Original article
Orthostatic hypotension is associated with more severe hypertension in elderly autonomous diabetic patients from the French Gerodiab study at inclusionL’hypotension orthostatique est associée à une hypertension artérielle plus sévère pour un traitement antihypertenseur similaire chez les patients diabétiques âgés autonomes à l’inclusion dans l’étude Gerodiab

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Abstract

Orthostatic hypotension (OH) has deleterious effects on patients’ cardiovascular prognoses. The combination of increased age and diabetes adds to the risk of OH. The aim of the study was to describe the elderly diabetic population relative to the degree of hypertension, the occurrence of complications, medications and cognitive function.

Methods

In the Gerodiab study (a 5-year French multicentre, prospective, observational study), a total of 987 type 2 diabetic autonomous patients, aged 77 ± 5 years, were recruited between June 2009 and July 2010. Clinical blood pressure measurements were taken supine and then after 1, 3 and 5 minutes in a standing position. OH was defined as a decrease in systolic blood pressure (SBP) of at least 20 mmHg and/or a decrease in diastolic blood pressure (DBP) of at least 10 mmHg at any of the measurements while standing.

Results

At inclusion 301 (30.5%) patients had OH; SBP and DBP at rest were higher in patients with OH than in those without (146 ± 21/78 ± 11 mmHg vs. 138 ± 17/72 ± 10 mmHg; P < 0.001). Individuals with OH exhibited higher pulse pressure (PP) than individuals without (68 ± 18 vs. 65 ± 15 mmHg; P < 0.05). A significant increase in waist-to-hip ratio was recorded in those with OH versus patients without (P < 0.01). Despite more severe hypertension (SBP > 160 mmHg at inclusion; P < 0.01), no significant difference was recorded in the mean number of antihypertensive drugs (1.7 ± 1.1), or in the class of antihypertensive drugs, including beta-blockers (P = 0.19) and diuretics (P = 0.84). Patients with OH were more likely to have a history of peripheral arterial disease and amputations (31% vs. 24%, P < 0.05, and 3.3% vs. 1.5%, P = 0.056). There was no significant association between OH and history of peripheral neuropathy (P = 0.37), stroke, heart failure or ischemic heart disease. In multivariate analysis, OH remained associated with severe hypertension (P < 0.01), increased waist-to-hip ratio (P < 0.05) and amputations (P < 0.05).

Conclusion

About one-third of elderly, autonomous diabetic patients had OH. They had more severe hypertension, with higher SBP, DBP and PP at rest. However, the number of anti-hypertensive drugs did not differ compared to patients without OH. This could reflect the medical teams’ fears about intensifying treatment.

Résumé

Les diabétiques âgés sont surexposés à l’hypotension orthostatique (HO), elle-même néfaste sur le pronostic cardiovasculaire. L’objectif était d’évaluer la fréquence de l’HO et ses facteurs associés dans la cohorte Gerodiab à l’inclusion.

Méthodes

L’étude Gerodiab a recruté 987 diabétiques de type 2 autonomes, de 70 ans ou plus. La pression artérielle était mesurée, après 5 min de repos, et à 1, 3 et 5 minutes après passage en orthostatisme. L’HO était définie par une baisse de PAS d’au moins 20 mmHg et/ou de PAD d’au moins 10 mmHg à 1, 3 ou 5 minutes. Les données (m ± SD; %) ont été comparées par test t ou du chi2 ; l’analyse multivariée a été réalisée par modèle logistique.

Résultats

Trois cent un (30,5 %) patients avaient une HO ; la PAS et la PAD étaient plus élevées au repos chez les patients présentant une HO (146 ± 21 et 78 ± 11 vs. 138 ± 17 et 72 ± 10 mmHg ; p < 0,001). Ils avaient également une HTA plus sévère (p < 0,01). Les patients avec HO présentaient une pression pulsée plus élevée (68 ± 18 vs 65 ± 15 mmHg ; p < 0,05). Leur ratio taille-hanche était augmenté (p < 0,01). Aucune différence significative n’était constatée pour les traitements antihypertenseurs, notamment bêta-bloquants et diurétiques, l’âge, l’ancienneté du diabète ou les scores gériatriques. Les patients avec HO avaient plus souvent une artériopathie oblitérante des membres inférieurs (31 % vs 24 % ; p < 0,05) et des amputations (3,3 % vs 1,5 % ; p = 0,056). Ils n’avaient pas plus fréquemment de neuropathie périphérique, d’AVC, d’insuffisance cardiaque, de cardiopathie ischémique. En analyse multivariée, l’HO était associée successivement à l’HTA sévère (p < 0,01), au ratio taille-hanche (p < 0,05) et aux amputations (p < 0,05).

Conclusion

Un tiers environ des patients diabétiques âgés autonomes présente une HO. Ils ont une HTA plus sévère sans majoration du traitement antihypertenseur. L’HO pourrait constituer une limitation à l’intensification du traitement antihypertenseur dans cette population.

Introduction

Orthostatic hypotension (OH) is common in the elderly, affecting up to 30% of the general population over 65 years old [1], [2], [3]. Large differences have been reported in its prevalence, ranging from 18% to 60% of people living in institutions [4], [5]. OH may or may not be symptomatic [6]. Various hemodynamic mechanisms underlying orthostatic adjustments have been reported with ageing, including a decline in the efficiency of baroreflexes [7]. OH has deleterious effects on cardiovascular function, leading to an increased incidence of cerebrovascular disease, myocardial infarction and mortality [8].

Diabetes is another well-known condition that causes autonomic failure [9]. Compared with younger diabetic patients, the consequences of diabetes and ageing accumulate in the elderly, and exacerbate degenerative complications and the effects of co-morbidities [10]. Although numerous studies have investigated the macroangiopathic complications in type 2 diabetic patients under the age of 70 years, little is known about elderly diabetic patients, particularly regarding the impact of OH on the occurrence of complications [11]. Additionally, there is no clear data about possible relationships between OH and other geriatric parameters such as cognition, nutrition and mood in elderly diabetic patients.

The purpose of the present study was to assess the prevalence of orthostatic hypotension and its potential associations with the degree of hypertension, diabetic complications and cognitive function in diabetic patients aged 70 years and older from the Gerodiab cohort at inclusion.

Section snippets

Material and methods

The Gerodiab study is a French multicentre, prospective, observational 5-year follow-up study designed to analyze glycemic control, morbidity and mortality in type 2 diabetic patients aged 70 years and older, with relatively preserved autonomy (Activity of Daily Living score > 3/6). Protocol details and a description of the population at inclusion have been published previously [12]. Data collection was primarily based on the patient history, including demographic data, cardiovascular risk

Results

An analysis was done on the baseline data of 987 patients, 52% of whom were women, aged 77 ± 5 years (median: 77 years; range 70–101 years), with diabetes duration of 18 ± 11 years and an HbA1c of 7.6 ± 1.3%.

Discussion

This analysis concerns the baseline data of 987 outpatients with type 2 diabetes, all aged 70 years or older, with relatively preserved autonomy, and who were consecutively included in the Gerodiab prospective cohort. It showed that almost one-third of patients had orthostatic hypotension. The main result concerns the association between OH and severe hypertension, which showed no significant difference in the nature or the number of antihypertensive drugs used.

OH was also associated with

Conclusion

In our analysis concerning the baseline data of 987 outpatients with type 2 diabetes, all aged 70 years or older and with relatively preserved autonomy, about one-third of them had OH. They had more severe hypertension and higher SBP, DBP and pulse pressure at rest, suggesting an association between peripheral vascular disease and OH. However, the nature and the number of anti-hypertensive drugs did not differ between patients with and without OH. This could reflect the medical teams’ fears

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Acknowledgments

We wish to thank the CRO Umanis (D. Dubois, C. Hilbert, A. Ourliac, D. Boichut) for the data collection and management. The complete list of authors and members of the SFD-SFGG group appears in Appendix A Scientific Committee of the SFD/SFGG Intergroup, Appendix B Study Investigators.

Funding: this work was supported by one grant from the national French Hospital Clinical Research Programme (PHRC; Programme Hospitalier de Recherche Clinique), one grant from the Francophone Society for Diabetes

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