Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Orthostatic Hypotension in Middle-Aged Adults
JAMA Intern Med; ePub 2017 Jul 24; Juraschek, et al
Orthostatic hypotension (OH) should be assessed within 1 minute of standing in middle-aged adults, contrary to usual recommendations to delay orthostatic hypotension assessments by 3 minutes, a recent study found. The prospective cohort study of 11,429 middle-aged adults (mean age 54 years; 54% women, 26% black) in the Atherosclerosis Risk in Communities Study (1987-1989) compared early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes. OH, defined as a drop in blood pressure (BP) from the supine to standing position, was measured up to 5 times at 25-second intervals. The association of each of the 5 OH measurements was determined with history of dizziness on standing and risk of fall, fracture, syncope, motor vehicle crashes, and all-cause mortality over a median of 23 years of follow-up. Researchers found:
- OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds) was the only measurement associated with higher odds of dizziness (OR, 1.49).
- Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1,000 person-years.
- Measurement 2 (mean [SD] 53 [7.5] seconds) was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1,000 person-years.
Juraschek SP, Daya N, Rawlings AM, et al. Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults. [Published online ahead of print July 24, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.2937.
This study confirms what many clinicians have thought for years: that taking orthostatic signs after 1 minute of standing, when patients actually describe being dizzy, makes more sense than the standard recommendations of waiting 2-3 minutes until taking orthostatic signs. This study demonstrates that the relationship between orthostatic signs and clinical symptoms of dizziness described by patients is firmer for orthostatic blood pressures taken at 30 seconds and 1 minute than for those taken at 3 minutes. In addition, orthostatic BP taken at less than 1 minute is more closely associated with all related clinical events including fracture, syncope, falls, motor vehicle accidents, and death. From this point forward there is firm clinical evidence that when assessing patients with symptoms that may be due to orthostatic hypotension, it is best to take orthostatic signs at 1 minute or less after standing. —Neil Skolnik, MD