cardiovascular-agents and Hypotension--Orthostatic

In this, the second of two articles, we continue our evaluation of drug therapies in older adults. Having previously described the pharmacokinetic and pharmacodynamic consequences of physiological ageing, along with the challenge of appropriate prescribing, we proposed four key questions which should be considered when prescribing for this cohort of the population. Does this agent reflect the priorities of the patient? Are there alternatives - with greater efficacy, effectiveness or tolerability - that might be considered? Are the dose, frequency and formulation appropriate? How does this prescription relate to concurrent medication? We also highlighted the reliance on subgroup analysis to demonstrate the efficacy of drug therapies for older adults in osteoporosis and the underutilisation of appropriate treatments for patients with Alzheimer's disease as a result of flawed guidelines. Here we describe current drug therapies in systolic heart failure, noting the limited inclusion of older adults in key trials, while also reviewing the pharmacological treatment of orthostatic hypotension. In doing so, we advocate the intermittent use of midodrine as a first-line treatment for orthostasis in older adults, counter to the generic guidelines produced by various learned societies, but in keeping with the scant trial data available.

Topics: Age Factors; Cardiovascular Agents; Geriatrics; Heart Failure, Systolic; Humans; Hypotension, Orthostatic

The 'short' and 'long-term' benefits of pharmacological interventions to treat orthostatic hypotension (OH) remain unclear. The aim was to systematically examine the published literature on the effectiveness of different drug regimens for the treatment of OH.. Systematic review.. MEDLINE (1950-Week 7, 2011), EMBASE (1980-Week 7, 2011), CINAHL (1981-Week 7, 2011) databases and hand-searching of bibliographies were used to identify suitable papers.. Studies selected were those, which investigated drug treatment of OH in a single- or double-blind randomised controlled trial (RCT) in humans over 18 years of age.. Data were extracted from suitable full-text articles by three investigators independently.. The 13 trials met the criteria for systematic review amongst which was considerable variation in the size of postural blood pressure (BP) change with active treatment. However, there was evidence that commonly used drugs midodrine or fludrocortisone therapy did increase standing or head-up-tilt (HUT) systolic blood pressure in certain patient groups.. The evidence that pharmacological therapy is of benefit for the treatment of OH is limited by the lack of good quality clinical trial evidence. Further well-designed RCTs of pharmacological treatment of OH investigating the impact on postural symptoms as well as actual BP changes are needed.

Topics: Adult; Aged; Cardiovascular Agents; Double-Blind Method; Female; Fludrocortisone; Humans; Hypotension, Orthostatic; Male; Middle Aged; Midodrine; Octreotide; Pyridostigmine Bromide; Randomized Controlled Trials as Topic; Single-Blind Method; Treatment Outcome; Young Adult

orthostatic hypotension (OH) affects up to 30% of adults over 65 and frequently contributes to falls and syncopal episodes. Current guidelines suggest a wide range of treatments, but systematic reviews of the evidence base for such recommendations are lacking.. we performed a systematic review to assess the evidence for all non-pharmacological and pharmacological interventions for OH. Our search included the following databases: MEDLINE; EMBASE; CINAHL; and the Cochrane library. We searched grey literature and references from included studies and other reviews. We included randomised, placebo-controlled trials, which measured postural drop as an outcome. Study quality was assessed using pre-specified measures of bias.. overall, 36 trials (21 interventions) were included. We identified a heterogeneous population and a wide variety of study methods, precluding meta-analysis. Most trials were of poor quality with high risk of bias. Changes in postural drop and symptoms were frequently inconsistent. Compression bandages, indomethacin, oxilofrine, potassium chloride and yohimbine improved the postural drop. Several vasoactive drugs-including midodrine and pyridostigmine-improved the standing blood pressure, but overall worsened the postural drop.. many commonly recommended interventions for OH have a limited evidence base supporting their use. High quality, randomised, controlled trials are needed to underpin clinical practice for this condition.

Topics: Adult; Aged; Aged, 80 and over; Blood Pressure; Cardiovascular Agents; Compression Bandages; Female; Humans; Hypotension, Orthostatic; Male; Middle Aged; Treatment Outcome; Vasoconstrictor Agents

Several cardiovascular drugs may induce or worsen orthostatic hypotension especially in patients treated for hypertension, coronary artery disease and heart failure. Orthostatic hypotension is more frequent in polymedicated elderly patients with co-morbidities (prevalence 23%). In hypertensive elderly patients, the combination of three antihypertensive agents including a beta-blocker induces more frequently orthostatic hypotension. Supplementation in water and especially salt is generally not recommended in case of hypertension and heart failure. Education of patient to preventive counter-pressure maneuvers and muscle training of the lower limbs must be part of treatment. Midodrine causes supine hypertension in almost 25% of patients precluding to take this medication at the end of the afternoon. In severe heart failure, midodrine seems to be helpful to optimize drug treatment in patients suffering from hypotension.

Topics: Age Factors; Aged; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Contraindications; Drinking Water; Drug Therapy, Combination; Heart Failure; Humans; Hypotension, Orthostatic; Iatrogenic Disease; Midodrine; Patient Education as Topic; Polypharmacy; Vasoconstrictor Agents

Topics: Cardiovascular Agents; Chronic Disease; Diabetic Neuropathies; Diagnosis, Differential; Humans; Hypotension, Orthostatic

Orthostatic hypotension (OH) is a fall in blood pressure after assuming an upright position. Whereas asymptomatic patients usually need no treatment, the majority of symptomatic patients can be cured by avoidance of trigger mechanisms and the use of physical countermaneuvers and non-pharmacological interventions. Several pharmacological therapies are available and generally fludrocortisone and midodrine are the drugs of first choice. Recently, highly individualized therapy with ambulatory norepinephrine therapy was able to mobilize otherwise immobile patients.

Topics: Cardiovascular Agents; Humans; Hypotension, Orthostatic; Posture

The disorders of autonomic control associated with orthostatic intolerance are a diverse group of infirmities that can result in syncope and near syncope (as well as a host of other complaints). A basic understanding of these disorders is essential to both diagnosis and proper treatment. These infirmities are not new, what has changed is our ability to recognize them. It has been said that "the world undergoes change in the human consciousness. As this consciousness changes, so does the world." On going studies will continue to help better define the broad spectrum of these disorders, and to elaborate better diagnostic and treatment modalities.

Topics: Autonomic Agents; Autonomic Nervous System Diseases; Cardiovascular Agents; Humans; Hypotension, Orthostatic; Patient Education as Topic; Posture; Syncope

Topics: Autonomic Agents; Cardiovascular Agents; Combined Modality Therapy; Humans; Hypotension, Orthostatic

Topics: Antihypertensive Agents; Cardiovascular Agents; Humans; Hypotension, Orthostatic; Syncope

Topics: Anesthesia, General; Anesthesia, Inhalation; Anesthesia, Spinal; Anesthetics; Cardiovascular Agents; Heart Failure; Hemodynamics; Humans; Hypotension, Orthostatic; Intraoperative Complications; Postoperative Complications; Shock, Cardiogenic

Topics: Cardiovascular Agents; Hemodynamics; Humans; Hypotension, Orthostatic; Muscle, Smooth, Vascular; Risk Factors

Although postprandial and orthostatic hypotension are commonly observed in nursing home residents, their reproducibility, relationship to each other, and association with chronic use of cardiovascular medications are poorly understood.. We examined blood pressure (BP) and heart rate (HR) before and after postural change, and before and after a 419-kcal meal in 22 nursing home residents (mean age 89 +/- 5 (SD) years), each on two occasions, to determine reproducibility changes. These studies were repeated in 17 residents, with and without previous administration of cardiovascular medications, in random order.. Hebrew Rehabilitation Center for the Aged, an academic long-term care facility.. Systolic BP declined an average (+/- SE) of 16 +/- 4 mm Hg and 12 +/- 4 mm Hg during the first and second meal studies, respectively. Mean intra-class correlation of postprandial systolic BP values during the two studies was 0.88 (95% CI 0.85-0.97). Systolic BP increased significantly during the first posture test to a maximum of 8 +/- 6 mm Hg at 6 minutes. There was no significant difference over time in postural systolic BP between the two tests. Repeated postural studies showed a mean intra-class correlation of 0.72 (95% CI 0.62-0.92) for changes in systolic BP. Cardiovascular medications had no additional effect on postprandial or orthostatic BP and HR changes. During the first studies, 10 subjects had postprandial hypotension, and three subjects had orthostatic hypotension, but only two of 22 subjects had both.. Patterns of systolic BP response to meals or postural change are reproducible. BP responses to meals and postural change seem to be unaffected by potentially hypotensive medications in chronic users. Postprandial hypotension is distinct from orthostatic hypotension, occurring more commonly than orthostatic hypotension and infrequently together in the same patients.

Topics: Aged; Aged, 80 and over; Analysis of Variance; Blood Pressure; Boston; Cardiovascular Agents; Eating; Female; Homes for the Aged; Humans; Hypertension; Hypotension, Orthostatic; Male; Nursing Homes; Posture; Reproducibility of Results; Time Factors

To evaluate the therapeutic value of various antihypotensive agents we investigated amezinium (AMZ; CAS 30578-37-1), dihydroergotamine (DHE; CAS 511-12-6), midodrine (MDD; CAS 42794-76-3), and oxilofrine (OXF; CAS 365-26-4) in volunteers during passive orthostasis in a randomized double-blind study against placebo (PCB). Blood pressure, heart rate, and circulating catecholamines were determined before and after i.v. injections of the mentioned agents before and during 10 min of passive orthostasis. Echocardiographic and venous plethysmographic data were obtained during resting before and after the administration of the drugs. Resting heart rate decreased after injection of PCB, AMZ, DHE, and MDD. During tilting no significant changes in heart rate could be observed. Blood pressure remained unchanged at rest and during orthostasis after all agents injected. DHE and MDD lowered circulating noradrenaline. Echocardiographic parameters were changed after administration of AMZ (increase in stroke volume index (SVI) and ejection fraction (EF)), MDD (increase in enddiastolic volume index and SVI), and OXF (increase in SVI, EF, and cardiac index). The venous capacity of the lower left leg was only significantly decreased after injection of DHE, indicating an increased venous tone of the leg veins. The observed changes in sympathetic and cardiovascular parameters are in agreement with their sympathomimetic actions and allow a differential therapeutic classification: DHE and MDD are suitable agents for patients with sympathotonic orthostatic reaction; if asympathotonic orthostatic reaction occurs MDD, AMX and OXF should be recommended to those patients.

Topics: Adult; Blood Pressure; Cardiovascular Agents; Catecholamines; Double-Blind Method; Electrocardiography; Female; Heart Rate; Hemodynamics; Humans; Hypotension, Orthostatic; Male; Stroke Volume

Study of cardiovascular drugs usage, among elderly subjects admitted to the emergency department for syncopal falls in Rhône-Alpes region. Polypharmacy and cardiovascular medication usage are risk factors for falls in the elderly. This study included subjects aged 75 and over, admitted in the emergency department for falls, based on evaluation data of professional practices carried out in the Nord Alpine region by the French Network of North-Alps Emergency Departments (Réseau Nord Alpin des Urgences, RENAU). The patients included were divided into 4 groups: "syncope", "accidental falls", "repeated falls" and "other types of fall". From the emergency room admission prescriptions, we studied the consumption of cardiovascular drugs in number and quality in the "syncope" group compared to other types of falls. The main objective in this study was to highlight higher cardiovascular drug usage among the elderly patients admitted to the emergency department for syncopal falls, in comparison with other types of falls. We included 1,476 patients among whom 262 patients came for "syncopal falls". We found superior usage of cardiovascular medication among syncopal falls compared to other type of falls (p < 0,01). However, there is no statistically significant association between inappropriate cardiovascular drug prescriptions, and the type of falls. The "standardized" fall assessment whose orthostatic hypotension investigation, is not always exhaustive in the emergency room. Orthostatic hypotension diagnostic is insufficiently sought in the emergency room. This study highlights a significantly higher usage of diuretic medication within the syncope group, in comparison to the other groups, and especially loop diuretic. Antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, calcium inhibitor) are also recurrent within the syncope group compared to the others. A careful supervising of these prescriptions among elderly patients seems required. These data prompt to revise prescriptions during fall related hospitalizations, and then with the primary-care physician, or with the cardiologist.

Topics: Accidental Falls; Aged; Cardiovascular Agents; Emergency Service, Hospital; Hospitalization; Humans; Hypotension, Orthostatic; Syncope

Orthostatic hypotension (OH) is a disabling condition accompanying several diseases. It has increased morbidity and mortality, and limited chances of treatment. We report a case of a patient with stable ischemic heart disease and severe OH unresponsive to usual care. A baseline 75° head-up tilt test (HUT) was positive for symptomatic OH, i.e. pre-syncope with a systolic arterial pressure drop of 35 mmHg. On top of optimal treatment, ivabradine was started. Symptoms improved within 24 hours. At a repeated HUT, the patient could tolerate the up-right position up to 25 minutes. He was able to undergo an individualized training program with further amelioration of quality of life. Thereafter, titration of ACE inhibitors became possible. Lasting benefits were present at a 6-month follow-up. To our knowledge, this is the first reported case of successful use of ivabradine to integrate cardiac rehabilitation for management of a highly disabling OH.. L’ipotensione ortostatica è una condizione disabilitante che si accompagna a diverse patologie, è di sempre più frequente riscontro, aumenta la mortalità e ha limitate opzioni terapeutiche. Il caso clinico riportato è quello di un paziente con cardiopatia ischemica stabile e grave ipotensione ortostatica, nonostante l’adozione di tutte le terapie standard. A un primo tilt test a 75° eseguito in condizioni basali, il paziente ha sviluppato ipotensione ortostatica grave (riduzione della pressione sistolica di 35 mmHg) con pre-sincope. Alla terapia in atto è stata aggiunta ivabradina 5 mg due volte al giorno. Nelle 24 ore successive si è assistito a un netto miglioramento soggettivo. È stato quindi ripetuto il tilt test di durata 25 minuti, che il paziente ha ben tollerato. In corso di proseguimento della terapia con ivabradina il paziente è stato in grado di completare un programma di allenamento fisico individualizzato che ha ulteriormente migliorato la sua qualità di vita ed ha anche permesso di titolare correttamente la terapia con ACE inibitori. A una visita di controllo dopo 6 mesi, il paziente riferiva assenza di episodi sincopali o pre-sincopali. In conclusione, questo è il primo caso di utilizzo efficace dell’ivabradina, in associazione con un programma di riabilitazione cardiologica, per il trattamento dell’ipotensione ortostatica grave in un paziente con cardiopatia ischemica.

Topics: Aged; Angiotensin-Converting Enzyme Inhibitors; Cardiac Rehabilitation; Cardiovascular Agents; Humans; Hypotension, Orthostatic; Ivabradine; Male; Myocardial Ischemia; Quality of Life; Standing Position; Tilt-Table Test; Time Factors

. To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients.. . This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used.. . The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r. . No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

Topics: Acute Disease; Aged; Aged, 80 and over; Belgium; Blood Pressure; Cardiovascular Agents; Dose-Response Relationship, Drug; Female; Hospitalization; Humans; Hypotension, Orthostatic; Linear Models; Male; Multivariate Analysis; Patient Positioning; Psychotropic Drugs

Topics: Cardiovascular Agents; Geriatrics; Heart Failure, Systolic; Humans; Hypotension, Orthostatic

Topics: Cardiovascular Agents; Geriatrics; Heart Failure, Systolic; Humans; Hypotension, Orthostatic

Topics: Cardiovascular Agents; Female; Humans; Hypotension, Orthostatic; Male

Topics: Capillary Leak Syndrome; Cardiovascular Agents; Combined Modality Therapy; Diagnosis, Differential; Emergencies; Fatal Outcome; Female; Fluid Therapy; Humans; Hypotension, Orthostatic; Middle Aged; Monoclonal Gammopathy of Undetermined Significance; Multiple Myeloma; Pasteurella Infections; Pasteurella multocida; POEMS Syndrome; Respiration, Artificial; Shock, Septic; Skin Diseases, Bacterial; Ventricular Dysfunction, Left

To determine whether outcomes of tilt-table tests improved after withdrawal of fall-risk-increasing drugs (FRIDs).. Prospective cohort study.. Geriatric outpatient clinic.. Two hundred eleven new, consecutive outpatients, recruited from April 2003 until December 2004.. Tilt-table testing was performed on all participants at baseline. Subsequently, FRIDs were withdrawn in all fallers in whom it was safely possible. At a mean follow-up of 6.7 months, tilt-table testing was repeated in 137 participants. Tilt-table testing addressed carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), and vasovagal collapse (VVC). Odds ratios (ORs) of tilt-table-test normalization according to withdrawal (discontinuation or dose reduction) of FRIDs were calculated using multivariate logistic regression analysis.. After adjustment for confounders, the reduction of abnormal test outcomes (ORs) according to overall FRID withdrawal was 0.34 (95% confidence interval (CI)=0.06-1.86) for CSH, 0.35 (95% CI=0.13-0.99) for OH, and 0.27 (95% CI=0.02-3.31) for VVC. For the subgroup of cardiovascular FRIDs, the adjusted OR was 0.13 (95% CI=0.03-0.59) for CSH, 0.44 (95% CI=0.18-1.0) for OH, and 0.21 (95% CI=0.03-1.51) for VVC.. OH improved significantly after withdrawal of FRIDs. Subgroup analysis of cardiovascular FRID withdrawal showed a significant reduction in OH and CSH. These results imply that FRID withdrawal can cause substantial improvement in cardiovascular homeostasis. Derangement of cardiovascular homeostasis may be an important mechanism by which FRID use results in falls.

Topics: Accidental Falls; Aged; Cardiovascular Agents; Carotid Sinus; Female; Humans; Hypotension; Hypotension, Orthostatic; Male; Mobility Limitation; Psychotropic Drugs; Risk Factors; Syncope; Syncope, Vasovagal; Tilt-Table Test

Topics: Adolescent; Autonomic Nervous System Diseases; Cardiovascular Agents; Child; Child, Preschool; Diagnosis, Differential; Diet; Humans; Hypotension, Orthostatic; Infant; Physical Examination; Reflex; Respiration Disorders; Syncope, Vasovagal; Tachycardia

Topics: Cardiovascular Agents; Humans; Hypotension, Orthostatic; Pyridostigmine Bromide

Topics: Cardiovascular Agents; Dihydroergotoxine; Ergot Alkaloids; Hypotension; Hypotension, Orthostatic

Twenty-one patients have been treated for hypertension with oral doses of hexamethonium salts, Apresoline(R) or combinations of both. Three of 18 patients had good or excellent response to hexamethonium alone. Five of 13 treated with hexamethonium salts plus Apresoline had good or excellent results, as did 8 of 14 treated with Apresoline alone. The addition of very small doses of hexamethonium chloride to optimal doses of Apresoline improved the effect of the Apresoline in three patients. Postural hypotension and constipation due to hexamethonium were the most serious undesirable effects.

Topics: Cardiovascular Agents; Constipation; Hexamethonium; Hydralazine; Hypertension; Hypotension, Orthostatic; Muscle Relaxants, Central; Salts; Sympatholytics