Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults

Stephen P. Juraschek, Natalie Daya, Andreea M. Rawlings, Lawrence Appel, Edgar R Miller, B. Gwen Windham, Michael E. Griswold, Gerardo Heiss, Elizabeth Selvin

Research output: Contribution to journalArticle

Abstract

IMPORTANCE Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. It is not known whether measurements performed immediately after standing predict adverse events as strongly as measurements performed closer to 3 minutes. OBJECTIVE To compare early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS Thiswas a prospective cohort study of middle-aged (range, 44-66 years) participants in the Atherosclerosis Risk in Communities Study (1987-1989). EXPOSURES Orthostatic hypotension, defined as a drop in blood pressure (BP) (systolic BP 20mmHg or diastolic BP10mmHg) from the supine to standing position, was measured up to 5 times at 25-second intervals. MAIN OUTCOMES AND MEASURES We determined the association of each of the 5 OH measurements with history of dizziness on standing (logistic regression) and risk of fall, fracture, syncope, motor vehicle crashes, and all-cause mortality (Cox regression) over a median of 23 years of follow-up (through December 31, 2013). RESULTS In 11 429 participants (mean age, 54 years; 6220 [54%] were women; 2934 [26%] were black) with at least 4 OH measurements after standing, after adjustment OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds; range, 21-62 seconds) was the only measurement associated with higher odds of dizziness (odds ratio [OR], 1.49; 95%CI, 1.18-1.89). Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1000 person-years. Measurement 2 was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1000 person-years. Furthermore, after adjustment measurement 1 was significantly associated with risk of fall (hazard ratio [HR], 1.22; 95%CI, 1.03-1.44), fracture (HR, 1.16; 95%CI, 1.01-1.34), syncope (HR, 1.40; 95%CI, 1.20-1.63), and mortality (HR, 1.36; 95%CI, 1.23-1.51). Measurement 2 (mean [SD], 53 [7.5] seconds; range, 43-83 seconds) was associated with all long-term outcomes, including motor vehicle crashes (HR, 1.43; 95%CI, 1.04-1.96). Measurements obtained after 1 minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes. CONCLUSIONS AND RELEVANCE In contrast with prevailing recommendations, OH measurements performed within 1 minute of standing were the most strongly related to dizziness and individual adverse outcomes, suggesting that OH be assessed within 1 minute of standing.

Original languageEnglish (US)
Pages (from-to)1316-1323
Number of pages8
JournalJAMA Internal Medicine
Volume177
Issue number9
DOIs
StatePublished - Sep 1 2017

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Orthostatic Hypotension
Dizziness
Syncope
Motor Vehicles
Blood Pressure
Posture
Mortality
Atherosclerosis
Cohort Studies
Logistic Models
Odds Ratio
Prospective Studies
Guidelines

ASJC Scopus subject areas

  • Internal Medicine

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Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults. / Juraschek, Stephen P.; Daya, Natalie; Rawlings, Andreea M.; Appel, Lawrence; Miller, Edgar R; Windham, B. Gwen; Griswold, Michael E.; Heiss, Gerardo; Selvin, Elizabeth.

In: JAMA Internal Medicine, Vol. 177, No. 9, 01.09.2017, p. 1316-1323.

Research output: Contribution to journalArticle

Juraschek, Stephen P. ; Daya, Natalie ; Rawlings, Andreea M. ; Appel, Lawrence ; Miller, Edgar R ; Windham, B. Gwen ; Griswold, Michael E. ; Heiss, Gerardo ; Selvin, Elizabeth. / Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults. In: JAMA Internal Medicine. 2017 ; Vol. 177, No. 9. pp. 1316-1323.
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abstract = "IMPORTANCE Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. It is not known whether measurements performed immediately after standing predict adverse events as strongly as measurements performed closer to 3 minutes. OBJECTIVE To compare early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS Thiswas a prospective cohort study of middle-aged (range, 44-66 years) participants in the Atherosclerosis Risk in Communities Study (1987-1989). EXPOSURES Orthostatic hypotension, defined as a drop in blood pressure (BP) (systolic BP 20mmHg or diastolic BP10mmHg) from the supine to standing position, was measured up to 5 times at 25-second intervals. MAIN OUTCOMES AND MEASURES We determined the association of each of the 5 OH measurements with history of dizziness on standing (logistic regression) and risk of fall, fracture, syncope, motor vehicle crashes, and all-cause mortality (Cox regression) over a median of 23 years of follow-up (through December 31, 2013). RESULTS In 11 429 participants (mean age, 54 years; 6220 [54{\%}] were women; 2934 [26{\%}] were black) with at least 4 OH measurements after standing, after adjustment OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds; range, 21-62 seconds) was the only measurement associated with higher odds of dizziness (odds ratio [OR], 1.49; 95{\%}CI, 1.18-1.89). Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1000 person-years. Measurement 2 was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1000 person-years. Furthermore, after adjustment measurement 1 was significantly associated with risk of fall (hazard ratio [HR], 1.22; 95{\%}CI, 1.03-1.44), fracture (HR, 1.16; 95{\%}CI, 1.01-1.34), syncope (HR, 1.40; 95{\%}CI, 1.20-1.63), and mortality (HR, 1.36; 95{\%}CI, 1.23-1.51). Measurement 2 (mean [SD], 53 [7.5] seconds; range, 43-83 seconds) was associated with all long-term outcomes, including motor vehicle crashes (HR, 1.43; 95{\%}CI, 1.04-1.96). Measurements obtained after 1 minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes. CONCLUSIONS AND RELEVANCE In contrast with prevailing recommendations, OH measurements performed within 1 minute of standing were the most strongly related to dizziness and individual adverse outcomes, suggesting that OH be assessed within 1 minute of standing.",
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T1 - Association of history of dizziness and long-term adverse outcomes with early vs later orthostatic hypotension assessment times in middle-aged adults

AU - Juraschek, Stephen P.

AU - Daya, Natalie

AU - Rawlings, Andreea M.

AU - Appel, Lawrence

AU - Miller, Edgar R

AU - Windham, B. Gwen

AU - Griswold, Michael E.

AU - Heiss, Gerardo

AU - Selvin, Elizabeth

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N2 - IMPORTANCE Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. It is not known whether measurements performed immediately after standing predict adverse events as strongly as measurements performed closer to 3 minutes. OBJECTIVE To compare early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS Thiswas a prospective cohort study of middle-aged (range, 44-66 years) participants in the Atherosclerosis Risk in Communities Study (1987-1989). EXPOSURES Orthostatic hypotension, defined as a drop in blood pressure (BP) (systolic BP 20mmHg or diastolic BP10mmHg) from the supine to standing position, was measured up to 5 times at 25-second intervals. MAIN OUTCOMES AND MEASURES We determined the association of each of the 5 OH measurements with history of dizziness on standing (logistic regression) and risk of fall, fracture, syncope, motor vehicle crashes, and all-cause mortality (Cox regression) over a median of 23 years of follow-up (through December 31, 2013). RESULTS In 11 429 participants (mean age, 54 years; 6220 [54%] were women; 2934 [26%] were black) with at least 4 OH measurements after standing, after adjustment OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds; range, 21-62 seconds) was the only measurement associated with higher odds of dizziness (odds ratio [OR], 1.49; 95%CI, 1.18-1.89). Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1000 person-years. Measurement 2 was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1000 person-years. Furthermore, after adjustment measurement 1 was significantly associated with risk of fall (hazard ratio [HR], 1.22; 95%CI, 1.03-1.44), fracture (HR, 1.16; 95%CI, 1.01-1.34), syncope (HR, 1.40; 95%CI, 1.20-1.63), and mortality (HR, 1.36; 95%CI, 1.23-1.51). Measurement 2 (mean [SD], 53 [7.5] seconds; range, 43-83 seconds) was associated with all long-term outcomes, including motor vehicle crashes (HR, 1.43; 95%CI, 1.04-1.96). Measurements obtained after 1 minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes. CONCLUSIONS AND RELEVANCE In contrast with prevailing recommendations, OH measurements performed within 1 minute of standing were the most strongly related to dizziness and individual adverse outcomes, suggesting that OH be assessed within 1 minute of standing.

AB - IMPORTANCE Guidelines recommend assessing orthostatic hypotension (OH) 3 minutes after rising from supine to standing positions. It is not known whether measurements performed immediately after standing predict adverse events as strongly as measurements performed closer to 3 minutes. OBJECTIVE To compare early vs later OH measurements and their association with history of dizziness and longitudinal adverse outcomes. DESIGN, SETTING, AND PARTICIPANTS Thiswas a prospective cohort study of middle-aged (range, 44-66 years) participants in the Atherosclerosis Risk in Communities Study (1987-1989). EXPOSURES Orthostatic hypotension, defined as a drop in blood pressure (BP) (systolic BP 20mmHg or diastolic BP10mmHg) from the supine to standing position, was measured up to 5 times at 25-second intervals. MAIN OUTCOMES AND MEASURES We determined the association of each of the 5 OH measurements with history of dizziness on standing (logistic regression) and risk of fall, fracture, syncope, motor vehicle crashes, and all-cause mortality (Cox regression) over a median of 23 years of follow-up (through December 31, 2013). RESULTS In 11 429 participants (mean age, 54 years; 6220 [54%] were women; 2934 [26%] were black) with at least 4 OH measurements after standing, after adjustment OH assessed at measurement 1 (mean [SD], 28 [5.4] seconds; range, 21-62 seconds) was the only measurement associated with higher odds of dizziness (odds ratio [OR], 1.49; 95%CI, 1.18-1.89). Measurement 1 was associated with the highest rates of fracture, syncope, and death at 18.9, 17.0, and 31.4 per 1000 person-years. Measurement 2 was associated with the highest rate of falls and motor vehicle crashes at 13.2 and 2.5 per 1000 person-years. Furthermore, after adjustment measurement 1 was significantly associated with risk of fall (hazard ratio [HR], 1.22; 95%CI, 1.03-1.44), fracture (HR, 1.16; 95%CI, 1.01-1.34), syncope (HR, 1.40; 95%CI, 1.20-1.63), and mortality (HR, 1.36; 95%CI, 1.23-1.51). Measurement 2 (mean [SD], 53 [7.5] seconds; range, 43-83 seconds) was associated with all long-term outcomes, including motor vehicle crashes (HR, 1.43; 95%CI, 1.04-1.96). Measurements obtained after 1 minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes. CONCLUSIONS AND RELEVANCE In contrast with prevailing recommendations, OH measurements performed within 1 minute of standing were the most strongly related to dizziness and individual adverse outcomes, suggesting that OH be assessed within 1 minute of standing.

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