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Blood pressure rise on standing could lead to higher risk of cardiovascular events

A substantial rise in blood pressure upon standing may identify young and middle-aged adults who are at higher risk of serious cardiovascular events, such as heart attack and stroke, according to new research.

Photo credit: American Heart Association

A substantial rise in blood pressure upon standing may identify young and middle-aged adults who are at higher risk of serious cardiovascular events, such as heart attack and stroke, according to new research.

The study, published in the American Heart Association’s peer-reviewed journal Hypertension, found that patients with top 10% rise in blood pressure were almost twice as likely as other participants to experience a major cardiovascular event. In addition, they did not generally have a higher risk profile for cardiovascular events during their initial evaluation.

Professor Paolo Palatini, lead author of the study and a professor of internal medicine at the University of Padova in Padova, Italy, said: “This finding may warrant starting blood-pressure-lowering treatment including medicines earlier in patients with exaggerated blood pressure response to standing.”

Typically, systolic blood pressure falls slightly upon standing up. In this study, researchers assessed whether the opposite response, a significant rise in systolic blood pressure upon standing, is a risk factor for heart attack and other serious cardiovascular events.

They evaluated 1,207 people who were part of the HARVEST study, a prospective study that began in Italy in 1990 and included adults ages 18-45 years old with untreated stage 1 hypertension. Stage 1 hypertension was defined as systolic blood pressure of 140-159mmHg and/or diastolic BP 90-100mmHg. None had taken blood pressure-lowering medication prior to the study, and all were initially estimated at low risk for major cardiovascular events based on their lifestyle and medical history (no diabetes, renal impairment or other cardiovascular diseases). At enrolment, participants were an average age of 33 years, 72% were men, and all were white.

At enrolment, six blood pressure measurements for each participant were taken in various physical positions, including when lying down and after standing up. The 120 participants with the highest rise (top 10%) in blood pressure upon standing averaged an 11.4mmHg increase; all increases in this group were greater than 6.5mmHg. The remaining participants averaged a 3.8mmHg fall in systolic blood pressure upon standing.

A small increase in standing blood pressure was predictive of major cardiac events

The researchers compared heart disease risk factors, laboratory measures and the occurrence of major cardiovascular events (heart attack, heart-related chest pain, stroke, aneurysm of the aortic artery, clogged peripheral arteries) and chronic kidney disease among participants in the two groups.

In some analyses, the development of atrial fibrillation, an arrhythmia that is a major risk factor for stroke, was also noted. Results were adjusted for age, gender, parental history of heart disease, and several lifestyle factors and measurements taken during study enrolment.

During an average 17-year follow-up 105 major cardiovascular events occurred. The most common were heart attack, heart-related chest pain and stroke.

People in the group with top 10% rise in blood pressure were also more likely to be smokers (32.1% vs. 19.9% in the non-rising group), yet physical activity levels were comparable, and they were not more likely to be overweight or obese, and no more likely to have a family history of cardiovascular events.

They also had more favourable cholesterol levels (lower total cholesterol and higher high-density-lipoprotein cholesterol) and had lower systolic blood pressure when lying down than the other group (140.5mmHg vs. 146.0mmHg, respectively), yet blood pressure measures 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 heart events or stroke.

Dr Palatini added: “The results of the study confirmed our initial hypothesis – a pronounced increase in blood pressure from lying to standing could be prognosticlly important in young people with high blood pressure. We were rather surprised that even a relatively small increase in standing blood pressure (6-7mmHg) was predictive of major cardiac events in the long run.”

Results from this study may not be generalisable to people from other ethnic or racial groups since all study participants reported white race/ethnicity. In addition, there were not enough women in the sample to analyse whether the association between rising standing blood pressure and adverse heart events was different among men and women. Because of the relatively small number of major adverse cardiac events in this sample of young people, the results need to be confirmed in larger studies.

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