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• W3022242589 abstract "Orthostatic hypotension, a possible marker of autonomic dysfunction, reflects the failure of reflexive cardiovascular mechanisms to compensate for the drop in venous return in the upright posture. Orthostatic hypotension is a manifestation of structural and functional aberrations in the cardiovascular system. Although orthostatic hypotension is often asymptomatic, it is at times associated with syncope and systemic cardiovascular disease (CVD). It is not well appreciated that orthostatic hypotension is of considerable prognostic value as it is linked to excessive morbidity and mortality. Thus, it is important to recognize orthostatic hypotension as a distinct pathophysiological entity and possibly as a ‘Syndrome’. In this issue of the Journal, Cremer and colleagues report important findings from a cross sectional study of an elderly population with orthostatic hypotension [1]: the findings show that orthostatic hypotension does not occur in isolation but in conjunction with blood pressure variability and arterial stiffness. These observations seem to indicate that orthostatic hypotension is merely a component of a much broader cardiovascular dysfunction. Orthostatic hypotension can be because of neurogenic and nonneurogenic conditions. As stated earlier, orthostatic hypotension is often asymptomatic but when organ hypoperfusion causes symptoms, the condition is dubbed as orthostatic intolerance [2,3]. The development of symptoms depends on a number of factors, such as age, comorbidities, volume status, and concomitant drug therapy. Thus it is hard to predict which patient with orthostatic hypotension is likely to be symptomatic and at ‘risk’. The findings of the study by Cremer and colleagues indirectly suggest that orthostatic hypotension in association with blood pressure variability and vascular stiffness should be regarded as a distinct entity and may constitute a high-risk group. A vast majority of studies in hypertension utilize basic blood pressure level to predict cardiovascular risk. However, blood pressure fluctuates considerably in the short-term as well as in the long-term; this variability, if large, is recognized as an independent cardiovascular risk factor [4–6]. Measurement of blood pressure variability has been difficult but with proper continuous blood pressure measurements out of the office (ambulatory blood pressure monitoring), we are now able to detect minute-to-minute and day-to-day blood pressure variability with precision. It is recognized that blood pressure variability by itself is a powerful independent cardiovascular risk factor. Both orthostatic hypotension and blood pressure variability can be attributed to autonomic dysfunction [7]. As orthostatic hypotension is associated with blood pressure variability and nocturnal ‘nondipping’, the condition obviously has a prognostic value. The study by Cremer and colleagues performed in the elderly (age = 80+ years) also found that orthostatic hypotension was associated with increased pulse wave velocity (PWV) signalling that the condition is a barometer of vascular stiffness. The coupling of orthostatic hypotension with loss of arterial elasticity further advances the concept that orthostatic hypotension is a part and parcel of generalized vascular disease. An interconnection between orthostatic hypotension and arterial stiffness has been described previously [8]. The overall evidence demonstrates that vascular stiffness is accompanied by diminished cardiovascular adaptation to the standing position [9,10]. It is accepted that aging is an independent risk factor for vascular stiffness. Does this mean that not only hypertension but orthostatic hypotension is a age-related disorder? Normally, the elastic properties of large arteries assure that the pulsatile pressure and blood flow are in a physiological balance resulting in adequate oxygen delivery and metabolism at the microcirculation. Although aging is undoubtedly a determinant of vascular stiffness, the question is whether this phenomenon is influenced not by hypertension but by orthostatic hypotension! Interestingly, therefore, both hypertension and hypotension are associated with atherosclerosis. Are there common pathophysiological pathways (structural or biochemical) in the co-occurrence of orthostatic hypotension and vascular stiffness? The co-existence of orthostatic hypotension, blood pressure variability, and vascular stiffness represents a syndrome with important prognostic implications for public health. These three entities are independent risk factors for CVD and their confluence, therefore, is of impactful added significance. Even in the middle-age population, the Malmo project [11] found orthostatic hypotension is associated with excessive cardiovascular events. One can only surmise then that the situation gets worse in the elderly. In this context, it should be recalled that a higher variability in the blood pressure is associated with white matter hyper-intensity in the brain, which denotes possible risk for dementia and cerebrovascular disease [12]. A greater blood pressure variability is also associated with significant cardiovascular dysfunction [13]. The clinicians should now recognize that orthostatic hypotension does not merely occur in isolation but often co-exists with blood pressure variability and vascular stiffness -- all of which independently predict poor prognosis. So, what does this mean for therapies to remedy the ‘syndrome’. Pharmacological therapy of orthostatic hypotension is fraught with uncertain and unpredictable results. If orthostatic hypotension is accompanied by supine hypertension (which is often the case in the elderly), therapeutic options for orthostatic hypotension may aggravate supine hypertension [14]. For example, beta-blockers may influence various cardiovascular parameters in patients with orthostatic hypotension. The management of supine hypertension in patients with orthostatic hypotension is one of the most difficult scenarios in clinical medicine with no solutions in sight. Blood pressure variability can be influenced to some extent by calcium channel blockers [15]. What is the role of other drugs like diuretics and RAAS blockers on blood pressure variability? It will be of considerable interest to evaluate the effects of conventional and experimental drug therapy on vascular stiffness. It seems logical to explore vascular stiffness as a target for therapeutic intervention not only with conventional therapies but also with novel/experimental approaches, such as arginase inhibition, collagen interruption, and antifibrotic agents. Continued population and pathophysiology research in the field of orthostatic hypotension will likely yield ‘rational’ and innovative therapeutic options in the future not merely to correct orthostatic hypotension but to reverse the syndrome of orthostatic hypotension, blood pressure variability, and vascular stiffness. Such ‘targeted’ therapies may be of considerable benefit to patients with symptomatic orthostatic hypotension who otherwise tend to have a poor quality of life and adverse prognosis. ACKNOWLEDGEMENTS The author thanks Ms N. Madhavi Latha for her excellent editorial and typing assistance in preparing this manuscript. Conflicts of interest There are no conflicts of interest." @default.
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• W3022242589 date "2020-06-01" @default.
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• W3022242589 title "The triad of orthostatic hypotension, blood pressure variability, and arterial stiffness: a new syndrome?" @default.
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