Orthostatic hypotension among outpatients with ischemic stroke

https://doi.org/10.1016/j.jns.2011.10.031Get rights and content

Abstract

Background

The treatment of hypertension is an essential component of stroke prevention; however, the clinical management of patients with cerebrovascular disease is complicated by orthostatic hypotension (OH). The primary objectives were to: determine the prevalence of OH in a stroke outpatient clinic; describe categories of OH; and identify factors independently associated with the presence of OH.

Methods

Veterans with stroke, cared for in a multidisciplinary stroke clinic, were included. OH was defined as a ≥ 20 mm Hg fall in systolic blood pressure (BP), a ≥ 10 mm Hg fall in diastolic BP, or a ≥ 10 mm Hg fall in systolic BP with symptoms. Multivariable logistic regression was used to identify factors associated with OH including demographics, comorbidites, stroke severity, and baseline BP.

Results

Among 60 patients with stroke, 16 (27%) patients had OH. Among those with OH, half were hypertensive, seven were normotensive, and one was hypotensive. A history of coronary artery disease was independently associated with the presence of OH.

Conclusions

Orthostatic hypotension is present in about one quarter of outpatients with stroke, and coronary artery disease appears to be a risk factor. Stroke patients should be screened for OH given that the presence of positional BP changes may alter clinical management.

Introduction

Approximately 795,000 strokes occur each year in the United States[1]. A key component of stroke prevention is hypertension management[2], [3]. Hypertension management has been associated with a 30–40% stroke risk reduction[3]. Given that approximately three-quarters of patients with stroke or transient ischemic attack (TIA) have hypertension[4], the majority of patients with cerebrovascular disease are eligible for hypertension management as a means of reducing their risk of recurrent vascular events.

The management of hypertension can be complicated by the presence of orthostatic hypotension (OH), defined as a fall in blood pressure when changing position from sitting or supine to standing[5]. OH can occur in patients who are normotensive, hypotensive, or hypertensive. OH is a known risk factor for recurrent stroke in outpatients[6], [7], and may be an additional risk factor for falls among patients with prior stroke or transient ischemic attack (TIA)[8], [9].

The prevalence of OH among older community-dwelling adults ranges from 15% to 26%, and the prevalence increases with older age[10]. In the general population, diabetes and coronary artery disease have been associated with the presence of OH[10]. Previous studies have examined the prevalence of OH post-stroke in acute [11], [12] and rehabilitation [13] settings, but have not focused on the outpatient setting, where most blood pressure management occurs. To our knowledge, no studies have assessed the fall risk associated with OH in stroke patients. The factors that have been associated with the presence of OH among stroke patients in the inpatient rehabilitation setting include older age, lower functional status, and more severe hemiparesis; [13] no particular factor has been associated with OH in the acute setting[12].

The primary objectives of this study were to: (1) determine the prevalence of OH among stroke patients in an outpatient clinic; (2) describe the categories of OH (hypertensive, normotensive, and hypotensive); and (3) identify the factors that were independently associated with the presence of any OH. The secondary objective was to examine the fall risk among patients with OH.

Section snippets

Design

This study was a secondary analysis of medical record data obtained from the outpatient Veterans Administration (VA) Connecticut Healthcare System Multidisciplinary Stroke Clinic Program. Patients were referred if clinicians thought they would benefit from interdisciplinary care (e.g., those with complex needs or recently discharged from acute stroke setting). Each veteran in this clinic and their caregiver (if available) were evaluated by five clinicians, one each from nursing, health

Results

Among 162 patients cared for in the clinic during the study timeframe, 116 had a stroke, and 60 patients had complete data regarding OH at the time of the first visit. The demographics and stroke characteristics of the 60 patients are provided in Table 1. The majority of the participants were male (95%), white (73%), with an average age of 66 years (standard deviation, 11).

Discussion

This study documents the prevalence of orthostatic hypotension among outpatients with stroke at a single center. Our finding that one-quarter of patients with cerebrovascular disease have OH is similar to results from studies of people aged ≥ 85 but is a higher prevalence than reported from previous studies of people ≥ 65 living in the community[10]. The prevalence of OH in studies of stroke patients in different settings ranged from approximately one-in-five in the acute setting to as many as

Conclusion

In summary, despite the above limitations, our study suggests that orthostatic hypotension is present in about one-quarter of outpatients with cerebrovascular disease, and those with coronary artery disease appear to be at greatest risk. Since the most common clinical scenario is OH with hypertension, we recommend that all patients with stroke and TIA receive screening for OH regardless of measured blood pressure or the presence of orthostatic symptoms. In addition, fall risk is elevated in

Disclosure

The authors have no conflict of interest to declare.

Acknowledgments

Funding: This project was supported by a Locally Initiated Project (LIP) grant from the Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) program. Dr. Schmid is supported by a career development award from the VA Rehabilitation Research and Development (RR&D) Service.

References (33)

  • R.L. Sacco et al.

    Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: the Northern Manhattan Stroke Study

    Neurology

    (1994)
  • Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology

    Neurology

    (1996)
  • B.H. Dobkin

    Orthostatic hypotension as a risk factor for symptomatic occlusive cerebrovascular disease

    Neurology

    (1989)
  • M.L. Eigenbrodt et al.

    Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987–1996

    Stroke

    (2000)
  • D.A. Ganz et al.

    Will my patient fall?

    JAMA

    (2007)
  • L.M. Allan et al.

    Incidence and prediction of falls in dementia: a prospective study in older people

    PLoS One

    (2009)
  • Cited by (20)

    • Dietary sodium and health: How much is too much for those with orthostatic disorders?

      2022, Autonomic Neuroscience: Basic and Clinical
      Citation Excerpt :

      Yet, our lab recently demonstrated that an acute high sodium meal (1495 mg) did not impair cerebrovascular reactivity during a hyper and hypocapnia perturbation in healthy young adults compared to an acute low sodium meal (138 mg) (Migdal et al., 2020b). OH is predictive of ischemic stroke (Eigenbrodt et al., 2000), and OH is present in ~¼ of patients with a stroke (Phipps et al., 2012). In response to a normocapnic head up tilt test, cerebral autoregulation is impaired in patients with POTS as demonstrated by decreased cerebral blood flow with greater variability compared to healthy controls (Ocon et al., 2009).

    • Diagnostic Imaging: Brain

      2016, Diagnostic Imaging: Brain
    • Imaging in Neurology

      2016, Imaging in Neurology
    • Autonomic symptoms in hypertensive patients with post-acute minor ischemic stroke

      2015, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      A study showed that OH was common in elderly stroke patients with severe disability [28]. In addition, OH in stroke patients was associated with falls [29]. Xiong et al. [6] found that OH was significant in large but not in small vessel infarctions.

    View all citing articles on Scopus
    View full text