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Orthostatic hypertension—a new haemodynamic cardiovascular risk factor

Nature Reviews Nephrology volume 9, pages 726–738 (2013)Cite this article

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Abstract

Orthostatic hypertension—a condition characterized by a hyperactive pressor response to orthostatic stress—is an emerging risk factor for cardiovascular disease and is associated with hypertensive target-organ damage (resulting in silent cerebrovascular disease, left ventricular hypertrophy, carotid atherosclerosis and/or chronic kidney disease) and cardiovascular events (such as coronary artery disease and lacunar stroke). The condition is also considered to be a form of prehypertension as it precedes hypertension in young, normotensive adults. Orthostatic blood pressure changes can be assessed using orthostatic stress tests, including clinic active standing tests, home blood pressure monitoring and the head-up tilting test. Devices for home and for ambulatory blood pressure monitoring that are equipped with position sensors and do not induce a white-coat effect have increased the sensitivity and specificity of diagnosis of out-of-clinic orthostatic hypertension. Potential major mechanisms of orthostatic hypertension are sympathetic hyperactivity (as a result of hypersensitivity of the cardiopulmonary and arterial baroreceptor reflex) and α-adrenergic hyperactivation. Orthostatic hypertension is also associated with morning blood pressure surge and extreme nocturnal blood pressure dipping, both of which increase the pulsatile haemodynamic stress of central arterial pressure and blood flow in patients with systemic haemodynamic atherothrombotic syndrome.

Key Points

  • Orthostatic hypertension is characterized by a hyper-reactive pressor response to orthostatic stress and is an emerging risk factor for organ damage and cardiovascular disease

  • The condition increases the pulsatile haemodynamic stress of central arterial pressure and blood flow, resulting in progression of systemic haemodynamic atherothrombotic syndrome

  • Orthostatic hypertension precedes hypertension and is considered to be a form of prehypertension and a biomarker of masked hypertension in patients with normal sitting blood pressure levels

  • Sympathetic hyperactivity (resulting from hypersensitivity of the cardiopulmonary and arterial baroreceptor reflex) and α-adrenergic hyper-reactive vascular disease are potential major mechanisms of orthostatic hypertension

  • Further studies are needed to demonstrate whether orthostatic hypertension is only a marker or one of the leading causes of target-organ damage and cardiovascular events

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Figure 1: Orthostatic blood pressure changes evaluated using the head-up tilting test in elderly patients with hypertension.
Figure 2: Diagnosis and management of orthostatic hypertension.
Figure 3: Orthostatic hypertension and related diseases.
Figure 4: Orthostatic hypertension and related blood pressure variability.
Figure 5: Systemic haemodynamic atherothrombotic syndrome—risk factors and clinical manifestations.
Figure 6: The vicious cycle between pulsatile haemodynamic stress and vascular disease in SHATS.
Figure 7: Potential cardiovascular reactive mechanism of orthostatic sympathetic hyperactivity syndrome.

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Acknowledgements

This author's work was supported by the Foundation for Development of the Community, Tochigi, Japan, by a Grant-in-Aid for Scientific Research (B 21390247) from The Ministry of Education, Culture, Sports, Science and Technology (MEXT), Japan, and by a MEXT-Supported Program for the Strategic Research Foundation at Private Universities, 2011-2015 “Cooperative Basic and Clinical Research on Circadian Medicine” (S1101022).

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  1. Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1, Yakushiji, Tochigi, 329-0498, Shimotsuke, Japan

    Kazuomi Kario

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Kario, K. Orthostatic hypertension—a new haemodynamic cardiovascular risk factor. Nat Rev Nephrol 9, 726–738 (2013). https://doi.org/10.1038/nrneph.2013.224

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