Value of Orthostatic Hypotension as a Prognostic Bed-Side Test in Heart Failure

Tarek M. Abdel Rahman

Cardiology Department, El Minia University Hospital, Minya, Egypt.

DOI: 10.4236/wjcs.2012.24022                

Abstract

Background: Neurohumoral compensatory mechanisms play an important role in stabilizing the functional activity of patients with heart failure using the arms of autonomic nervous system. Orthostatic Hypotension (OH) is one of the most incapacitating symptoms of Cardiac Autonomic Dysfunction (CAD). OH can include sympathetic withdrawal which in turn leads to marked disability and deterioration of heart failure symptoms. Progressive Autonomic Dysfunction (AD) associated with progressive deterioration and impact on mortality of many diseases as hypertension, diabetes and other chronic diseases. The idea of using (OH) as a bed-side simple test expecting the risk of deterioration of cardiac function and furthermore on mortality open a gateway for preventive medicine and care to these group of patients. For more confidential prove, studying subjective and objective factors in heart failure patients became necessary to support these idea. Methods and Results: Sixty-Four patients with known history of heart failure were collected. All patients taking the fixed regiment of 4 drugs (diuretic, ACE inhibitor, Digitalis and B-blocker) in appropriate tolerated doses for two weeks prior to the study. History taking and all routine investigations were done for all patients. Grouping is based upon wither they have (OH) or not. Group-A found to have normal Bp response to standing; they were 24 patients (18 male and 6 female) of mean Age (45 ± 8 years). Group-B discovered to have significant (OH) and was 22 patients (16 males and 6 females) of mean Age (43 ± 4 years). The first Clinical and Echocardiographic examination was done and considered as a base-line characteristic. Then, a Call-back after 6 months for follow-up and second visit examination is recorded. Furthermore, every patient was advised to report changes in his clinical symptoms in a note-book describing five main items to answer a questionnaire at the end of the study involves [times of admission to hospital, need for treatment modification, numbers of paroxysmal nocturnal dysnea, numbers of arrhythmic episodes and manifest lower limb edema]. At the end of the study, statistical methods are used to clarify the changes in their data and detect deterioration of cardiac functions by Echocardiographic results and their answers to the questionnaire. In the first visit, comparison of demographic, clinical and Echocardiographic data revealed no significant variations—odd values are excluded and the remaining 46 patients are then tested for their Bp response to standing and classified into two groups. Group-A (normal Bp response) and Group-B (having orthostatic hypotension). Group-A were 24 patients (18 male and 6 female) of mean Age (45 ± 8 years). Group-B were 22 patients (16 males and 6 females) of mean Age (43 ± 4 years). In the second visit (6-month later), divergence of data is observed and was statistically significant. Group-B was found to have a lower EF% and FS% (p = 0.01), a lower Dp/Dt (p = 0.01) and a higher Tie-Index and MR-jet area (p = 0.01). This means that, patients having orthostatic hypotension underwent significant deterioration of cardiac functions after a period of six-months. Indeed, the questionnaire proved frequent times of hospital admissions, paroxysmal nocturnal dysnea, need for treatment modification, arrhythmias and lower limb edema in group-B. Discussion: The present study conclude that, heart failure-patients having orthostatic

Keywords

Orthostatic; Hypotension; Heart Failure

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	I. B. Goldstein and D. Shapiro, “The Cardiovascular Response to Postural Change as a Function of Race,” Biological Psychology, Vol. 39, No. 2-3, 1995, pp. 173-186.
[2]	C. J. Nardo, L. E. Chambless, K. C. Light, et al., “Descriptive Epidemiology of Blood Pressure Response to Change in Body Position: The ARIC Study,” Hypertension, Vol. 33, No. 5, 1999, pp. 1123-1129. doi:10.1161/01.HYP.33.5.1123
[3]	The Consensus Committee of the American Autonomic Society and the American Academy of Neurology, “Consensus Statement on the Definition of Orthostatic Hypotension, Pure Autonomic Failure, and Multiple System Atrophy,” Neurology, Vol. 46, No. 5, 1996 p. 1470. doi:10.1212/WNL.46.5.1470
[4]	K. M. Rose, I. Holme, K. C. Light, et al., “Association between the Blood Pressure Response to a Change in Posture and the 6-Year Incidence of Hypertension: Prospective Findings from the ARIC Study,” Journal of Human Hypertension, Vol. 16, No. 11, 2002, pp. 771-777. doi:10.1038/sj.jhh.1001482
[5]	M. L. Eigenbrodt, K. M. Rose, D. J. Couper, et al., “Orthostatic Hypotension as a Risk Factor for Stroke: The Atherosclerosis Risk in Communities (ARIC) Study,” Stroke, Vol. 31, 2000, pp. 2307-2313. doi:10.1161/01.STR.31.10.2307
[6]	H. Luukinen, K. Koski and P. Laippala, “Orthostatic Hypotension and the Risk of Myocardial Infarction in the Home-Dwelling Elderly,” Journal of Internal Medicine, Vol. 255, No. 4, 2004, pp. 486-493. doi:10.1111/j.1365-2796.2004.01313.x
[7]	K. M. Rose, I. Holme, K. C. Light, et al., “Association between the Blood Pressure Response to a Change in Posture and the 6-Year Incidence of Hypertension: Prospective Findings from the ARIC Study,” Journal of Human Hypertension, Vol. 16, No. 11, 2002, pp. 771-777. doi:10.1038/sj.jhh.1001482
[8]	M. L. Eigenbrodt, K. M. Rose, D. J. Couper, et al., “Orthostatic Hypotension as a Risk Factor for Stroke: The Atherosclerosis Risk in Communities (ARIC) Study, 1987- 1996,” Stroke, Vol. 31, 2000, pp. 2307-2313. doi:10.1161/01.STR.31.10.2307
[9]	H. Luukinen and K. Airaksinen, “Orthostatic Hypotension Predicts Vascular Death in Older Diabetic Patients,” Diabetes Research and Clinical Practice, Vol. 67, No. 2, 2005, pp. 163-166. doi:10.1016/j.diabres.2004.06.009
[10]	J. J. Smith, C. M. Porth and M. Erickson, “Hemodynamic Response to the Upright Posture,” The Journal of Clinical Pharmacology, Vol. 34, No. 5, 1994, pp. 375-386.
[11]	C. J. Mathias and J. R. Kimber, “Postural Hypotension: Causes, Clinical Features, Investigation, and Management,” Annual Review of Medicine, Vol. 50, 1999, pp. 317-336. doi:10.1146/annurev.med.50.1.317
[12]	L. M. Allcock, R. A. Kenny, U. P. Mosimann, et al., “Orthostatic Hypotension in Parkinson’s Disease: Association with Cognitive Decline,” International Journal of Geriatric Psychiatry, Vol. 21, No. 8, 2006, pp. 778-783. doi:10.1002/gps.1562
[13]	S. Gates, J. D. Fisher, M. W. Cooke, et al., “Multifactorial Assessment and Targeted Intervention for Preventing Falls and Injuries among Older People in Community and Emergency Care Settings: Systematic Review and Meta-Analysis,” British Medical Journal, Vol. 336, No. 19, 2008, pp. 130-133.
[14]	M. A. Weber, N. K. Wenger and S. Scheidt, “A Focus on Heart Failure and Other Age-Related Cardiovascular Conditions,” American Journal of Geriatric Cardiology, Vol. 14, No. 5, 2005, pp. 221-223. doi:10.1111/j.1076-7460.2005.04223.x
[15]	C. L. Avery, P. P. Chang, W. D. Rosamond, et al., “The Population Burden of Heart Failure Attributable to Modifiable Risk Factors: The ARIC (Atherosclerosis Risk in Communities) Study,” American College of Cardiology, Vol. 60, No. 17, 2012, pp. 1640-1646. doi:10.1016/j.jacc.2012.07.022
[16]	K. M. Rose, H. A. Tyroler, C. J. Nardo, et al., “Orthostatic Hypotension and the Incidence of Coronary Heart Disease: The Atherosclerosis Risk in Communities Study,” American Journal of Hypertension, Vol. 13, No. 6, 2000, pp. 571-578. doi:10.1016/S0895-7061(99)00257-5
[17]	K. M. Rose, M. L. Eigenbrodt, R. L. Biga, et al., “Orthostatic Hypotension Predicts Mortality in Middle-Aged Adults: The Atherosclerosis Risk in Communities (ARIC) Study,” Circulation, Vol. 114, No. 7, 2006, pp. 630-636. doi:10.1161/CIRCULATIONAHA.105.598722
[18]	M. L. Eigenbrodt, K. M. Rose, D. J. Couper, et al., “Orthostatic Hypotension as a Risk Factor For Stroke: The Atherosclerosis Risk in Communities (ARIC) Study, 1987-1996,” Stroke, Vol. 31, No. *, 2000, pp. 2307-2313. doi:10.1161/01.STR.31.10.2307
[19]	A. I. Vinik, B. Aysin and J. Colombo, “Dynamic Enhanced Frequency Domain Analysis Indicates a Significant Decline in Autonomic Function before Age 50,” Diabetes Technology Conference, San Francisco, 2005.
[20]	A. I. Vinik, R. Freeman and T. Erbas, “Diabetic Autonomic Neuropathy,” Seminars in Neurology, Vol. 23, No. 4, 2003, pp. 365-372. doi:10.1055/s-2004-817720
[21]	S. M. Grundy, I. J. Benjamin, G. L. Burke, et al., “Diabetes and Cardiovascular Disease: A Statement for Healthcare Professionals from the American Heart Association,” Circulation, Vol. 100, No. 13, 1999, pp. 1134-1146. doi:10.1161/01.CIR.100.10.1134
[22]	R. Freeman, “Treatment of Orthostatic Hypotension,” Seminars in Neurology, Vol. 23, No. 4, 2003, pp. 435-442. doi:10.1055/s-2004-817727
[23]	B. Aysin, E. Aysin and A. Vinik, “Diabetes May Accelerate the Onset of Orthostasis,” The 6th Annual Diabetes Technology Meeting, Atlanta, 2006.
[24]	R. R. Arora, E. Aysin and J. Colombo, “Therapeutic Implications of Sympathetic Stimulus in Orthostatic Patients: Measured by Spectral Domain Analysis,” AHA Scientific Sessions, Orlando, 2007
[25]	C. Borst, W. Weiling, J. F. van Brederode, A. J. Dunning, et al., “Mechanisms of Initial Heart Rate Response to Postural Change,” American Journal of Physiology, Vol. 243, No. 5, 1982, pp. 676-681.
[26]	S. Maule, E. Catalfamo, S. D. Colle, et al., “Cardiovascular Autonomic Function in 422 Patients with Orthostatic Symptoms,” American Journal of Hypertension, Vol. 16, 2003, p. 505.
[27]	American Academy of Neurology, “Clinical Autonomic Testing Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, Neurology, Vol. 46, No. 3, 1996, pp. 873-880.
[28]	A. M. Aring, D. E. Jones and J. M. Falko, “Evaluation and Prevention of Diabetic Neuropathy,” American Family Physician, Vol. 71, No. 11, 2005, pp. 2123-2130.
[29]	J. J. Smith, C. M. Porth and M. Erickson, “Hemodynamic Response to the Upright Posture,” The Journal of Clinical Pharmacology, Vol. 34, No. 5, 1994, pp. 375-386.
[30]	W. B. Applegate, B. R. Davis, H. R. Black, et al., “Prevalence of Postural Hypotension at Baseline in the Systolic Hypertension in the Elderly Program (SHEP) Cohort,” Journal of the American Geriatrics Society, Vol. 39, No. 11, 1991, pp. 1057-1064.
[31]	H. Luukinen, K. Koski and P. Laippala, “Orthostatic Hypotension and the Risk of Myocardial Infarction in the Home-Dwelling Elderly,” Journal of Internal Medicine, Vol. 255, No. 4, 2004, pp. 486-493. doi:10.1111/j.1365-2796.2004.01313.x
[32]	C. A. Ray and K. D. Monahan, “Aging Attenuates the Vestibulosympathetic Reflex in Humans,” Circulation, Vol. 105, No. 8, 2002, pp. 956-961. doi:10.1161/hc0802.104289
[33]	C. Shin, R. D. Abbott, H. Lee, et al., “Prevalence and Correlates of Orthostatic Hypotension in Middle-Aged Men and Women in Korea: The Korean Health and Genome Study,” Journal of Human Hypertension, Vol. 18, 2004, pp. 717-723. doi:10.1038/sj.jhh.1001732
[34]	V. Litvinov, I. Alon, et al., “Seating-Induced Postural Hypotension Is Common in Older Patients with Decompensated Heart Failure and May Be Prevented by Lower Limb Compression Bandaging,” Circulation, Vol. 55, No. 2, 2009, pp. 138-144.
[35]	A. Fedorowski, B. Hedblad and O. Melander, “Directionality of Blood Pressure Response to Standing May Determine Development of Heart Failure: Prospective Cohort Study,” European Journal of Heart Failure, Vol. 13, No. 5, 2011, 496-503. doi:10.1093/eurjhf/hfr013
[36]	A. Fedorowski, G. Engstr?m and B. Hedblad, “Orthostatic Hypotension Predicts Incidence of Heart Failure: The Malm? Preventive Project,” American Journal of Hypertension, Vol. 23, No. 11, 2010, pp. 1209-1215. doi:10.1038/ajh.2010.150
[37]	K. Potocka-Plazak and W. Plazak, “Orthostatic Hypotension in Elderly Women with Congestive Heart Failure,” Aging (Milano), Vol. 13, No. 5, 2001, pp. 378-84.
[38]	M. D. Ali-Ahmed, R. M. Allman, C. Gregg, et al., “Incident Heart Failure Hospitalization and Subsequent Mortality in Chronic Heart Failure: A Propensity-Matched Study,” Journal of Cardiac Failure, Vol. 14, No. 3, 2008, pp. 211-218. doi:10.1016/j.cardfail.2007.12.001
[39]	M. Gheorghiade, F. Zannad, G. Sopko, et al., “Acute Heart Failure Syndromes: Current State and Framework for Future Research,” Circulation, Vol. 112, No. 65, 2005, pp. 3958-3968. doi:10.1161/CIRCULATIONAHA.105.590091
[40]	G. D. Schiff, S. Fung, T. Speroff, et al., “Decompensated Heart Failure: Symptoms, Patterns of Onset, and Contributing Factors,” American Journal of Medicine, Vol. 114, No. 8, 2003, pp. 625-630. doi:10.1016/S0002-9343(03)00132-3
[41]	E. R. Perna, S. M. Macin, J. P. Cimbaro-Canella, et al., “Minor Myocardial Damage Detected by Troponin T Is a Powerful Predictor of Long-Term Prognosis in Patients with Acute Decompensated Heart Failure,” International Journal of Cardiology, Vol. 99, No. 2, 2005, pp. 253-261. doi:10.1016/j.ijcard.2004.01.017
[42]	The SOLVD Investigators, “Effect of Enalapril on Survival in Patients with Reduced Left Ventricular Ejection Fractions and Congestive Heart Failure,” The New England Journal of Medicine, Vol. 325, 1991, pp. 293-302. doi:10.1056/NEJM199108013250501
[43]	P. M. Rothwell, “Treating Individuals 2. Subgroup Analysis in Randomised Controlled Trials: Importance, Indications, and Interpretation,” Lancet, Vol. 365, No. 9454, 2005, pp. 176-186. doi:10.1016/S0140-6736(05)17709-5
[44]	M. Kosiborod, G. E. Soto, P. G. Jones, et al., “Outcomes Research, Identifying Heart Failure Patients at High Risk for Near-Term Cardiovascular Events With Serial Health Status Assessments,” Circulation, Vol. 115, No. 15, 2007, pp. 1975-1981.