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Classification of blood pressure categories (AHA)
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Among young and middle-aged adults with high blood pressure, a substantial increase in blood pressure upon standing may identify those at higher risk of serious cardiovascular events, such as heart attack and stroke, according to new research published today in the American Heart Association magazine. Peer-reviewed journal Hypertension.
“This finding may justify starting blood pressure-lowering treatment, including medications, earlier in patients with an exaggerated blood pressure response to standing,” said Paolo Palatini, MD, senior author of the study and professor of internal medicine at the University of Padua in Padua. , Italy.
Nearly half of Americans and about 40% of people worldwide have high blood pressure, considered the leading cause of preventable death in the world. According to 2022 heart disease statistics from the American Heart Association, people with hypertension in midlife are five times more likely to have impaired cognitive function and twice as likely to experience reduced executive function, dementia, and Alzheimer’s disease. .
Typically, systolic blood pressure drops slightly when standing.
In this study, researchers evaluated whether the opposite response, a significant increase in systolic blood pressure upon standing, is a risk factor for heart attack and other serious cardiovascular events.
Researchers evaluated 1,207 people who were part of the HARVEST study, a prospective study that began in Italy in 1990 and included adults ages 18 to 45 with untreated stage 1 hypertension. Stage 1 hypertension was defined as systolic blood pressure of 140-159 mm Hg and/or diastolic BP of 90-100 mm Hg.
None had taken blood pressure-lowering medications before the study, and all were initially estimated to be at low risk for major cardiovascular events based on their lifestyle and medical history (no diabetes, kidney failure, or other cardiovascular diseases). At enrollment, participants had an average age of 33 years , 72% were male, and all were white.
At enrollment, six blood pressure measurements were taken for each participant in various physical positions, including lying down and after standing. The 120 participants with the highest (top 10%) increase in blood pressure upon standing averaged an increase of 11.4 mm Hg; all increases in this group were greater than 6.5 mm Hg. The remaining participants averaged a 3.8 mm Hg drop in systolic blood pressure upon standing.
Researchers compared heart disease risk factors, laboratory measures, and the occurrence of major cardiovascular events (heart attack, heart-related chest pain, stroke, aortic artery aneurysm, blocked peripheral arteries) and chronic kidney disease. between the participants of the two groups.
In some analyses, the development of atrial fibrillation, an arrhythmia that is a major risk factor for stroke, was also observed. Results were adjusted for age, sex, parental history of heart disease, and several lifestyle factors and measures taken during study enrollment.
During an average follow-up of 17 years, 105 major cardiovascular events occurred. The most common were myocardial infarction, heart-related chest pain, and stroke.
People in the group with the top 10% increase in blood pressure:
- They were almost twice as likely as other participants to experience a major cardiovascular event.
- They generally did not have a higher risk profile for cardiovascular events during their initial evaluation (outside of exaggerated blood pressure response to standing).
- They were more likely to be smokers (32.1% vs. 19.9% in the non-increasing group), but physical activity levels were comparable, and they were not more likely to be overweight or obese, nor more likely having a family history of cardiovascular events.
- They had more favorable cholesterol levels (lower total cholesterol and higher high-density lipoprotein cholesterol).
- They had lower systolic blood pressure when lying down than the other group (140.5 mm Hg vs. 146.0 mm Hg, respectively), but blood pressure measurements were higher when taken over 24 hours.
After adjusting for average blood pressure taken over 24 hours, an exaggerated blood pressure response to standing remained an independent predictor of adverse cardiac events or stroke.
“The results of the study confirmed our initial hypothesis: a pronounced increase in blood pressure when changing from lying to standing could have prognostic significance in young people with high blood pressure. “We were quite surprised that even a relatively small increase in standing blood pressure (6-7 mm Hg) was predictive of major long-term cardiac events,” Palatini said.
In a subset of 630 participants who had stress hormones measured in 24-hour urine samples, the epinephrine/creatinine ratio was higher in people with increased standing blood pressure compared to those with Standing blood pressure did not increase (118.4 nmol/mol vs. 77.0 nmol/mol, respectively).
“ Epinephrine levels are an estimate of the overall effect of stressful stimuli over the 24 hours. “This suggests that those with higher blood pressure when standing may have a greater sympathetic response [the fight-or-flight response] to stressors,” Palatini said. “In general, this causes an increase in average blood pressure.”
"The findings suggest that blood pressure should be measured while standing to tailor treatment for patients with high blood pressure and potentially a more aggressive approach to lifestyle changes and lowering therapy may be considered." blood pressure for people with high blood pressure. hyperreactor] blood pressure response to standing,” he said.
The results of this study may not be generalizable to people from other racial/ethnic groups, as all study participants reported White race/ethnicity. Additionally, there were not enough women in the sample to analyze whether the association between increased standing blood pressure and adverse cardiac events was different between men and women. Due to the relatively small number of major adverse cardiac events in this young sample, the results need to be confirmed in larger studies.
Co-authors are Lucio Mos, MD; Francesca Saladini, MD; and Marcello Rattazzi, MD Author disclosures are listed in the manuscript.
The study was funded by the Association “18 Maggio 1370” in Italy.
