Orthostatic hypotension among outpatients with ischemic stroke
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.
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2015, Clinical Neurology and NeurosurgeryCitation 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.