Orthostatic Hypotension and Symptoms in the AASK Trial

Abstract

Background: Multiple definitions are used to characterize orthostatic hypotension (OH), but the degree to which these definitions correspond with orthostatic symptoms is unknown.

Methods: We analyzed data from African American Study of Kidney Disease and Hypertension (AASK), a randomized trial of African Americans with hypertension and kidney disease, to characterize the relationship between OH definitions and self-reported syncope, dizziness, or light-headedness. Orthostatic changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), or heart rate (HR) were determined each visit after standing 2:45 minutes. OH was defined using the consensus definition (a drop in SBP ≥20 mm Hg or DBP ≥10 mm Hg) or an often used clinical substitute based on HR (an increase ≥20 bpm).

Results: Among 1,094 participants (mean age 54.5 ± 10.7 years, 38.9% female), there were 52,636 visits (mean 48/person). Mean resting SBP, DBP, and HR at baseline were 147.7 ± 22.3 mm Hg, 92.2 ± 13.4 mm Hg, and 71.1 ± 11.7 bpm, respectively. While the OH consensus definition was associated with syncope (odds ratio 2.49; 95% confidence interval: 1.13, 5.51), dizziness (1.89; 1.53, 2.33), and light-headedness (1.84; 1.52, 2.23), the clinical HR definition was only associated with dizziness (1.28; 1.07, 1.52). None of the OH components (SBP, DBP, or HR) reflected a natural threshold in the prevalence of symptoms; definitions using each of the 3 components were highly specific (≥96%) with low sensitivity (1-5%).

Conclusions: While the consensus definition was more strongly associated with symptoms, OH definitions did not reflect natural thresholds in symptoms and were insensitive. This implies that the absence of OH using either consensus or clinical definitions does not exclude orthostatic symptoms, which has implications for evaluating clinical events like falls.

Clinical trials registration: Trial Number: NCT01206062 (clinicaltrials.gov).

Figures

Figure 1.

Association of postural change in (a) systolic blood pressure (SBP), (b) diastolic blood pressure (DBP), and (c) heart rate (HR) with the unadjusted proportion (%) of participants, who report syncope. Relationships were modeled via generalized estimating equations to account for repeated assessments. Dashed vertical lines (gray shade) represent conventional cut points for orthostatic hypotension. Black line represents the probability density.

Figure 2.

Association of postural change in (a) systolic blood pressure (SBP), (b) diastolic blood pressure (DBP), and (c) heart rate (HR) with the unadjusted proportion (%) of participants, who report feeling light-headedness (dashed line) or dizzy (solid line). Relationships were modeled via generalized estimating equations to account for repeated assessments. Dashed vertical lines (gray shade) represent conventional cut points for orthostatic hypotension. Black line represents the probability density.