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Systolic and diastolic component of orthostatic hypotension and cardiovascular events in hypertensive patients: the Captopril Prevention Project

Fedorowski, Artura,b; Wahlstrand, Björnc; Hedner, Thomasc; Melander, Ollea

doi: 10.1097/HJH.0b013e328365cd59
ORIGINAL PAPERS: Orthostatic hypotension

Objective: Impact of SBP vs. DBP decrement during orthostasis on cardiovascular events in hypertension is not clear.

Methods: We assessed prospective association of orthostatic hypotension with mortality and major cardiovascular events [myocardial infarction (MI) and stroke] among 8788 treated hypertensive patients (52.2% men; mean age 52 years, mean BP 161/99 mmHg) without history of MI or stroke at baseline. Orthostatic hypotension was defined according to combined international consensus criteria, and as either systolic (decrease ≥20 mmHg) or diastolic orthostatic hypotension (decrease ≥10 mmHg). Final Cox regression model was adjusted for age, sex, supine SBP and DBP, diabetes, smoking, and total cholesterol.

Results: A total of 1060 (12.1%) study participants fulfilled combined orthostatic hypotension criteria, of these 886 (10.1%) met systolic and 290 (3.3%) diastolic criterion. In the crude analysis, combined orthostatic hypotension criteria were predictive of the composite endpoint, major cardiovascular event, total mortality, and stroke but not MI. After full adjustment, combined orthostatic hypotension criteria and systolic orthostatic hypotension were independently associated with stroke only (hazard ratio: 1.48, 1.07–2.05, P = 0.019, and 1.53, 1.08–2.15, P = 0.015, respectively), whereas the composite endpoint tended in the same direction (hazard ratio: 1.21, 0.98–1.51, P = 0.075, and 1.24, 0.99–1.55, P = 0.066, respectively). In contrast, diastolic orthostatic hypotension was associated with increased risk of MI (hazard ratio: 2.04, 1.20–3.46, P = 0.008).

Conclusion: Orthostatic hypotension has a dual role in cardiovascular events among hypertensive patients: SBP fall indicates higher risk of stroke, whereas DBP fall confers higher risk of MI.

aDepartment of Clinical Sciences, Lund University, Clinical Research Center

bArrhythmia Department, Skåne University Hospital, Malmö

cInstitute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Correspondence to Artur Fedorowski, MD, PhD, Arrhythmia Department, Inga Marie Nilssons gata 46, Skåne University Hospital, 205 02 Malmö, Sweden. E-mail:

Abbreviations: BP, blood pressure; CAPPP, The Captopril Prevention Project; CCB, calcium channel blocker; CVD, cardiovascular disease; MI, myocardial infarction

Received 20 March, 2013

Revised 31 July, 2013

Accepted 13 August, 2013

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins