PHOENIX, AZ — In the large sample of 40- to 60-year-old community-dwelling adults in the Atherosclerosis Risk in Communities (ARIC) study, those who had orthostatic (postural) hypotension were more likely to fall within the next 2 decades, especially if they had diastolic postural hypotension, independent of other risk factors[1].

"This proves an important concept, that orthostatic hypotension is very relevant, even long in advance of a clinical event occurring," Dr Stephen P Juraschek (Johns Hopkins University, Baltimore, MD) told heartwire from Medscape, at a moderated poster session at the recent American Heart Association (AHA) Epidemiology and Prevention and Lifestyle and Cardiometabolic Health (EPI|Lifestyle) 2016 Scientific Sessions. Moreover, orthostatic hypotension can be easily assessed in a clinical setting, he added, and steps can be taken to address it, such as adjusting medications.

Second, "I think it is important for us to go back and look at and reevaluate how we characterize postural hypotension," he said. The accepted definition—a drop in systolic blood pressure of at least 20 mm Hg or drop in diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing up—was originally developed by a consensus panel in the 1980s, he noted.

The current study suggests that diastolic postural hypotension is a stronger predictor, and the relationship between a drop in blood pressure and an increased risk of a fall is a continuous one, as opposed to having a single threshold. For example, if clinicians are looking for a drop of diastolic blood pressure of 10 mm Hg, "we're missing a lot of risk in folks who only drop 5 or 6 or 7 mm Hg," he said. Moreover, the study raises the question, "Is the 3 minutes recommended by consensus the appropriate time lag or could it be done at 2 minutes or 1 minute?" The current study evaluated it at 2 minutes, he noted.

This study is important because falls "are really detrimental with a lot of negative sequelae," Dr Ruth Taylor–Piliae (University of Arizona, Tucson), who moderated this healthy-aging poster session, pointed out to heartwire . "It's not just expense; it's not just fractures; it causes a whole cascade, a negative spiral, once an older adult has a fall," she noted.

Systolic, Diastolic Postural Hypotension, and Future Falls

Orthostatic hypotension, possibly from hypertension treatment, can precipitate falls. But previous prospective studies looking at this risk were small and reported conflicting findings, Juraschek and colleagues explain.

They aimed, first, to determine whether orthostatic hypotension in midlife predicts the risk of a future fall, and second, to characterize how postural changes in systolic and diastolic blood pressure affect this risk.

The researchers investigated this in 12,661 adults who had a mean age of 54 in 1987–1989 when they enrolled in the prospective ARIC study. About half of the study participants were women (55%), about a quarter were black (26%), and they had a mean body-mass index (BMI) of about 27.

One in 20 (651 participants; 5%) had orthostatic hypotension (defined as a >20 mm Hg drop in systolic blood pressure or a >10 mm Hg drop in diastolic blood pressure 2 minutes after going from a supine to a standing position).

Compared with the other participants, those with orthostatic hypotension were more likely to have hypertension (59% vs 33%) and diabetes (22% vs 11%), and they had a higher mean resting blood pressure (131/76 mm Hg vs 121/73 mm Hg).

During a 23-year follow-up, there were 2274 falls. More falls occurred in the participants with vs without postural hypotension (2.8 falls per 1000 person-years vs 2.3 falls per 1000 person-years, P=0.03).

Participants with postural hypotension were 25% more likely to fall than those without postural hypotension (HR 1.25, 95% CI 1.04–1.49), after adjustment for demographics (age, sex, race, education), resting systolic and diastolic blood pressures, other health measures (BMI, hypertension, diabetes, smoking, estimated glomerular filtration rate, alcohol use, leisure index), history of heart disease (coronary heart disease, stroke, congestive heart failure), and medication use (antihypertensives used in the past 2 weeks; use of diuretics, sedatives, hypnotics, antipsychotics, anticholinergics).

Postural changes in diastolic blood pressure were more strongly tied to risks of falls than postural changes in systolic blood pressure (HR 1.07 per 5-mm-Hg drop in diastolic blood pressure, P<0.001; HR 1.02 per 5-mm-Hg drop in systolic blood pressure, P=0.01, after adjustment for the same variables).

In addition, the association between systolic or diastolic postural hypotension and the risk of a fall extended above and below the traditional cut points used to define orthostatic hypotension.

Thus "future research should critically reevaluate the definition of orthostatic hypotension using other clinically relevant outcomes to better characterize this clinical sign," Juraschek and colleagues urge.

The authors have no relevant financial relationships.

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