesting impaired afferent baroreceptor activity, probably secondary to involvement of the carotid sinus. Cardiovascular autonomic testing and assessment of postural hypotension and factors enhancing it may be of clinical relevance in such patients, especially as the symptoms of postural hypotension overlap with those due to thromboembolism.

Relationship between baroreceptor reflex function and end-organ damage in spontaneously hypertensive rats

The purpose of this study was to further illustrate the relationship between baroreceptor reflex sensitivity (BRS) and hypertensive end-organ damage (EOD) and to test the hypothesis that impairment of BRS aggravates EOD in hypertension. We studied baroreflex-mediated changes in heart rate [expressed as baroreceptor sensitivity to heart rate control (BRS(HR))] and blood pressure [expressed as baroreceptor sensitivity to blood pressure control (BRS(BP))] in spontaneously hypertensive rats (SHR) and Wistar-Kyoto rats (WKY) that were used as controls, both at the age of 50-52 wk. Rats were also instrumented to record BP, HR, and BP variability (BPV) in the conscious, unrestrained state. In SHR compared with WKY, BP and BPV were significantly increased, whereas BRS(HR) and BRS(BP) were significantly decreased. SHR had remarkable EOD when compared with WKY (EOD score: 6.3 +/- 2.5 vs. 2.9 +/- 0.8, P < 0.01). Univariate regressive analysis demonstrated that EOD score was increased with BP and BPV and decreased with BRS. In multivariate analysis, EOD score was predicted by greater systolic BP and lower BRS and HR variability. These results indicate that BRS is negatively related to BPV and EOD score, and impaired BRS might be one of the major causes for hypertensive EOD.

Exercise training and heart rate variability in older people

PURPOSE

Heart rate variability (HRV), a characteristic that is potentially increased by physical activity, has been associated with incidence of cardiac events and total mortality. Since the incidence of cardiac events among older people is high and their physical activity levels and HRV are generally low, it is important to investigate whether regular physical activity can modify HRV in this age group. The purpose of the study was to investigate the effect of regular physical activity on HRV in older men and women.

METHODS

In a randomized controlled trial, the effect of six months' training on HRV was investigated in a group of 51 older men and women (67.0 +/- 5.1 yr). The training group gathered three times per week for 45 min supervised training.

RESULTS

At the end of the intervention period, HRV was higher primarily during the day. During daytime, the SD of all normal intervals (+6%) as well as the low frequency component (+ 15%) and the very low frequency component (+ 10%) of HRV were significantly increased (P < 0.05) as compared with the control group. Effects of training were most pronounced in subjects inactive in sports at baseline.

CONCLUSION

This study demonstrates that regular physical activity increases HRV (specifically in the very low and low frequency components) in older subjects. Hence, in older subjects, physical training may be an effective means to modify positively a factor that is associated with increased incidence of cardiac events.

Descriptive epidemiology of blood pressure response to change in body position. The ARIC study

The epidemiology of a common measure of cardiovascular reactivity, the change in systolic blood pressure (DeltaSBP) from the supine to the standing position, is described in a cohort of 13 340 men and women aged 45 to 65 years enrolled in the Atherosclerosis Risk in Communities (ARIC) Study. The distribution of DeltaSBP was found to be symmetrical and unimodal, with a mean value near zero (-0.45 mm Hg). The range of DeltaSBP was from -63.2 to 54.3 mm Hg, and the standard deviation was 10.8. Stratification of DeltaSBP by race and gender shows a slight shift in distribution toward higher values for black men and women. DeltaSBP was categorized into deciles. Participants in the top 30% and bottom 30% of the distribution were compared with individuals in the middle 40% of the distribution, who had little or no change in SBP on standing. Participants in the bottom 30% (ie, SBP decreased on standing) were significantly older, had a greater prevalence of hypertension and peripheral vascular disease, had higher values of SBP, and had more cigarette-years of smoking. Among participants in the top 30% (ie, SBP increased on standing), a significantly larger proportion were black, mean seated SBP was higher, and the predicted risk of developing coronary heart disease after 8 years was greater. The response of SBP to change in posture showed considerable variability in a population sample of middle-aged adults. Cardiovascular morbidity, sociodemographic factors, and cigarette smoking were associated with the magnitude and direction of the postural change.

Use of sublingual nitroglycerin during head-up tilt-table testing in patients >60 years of age

Previous work had demonstrated a reduced specificity associated with head-up tilt protocols using high-dose isoproterenol in patients between 20 and 50 years of age. We evaluated the specificity of head-up tilt testing using different isoproterenol infusion doses and administration of nitroglycerin in patients aged >60 years. In addition, whether the same protocols have impact on the sensitivity of the test was also assessed. One hundred sixty subjects were included in this study. Seventy-six were volunteers randomized to either head-up tilt test with low-dose, 3- and 5-microg/min of isoproterenol (group I) or to a protocol including 0.4 mg of sublingual nitroglycerin (group II). In addition, after an upright tilt drug-free state, 58 patients with a history of syncope underwent repeat head-up tilt with increasing doses of isoproterenol infusion, followed by sublingual nitroglycerin if the test result remained negative. The remaining 33 patients were subjected to the nitroglycerin protocol after the drug-free state phase. In the control groups, the incidence of false-positive responses was 88% and 95%, respectively. In patients with syncope after a negative test result during 5 microg of isoproterenol infusion, nitroglycerin administration increased the number of positive responses from 45% to 79%. The percentage of positive tilt in patients undergoing nitroglycerin administration after the drug-free state part of the protocol was 78%. Administration of nitroglycerin was the most significant predictor of a positive upright tilt in patients with syncope. In subjects aged >60 years, head-up tilt protocols with high-dose isoproterenol infusion and nitroglycerin maintained an adequate specificity. In this subset of patients, nitroglycerin seemed to provide a better sensitivity than isoproterenol.

Baroreceptor sensitivity response to phase IV of the Valsalva maneuver in spinal cord injury

Due to the increased prevalence of ischemic heart disease and hypertension reported in individuals with chronic spinal cord injury (SCI), we investigated whether subjects with low level SCI (paraplegia), without apparent evidence of coronary artery disease, exhibit normal baroreceptor and autonomic function. Eighteen males participated in this study: seven normotensive with paraplegia, five hypertensive with paraplegia and six normotensive non-SCI controls. The Valsalva maneuver was performed by maintaining a pressure of 40 mmHg over 15 s and R-R intervals (RRI) and arterial blood pressure were measured continuously. Phase IV of the Valsalva maneuver was determined by linear regression analysis between RRI and systolic pressure, with a final slope calculated. The power spectra for RRI and blood pressure variability parameters were also analyzed, in addition to the index alpha, a frequency domain estimate of the overall gain in baroreceptor control of the RRI-arterial blood pressure. The normotensive subjects with paraplegia were found to have an impaired baroreceptor response when compared with age-matched, non-SCI controls. In addition, the levels of both the low frequency and high frequency spectral components of RRI and the index alpha were reduced in these individuals at rest. These cumulative findings strongly suggest that the integrity of the sinoaortic baroreceptors, as well as efferent parasympathetic function, may be compromised in otherwise apparently healthy individuals with chronic paraplegia.

Determinants of circadian blood pressure variation: a community-based study in Ohasama

We investigated factors affecting the nocturnal decline in blood pressure (BP). A cross sectional study was done in 706 community-based untreated subjects > or = 20 years of age. Screening and ambulatory BPs were measured and the effects of age and the ambulatory BP on the nocturnal decline were examined. Bivariate analysis demonstrated that the magnitude of the decline and the percent decline in the nocturnal BP increased with increase in daytime ambulatory BP and decreased with increase in nighttime ambulatory BP. Although the magnitude of the nocturnal decline in BP increased with increasing daytime BP, the nocturnal BP in hypertensives was still higher than those in normotensives. The magnitude decreased with increasing age in men but not in women, while the percent decline decreased with increasing age in both men and women. Since bivariate analysis demonstrated that the daytime BP, nighttime BP, and standard deviation of the 24-hour BP strongly correlated with the magnitude of the nocturnal decline, these parameters were excluded as independent variables from the multivariate analysis. In the multivariate analysis the nighttime pulse pressure was negatively and daytime pulse pressure was positively associated with the magnitude of the decline and the percent decline in the nocturnal BP. A non-dipping circadian variation was frequently observed in elderly normotensive men but the rate of nondipper was rather low in hypertensive individuals in the general population. A marked dipping pattern was frequently observed in hypertensive women > or = 70 years of age. The nocturnal BP levels in subjects with daytime hypertension are higher than those in subjects with daytime normotension. Therefore, BP must ideally be lowered over 24-hour period in hypertensive subjects. The diminished magnitude of the decline and the decrease in the percent decline in the nocturnal BP in the elderly may be mediated by the disturbed baroreflex function due to the decrease in compliance of large elastic artery. However, in some elderly hypertensive women, excess nocturnal decline in BP is observed. In such subjects, we should take care of the nocturnal BP levels during treatment.

Factors affecting the nocturnal decrease in blood pressure: a community-based study in Ohasama

OBJECTIVE

To investigate factors affecting the nocturnal decrease in blood pressure.

DESIGN

A cross-sectional study of 823 community-based untreated subjects aged > 20 years. Screening and ambulatory blood pressures were measured and the effects of age and the ambulatory blood pressure on the nocturnal decrease were examined.

RESULTS

The magnitude of the decrease and the percentage decrease in the nocturnal blood pressure increased with increasing daytime ambulatory blood pressure and decreased with increasing night-time ambulatory blood pressure. Although the magnitude of the nocturnal decrease in blood pressure increased with increasing daytime blood pressure, the nocturnal blood pressure levels in hypertensives were still higher than those in normotensive subjects. The magnitude decreased with increasing age for men but not for women, whereas the percentage decrease decreased with increasing age both for men and for women. The SD of the 24 h blood pressure correlated strongly to the magnitude of the nocturnal decrease (systolic blood pressure r = 0.62, P < 0.0001; diastolic blood pressure r = 0.52, P < 0.0001), suggesting that the SD of the 24 h blood pressure is representative of the nocturnal decrease. A minimal nocturnal decrease was observed frequently in elderly normotensive men but infrequently in hypertensive individuals from the general population. A marked nocturnal decrease was observed frequently in hypertensive women aged > 70 years.

CONCLUSION

Although the magnitude of the nocturnal decrease in blood pressure increased with increasing daytime blood pressure, the nocturnal blood pressure levels increased with increasing daytime ambulatory blood pressure. Therefore, the blood pressure in hypertensive subjects should essentially be lowered throughout the 24 h period. A marked nocturnal decrease in blood pressure in some elderly hypertensive women was observed without treatment. The nocturnal blood pressure levels of such subjects should be considered during treatment.

Syncope in the elderly

Age-related physiologic changes and disease-related abnormalities predispose older adults to syncope. It is important to know the physiologic changes that occur with normal aging to understand better their interaction with disease processes and to facilitate better evaluation and treatment of syncope when it occurs. Attention to situational stresses, such as posture changes, meals, or medications, is also likely to increase the diagnostic yield and improve therapeutic strategies that can reduce morbidity and potential mortality of recurrent episodes. Therapy should be directed toward minimizing multiple factors that contribute to syncope, avoiding iatrogenic medication effects, and treating specific contributory diseases.

Reproducibility of orthostatic hypotension in symptomatic elderly

PURPOSE

Variations in the reported prevalence of orthostatic hypotension (4% to 33%) are attributed to population selection and varied criteria used to define orthostatic hypotension. Variation in the reproducibility of hemodynamic responses to orthostasis could be a further confounding variable. The purpose of this study was to evaluate reproducibility of orthostatic blood pressure changes in patients with documented symptomatic orthostatic hypotension.

PATIENTS AND METHODS

Forty outpatients (mean age 77+/- 8 years; 24 women) were recruited after initial presentation to a morning outpatient clinic with postural symptoms of dizziness (92%), falls (67.5%), or syncope (30%). Patients had a symptomatic drop in orthostatic systolic blood pressure of >20 mm Hg documented in clinic. Subsequent cardiovascular assessment included autonomic function tests, carotid sinus massage (supine and erect), and prolonged head-up tilt tests. Blood pressure and heart rate measurements were repeated during standing and head-up tilt on two further attendances in the morning.

RESULTS

A total of 67.5% patients had a drop in systolic blood pressure of >20 mm Hg on both visits during orthostatic stimuli; in the remainder, the response was not reproducible, and 5% had no significant orthostatic drop at either attendance. In 19 patients autonomic function tests were abnormal; orthostatic hypotension was reproducible in 79% of this group. In patients with normal autonomic function tests, 57% had reproducible orthostatic hypotension, of which only 60% were reproducible in those patients when further assessed in the afternoon.

CONCLUSIONS

Orthostatic blood pressure responses may not be reproducible in patients with documented symptomatic orthostatic hypotension, particularly if autonomic function is normal and measurements are taken in the afternoon. Repeated systolic blood pressure measurements in the morning may be necessary to make a diagnosis in older patients with suspected orthostatic hypotension.

Pathophysiology of carotid sinus hypersensitivity in elderly patients

Carotid sinus hypersensitivity (CSH) is recognised in up to 45% of elderly patients with syncope, falls, and dizziness that may not be attributed to specific myocardial sinus node dysfunction, various diseases that affect pacemaker activity, cardiac output and blood supply to the brain. The pathophysiology of CSH is unclear but it is associated with ageing, hypertension, and ischaemic heart disease. CSH is potentially treatable with dual chamber pacing for prolonged sinus arrest (cardio-inhibitory CSH) but therapy for the more prevalent hypotension (vasodepressor CSH) is unsatisfactory. However, hypersensitivity of the carotid sinus is not consistent with the known blunting effects of senescence and hypertension on baroreflex sensitivity. The present hypothesis proposes that CSH in elderly patients results from up-regulation of brainstem postsynaptic alpha-2 adrenoceptors. Reduced carotid sinus compliance in elderly arteriosclerotic hypertensive patients will reduce afferent impulse traffic in the baroreflex pathway. Such relative deafferentation may be expected to cause baroreflex postsynaptic hypersensitivity, mediated by up-regulation of the dominant postsynaptic receptor population in the baroreflex pathway, ie, alpha-2 adrenoceptors. Vigorous carotid sinus stimulation, eg, massage, could thus cause an overshoot baroreflex efferent response, resulting in profound hypotension and bradycardia. Hypotension and bradycardia are compounded by the effects of age, hypertension, ischaemic heart disease and arteriosclerosis on rapid cardiovascular compensation, resulting in cerebral hypoperfusion and syncope. Thus CSH in elderly patients should be considered as a clinical marker of widespread arteriosclerotic disease, rather than as a distinct disease entity. If correct, this hypothesis has potentially important implications for the pharmacotherapy of hypotension-related symptoms in elderly arteriosclerotic patients.

Regional sympathetic innervation of the heart by means of metaiodobenzylguanidine imaging in silent ischemia

Metaiodobenzylguanidine was used to determine regional cardiac sympathetic innervation and whether it is reduced in silent ischemia. Patients with silent ischemia (group 1, n = 6) and angina (group 2, n = 5) and normal subjects (n = 6) underwent single-photon emission tomography at 4 hours. From base to midventricle, uptake increased in group 1 (p < 0.006), group 2 (p < 0.01), and the normal subjects (p < 0.004). In group 1 anterior ventricular uptake was greater than inferior uptake at the midventricle (p < 0.03) and apex (p < 0.05). In group 2 the same relationship was demonstrated at midventricle (p < 0.01) and apex (p < 0.05). Group 2 uptake was only significantly greater than group 1 at midventricle (p < 0.05). Innervation is greatest in midventricle and the apex of the left ventricle and greater in the anterior wall compared with the inferior wall. There is no evidence of reduced innervation in silent ischemia.

Circadian blood pressure rhythms in elderly hypertensive patients

Blood pressure was recorded for 24 h in 121 essential hypertensive patients aged between 20 and 90 years. To characterize the circadian blood pressure rhythm, the differences between the daytime blood pressures (recorded at 8-min intervals between 8 a.m. and 10 p.m.) and the night-time blood pressures (recorded at 30-min intervals between 10 p.m. and 8 a.m.) were calculated. The difference between daytime and night-time blood pressures was significantly (P less than 0.01) decreased in elderly hypertensive patients aged between 65 and 90 years compared with in those aged 20-39 years. In patients with heart insufficiency the circadian blood pressure rhythmicity was significantly (P less than 0.05) further reduced compared with in uncomplicated hypertensives. This may be explained by increased sympathetic tonus in patients with heart insufficiency and reduced vascular compliance may be the cause of the overall reduced circadian blood pressure rhythmicity in elderly hypertensive patients.

Comparison of differences in the hemodynamic response to passive postural stress in healthy subjects greater than 70 years and less than 30 years of age

To test the hypothesis that age-related increases in arterial pressure alter the cardiovascular response to physiologic stress, 9 healthy elderly volunteers (74 +/- 2 years) and 7 young subjects (27 +/- 3 years) were subjected to a standard 60 degrees upright tilt. Cardiac volumes were measured with patients in the supine position and 5 minutes after they assumed an upright posture using radionuclide ventriculography, while heart rate, blood pressure and forearm cutaneous flow were recorded continuously and simultaneously. Only the expected age-related increase in mean arterial pressure (young subjects, 79 +/- 1 mm Hg; elderly subjects, 99 +/- 3 mm Hg; p less than 0.001) distinguished the 2 groups at baseline. However, during upright tilt, elderly subjects had significant decreases in stroke volume (supine [108 +/- 9 ml] vs upright [78 +/- 9 ml]; p less than 0.01) and cardiac index (supine [3.4 +/- 0.2 liters/min/m2] vs upright [2.8 +/- 0.2 liters/min/m2]; p less than 0.05) because of an inability to reduce end-systolic volume (supine, 44 +/- 6 ml; upright, 51 +/- 7 ml); however, mean arterial pressure was maintained through an increase in peripheral resistance. In contrast, the young relied solely on cardiac adaptations to postural stress by decreasing end-systolic volume (supine, 62 +/- 5 ml; upright, 39 +/- 5 ml; p less than 0.01) and increasing heart rate (57 +/- 2 min-1 to 71 +/- 3 min-1, p less than 0.01), whereby cardiac output and mean arterial pressure were maintained during tilt.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-related changes in autonomic control: the use of beta blockers in the treatment of hypertension

Functional decrements in autonomic control and reflex activity in the elderly resemble the effects of beta-adrenoreceptor blockade. This arises partly from an age-related decrease in intrinsic beta-adrenoreceptor sensitivity and partly from effector changes associated with degenerative processes such as arteriosclerosis. In the elderly, compensatory adjustments in cardiovascular control result from both sympathetic and parasympathetic dysfunction. The characteristics of aging in autonomic nervous control are examined in relation to the treatment of essential hypertension by beta blockers in the elderly. Increased cardiac output with exercise depends more on increased intracardiac volume than on sympathetic modulation of heart rate in older people. Baroreceptor-dependent and renin blood pressure responses are diminished. The cold pressor response, which is found to be greater in the elderly than in young adults, is abolished by alpha and not beta blockers. Blood viscosity and blood platelets also increase in moderately cold conditions, and a beta blocker with vasodilator and antiplatelet activity may therefore be useful. Trigeminal cardiorespiratory reflex responses to facial cooling evoke a higher blood pressure but smaller bradycardia in old people. These constraints of autonomic nerve function on the use of beta blockers for treating hypertension are imposed on a background of altered drug pharmacokinetics and pharmacodynamics in the elderly.

Forearm blood flow response to posture change in the very old: non-invasive measurement by venous occlusion plethysmography

Little is known about the peripheral vascular response to posture change in very elderly people who are vulnerable to the development of orthostatic hypotension. This is due, in part, to the risks of currently utilized invasive vascular monitoring techniques in the elderly population. We studied the forearm vascular response to active standing in 18 healthy young, 10 healthy old, and 19 impaired elderly subjects, using the non-invasive technique of venous occlusion plethysmography. In six subjects this technique was compared to duplex doppler ultrasonography for the measurement of postural changes in forearm blood flow. Forearm blood flow changes determined by venous occlusion plethysmography were 11% larger than doppler measurements, but the two methods strongly correlated (r = 0.90, P less than .001). Mean forearm vascular resistance increased to a significantly greater extent at 1 minute of standing in young subjects than in both groups of old, although the response was quite variable in all groups. Two healthy elderly (20%) and eight impaired elderly (40%) subjects had unexpected forearm vasodilatation at 1 minute of standing. By 3 minutes, forearm vascular resistance had increased by similar amounts in all three groups of subjects. Five impaired elderly and no healthy young or healthy old subjects had orthostatic hypotension, defined as greater than or equal to 10 mm Hg decline in mean arterial blood pressure at 1 or 3 minutes of standing. Forearm vascular resistance changes did not correlate with blood pressure response to standing. Thus, forearm vascular response to 1 minute of active standing is attenuated in many elderly subjects. This abnormality may impair adaptation to orthostatic stress in advanced age.

Spectral characteristics of heart rate variability before and during postural tilt. Relations to aging and risk of syncope

Fourier analysis of heart rate (HR) may be used to characterize overall HR variability as well as low- and high-frequency components attributable to sympathetic and vagal influences, respectively. We analyzed HR spectral characteristics of 12 healthy young (18-35 years) and 10 healthy old (71-94 years) subjects before and during 60 degrees head-up tilt. Total spectral power in the 0.01-0.40-Hz frequency range and low-frequency (0.06-0.10 Hz) and high-frequency (0.15-0.40 Hz) components of the HR power spectrum were significantly lower in old than in young subjects in supine and upright positions. To characterize and compare overall HR variability in young and old subjects, we computed the regression lines relating the log amplitude to the log frequency of the supine HR spectra (l/fx plots). The regression lines for old subjects were lower and steeper (mean slope, -0.78 [5%, 95% confidence limits (CL), -0.73, -0.83]) than in young (mean slope, -0.67 [CL, -0.62, -0.72]), indicating not only reduced overall spectral amplitude but also relatively greater attenuation of high-frequency HR components in the old subjects. This finding illustrates a novel way to quantify the loss of autonomic influences on HR regulation as a function of age. During postural tilt, HR variability was unchanged in the old subjects. For the entire group of young subjects, total HR variability increased during tilt. Six young subjects developed vasovagal syncope during tilt, enabling us to examine differences in the HR spectra of these subjects while they were asymptomatic before syncope.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced supine cardiac volumes and diastolic filling rates in elderly patients with chronic medical conditions. Implications for postural blood pressure homeostasis

Very elderly individuals with multiple chronic illnesses are at high risk of orthostatic hypotension, falls, and associated morbidity and mortality. Alterations in cardiac volumes and filling characteristics may contribute in part to an increased prevalence of orthostatic hypotension and falls in these people. In this study cardiac function was evaluated with gated radionuclide ventriculography in eight healthy young subjects (19-38 years) and 25 elderly persons with stable chronic illnesses (73-96 years), 14 of whom had a history of recurrent falls. Blood pressure was measured supine during the radionuclide ventriculography, then after one minute of standing. Supine stroke volume index, end diastolic volume index, cardiac index, and peak filling rates were significantly lower in elderly subjects compared to young, and ejection fraction and end systolic volume index (measures of systolic function) were the same in young and old. Compared to the young, elderly subjects had a reduction in ventricular filling during the first third of diastole, but an augmentation in the last third, during atrial contraction. Within the group of elderly subjects, the directional change in systolic blood pressure during orthostasis was significantly correlated with basal supine systolic blood pressure (R = 0.81, P less than .0001) and supine cardiac index (R = 0.66, P = .002). Thus, very old people representative of those seen in clinical practice have reduced cardiac volumes and impaired early diastolic filling, a result possibly related to elevations in systolic blood pressure. These changes in cardiac structure and function may contribute, in part, to orthostatic hypotension in advanced age.

The influence of oral glucose loading on baroreflex function in the elderly

Blood pressure in the elderly may decrease after a meal or after oral glucose loading. It has been suggested that eating may affect blood pressure homeostasis through an insulin-induced blunting of baroreflex sensitivity. We investigated the effects of oral glucose loading on baroreflex sensitivity in young normotensives and in elderly normo-and hypertensive subjects. Blood pressure was measured by a new noninvasive device, Finapres, which measures blood pressure continuously in the finger. Baroreflex sensitivity was estimated with the phenylephrine and nitroglycerin method. In both elderly groups mean arterial pressure fell significantly after the glucose load (11 +/- 1 mm Hg, P less than .001 in the hypertensives, and 8 +/- 2 mm Hg, P less than .01 in the normotensive subjects), whereas no change in blood pressure was found in the young group. Baroreflex sensitivity was lower in both elderly groups than in young normotensives. Glucose loading had no influence on baroreflex sensitivity in the three groups. Therefore, we conclude that other factors are involved in the phenomenon of postprandial hypotension in the elderly.

The influence of age and blood pressure on the hemodynamic and humoral response to head-up tilt

It has been reported that postural hypotension in the elderly is common. However, these studies included institutionalized and more or less disabled persons. Furthermore, postural hypotension may be related to baseline blood pressure. In this study, the influence of age and blood pressure on the hemodynamic and plasma catecholamine responses to orthostatic stress was investigated in young and old normotensive and hypertensive healthy subjects. In normotensive and hypertensive elderly persons, the percentage blood pressure responses during tilt were not significantly different from that seen in young normotensives. We measured a slight decrease of systolic blood pressure and a slight increase of diastolic blood pressure. The hypertensive young patients showed an enhanced diastolic blood pressure response with no fall in systolic blood pressure, in contrast to the normotensive young subjects. Both elderly groups had a lower increase of heart rate than the young subjects. The percentage increase in norepinephrine after tilting was significantly lower in elderly hypertensives than in elderly normotensives and young hypertensives. The presence of hypertension was associated with a decrease in blood pressure, but age had no influence on the change in blood pressure during tilt. In this group of healthy elderly subjects, there was no significant orthostatic hypotension when the blood pressure course of the entire tilt test was taken into account.

Blood pressure reduction after oral glucose loading and its relation to age, blood pressure and insulin

Recently it was shown that blood pressure (BP) in the elderly may decrease after a meal. The pathophysiologic mechanism of this phenomenon is unknown. It has been suggested that a failure of insulin-mediated sympathetic nervous system activation plays a role. To evaluate the role of endogenous insulin, the effects of oral glucose and oral fructose loading on BP, heart rate and norepinephrine levels were studied in 10 young normotensive volunteers (YN), 10 young hypertensive patients (YH), 10 elderly normotensive volunteers (EN) and 10 elderly hypertensive patients (EH). Fructose, 75 g/300 ml of water, elicited--in contrast to the same amount of glucose--only a small increase in insulin and glucose levels. After glucose loading, mean arterial BP decreased by 17 mm Hg in the EH group (p less than 0.001), 6 mm Hg in the EN group (p less than 0.01) and 7 mm Hg in the YH group (p less than 0.001), and did not change in the YN group. After oral fructose loading, BP did not change in any group. In all groups except the YN group, the increases in norepinephrine level and heart rate after both tests were not significantly different. These findings suggest that the BP reduction after glucose loading is related to glucose-mediated factors. A failure of insulin-mediated sympathetic nervous system activation does not appear to play a major role.

Clinical consequences of age-related impairments in vascular compliance

Advancing age is associated with progressive reductions in the vascular distensibility of major vessels. Two clinically relevant consequences of physiologically impaired arterial compliance of aging, increased systolic blood pressure and decreased carotid arterial baroreflex sensitivity, are discussed. While arterial thickening and stiffening with age are associated with increased systolic blood pressure, diastolic blood pressure is generally stable or even decreases slightly with advancing age. Thus, the prevalence of isolated systolic hypertension increases dramatically with age. This long-neglected abnormality has recently attracted attention, and the view that systolic hypertension is harmless and its treatment fraught with a high incidence of serious adverse effects has now been shown to be myth. Several studies indicate substantial risk associated with isolated systolic hypertension, especially with regard to increasing prevalence of stroke. A recent multicenter trial has shown that systolic blood pressure can be safely lowered with low doses of thiazide diuretics. Currently, a National Institutes of Health sponsored multicenter trial aims to determine whether treatment of isolated systolic hypertension is associated with reduced risk. Age-related impairments in baroreflex sensitivity reduce the capacity of normal elderly persons to increase the heart rate in response to hypotensive stress and contribute to the increased prevalence with advancing age of orthostatic hypotension. This must be taken into account in the design of pharmacologic treatment regimens in older persons.

Computerized evaluation of Valsalva's Maneuver before and during alpha-adrenoceptor blockade with alfuzosin

Methodological differences exist in the evaluation of Valsalva's Maneuver. Linear and nonlinear mathematical models were described for beat-to-beat changes in blood pressure and R-R intervals occurring during the strain and release phases of Valsalva's Maneuver. This study indicated that the strain phase is linear, whereas the release phase is nonlinear; the release phase consists of a "lag phase," a "breakpoint," and an "overshoot phase." The alpha-adrenoceptor antagonist, alfuzosin, reduced baroreflex-mediated tachycardia during the strain phase and prolonged the "time lag" and "pressure lag" during the release phase; the latter change was due entirely to the reduced systolic pressure that occurred with alfuzosin at the end of the strain phase.