Simple DROP Score Appears to Identify Postural Hypotension

Marlene Busko

June 29, 2015

MILAN, ITALY — Researchers have developed a simple, five-point score, the DROP score, that appears to predict the likelihood of postural hypotension in elderly people[1]. "We envision this may be of some use in deciding who to screen [for postural hypotension] in busy primary-care settings," said Dr Christopher E Clark (University of Exeter Medical School, Exeter, UK), presenting this research at a late-breaking session at the European Society of Hypertension (ESH) 2015 Scientific Sessions.

Clark and colleagues analyzed data from the InChianti data set of people living around Chianti, Italy, and found that five variables helped spot those with postural hypertension: being older than 65, having fallen in the previous year, and having hypertension, stroke, or angina. Each factor was given one point, for a maximum score of 5. Having a higher score was linked with a greater risk of all-cause mortality in the subsequent decade. Perhaps surprisingly, diabetes was not one of the five predictors of postural hypotension.

However, at least one expert was skeptical of this simple scoring system. In a comment to heartwire from Medscape, session cochair Dr Cristina Giannattasio (Milano-Bicocca University, Milan) said she was not yet convinced that this "DROP score" would be a helpful risk predictor. She was surprised that having diabetes did not confer an increased risk of postural hypotension in this cohort.

In his presentation, Clark acknowledged that this is preliminary research and said that the group is conducting further study to refine and validate the DROP score.

Postural Hypotension Doubled Risk of 10-Year Death

Having postural hypotension, when blood pressure drops in the first few minutes after rising to a standing position, puts people at risk of falling and is associated with an increased risk of earlier death in elderly patients, Clark noted.

Although guidelines recommend that blood pressure should be measured 1 and 3 minutes after standing, this is seldom done in clinical practice, he added. Moreover, guidelines are inconsistent about who should be tested for postural hypotension. The 2011 NICE guidelines recommend testing patients who fall or have symptoms such as feeling dizzy when they get up from a lying position, whereas the 2013 ESH/European Society of Cardiology guidelines recommend testing elderly, diabetic patients.

Clark and colleagues aimed to identify risk factors associated with postural hypotension, using data from patients in the InChianti study. That study was designed to determine causes of walking difficulties in older people; participants underwent baseline testing in 1998 and are being followed every 3 years.

At recruitment, the participants had blood pressure measured when they were lying down and then 1 and 3 minutes after standing, to determine whether they had postural hypotension. Systolic postural hypotension was defined as a >20-mm-Hg fall in supine blood pressure on standing.

A total of 101/1352 participants (7.5%) and 89/1352 participants (6.6%) participants had postural hypotension 1 minute and 3 minutes after standing, respectively. This was a lower prevalence than in the Systolic Hypertension in the Elderly (SHEP) cohort, where 10.4% and 12.0% of the participants had postural hypotension at 1 minute and 3 minutes after standing, respectively[2], Clark noted, but that was a more selected population.

In the current analysis, compared with their peers, participants with postural hypotension were significantly older (mean age of 75.1 vs 68.5) and significantly more likely to have hypertension (65.3% vs 37.4%), angina (13.5% vs 6.9%), and stroke (15.8% vs 3.4%) and to have had a fall in the past year (33.7% vs 20.1%). They were also significantly more likely to be taking diuretics or digoxin, to need help climbing the stairs, and to have Parkinson's disease. However, the incidence of diabetes was the same in both groups (around 9%).

Five variables (being older than 65, having any falls in the previous year, and having hypertension, stroke, or angina) were powerful predictors of postural hypotension, Clark said.

A simple scoring system of 0 to 5 according to the presence of each of these variables suggests that if five people who have a DROP score of 4 are screened, one  will have postural hypotension and if eight people with a score of 3 are screened, one will have postural hypotension, he added. It would be necessary to screen 34 people with a DROP score of 2 to identify one person with postural hypotension.

Patients with postural hypotension had an increased risk of dying within a decade. Compared with other participants in the InChianti study, those with postural hypotension at 1 minute or 3 minutes were twice as likely to die from any cause within 10 years (HR 2.0; 95% CI 1.5–2.7).

Thus, the likelihood of having postural hypotension can largely be predicted from medical history, specifically by looking for these five risk factors, Clark said. The group is plans to refine and validate this risk predictor.

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