geoffrey modest medical blogs

one pretty common phenomenon in my very elderly  is that their blood pressure seems to decrease as they age, leading to my down-titrating their antihypertensives and occasionally stopping them. prior studies regarding this phenomenon have produced mixed results, some suggesting this is just a near-terminal event. But, a recent large long term study pretty conclusively validated this observation as being “normal” (see Delgado J. JAMA Intern Med. 2018;178(1):93-99). Details: -- 46,634 participants >60yo from 674 primary care practices in the UK who had died from 2010 to 2014 and had been followed at least 20 years prior to death. All had been tracked i n  the population-based Clinical Practice Research Datalink, which linked primary care and  hospitalization electronic medical records -- 51.7% female; mean age at death was 82.4 years ​ (women were 45.5% of those dying age 60-69, but 64.6% of those at least ...

One of the more common problems with managing patients with heart failure who have reduced ejection fraction ( HFrEF ) is that, though there are great medications available to reduce morbidity and mortality, they all reduce blood pressure, and many patients cannot tolerate the addition of all of these medications at their target doses.  In this light, a post-hoc analysis of the SOLVD trial was helpful, finding that below-target enalapril had similar clinical efficacy as the full target dose (see  doi:10.1002/ejhf.937).   Details: --2458 patients with  HFrEF  (EF<35%) were randomized to enalapril 5-10mg/d vs placebo; then 1 month later, were blindly up-titrated to target enalapril or placebo dose of 20mg/d. Followed average of 2.7  yrs , with 4.6  yrs  for all-cause mortality (primary endpoint in SOLVD) --mean age 60, 20% women, NYHA class II in 54%/NYHA class III in 30%, 20% current smoker, 72% ischemic heart failure, 65...

Yet another article came out indicating that initial orthostatic hypotension, measured immediately after standing, had a strong association with dizziness as well as long-term adverse outcomes measurement (s ee  doi:10.1001/jamainternmed.2017.2937) .  Details: -- cohort study of 11,429 participants in the Atherosclerosis Risk in Communities Study (1987-1989) -- mean age 54, 54% women, 26% black/74% white, blood pressure 120/73, heart rate 67, eGFR 102, BMI 27, diabetes 11%, hypertension 33% and 28% taking meds with in the past 2 weeks, 5% coronary heart disease, 2% stroke, heart failure 4%, dizzy on standing 10%, diuretics 16%, alcohol never used 24%/former 18%/current 58%, smoking never 41%/former 33%/current 26% -- orthostatic hypotension (OH) was defined as a drop in systolic blood pressure of at least 20 mmHg, or diastolic at least 10 mmHg when going from supine to standing position, after initially lying down for 20 minutes. Blood pressure was measured...

Circulation had a recent article on the prevalence of orthostatic hypotension in Ireland (see  hypotension orthostatic with age circ 2014​ ​ in the dropbox, or  doi:10.1161/CIRCULATIONAHA.114.009831 ​). This study involved 4475 community-based people over age 50 from a nationally representative cohort study (TILDA -- The Irish Longitudinal Study on Ageing -- that's how they spell "aging"...), recording blood pressure and pulse response to standing. they looked at initial orthostatic hypotension, defined as a BP decrease of >40 mmHg systolic or >20 mmHg diastolic within 15 seconds of standing and associated with symptoms of cerebral hypoperfusion, and typical orthostatic hypotension, defines as a BP decrease of >20 mmHg in systolic or >10 mmHg in systolic after 3 minutes of standing. Findings: --Cohort baseline characteristics: average age 62.8, 51.8% female, 19% smokers, 7.5% diabetes, 34.5% hypertensive, total of <11% with...