Gender Differences in Orthostatic Hypotension

doi:10.1097/MAJ.0b013e318208752b

The American Journal of the Medical Sciences

Volume 342, Issue 3, September 2011, Pages 221-225

https://doi.org/10.1097/MAJ.0b013e318208752b Get rights and content

Abstract

Orthostatic hypotension is a decrease in systolic blood pressure of more than 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg, within 3 minutes of changing from a supine to an upright position. The typical clinical presentation of orthostatic hypotension includes dizziness, syncope, blurry vision and loss of balance. Symptoms may be more frequent in women, but the complicating roles played by comorbid factors and the estrogen mechanisms are not well understood. Women have a more active parasympathetic system, higher estrogen levels and a lower center of gravity. Thus, women less effectively compensate for the drop of blood pressure in response to positional change. An understanding of these mechanisms contributing to orthostatic hypotension may improve diagnosis and treatment of the problem.

Section snippets

THE FUNCTION OF THE ANS

The ANS senses stressors such as positional change and activates the sympathetic system. The system is activated to respond to sudden deviations such as postural change to maintain adequate blood perfusion.²² Blood flow regulation by the sympathetic system occurs through 2 distinct mechanisms: alpha-adrenergic and beta-adrenergic mechanisms. These 2 mechanisms use catecholamines (epinephrine and NE) to affect the adrenergic receptors on their target organs such as heart and blood vessels. The

CARDIAC AUTONOMIC REGULATION

The opposing actions between parasympathetic and sympathetic systems lead indirectly to changes in cardiac functions such as heart rate, vascular tone and cardiac contractility. Many studies have shown that women and men differ in their cardiovascular responsivity to postural change.25., 26. Women exhibit a larger increase in heart rate, whereas men show increased vascular resistance and vasoconstriction.25., 26. Women exhibit more parasympathetic activity at rest and, therefore, experience

THE IMPACT OF HORMONES ON THE ANS

Hormones such as renin, angiotensin, catecholamines and estrogen also control the ANS, thereby regulating BP and vascular tone.³⁶ The renin-angiotensin system causes the primary alteration in BP. When a reduction in BP is detected, the kidney increases its release of renin that in turn converts the inactive form of angiotensinogen to angiotensin. Angiotensin acts as vasoconstrictor to elevate and restore the BP. The renin-angiotensin system releases aldosterone and increases BP by enhancing

ANATOMICAL DIFFERENCES

Women have a lower center of gravity (COG) than men by 8% to 15%.²¹ COG is defined by the relationship between mass and height. The ratio in men is simply an elevated height to a lesser mass. Women have a lower height but a higher mass in the lower extremities. Therefore, a woman’s COG is proportioned toward the pelvis, which may assist in the child-bearing process. In the study by Summers et al,²¹ it was apparent that a higher mass ratio in the lower area of the body resulted in increased

CONCLUSION

Although orthostatic hypotension is vastly undiagnosed, its sequelae are very widely recognized, and these include reductions in quality of life as a result of falls along with various symptoms ranging from dizziness to syncope. The distribution of complications related to OH is measurably different in men and women. Women are at an increased risk for OH as a result of common variables related to body size and hormones. For example, the smaller size of women results in the reduced size of 1 of

REFERENCES (42)

SchwartzG.L. et al.
Interacting effects of gender and genotype on blood pressure response to hydrochlorothiazide
Kidney Int
(2002)
GoldsteinD.S.
2-Stress induced activation of the sympathetic nervous system
Baillière’s Clin Endocrinol Metab
(1987)
KarioK. et al.
Lower standing systolic blood pressure as a predictor of falls in the elderly: a community-based prospective study
J Am Coll Cardiol
(2001)
LuukinenH. et al.
Prognosis of diastolic and systolic orthostatic hypotension in older persons
Arch Intern Med
(1999)
ConvertinoV.A.
Gender differences in autonomic functions associated with blood pressure regulation
Am J Physiol Regul Integr Comp Physiol
(1998)
ShinC. et al.
Prevalence and correlates of orthostatic hypotension in middle-aged men and women in Korea: the Korean Health and Genome Study
J Hum Hypertens
(2004)
ShoemakerJ.K. et al.
Gender affects sympathetic and hemodynamic response in postural stress
Am J Physiol Heart Circ Physiol
(2001)
MedowM.S. et al.
Pathophysiology, diagnosis, and treatment of orthostatic hypotension and vasovagal syncope
Cardiol Rev
(2008)
OkaH. et al.
Characteristics of orthostatic hypotension in parkinson’s disease
Brain
(2007)
ShiaboC. et al.
Orthostatic hypotension related hospitalization in the United States
Am J Med
(2007)

SclaterA. et al.

Orthostatic hypotension: A primary care primer for assessment and treatment

Geriatrics

(2004)

MontastrucJ.L. et al.

Drug-induced orthostatic hypotension: a five-year experience in a regional pharmacovigilance centre in France

Clin Drug Investig

(1997)

FigueroaJ.J. et al.

Preventing and treating orthostatic hypotension: as easy as A, B, C

Cleveland Clin J Med

(2010)

GraysonC.E.

What is low blood pressure?

Hunterdon Healthcare System

(2002)

PrilipkoO. et al.

Orthostatic intolerance and syncope associated with Chiari type I malformation

J Neurol Neurosurg Psychiatry

(2004)

ParkJ. et al.

Gender difference in patients with recurrent neurally mediated syncope

Yonsei Med J

(2010)

LanskaD.J.

Cough syncope

Medlink Neurology

(2004)

FedorowskiA. et al.

Orthostatic hypotension in genetically related hypertensive and normotensive individuals

J Hypertens

(2009)

EvansJ.M. et al.

Gender differences in autonomic cardiovascular regulation: spectral, hormonal, and hemodynamic indexes

J Appl Physiol

(2001)

RamaekersD. et al.

Heart rate variability and heart rate in healthy volunteers. Is the female autonomic nervous system cardioprotective?

Eur Heart J

(1998)

WattG.C.M. et al.

Abnormalities of glucocorticoid metabolism and the renin-angiotensin system: a four-corners approach to the identification of genetic determinants of blood pressure

J Hypertens

(1992)

Cited by (39)

Prolonged unloading of the cardiovascular system during bedrest and spaceflight weakens neural coupling between blood pressure and heart rate
2022, Acta Astronautica
Citation Excerpt :
Sex may also play a role in susceptibility to post-flight/bedrest orthostatic intolerance. There is a growing body of evidence to suggest that autonomic cardiovascular control is different between males and females, both at rest and when exposed to orthostatic stress [19–21]. A compilation of astronaut presyncopal events (25 female, and 140 male) after short duration spaceflight (5–16 days) showed presyncope occurring in 28% of the females and 7% of the males [22], associated with low vascular resistance [23].
Impaired baroreflex control following bedrest and spaceflight severely affects rate of recovery and return to ambulatory tasks. Post-bedrest/spaceflight orthostatic intolerance remains a major concern for bedrest confined older patients and for astronauts on long-duration missions. Here, we investigated how baroreflex changes following cardiovascular unloading were associated with autonomic neural coupling between blood pressure and heart rate in returning astronauts and in healthy participants who had undergone prolonged bedrest. Cardiovascular data collected from 27 shuttle astronauts (8–16 days) were compared with 19 head-down tilt bedrest (HDBR, 60 days) volunteers. In each group, beat-by-beat systolic blood pressure (SBP) and heart period (R-to-R intervals, RR) were collected simultaneously during a supine-to-stand test (5–10 min) conducted around 10 days before launch or HDBR and within 120 min of landing or exiting HDBR. Indices characterizing interaction time (fraction time active), response gain (gain), and control directionality (causality) between SBP and RR (SBP→RR: neural reflex, and RR→SBP: mechanical coupling) during standing were derived from the beat-by-beat data. Following spaceflight, cardiac baroreflex fraction time active was reduced along with neural reflex causality, with much larger reductions seen with HDBR. No change in mechanical causality pre-post flight or HDBR was observed; however, comparison of male and female astronauts indicated that neural and mechanical causality were both lower in females. Altogether, these findings suggest that changes in blood pressure regulation after bedrest and spaceflight are primarily reflex/neurally mediated and provides a target for therapeutic approaches to cardiovascular deconditioning.
Stress-related dysautonomias and neurocardiology-based treatment approaches
2022, Autonomic Neuroscience: Basic and Clinical
Citation Excerpt :
OH occurs when mechanisms for the regulation of orthostatic blood pressure control fails, such as baroreflex function, normal blood volume, and defenses against excessive venous pooling (Low and Tomalia, 2015). Unlike POTS, prevalence of OH increases with aging, OH occurs 10–30% of elderly persons (Low and Tomalia, 2015; Cheng et al., 2011). POTS has strong associations with some psychiatric disorders such as anxiety disorders (including panic disorder and agoraphobia), depression, cognitive problems, eating disorders, and attention-deficit/hyperactivity disorder (ADHD) (Raj et al., 2018), and is often misdiagnosed as an anxiety disorder (Raj et al., 2018; Schmidt et al., 2017).
Cardiovascular and psychiatric disorders are among the most commonly treated conditions worldwide. Research in neurocardiology, psychiatry, and epidemiology have defined bidirectional relationships between psychiatric disorders and heart disease, affirming the role of impaired autonomic nervous system, or dysautonomia in the prognosis and development in these disorders. These studies have fueled rapid clinical translation of experimental findings, with potential to complement existing pharmacological therapies. In this review, we comprehensively discuss the state-of-the-art investigations and novel treatment approaches for stress-related dysautonomias, emphasizing the effects of stress on the cardiac neuronal hierarchy. Increasing evidence suggests that autonomic modulation stands as an attractive therapeutic strategy in the treatment of dysautonomias that could complement existing therapies and possibly reduce the burden of drug-related side effects and treatment-resistant conditions. Further investigations regarding treatment optimization, selectivity, usability, and ethical concerns are required.
Optimal systolic blood pressure and reduced long-term mortality in older hypertensive women with prior coronary events – An analysis from INVEST<sup>☆</sup>
2020, International Journal of Cardiology: Hypertension
Citation Excerpt :
SBP lowering <140 mmHg may be associated with higher rates of renal failure [10,11]. Orthostatic hypotension, which is more frequent in women [14], may also contribute to worse outcomes. However, contemporary studies conducted in mainly male populations failed to support an association between lower BP targets and a higher incidence of orthostatic hypotension [12,13].
Hypertension and coronary artery disease (CAD) are a prevalent combination in older women, however limited data are available to guide blood pressure (BP) management. We hypothesized that older women with hypertension and CAD may not derive long-term benefit by achieving systolic BP (SBP) < 130 mmHg.
We analyzed long-term all-cause mortality data from the International Verapamil SR/Trandolapril Study (INVEST), stratified by risk attributable to clinical severity of CAD (women with prior coronary events of myocardial infarction or revascularization considered high risk, all others at low risk) and by age group (50–64 or ≥65 years). The prognostic impact of achieving mean in-trial SBP <130 (referent group) was compared with 130–139 and ≥ 140 mmHg using Cox proportional hazards, adjusting for demographic and clinical characteristics.
SBPs <130, 130–139, and ≥140 were achieved in 2960, 3024, and 3232 women, respectively. Among high-risk women aged ≥65 years, those achieving SBP 130–139 mmHg had lower mortality up to 16.7 years later than those with SBP <130 (hazard ratio [HR] 0.81, 95% CI 0.69–0.96). High-risk women aged 50–64 achieving SBP 130–139 had a similar mortality risk as those with SBP <130 (HR 1.21, 95% CI 0.87–1.68), while those achieving SBP ≥140 mmHg had a higher mortality risk than SBP < 130 (HR 1.92, 95% CI 1.37–2.68). A similar pattern was observed among low-risk women ≥65 and <65 years old.
Among women ≥65 years old with hypertension and prior coronary events, in-trial SBP between 130 and 139 mmHg was associated with lower mortality over the long term versus SBP <130 mmHg.
Evaluation of orthostatic hypotension frequency and associated factors in type 2 diabetics
2019, Annales de Cardiologie et d'Angeiologie
L’hypotension orthostatique est un critère majeur de neuropathie autonome cardiaque du diabète. Elle est associée à un surcroît de mortalité globale et cardiovasculaire.
L’objectif est d’évaluer la fréquence et les facteurs associés à une hypotension orthostatique dans le diabète de type 2.
Cette étude transversale prospective inclut des patients adultes ayant un diabète de type 2. L’hypotension orthostatique a été définie comme une diminution de la pression artérielle systolique > 20 mmHg ou une diminution de la pression artérielle diastolique > 10 mmHg, après 3 minutes de position debout. La pression artérielle a été mesurée avec un dispositif électronique validé. Les facteurs de risque vasculaire et complications micro- et macrovasculaires ont été recherchés systématiquement par les moyens diagnostiques appropriés.
Nous avons évalué 300 patients diabétiques. Les femmes représentent 57 %. L’âge moyen était de 58 ans. La durée moyenne du diabète était de 8 ans. Les médicaments antidiabétiques étaient la metformine (82 %), les sulfonylurées (36 %) et l’insuline (40 %). Une hypertension artérielle était présente dans 49 % des cas. Les antihypertenseurs étaient les antagonistes des récepteurs de l’angiotensine II (50 %), les diurétiques (47 %), les inhibiteurs de l’enzyme de conversion de l’angiotensine (24 %), les bêtabloquants (17 %) et les inhibiteurs des canaux calciques (17 %). Une hypotension orthostatique a été identifiée chez 26 patients (8,6 %). En analyse multivariée, les facteurs associés à l’hypotension orthostatique sont l’élévation la pression artérielle systolique et l’insulinothérapie.
L’hypotension orthostatique est relativement peu fréquente chez nos patients atteints de diabète de type 2. Elle est associée de manière significative à l’élévation la pression artérielle systolique et à l’insulinothérapie.
Orthostatic hypotension is a major criterion for diabetic autonomic cardiac neuropathy. It increases overall and cardiovascular mortality.
The aim of our study was to evaluate the orthostatic hypotension frequency in type 2 diabetics and to investigate the associated factors.
This prospective cross-sectional study included adult patients with type 2 diabetes. Orthostatic hypotension was defined as a decrease in the systolic arterial pressure > 20 mm-Hg or a decrease in the diastolic arterial pressure > 10 mm-Hg, after 3 minutes of standing position. The arterial pressure was measured with a validated electronic device. Vascular risk factors and micro and macro-vascular complications were systematically investigated by the appropriate diagnostic means.
We evaluated 300 diabetic patients. Of these women represented 57%. The mean age was 58 years old. The average duration of diabetes was 8 years. The antidiabetic drugs were metformin (82%), sulfonylureas (36%) and insulin (40%). High blood pressure was present in 49% among whom 50% of patients received angiotensin II receptor blockers, 47% diuretics, 24% angiotensin converting enzyme inhibitors, 17% beta blockers, and 17% calcium channel blockers. Orthostatic hypotension has been identified in 26 patients (8.6%). In multivariate analysis, the associated factors with orthostatic hypotension were elevated systolic blood pressure and insulin treatment.
The frequency of orthostatic hypotension is relatively low in our patients with type 2 diabetes and it was significantly associated with systolic blood pressure and insulin treatment.
Prevalence and associative factors of orthostatic hypotension in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study
2017, Archives of Gerontology and Geriatrics
Citation Excerpt :
Furthermore, a meta-analysis has reported association of OH with cardiovascular disease and 36.0% increase in risk of mortality (Angelousi et al., 2014). In addition to chronic medical conditions, previous studies showed associations between OH with increasing age (Gore, 2014), women (Cheng, Vyas, Hymen, & Perlmuter, 2011), and cognitive impairment (Bengtsson-Lindberg et al., 2015; Mehrabian et al., 2010), though no association was seen in some other studies (Aung, Corcoran, Nagalingam, Paul, & Newnham, 2012; Casiglia et al., 2014; Yap, Niti, Yap, & Ng, 2008). Singapore is a developed country located in Southeast Asia comprising 74.3% Chinese, 13.3% Malays, 9.1% Indians, and 3.3% of other races.
Orthostatic hypotension (OH) is commonly reported among older adults and is associated with an increased risk of mortality. This study aimed to describe the prevalence and investigate the possible associations between OH with sociodemographic variables, chronic medical conditions, health service utilisation, dementia and cognitive status among older adults residing in Singapore.
Data was collected from 2266 participants aged 60 years and older who participated in the Well-being of the Singapore Elderly (WiSE) study in 2013. Face-to-face interviews were conducted and data collected includes sociodemographic information, blood pressure measurements, medical history, health services utilisation, and cognitive status.
The prevalence of OH among older adults in Singapore was 7.8%. OH was highest in participants aged 85 years and above (OR: 2.33; 1.26–4.30; p = 0.007) compared to those aged 75–84 years (OR: 1.76; 1.08-2.85; p = 0.023). Participants with hypertension were more likely to have OH (OR: 3.03; 1.56–5.88, p = 0.001) than those without hypertension. Those with dementia were also more likely to have OH than those with normal cognitive status (p = 0.007).
Older age, hypertension, and dementia were independently associated with OH in the older adult population in Singapore. Interventions such as home safety assessment and preventive measures should be implemented to improve older adult’s functional capacity and quality of life to prevent injury.
Influence of sex, menstrual cycle, and oral contraceptives on cerebrovascular resistance and cardiorespiratory function during Valsalva or standing
2017, Journal of Applied Physiology

View all citing articles on Scopus

View full text

Review ArticleGender Differences in Orthostatic Hypotension

Abstract

Section snippets

THE FUNCTION OF THE ANS

CARDIAC AUTONOMIC REGULATION

THE IMPACT OF HORMONES ON THE ANS

ANATOMICAL DIFFERENCES

CONCLUSION

Kidney Int

Baillière’s Clin Endocrinol Metab

J Am Coll Cardiol

Prognosis of diastolic and systolic orthostatic hypotension in older persons

Arch Intern Med

Gender differences in autonomic functions associated with blood pressure regulation

Am J Physiol Regul Integr Comp Physiol

Prevalence and correlates of orthostatic hypotension in middle-aged men and women in Korea: the Korean Health and Genome Study

J Hum Hypertens

Gender affects sympathetic and hemodynamic response in postural stress

Am J Physiol Heart Circ Physiol

Pathophysiology, diagnosis, and treatment of orthostatic hypotension and vasovagal syncope

Cardiol Rev

Characteristics of orthostatic hypotension in parkinson’s disease

Brain

Orthostatic hypotension related hospitalization in the United States

Am J Med

Orthostatic hypotension: A primary care primer for assessment and treatment

Geriatrics

Drug-induced orthostatic hypotension: a five-year experience in a regional pharmacovigilance centre in France

Clin Drug Investig

Preventing and treating orthostatic hypotension: as easy as A, B, C

Cleveland Clin J Med

What is low blood pressure?

Hunterdon Healthcare System

Orthostatic intolerance and syncope associated with Chiari type I malformation

J Neurol Neurosurg Psychiatry

Gender difference in patients with recurrent neurally mediated syncope

Yonsei Med J

Cough syncope

Medlink Neurology

Orthostatic hypotension in genetically related hypertensive and normotensive individuals

J Hypertens

Gender differences in autonomic cardiovascular regulation: spectral, hormonal, and hemodynamic indexes

J Appl Physiol

Heart rate variability and heart rate in healthy volunteers. Is the female autonomic nervous system cardioprotective?

Eur Heart J

Abnormalities of glucocorticoid metabolism and the renin-angiotensin system: a four-corners approach to the identification of genetic determinants of blood pressure

J Hypertens

Review Article
Gender Differences in Orthostatic Hypotension