Orthostatic hypertension

Other names| Postural hypertension
Specialty| Neurology, cardiology

Orthostatic hypertension is a medical condition consisting of an abrupt increase in blood pressure (BP) when a person stands up.[1] Orthostatic hypertension is diagnosed by a rise in systolic BP of 20 mmHg or more when standing, in combination with a standing systolic BP of at least 140 mmHg. When systolic BP remains under 140 mmHg, this is called exaggerated blood pressure response to standing (ERTS).[2][3]

High diastolic blood pressure measured while standing in a person who stood up shortly after waking up.

When it affects an individual's ability to remain upright, orthostatic hypertension is considered as a form of orthostatic intolerance. The body's inability to regulate blood pressure can be a type of dysautonomia.

Baroreflex and autonomic pathways normally ensure that blood pressure is maintained despite various stimuli, including postural change. The precise mechanism of orthostatic hypertension remains unclear, but alpha-adrenergic activity may be the predominant mechanism of orthostatic hypertension in elderly hypertensive patients.[4] Other mechanisms are proposed for other groups with this disorder.[1]

A prevalence of 1.1% was found in a large population study.[5] The risk of orthostatic hypertension has been found to increase with age, with it being found in 16.3% of older hypertensive patients.[6]

## Contents

* 1 Causes
* 2 Signs and symptoms
* 2.1 Connections to other disorders
* 3 Risks
* 4 Diagnosis
* 5 Treatments
* 6 Epidemiology
* 7 See also
* 8 References
* 9 Further reading

## Causes

The causes of this condition are not well understood, but research suggests that it may be caused by a combination of hemodynamic and neurohumoral factors.[7]

Some studies have found that orthostatic hypertension may be caused by increased vascular resistance, possibly due to excess plasma shifts or increased blood viscosity. Other studies have suggested that it may be caused by a reduction in cardiac preload, or an increase in venous pooling.[7]

Research suggests that it may be caused by an overshoot in neurohumoral adjustments to standing. Some studies have found that patients with orthostatic hypertension have normal levels of venous plasma norepinephrine, but that these levels increase excessively upon standing.[8][9] However, other studies have not found elevated levels of norepinephrine in patients with orthostatic hypertension compared to hypertensive controls.[10] These findings suggest that the causes of orthostatic hypertension may be multifactorial and more research is needed to fully understand the underlying mechanisms.[7]

## Signs and symptoms

* Mild or moderate orthostatic hypertension may present without any symptoms other than the orthostatic hypertension BP findings. More severe orthostatic hypertension may present with the typical symptoms of hypertension.
* Orthostatic venous pooling is common with orthostatic diastolic hypertension. This occurs in the legs while standing.[11][12]

### Connections to other disorders

* Essential hypertension
* Other kinds of dysautonomia may coexist, e.g., postural orthostatic tachycardia syndrome (POTS) is common with this condition, orthostatic hypotension with the BP going both high and low at times due to autonomic dysfunction
* Type 2 diabetes[1]
* Vascular adrenergic hypersensitivity: Orthostatic hypertension can be secondary to this[13]
* Anorexia nervosa: Many people suffering from anorexia experience orthostatic hypertension[14]
* Hypovolemia can cause orthostatic hypertension
* Renal arterial stenosis (narrowing of the kidney arteries) with nephroptosis (kidney drops on standing) have been known to cause orthostatic hypertension.[15]
* Aortitis (inflammation of the aorta) with nephroptosis: "This orthostatic hypertension largely may be due to an activation of the renin system caused by nephroptosis and partly due to a reduced baroreflex sensitivity caused by aortitis"[16]
* Pheochromocytoma[17]

## Risks

* Blood pressure variability is associated with progression of target organ damage and cardiovascular risk.[18]
* Orthostatic hypertension was positively associated with peripheral arterial disease.[6]
* Increased occurrence of silent cerebrovascular ischemia[1][4]
* Systolic orthostatic hypertension increases stroke risk.[19]
* Orthostatic hypertension was associated with increased all-cause mortality.[20]

## Diagnosis

The blood pressure is first measured after a five-minute wait lying down. Upon standing, blood pressure is measured at one, three and five minutes. The blood pressure at 3 and 5 minutes is averaged. For those unable to stand up for this long, the condition can instead be assessed by a tilt table test.[2]

## Treatments

There is no evidence that those with an exaggerated response to standing and normal blood pressure require therapy. However, these individuals may be more likely to develop hypertension later in life.[21]

In patients with hypertensive blood pressure only when standing, blood pressure monitoring over 24 hours may help to assess average blood pressure and test for altered blood pressure patterns over the day. Extreme nighttime blood pressure dipping and masked morning hypertension may be observed in people with orthostatic hypertension. Finally, in individuals with orthostatic hypertension who are also hypertensive while sitting and lying down, antihypertensive medications should be prescribed. However, some antihypertensive medications, particularly diuretics, may exacerbate sympathetic activation with standing and thereby worsen orthostatic hypertension.[21]

Treatment of coexisting conditions, e.g., hypovolemia, also is used. Some specialists in severe cases give saline intravenously for hypovolemia, which, if it is the cause, brings the orthostatic hypertension down to a safe level. Pressure garments over the pelvis and the lower extremities may be used as part of treatment, due to the blood pooling issue occurring in many with the disorder.[11]

## Epidemiology

The prevalence of this condition has been studied in various populations. In a study conducted in 1922, it was found that 4.2% of 2000 apparently healthy aviators aged 18 to 42 years had an increase in diastolic blood pressure from below 90 mmHg while in the supine position to above 90 mmHg in the upright posture.[22]

Study which defined orthostatic hypertension as a sustained increase in systolic blood pressure of at least 20 mmHg and/or diastolic blood pressure of at least 10 mmHg within 3 minutes of standing, have reported a prevalence rate of orthostatic hypertension ranging from 5% to 30%. This range is generally consistent with the prevalence of orthostatic hypotension.[7]

## See also

* Orthostatic hypotension
* Orthostatic intolerance

## References

1. ↑ 1.0 1.1 1.2 1.3 "Orthostatic hypertension: when pressor reflexes overcompensate". Nature Clinical Practice. Nephrology 2 (8): 424–431. August 2006. doi:10.1038/ncpneph0228. PMID 16932477.
2. ↑ 2.0 2.1 Jordan, Jens; Biaggioni, Italo; Kotsis, Vasilios; Nilsson, Peter; Grassi, Guido; Fedorowski, Artur; Kario, Kazuomi (February 2023). "Consensus statement on the definition of orthostatic hypertension endorsed by the American Autonomic Society and the Japanese Society of Hypertension". Hypertension Research 46 (2): 291–294. doi:10.1038/s41440-022-01074-0. ISSN 1348-4214. PMID 36418529.
3. ↑ Palatini, Paolo; Kollias, Anastasios; Saladini, Francesca; Asmar, Roland; Bilo, Grzegorz; Kyriakoulis, Konstantinos G.; Parati, Gianfranco; Stergiou, George S. et al. (2024). "Assessment and management of exaggerated blood pressure response to standing and orthostatic hypertension: consensus statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability". Journal of Hypertension 42 (6): 939–947. doi:10.1097/HJH.0000000000003704. ISSN 1473-5598. PMID 38647124.
4. ↑ 4.0 4.1 "U-curve relationship between orthostatic blood pressure change and silent cerebrovascular disease in elderly hypertensives: orthostatic hypertension as a new cardiovascular risk factor". Journal of the American College of Cardiology 40 (1): 133–141. July 2002. doi:10.1016/S0735-1097(02)01923-X. PMID 12103267.
5. ↑ "Population-based study on the prevalence and correlates of orthostatic hypotension/hypertension and orthostatic dizziness". Hypertension Research 31 (5): 897–904. May 2008. doi:10.1291/hypres.31.897. PMID 18712045.
6. ↑ 6.0 6.1 "[Association of orthostatic hypertension and hypotension with target organ damage in middle and old-aged hypertensive patients]". Zhonghua Yi Xue Za Zhi 91 (4): 220–224. January 2011. PMID 21418863.
7. ↑ 7.0 7.1 7.2 7.3 Jordan, Jens; Ricci, Fabrizio; Hoffmann, Fabian; Hamrefors, Viktor; Fedorowski, Artur (May 2020). "Orthostatic Hypertension: Critical Appraisal of an Overlooked Condition". Hypertension 75 (5): 1151–1158. doi:10.1161/HYPERTENSIONAHA.120.14340. ISSN 0194-911X. PMID 32223382.
8. ↑ Streeten, D H; Auchincloss, J H; Anderson, G H; Richardson, R L; Thomas, F D; Miller, J W (March 1985). "Orthostatic hypertension. Pathogenetic studies.". Hypertension 7 (2): 196–203. doi:10.1161/01.HYP.7.2.196. ISSN 0194-911X. PMID 3980066.
9. ↑ Kario, Kazuomi; Eguchi, Kazuo; Hoshide, Satoshi; Hoshide, Yoko; Umeda, Yuji; Mitsuhashi, Takeshi; Shimada, Kazuyuki (2002-07-03). "U-curve relationship between orthostatic blood pressure change and silent cerebrovascular disease in elderly hypertensives: orthostatic hypertension as a new cardiovascular risk factor". Journal of the American College of Cardiology 40 (1): 133–141. doi:10.1016/s0735-1097(02)01923-x. ISSN 0735-1097. PMID 12103267.
10. ↑ Vriz, O.; Soon, G.; Lu, H.; Weder, A. B.; Canali, C.; Palatini, P. (May 1997). "Does orthostatic testing have any role in the evaluation of the young subject with mild hypertension?: an insight from the HARVEST study". American Journal of Hypertension 10 (5 Pt 1): 546–551. doi:10.1016/s0895-7061(96)00489-x. ISSN 0895-7061. PMID 9160766.
11. ↑ 11.0 11.1 "Orthostatic hypertension. Pathogenetic studies". Hypertension 7 (2): 196–203. 1985. doi:10.1161/01.hyp.7.2.196. PMID 3980066.
12. ↑ "Abnormal orthostatic changes in blood pressure and heart rate in subjects with intact sympathetic nervous function: evidence for excessive venous pooling". The Journal of Laboratory and Clinical Medicine 111 (3): 326–335. March 1988. PMID 3343547.
13. ↑ "Orthostatic hypertension due to vascular adrenergic hypersensitivity". Hypertension 28 (1): 42–46. July 1996. doi:10.1161/01.hyp.28.1.42. PMID 8675262.
14. ↑ "Autonomic Nervous System Function in Anorexia Nervosa: A Systematic Review". Frontiers in Neuroscience 15. 2021. doi:10.3389/fnins.2021.682208. PMID 34262430.
15. ↑ "Orthostatic hypertension due to coexistence of renal fibromuscular dysplasia and nephroptosis". Japanese Circulation Journal 52 (12): 1408–1414. December 1988. doi:10.1253/jcj.52.1408. PMID 2977192.
16. ↑ "Orthostatic hypertension with nephroptosis and aortitis disease". Archives of Internal Medicine 144 (1): 152–154. January 1984. doi:10.1001/archinte.144.1.152. PMID 6362595.
17. ↑ "Induction of acute renal porphyria in Japanese quail by Aroclor 1254". Biochemical Pharmacology 35 (20): 3637–3639. October 1986. doi:10.1016/0006-2952(86)90637-4. PMID 3094542.
18. ↑ "Orthostatic hypertension: a measure of blood pressure variation for predicting cardiovascular risk". Circulation Journal 73 (6): 1002–1007. June 2009. doi:10.1253/circj.cj-09-0286. PMID 19430163.
19. ↑ "Postural changes in blood pressure and incidence of ischemic stroke subtypes: the ARIC study". Hypertension 57 (2): 167–173. February 2011. doi:10.1161/HYPERTENSIONAHA.110.161844. PMID 21199999.
20. ↑ Kostis, W.J., Sargsyan, D., Mekkaoui, C. et al. Association of orthostatic hypertension with mortality in the Systolic Hypertension in the Elderly Program. J Hum Hypertens 33, 735–740 (2019). doi: 10.1038/s41371-019-0180-4
21. ↑ 21.0 21.1 Jordan, Jens; Biaggioni, Italo; Grassi, Guido; Fedorowski, Artur; Kario, Kazuomi (2023-12-31). "When Blood Pressure Increases with Standing: Consensus Definition for Diagnosing Orthostatic Hypertension". Blood Pressure 32 (1). doi:10.1080/08037051.2022.2161871. ISSN 0803-7051. PMID 36597193. 50px Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License
22. ↑ Schneider, Edward C.; Truesdell, Dorothy (1922-08-01). "A statistical study of the pulse rate and the arterial blood pressures in recumbency, standing, and after a standard exercise". American Journal of Physiology. Legacy Content 61 (3): 429–474. doi:10.1152/ajplegacy.1922.61.3.429. ISSN 0002-9513. https://journals.physiology.org/doi/abs/10.1152/ajplegacy.1922.61.3.429.

## Further reading

* "Consensus statement on the definition of orthostatic hypertension endorsed by the American Autonomic Society and the Japanese Society of Hypertension.". Clin Auton Res 33 (1): 69–73. September 2022. doi:10.1007/s10286-022-00897-8. PMID 36173501.
* "Orthostatic Hypertension: Critical Appraisal of an Overlooked Condition". Hypertension 75 (5): 1151–1158. May 2020. doi:10.1161/HYPERTENSIONAHA.120.14340. PMID 32223382.
* "Orthostatic hypertension: From pathophysiology to clinical applications and therapeutic considerations". Journal of Clinical Hypertension (Greenwich, Conn.) 21 (3): 426–433. March 2019. doi:10.1111/jch.13491. PMID 30724451.
* "Orthostatic Hypertension in Children: An Update". Frontiers in Pediatrics 8. 2020. doi:10.3389/fped.2020.00425. PMID 32850540.

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