Approaches to antihypertensive therapy in patients predisposed to symptomatic hypotension and syncope

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Abstract

The management of a hypertensive patient with a history of syncope is aimed at maintaining a balance between cardiovascular and hypotensive (syncope) risks. The article presents an analysis of the literature data regarding the relationship between these clinical problems, and also draws practical conclusions that allow to ensure the optimal reduction in blood pressure in the interests of preventing cardiovascular diseases without the threat of drug-related hypotension (fainting). Variants of syncope in patients with arterial hypertension are summarized, depending on the association with antihypertensive therapy. There presented an expert opinion on the recommended target level of systolic blood pressure (120 mm Hg) in hypertensive patients under 70 years of age with a low syncope but high cardiovascular risk, as well as the target level of systolic blood pressure (140 mm Hg) in patients with high syncope and low cardiovascular risk or in elderly and / or frail individuals with hypertension. There noted the admissibility of bringing the systolic blood pressure to the target value up to 160 mm Hg in persons with severe frailty or disability. Examples of normal and pathological (hypotensive) patterns of hemodynamic response in persons with hypertension to long-term passive orthostasis obtained during the tilt test and influencing the decision-making on the activity of antihypertensive therapy are given. The importance of an interdisciplinary team approach with the participation of experts in regulatory circulatory disorders and geriatrics, which can significantly improve the quality of management of patients with a combination of hypertension and syncope, is stated.

About the authors

Anton V. Barsukov

Military Medical Academy named after S.M. Kirov of the Ministry of Defense of the Russian Federation

Author for correspondence.
Email: avbarsukov@yandex.ru

doctor of medical sciences, professor

Russian Federation, Saint Petersburg

Dmitry V. Glukhovskoy

Military Medical Academy named after S.M. Kirov of the Ministry of Defense of the Russian Federation

Email: gluhovskoi@inbox.ru

candidate of medical sciences

Russian Federation, Saint Petersburg

Kristina E. Emelyanova

Military Medical Academy named after S.M. Kirov of the Ministry of Defense of the Russian Federation

Email: air-kristina@mail.ru

therapist

Russian Federation, Saint Petersburg

Irina A. Vasilyeva

Military Medical Academy named after S.M. Kirov of the Ministry of Defense of the Russian Federation

Email: vasilyeva-ia@yandex.ru

candidate of medical sciences

Russian Federation, Saint Petersburg

References

  1. Forouzanfar MH, Liu P, Roth GA, et al. Global burden of hypertension and systolic blood pressure of at least110 to 115mm Hg, 1990–2015. Journal of the American Medical Association. 2017;(317):165–182.
  2. Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet. 2014;(383):1899–1911.
  3. Zhou B, Kontis V, Bentham J, et al. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population based measurement studies with 19.1 million participants. Lancet. 2017;(389):37–55.
  4. Mamontov OV. The autonomic regulation of circulation and adverse events in hypertensive patients during follow-up study. Cardiology Research and Practice. 2019. Article ID 8391924:6.
  5. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension. 1. Overview, meta-analyses, and meta-regression analyses of randomized trials. Journal of Hypertension. 2014;(32):2285–2295.
  6. Wright JT, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine. 2015;(373):2103–2116.
  7. Sink KM, Evans GW, Shorr RI, et al. Syncope, hypotension, and falls in the treatment of hypertension: results from the randomized clinical systolic blood pressure intervention trial. Journal of the American Geriatrics Society. 2018;(66):679–686.
  8. Bress AP, Kramer H, Khatib R, et al. Potential Deaths Averted and Serious Adverse Events Incurred From Adoption of the SPRINT (Systolic Blood Pressure Intervention Trial) Intensive Blood Pressure Regimen in the United States: Projections From NHANES (National Health and Nutrition Examination Survey). Circulation. 2017;(135):1617–1628.
  9. Fanciulli A, Jordan J, Biaggioni I, et al. Consensus statement on the definition of neurogenic supine hypertension in cardiovascular autonomic failure by the American Autonomic Society (AAS) and the European Federation of Autonomic Societies (EFAS): endorsed by the European Academy of Neurology (EAN) and the European Society of Hypertension (ESH). Clinical Autonomic Research. 2018;(28):355–362.
  10. Nume AK, Carlson N, Gerds T, et al. Risk of postdischarge fall-related injuries among adult patients with syncope: a nationwide cohort study. PLoS One. 2018;13:e0206936.
  11. Sexton DJ, Canney M, Moore P, et al. Injurious falls and syncope in older community-dwelling adults meeting inclusion criteria for SPRINT. JAMA Internal Medicine. 2017;(177):1385–1387.
  12. Morrissey Y, Bedford M, Irving J, et al. Older people remain on blood pressure agents despite being hypotensive resulting in increased mortality and hospital admission. Age Ageing. 2016;(45):783–788.
  13. Canavan M, Smyth A, Bosch J, et al. Does lowering blood pressure with antihypertensive therapy preserve independence in activities of daily living? A systematic review. American Journal of Hypertension. 2015;(28):273–279.
  14. Rivasi G, Brignole M, Rafanelli M, et al. Blood pressure management in hypertensive patients with syncope: how to balance hypotensive and cardiovascular risk. Journal of Hypertension. 2020;(38):2356-2362.
  15. Brignole M, Moya A, de Lange FJ, et al. ESC Guidelines for the diagnosis and management of syncope. European Heart Journal. 2018;(39):1883–1948.
  16. Sutton R, Brignole M. Twenty-eight years of research permit reinterpretationof tilt-testing: hypotensive susceptibility rather than diagnosis. European Heart Journal. 2014;(35):2211–2212.
  17. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. Journal of Hypertension. 2018;(36):1953–2041.
  18. Bohm M, Schumacher H, Teo KK, et al. Achieved diastolic blood pressure and pulse pressure at target systolic blood pressure (120-140 mmHg) and cardiovascular outcomes in high risk patients: results from ONTARGET and TRANSCEND trials. European Heart Journal. 2018;(39):3105–3114.
  19. Sim JJ, Zhou H, Bhandari S, et al. Low systolic blood pressure from treatment and association with serious falls/syncope. American Journal of Preventive Medicine. 2018;(55):488–496.
  20. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. Journal of the American Medical Association. 2016;(315):2673–2682.
  21. Oates DJ, Berlowitz DR, Glickman M.E. et al. Blood pressure and survival in the oldest old. Journal of the American Geriatrics Society. 2007;(55):383–388.
  22. van Hateren KJ, Landman GW, Kleefstra N, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. American Journal of Medicine. 2010;(123):719–726.
  23. Ogliari G, Westendorp RG, Muller M, et al. Blood pressure and 10-year mortality risk in the Milan Geriatrics 75þ Cohort Study: role of functional and cognitive status. Age Ageing. 2015;(44): 932–937.
  24. Zanchetti A, Grassi G, Mancia G, et al. When should antihypertensive drugtreatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal. Journal of Hypertension. 2009;(27):923–934.
  25. Benetos A, Labat C, Rossignol P, et al. Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents: the PARTAGE study. JAMA Intern Medicine. 2015;(175):989–995.
  26. van Bemmel T, Gussekloo J, Westendorp RG, et al. In a population-based prospective study, no association between high blood pressure and mortality after age 85 years. Journal of Hypertension. 2006;(24):287–292.
  27. Russo G, Liguori I, Aran L, et al. Impact of SPRINT results on hypertension guidelines: implications for ‘frail’ elderly patients. Journal of Human Hypertension. 2018;(32):633–638.
  28. Wu C, Smit E, Peralta CA, et al. Functional status modifies the association of blood pressure with death in elders: health and retirement study. Journal of the American Geriatrics Society. 2017;(65):1482–1489.
  29. Liang Y, Molander L, Lövheim H, et al. Effects of biological age on the associations of blood pressure with cardiovascular and noncardiovascular mortality in old age: a population-based study. International Journal of Cardiology. 2016;(220):508–513.
  30. Charlesworth CJ, Peralta CA, Odden MC, et al. Functional status and antihypertensive therapy in older adults: a new perspective on old data. American Journal Hypertension. 2016;(29):690–695.
  31. Ceccofiglio A, Mussi C, Rafanelli M, et al. Increasing prevalence of orthostatic hypotension as a cause of syncope with advancing age and multimorbidity. Journal of the American Medical Directors Association. 2019;(20):586–588.
  32. Barsukov AV, Glukhovskoy DV. Algorithms for medical decisions in syncopal conditions. St. Petersburg: V.A.Korovin; 2020. (In Russ.).
  33. Mamontov OV. Autonomous circulatory dysfunction at different stages of the cardiovascular continuum. Prognostic and clinical-pathogenetic significance. [dissertation]: Saint Petersburg; 2020. (In Russ.).
  34. Solari D, Maggi R, Oddone D, et al. Stop vasodepressor drugs in reflex syncope: a randomized controlled trial. Heart. 2017;(103):449–455.
  35. Nikiforov VS. Structural and functional changes of the myocardium and heart valves in patients with coronary pathology of older age groups. Medical Council. 2018;(5):122–126. (In Russ.).
  36. Kryukov EV, Potekhin NP, Fursov AN, Zakharova EG. Comparative characteristics of patients suffering from arterial hypertension and stenosing atherosclerosis, depending on the localization of the pathological process in the vascular bed. Bulletin of the Russian Military Medical Academy. 2020; 1(69):36-38. (In Russ.).
  37. Rafanelli M, Ruffolo E, Chisciotti VM, et al. Clinical aspects and diagnostic relevance of neuroautonomic evaluation in patients with unexplained falls. Aging Clinical and Experimental Research. 2014; (26):33–37.
  38. Kimm H, Mok Y, Lee SJ, et al. The J-curve between diastolic blood pressure and risk of all-cause and cardiovascular death. Korean Circulation Journal. 2018;(48):36–47.
  39. Fedorowski A, Hamrefors V, Sutton R, et al. Do we need to evaluate diastolic blood pressure in patients with suspected orthostatic hypotension? Clinical Autonomic Research. 2017;(27):167–173.
  40. Conroy RM, Pyorala K, Fitzgerald AP, et al. SCORE project group. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. European Heart Journal. 2003;(24):987–1003.
  41. Finucane C, Savva GM, Boyle G, et al. Age-related normative changes in phasic orthostatic blood pressure in a large population study: findings from The Irish Longitudinal Study on Ageing (TILDA). Circulation. 2014;(130):1780–1789.
  42. Rockwood K, Mitnitski A, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal. 2005;(173):489–495.

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2. Fig. 1. A fragment of a modified long-term passive orthostatic sample in a patient M., 72 years old, suffering from arterial hypertension, and the presence of a history of myocardial infarction. The heart rate (upper curve) and blood pressure (lower curve) curves obtained in the continuous recording mode indicate a close to physiological hemodynamic response to orthostasis and sufficient baroreflector sensitivity

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3. Fig. 2. A fragment of a modified long-term passive orthostatic sample in a patient of G., 68 years old, suffering from arterial hypertension, and the absence of a history of significant cardiovascular pathology. The blood pressure curve (lower) indicates classical orthostatic hypotension, which at the 10th minute of the sample ended in a vasodepressor syncopal state. Pathological response to orthostasis has been associated with low baroreflector sensitivity

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Copyright (c) 2021 Barsukov A.V., Glukhovskoy D.V., Emelyanova K.E., Vasilyeva I.A.

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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