Prognosis of diastolic and systolic orthostatic hypotension in older persons

Background: Orthostatic hypotension (OH) predicts mortality in hypertensive persons with diabetes mellitus, but no increase in mortality has been foun d among random samples of home-dwelling persons with OH. We examined the ri sks of nonvascular and vascular deaths according to different definitions o f OH among home-dwelling elderly persons. Subjects and Methods: The study population consisted of all persons aged 70 years or older living in 5 rural municipalities (N = 969), of whom 833 (86 %) participated. Orthostatic tests were successfully carried out in 792 per sons by nurse examiners. Orthostatic hypotension was defined as a systolic blood pressure (BP) drop of 20 mm Hg or more or a diastolic BP drop of 10 m m Hg or more 1 minute or 3 minutes after standing up. Nonvascular and vascu lar deaths during the follow-up period were recorded. Data on diseases, sym ptoms, medications, the results of clinical examinations and tests, functio nal ability, and health behavior were collected at the beginning of the fol low-up period. Results: Of the sample, 30% had OH: the prevalence of systolic OH 1 minute and 3 minutes after standing up was 22% and 19%, respectively; that of dias tolic OH 1 minute and 3 minutes after standing up was 6% for each. No diffe rences in the occurrence of nonvascular deaths were found according to any of these definitions. By Cox multivariate regression analysis, the hazard r atio of vascular death associated with a diastolic BP reduction of 1 mm Hg 1 minute after standing up was 1.02 (P = .03), adjusted for systolic BP pos tural changes at 1 and 3 minutes and a diastolic BP change at 3 minutes. Ad justed for other significant factors associated with vascular death, the ha zard ratio for vascular death associated with diastolic OH 1 minute after s tanding up was 2.04 (95% confidence interval, 1.01-4.15). The-corresponding hazard ratio for systolic OH minutes after standing up was 1.69 (95% confi dence interval, 1.02-2.80). Using a cutoff point of 7 mm Hg or greater for a diastolic BP change 1 minute after standing up, the hazard ratio for vasc ular death was highest: 2.20 (95% confidence interval, 1.23-3.93). By logis tic regression analysis, the baseline associates of diastolic OH 1 minute a fter standing up were dizziness when turning the neck (odds ratio [OR], 2.4 4), the use of a calcium antagonist (OR, 2.31), the use of a diuretic medic ation (OR, 2.29), a high systolic BP (OR, 2.23), and a low body mass index (OR, 2.26). The baseline associates of systolic OH 3 minutes after standing up were male sex (OR, 1.52), diabetes mellitus (OR, 1.92), a high systolic BP (OR, 2.91), and a low body mass index (OR, 1.68). Conclusions: The presence of diastolic OH 1 minute and systolic OH 3 minute s after standing up predict vascular death in older persons. They differ fr om each other in their prevalence and in several associates, suggesting dif ferent pathophysiologic backgrounds. Clinicians should prescribe vasodilati ng and volume-depleting medications with caution for elderly persons with d iastolic OH 1 minute after standing up. Appropriate treatment of hypertensi on might be the best means to manage the different types of OH with poor va scular prognoses.