Orthostatic hypertension and major adverse events: a systematic review and meta-analysis

The relationship between physical activity, orthostatic blood pressure reactions and subclinical atherosclerosis: the Swedish CArdioPulmonary bioImage Study (SCAPIS)

An abnormal blood pressure (BP) response on standing is associated with atherosclerotic cardiovascular disease (CVD). The role of physical activity (PA) on orthostatic BP-reactions and its relation to subclinical atherosclerosis is unclear. We aimed to assess the association between PA and orthostatic BP-reactions, and whether PA modifies the relationship between orthostatic BP-reactions and subclinical atherosclerosis. A total of 5,396 middle aged subjects from the population-based SCAPIS-study were included. Associations between orthostatic BP-response and accelerometer-derived PA were studied using linear regression. Interaction analyses were performed to study modifying effects of PA on the relationship between orthostatic BP-response and subclinical coronary atherosclerosis, assessed by coronary artery calcium score (CACS). Moderate to vigorous PA (MVPA) was associated with less pronounced orthostatic systolic BP (SBP) increase but more pronounced orthostatic diastolic BP increase after adjusting for age, sex, total wear time, proportion weekend days and season (Beta per 1%-increase(mmHg):0.12; p = <0.01 and -0.06; p = 0.02, respectively). Subjects with high MVPA were less likely to have orthostatic hypertension (OHTN), but more likely to have orthostatic hypotension (OH; p = 0.002 for both). Individuals with higher CACS were more likely to have OH (p = 0.041) but not OHTN (p = 0.276). There were no interactions of PA on the association between orthostatic BP-response and CACS. In conclusion, physically active middle-aged individuals are less likely to show inappropriate SBP-increase upon standing, but more likely to have excessive SBP-decrease. PA does not modify the association between orthostatic BP-response and subclinical atherosclerosis. The relationship between PA, orthostatic BP and CVD is likely to be complex.

Hypertension and orthostatic hypertension in 85-year-olds and associations with mortality and cognitive decline in a longitudinal cohort study

Hypertension is a risk factor for cardiovascular disease, but the evidence for treatment and blood pressure (BP) targets in the elderly is less robust. Orthostatic hypertension is a potential risk factor for cardiovascular mortality and cognitive decline. All 85-years-olds in Linköping municipality, Sweden, were invited to a prospective birth cohort study including questionnaires, cognitive testing and physical examinations, including supine and orthostatic BP measurements. Logistic regression and Cox proportional hazard models were used to assess the impact of baseline supine and orthostatic BP on cognitive decline and all-cause mortality after 5- and 7.2 years respectively. Of 650 invited 85-year-olds, 322 were included. During follow-up, 190 persons died, and 28 persons developed cognitive decline. Neither elevated supine BP nor orthostatic hypertension were associated with cognitive decline. After adjustments, elevated supine BP was not associated with mortality in all participants, but was associated with lower all-cause mortality in participants with previously diagnosed hypertension, HR 0.59 (95% CI 0.41-0.85). Orthostatic hypertension was not associated with all-cause mortality, HR 0.56 (95% CI 0.26-1.22) after multiple adjustments. In 85-year-olds with known hypertension, elevated supine BP was associated with lower all-cause mortality. Orthostatic hypertension was not associated with cognitive decline but trended towards a lower all-cause mortality.

Effects of intensive blood pressure treatment on orthostatic hypertension: individual level meta-analysis

OBJECTIVE

To determine the effects of intensive blood pressure treatment on orthostatic hypertension.

DESIGN

Systematic review and individual participant data meta-analysis.

DATA SOURCES

MEDLINE, Embase, and Cochrane CENTRAL databases through 13 November 2023.

INCLUSION CRITERIA

Population: ≥500 adults, age ≥18 years with hypertension or elevated blood pressure; intervention: randomized trials of more intensive antihypertensive drug treatment (lower blood pressure goal or active agent) with duration ≥6 months; control: less intensive antihypertensive drug treatment (higher blood pressure goal or placebo); outcome: measured standing blood pressure.

MAIN OUTCOMES

Orthostatic hypertension, defined as an increase in systolic blood pressure ≥20 mm Hg or diastolic blood pressure ≥10 mm Hg after changing from sitting to standing.

DATA SYNTHESIS

Two investigators independently abstracted articles. Individual participant data from nine trials identified during the systematic review were appended together as a single dataset.

RESULTS

Of 31 124 participants with 315 497 standing blood pressure assessments, 9% had orthostatic hypotension (that is, a drop in blood pressure after standing of systolic ≥20 mm Hg or diastolic ≥10 mm Hg), 17% had orthostatic hypertension, and 3.2% had both a rise in systolic blood pressure and standing blood pressure ≥140 mm Hg at baseline. The effects of more intensive treatment were similar across trials with odds ratios for orthostatic hypertension ranging from 0.85 to 1.08 (I2=38.0%). During follow-up, 17% of patients assigned to more intensive treatment had orthostatic hypertension, whereas 19% of those assigned less intensive treatment had orthostatic hypertension. Compared with less intensive treatment, the risk of orthostatic hypertension was lower with more intensive blood pressure treatment (odds ratio 0.93, 95% confidence interval 0.90 to 0.96). Effects were greater among non-black versus black adults (odds ratio 0.86 v 0.97; P for interaction=0.003) and adults without diabetes versus those with diabetes (0.88 v 0.96; P for interaction=0.05) but did not differ by age ≥75 years, sex, baseline seated blood pressure ≥130/≥80 mm Hg, obesity, stage 3 kidney disease, stroke, cardiovascular disease, standing systolic blood pressure ≥140 mm Hg, or pre-randomization orthostatic hypertension (P for interactions ≥0.05).

CONCLUSIONS

In this pooled cohort of adults with elevated blood pressure or hypertension, orthostatic hypertension was common and more intensive blood pressure treatment modestly reduced the occurrence of orthostatic hypertension. These findings suggest that approaches generally used for seated hypertension may also prevent hypertension on standing.

STUDY REGISTRATION

Prospero CRD42020153753 (original proposal).

High variability in the reproducibility of key hemodynamic responses to head-up tilt

Increased blood pressure upon standing is considered a cardiovascular risk factor. We investigated the reproducibility of changes in aortic blood pressure, heart rate, stroke volume, cardiac output, and systemic vascular resistance during three passive head-up tilts (HUT) in 223 participants without cardiovascular medications (mean age 46 yr, BMI 28 kg/m2, 54% male). The median time gap between the first and the second HUT was 9 wk and the second and the third HUT was 4 wk. We utilized whole body impedance cardiography and radial artery tonometry as methods. The participants were divided into quartiles of the changes in each hemodynamic variable during the first HUT, and the reproducibility of these changes was tested during successive HUTs. During the first HUT, significant differences were present in all between-quartile comparisons (n = 6) of all variables. The differences persisted as follows: reduction of stroke volume in six out of six (6/6) between-quartile comparisons (P < 0.001), decrease in cardiac output (P < 0.001) and increase in heart rate in 5/6 comparisons (P < 0.001), change in systemic vascular resistance in 3/6 comparisons (P < 0.001), change in aortic systolic blood pressure in 1/6 comparisons (P = 0.043), and change in aortic diastolic blood pressure in none (P = 0.266). To conclude, the reproducibility of upright posture-induced changes is high for stroke volume, cardiac output, and heart rate, moderate for systemic vascular resistance, and modest for aortic blood pressure. Although an increase in blood pressure during upright posture may be a cardiovascular risk factor, this effect may be attributed to other underlying hemodynamic variables that exhibit more reproducible posture-related changes.NEW & NOTEWORTHY We examined the reproducibility of hemodynamic responses to three passive head-up tilts. The associated changes in stroke volume, cardiac output, and heart rate were highly reproducible. Systemic vascular resistance showed moderate reproducibility, whereas blood pressure changes during upright posture were modestly reproducible. If an exaggerated blood pressure response to upright posture is a cardiovascular risk factor, it is likely attributed to other hemodynamic variables that exhibit more reproducible posture-related changes.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Adverse pregnancy outcomes, familial predisposition, and cardiovascular risk: a Swedish nationwide study

BACKGROUND AND AIMS

Adverse pregnancy outcomes (APOs) are recognized as significant female-specific risk factors for cardiovascular disease (CVD). A potential shared familial susceptibility between APOs and CVD has been proposed, but not thoroughly explored. This study employs a quasi-experimental family comparison design to investigate shared familial predisposition between APOs and CVD, by assessing risk of CVD in APO-exposed women and their APO-free sisters.

METHODS

Nationwide population-based cohort study encompassing primiparous women, without prior CVD, with registered singleton births in the Swedish Medical Birth Register between 1992 and 2019, grouped into: women with ≥1 APO (165 628), APO-free sisters (60 769), and unrelated APO-free comparator women (992 108). All study participants were followed longitudinally, through linkage with national health registers, from delivery until 2021, for primary endpoint major adverse cardiac events, and its individual components: ischaemic heart disease, heart failure, and cerebrovascular events.

RESULTS

Over a median follow-up of 14 years, APO-exposed women exhibited increased rates of CVDs compared with APO-free comparators. Adverse pregnancy outcome-free sisters exhibited elevated adjusted hazard ratios (aHRs) of major adverse cardiac event {aHR 1.39 [95% confidence interval (CI) 1.13-1.71]}, heart failure [aHR 1.65 (95% CI 1.14-2.39)], and cerebrovascular events [aHR 1.37 (1.04-1.72)] compared with the APO-free comparators, while no significant increase in ischaemic heart disease was observed. Within-family analysis revealed lower CVD rates in APO-free sisters compared with their APO-exposed counterparts, except for no significant difference in cerebrovascular events.

CONCLUSIONS

Sisters of women with APOs face a moderately increased risk of CVD, suggesting a genetic and/or environmental influence on the association between APOs and CVDs. These findings underscore the need for evaluating the effectiveness of targeted preventive measures in women with APOs and their sisters.

Orthostatic and Standing Hypertension and Risk of Cardiovascular Disease

BACKGROUND

Orthostatic hypertension is an emerging risk factor for adverse events. Recent consensus statements combine an increase in blood pressure upon standing with standing hypertension, but whether these 2 components have similar risk associations with cardiovascular disease (CVD) is unknown.

METHODS

The ARIC study (Atherosclerosis Risk in Communities) measured supine and standing blood pressure during visit 1 (1987-1989). We defined systolic orthostatic increase (a rise in systolic blood pressure [SBP] ≥20 mm Hg, standing minus supine blood pressure) and elevated standing SBP (standing SBP ≥140 mm Hg) to examine the new consensus statement definition (rise in SBP ≥20 mm Hg and standing SBP ≥140 mm Hg). We used Cox regression to examine associations with incident coronary heart disease, heart failure, stroke, fatal coronary heart disease, and all-cause mortality.

RESULTS

Of 11 369 participants (56% female; 25% Black adults; mean age, 54 years) without CVD at baseline, 1.8% had systolic orthostatic increases, 20.1% had standing SBP ≥140 mm Hg, and 1.3% had systolic orthostatic increases with standing SBP ≥140 mm Hg. During up to 30 years of follow-up, orthostatic increases were not significantly associated with any of the adverse outcomes of interest, while standing SBP ≥140 mm Hg was significantly associated with all end points. In joint models comparing systolic orthostatic increases and standing SBP ≥140 mm Hg, standing SBP ≥140 mm Hg was significantly associated with a higher risk of CVD, and associations differed significantly from systolic orthostatic increases.

CONCLUSIONS

Unlike systolic orthostatic increases, standing SBP ≥140 mm Hg was strongly associated with CVD outcomes and death. These differences in CVD risk raise important concerns about combining systolic orthostatic increases and standing SBP ≥140 mm Hg in a consensus definition for orthostatic hypertension.

Association Between Orthostatic Hypotension With Coronary Slow Flow in Patients With Chest Pain: A Single Center Experience

BACKGROUND

Orthostatic hypotension (OH) is associated with different cardiovascular diseases, however, the association between OH and coronary slow flow (CSF) has never been evaluated before.

MATERIALS AND METHODS

Chest pain patients who underwent coronary angiography (CAG) and with normal coronary arteries in our department from January 1st, 2022 to August 31st, 2023 were retrospectively enrolled. Patients were divided into the CSF group and the normal blood flow (NBF) group. Relative clinical information, laboratory test results as well as the results of CAG were collected and analyzed. Both uni-variable and multi-variable logistic regression analyses were used to evaluate the association between OH and CSF in these patients.

RESULTS

Four thousand six hundred and twenty-seven patients underwent CAG and 655 patients had normal coronary arteries. In which, sixty-nine patients were diagnosed with CSF while 586 patients were diagnosed with NBF. Uni-variable analysis revealed that higher body weight index, faster heart rate in sitting position, accompanied with chronic kidney disease, did not take Antidiabetic therapy, higher level of aspartate transaminase, uric acid, triglyceride, total cholesterol, ApoB1, low-density lipoprotein cholesterol, homocysteine, B-type natriuretic peptide as well as OH are the risk factors for CSF in these patients. Multi-variable logistic regressing analysis further demonstrated that OH was the independent risk factor for predicting CSF in these patients.

CONCLUSIONS

Our finding suggests OH might be a useful predictor for CSF in patients with chest pain but normal coronary arteries.

Exploring the contribution of inter-individual factors to the development of physiological heat strain in older adults exposed to simulated indoor overheating

Older adults are at elevated risk of heat-related mortality due to age-associated declines in thermoregulatory and cardiovascular function. However, the inter-individual factors that exacerbate physiological heat strain during heat exposure remain unclear, making it challenging to identify more heat-vulnerable subgroups. We therefore explored factors contributing to inter-individual variability in physiological responses of older adults exposed to simulated hot weather. Thirty-seven older adults (61-80 years, 16 females) rested for 8 h in 31 and 36 °C (45% relative humidity). Core (rectal) temperature, heart rate (HR), HR variability, mean arterial pressure (MAP), and cardiac autonomic responses to standing were measured at baseline and end-exposure. Bootstrapped least absolute shrinkage and selection operator regression was used to evaluate whether variation in these responses was related to type 2 diabetes (T2D, n = 10), hypertension (n = 18), age, sex, body morphology, habitual physical activity levels, and/or heat-acclimatization. T2D was identified as a predictor of end-exposure HR (with vs. without: 13 beats/min (bootstrap 95% confidence interval: 6, 23)), seated MAP (-7 mmHg (-18, 1)), and the systolic pressure response to standing (20 mmHg (4, 36)). HR was also influenced by sex (female vs. male: 8 beats/min (1, 16)). No other predictors were identified. The inter-individual factors explored did not meaningfully contribute to the variation in body temperature responses in older adults exposed to simulated indoor overheating. By contrast, cardiovascular responses were exacerbated in females and individuals with T2D. These findings improve understanding of how inter-individual differences contribute to heat-induced physiological strain in older persons.

Cardiopulmonary deconditioning and plasma volume loss are not sufficient to provoke orthostatic hypertension

Orthostatic hypertension, defined by an increase of systolic blood pressure (SBP) of ≥20 mmHg upon standing, harbors an increased cardiovascular risk. We pooled data from two rigorously conducted head-down tilt bedrest studies to test the hypothesis that cardiopulmonary deconditioning and hypovolemia predispose to orthostatic hypertension. With bedrest, peak VO2 decreased by 6 ± 4 mlO2/min/kg (p < 0.0001) and plasma volume by 367 ± 348 ml (p < 0.0001). Supine SBP increased from 127 ± 9 mmHg before to 133 ± 10 mmHg after bedrest (p < 0.0001). In participants with stable hemodynamics following head-up tilt, the incidence of orthostatic hypertension was 2 out of 67 participants before bedrest and 2 out of 57 after bedrest. We conclude that in most healthy persons, cardiovascular deconditioning and volume loss associated with long-term bedrest are not sufficient to cause orthostatic hypertension.

Assessment and management of exaggerated blood pressure response to standing and orthostatic hypertension: consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability

Recent evidence suggests that an exaggerated blood pressure (BP) response to standing (ERTS) is associated with an increased risk of adverse outcomes, both in young and old individuals. In addition, ERTS has been shown to be an independent predictor of masked hypertension. In the vast majority of studies reporting on the prognostic value of orthostatic hypertension (OHT), the definition was based only on systolic office BP measurements. This consensus statement provides recommendations on the assessment and management of individuals with ERTS and/or OHT. ERTS is defined as an orthostatic increase in SBP at least 20 mmHg and OHT as an ERTS with standing SBP at least 140 mmHg. This statement recommends a standardized methodology to assess ERTS, by considering body and arm position, and the number and timing of BP measurements. ERTS/OHT should be confirmed in a second visit, to account for its limited reproducibility. The second assessment should evaluate BP changes from the supine to the standing posture. Ambulatory BP monitoring is recommended in most individuals with ERTS/OHT, especially if they have high-normal seated office BP. Implementation of lifestyle changes and close follow-up are recommended in individuals with ERTS/OHT and normotensive seated office BP. Whether antihypertensive treatment should be administered in the latter is unknown. Hypertensive patients with ERTS/OHT should be managed as any other hypertensive patient. Standardized standing BP measurement should be implemented in future epidemiological and interventional studies.

Evaluation of the prevalence of cardiometabolic disorders (diabetes, hypertension, and hyperlipidemia) diagnosed, undiagnosed, treated, and treatment goal in the elderly: Bushehr Elderly Health Program (BEH)

As the population ages, the global burden of cardiometabolic disorders will increase. This study aimed to investigate the prevalence of cardiometabolic disorders (diabetes, hypertension, and hyperlipidemia) in elderly and to evaluate the effects of various variables including age, sex, education, marital status, smoking, income, physical activity, dementia and depressed mood on untreated cardiometabolic disorders. This was a cross sectional study conducted in Bushehr Elderly Health Program. A total 2381 participants were included. Medical data were collected by trained interviewers. The mean age of the study participants was 69.34 years. Proportions of diabetes, hypertension, hyperlipidemia and hypercholesterolemia were 43.25%, 75.71%, 64.74% and 35.31% respectively. Untreated diabetes prevalence was higher for males (OR = 1.60, 95%CI = 1.20-2.15), older adults (OR = 1.02, 95%CI = 1.00-1.05), and pre-frail status (OR = 0.69, 95%CI = 0.52-0.92). Males (OR = 2.16, 95%CI = 1.64-2.84) and current smokers (OR = 1.42, 95%CI = 1.05-1.93), in contrast to married participants (OR = 0.25, 95%CI = 0.08-0.78), people with higher education levels (OR = 0.51, 95%CI = 0.29-0.89) and dementia (OR = 0.78, 95%CI = 0.61-1.00) were more likely to have untreated HTN. Untreated dyslipidemia is more common in smokers (OR = 1.78, 95%CI = 1.19-2.66) and males (OR = 1.66, 95%CI = 1.21-2.27), while untreated hypercholesteremia is more common in males (OR = 3.20, 95%CI = 1.53-6.69) and is reported lower in people with dementia (OR = 0.53, 95%CI = 0.28-1.01).