Orthostatic Hypotension-Related Hospitalizations in the United States

doi:10.1016/j.amjmed.2007.05.009

The American Journal of Medicine

Volume 120, Issue 11, November 2007, Pages 975-980

https://doi.org/10.1016/j.amjmed.2007.05.009 Get rights and content

Abstract

Background

Orthostatic hypotension has been commonly described in elderly persons and is associated with an increased risk of falls, syncope, and cerebrovascular events. Nevertheless, the precise burden of this condition in the US is currently unknown.

Methods

We analyzed discharge data from the Nationwide Inpatient Sample to identify orthostatic hypotension-related hospitalizations and associated comorbidities after excluding acute causes of this condition. National hospitalization rates were estimated using US census population estimates, and the medical conditions most frequently associated with orthostatic hypotension were assessed.

Results

In 2004, there were an estimated 80,095 orthostatic hypotension-related hospitalizations, yielding an overall rate of 36 (95% confidence interval, 34 to 38) hospitalizations per 100,000 US adults. Orthostatic hypotension was the primary diagnosis in 35% of these hospitalizations. The number of orthostatic hypotension-related hospitalizations increased steadily with age, and patients aged 75 years or older had the highest annual hospitalization rate, 233 per 100,000 (95% confidence interval, 217 to 249). The median length of hospital stay was 3 days (IQR 2-6) and the overall in-hospital mortality was 0.9%. Caucasian males were most likely to be hospitalized with orthostatic hypotension. Syncope was the most common comorbid condition reported among orthostatic hypotension patients.

Conclusions

Orthostatic hypotension is a relatively common condition among hospitalized US elderly patients. In light of the progressive aging of the US population, the contribution of orthostatic hypotension to morbidity and mortality is likely to increase, and deserves further scrutiny.

Section snippets

The Nationwide Inpatient Sample

The Nationwide Inpatient Sample (NIS), sponsored by the Agency for Healthcare Research and Quality, annually collects discharge-level information about clinical characteristics and resource utilization from a sample that approximates 20% of admissions to community hospitals in the US. Discharge diagnoses are recorded in up to 15 diagnosis fields using the International Classification of Diseases 9^th revision, Clinical Modification (ICD9-CM). The first listed diagnosis (primary) is considered

Results

During 2004, there were an estimated 38,661,786 total hospitalizations in the US. Among these, a total of 164,401 (0.43%) orthostatic hypotension-related hospitalizations were identified. Within this group, 84,306 (51%) orthostatic hypotension-related hospitalizations met our criteria for acute or transitory conditions and were excluded. Excluded patients encompassed 777 children aged 0-17 years. The 2 major reasons for exclusion were: hypovolemia/dehydration (68,540 hospitalizations) and

Discussion

To the best of our knowledge, this is the first study that examined the epidemiology of orthostatic hypotension among hospitalized patients in the US. We found that orthostatic hypotension-related hospitalization rates increased exponentially with age, and they were consistently higher in elderly males compared with females.

Previous assessments of the burden of orthostatic hypotension focused on geriatric wards, nursing homes, and elderly community dwellers, with estimated prevalence of 68%,¹⁸

Acknowledgments

Dr. Shibao is recipient of the International Fellowship in Clinical Pharmacology supported by the Merck Foundation. Dr. Raj is supported by grant K23-RR020783 from the National Institutes of Health.

References (31)

W.L. Ooi et al.
The association between orthostatic hypotension and recurrent falls in nursing home residents
Am J Med
(2000)
I. Biaggioni et al.
Hypertension in orthostatic hypotension and autonomic dysfunction
Cardiol Clin
(2002)
K.M. Rose et al.
Orthostatic hypotension and the incidence of coronary heart disease: the Atherosclerosis Risk in Communities study
Am J Hypertens
(2000)
T. Shoji et al.
Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients
Kidney Int
(2004)
F.P. Sarasin et al.
Prevalence of orthostatic hypotension among patients presenting with syncope in the ED
Am J Emerg Med
(2002)
T. Matsukawa et al.
Baroreflex control of muscle sympathetic nerve activity is attenuated in the elderly
J Auton Nerv Syst
(1998)
D. Atkins et al.
Syncope and orthostatic hypotension
Am J Med
(1991)
S.M. Parikh et al.
The nature of the autonomic dysfunction in multiple system atrophy
J Neurol Sci
(2002)
D.S. Goldstein
Dysautonomia in Parkinson’s disease: neurocardiological abnormalities
Lancet Neurol
(2003)
L.M. de Lau et al.
Epidemiology of Parkinson’s disease
Lancet Neurol
(2006)

Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy

J Neurol Sci

(1996)

P.V. Jonsson et al.

Hypotensive responses to common daily activities in institutionalized elderlyA potential risk for recurrent falls

Arch Intern Med

(1990)

C. Shibao et al.

Management of hypertension in the setting of autonomic failure: a pathophysiological approach

Hypertension

(2005)

C.J. Mathias

Orthostatic hypotension: causes, mechanisms, and influencing factors

Neurology

(1995)

P.A. Low

Diabetic autonomic neuropathy

Semin Neurol

(1996)

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Of our sample of 224 residents, we observed a prevalence of 20.5 % for neurogenic orthostatic hypotension and 32.1 % for orthostatic hypotension. Neither of them had diagnosis of neurogenic orthostatic hypotension documented. Parkinson's disease was associated with neurogenic orthostatic hypotension (OR-4.3; p = 0.002). Hypertension was prevalent in 69.6 % of residents with orthostatic vitals suggestive of neurogenic orthostatic hypotension.
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Orthostatic hypotension (OH) is a significant medical condition, with a prevalence that varies depending on the studied population, from 6% in healthy elderly, to up to 54% of nursing home residents. About half of hospitalized elderly are affected by OH, and the rate of OH-related hospitalizations increases exponentially with age. Patients aged 75 years and older have the highest annual hospitalization rate of 233 per 100,000. OH patients endure substantial disabilities and impaired quality of life. OH is associated with a 2.6-fold increase in the risk of falls, and is an independent risk factor for all-cause mortality as well as cardiovascular morbidity and mortality. The typical OH patient is frail and elderly, with multiple comorbidities, polypharmacy, and a high health care burden. Hypertension is the most common comorbidity among patients with OH, affecting approximately 70% of OH patients. Conversely, OH is present in about 10% of patients referred to hypertension specialists. The strong association between OH and hypertension complicates the treatment of OH because of the opposing effect of drugs used for the treatment of these conditions. There is a paucity of randomized controlled clinical trials on which to base treatment recommendations. Thus, understanding of the pathophysiology of OH is important to establish an appropriate treatment regimen.
Predicting hypotensive events in the ICU settings using patient's short-term physiological history and contextual data
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Hypotension frequently occurs in intensive care units (ICUs) and is correlated to worsening patient outcomes. In this study, we propose a machine learning (ML) algorithm that predicts hypotensive events in ICUs by extracting the information from patients' contextual data and physiological signals. The algorithm uses patients’ history including demographics, pre-ICU medication, and pre-existing comorbidities, and only five minutes of prior physiological history to predict hypotension up to 30 min in advance. We show that adding demographic information to the physiological data does not improve the algorithm's predictive performance of 84% sensitivity, 89% positive predictive value (PPV), and 98% specificity. Furthermore, the results show that including features extracted from patients’ pre-ICU medications and comorbidities lowers the learning algorithm’ prediction performance and leads to 2% degradation in its F1-score. The feature importance analysis showed that the ratio of MAP to HR (MAP2HR) and the average of RR intervals on the ECG (RRI), both extracted from physiological signals, have the highest weights in the prediction of hypotension.
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Baroreflexes regulate sympathetic and parasympathetic outflow to maintain BP. Classic orthostatic hypotension occurs when there is generalized autonomic failure (OH_gaf), often involving both the afferent and efferent limbs of the baroreflex. Afferent baroreflex failure occurs due to a selective lesion of the afferent limb. Initial OH (OH_ini) can occur in normal subjects, can be symptomatic and even cause syncope. With partial adrenergic failure, BP recovery after OH_ini is delayed, and patients with delayed BP recovery have increased morbidity and mortality. OH can be delayed in onset (OH_del) and occur after 3 min of standing. OH_del is also associated with increased morbidity and mortality depending on the underlying etiology. OH due to partial adrenergic failure can present with sympathetic overactivity, described as hyperadrenergic OH.
The management of OH begins with defining the phenotype, amount of adrenergic impairment, followed by patient education. Increasing severity requires progression from nonpharmacologic to pharmacologic measures.
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Citation Excerpt :
Orthostatic hypotension is a common cause of hospitalizations; approximately 80,000 hospitalizations are related to orthostatic hypotension every year in the United States. The overall rate is approximately 36 per 100,000 US adults and increases exponentially with age.1 In patients older than the age of 75 years, the annual hospitalization rate related to orthostatic hypotension increases to 233 per 100,000 patients.2
Orthostatic hypotension is a frequent cause of falls and syncope, impairing quality of life. It is an independent risk factor of mortality and a common cause of hospitalizations, which exponentially increases in the geriatric population. We present a management plan based on a systematic literature review and understanding of the underlying pathophysiology and relevant clinical pharmacology. Initial treatment measures include removing offending medications and avoiding large meals. Clinical assessment of the patients’ residual sympathetic tone can aid in the selection of initial therapy between norepinephrine “enhancers” or “replacers.” Role of splanchnic venous pooling is overlooked, and applying abdominal binders to improve venous return may be effective. The treatment goal is not normalizing upright blood pressure but increasing it above the cerebral autoregulation threshold required to improve symptoms. Hypertension is the most common associated comorbidity, and confining patients to bed while using pressor agents only increases supine blood pressure, leading to worsening pressure diuresis and orthostatic hypotension. Avoiding bedrest deconditioning and using pressors as part of an orthostatic rehab program are crucial in reducing hospital stay.

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Clinical Research StudyOrthostatic Hypotension-Related Hospitalizations in the United States

Abstract

Background

Methods

Results

Conclusions

Section snippets

The Nationwide Inpatient Sample

Results

Discussion

Acknowledgments

Am J Med

Cardiol Clin

Am J Hypertens

Kidney Int

Am J Emerg Med

J Auton Nerv Syst

Am J Med

J Neurol Sci

Lancet Neurol

Lancet Neurol

Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy

J Neurol Sci

Hypotensive responses to common daily activities in institutionalized elderlyA potential risk for recurrent falls

Arch Intern Med

Management of hypertension in the setting of autonomic failure: a pathophysiological approach

Hypertension

Orthostatic hypotension: causes, mechanisms, and influencing factors

Neurology

Diabetic autonomic neuropathy

Semin Neurol

Clinical Research Study
Orthostatic Hypotension-Related Hospitalizations in the United States