Orthostatic hypotension among outpatients with ischemic stroke Michael S. Phipps a, b, c, ⁎, Arlene A. Schmid d, e, f, g , John R. Kapoor h , Aldo J. Peixoto c, i , Linda S. Williams d, e, j, l , Dawn M. Bravata d, e, k, l a Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, CT, USA b Department of Neurology, Yale University School of Medicine, New Haven, CT, USA c Veterans Administration (VA) Connecticut Healthcare System, West Haven Medical Center, West Haven, CT, USA d Richard L. Roudebush VA Medical Center, Health Services Research and Development (HSR&D) Center on Implementing Evidence-Based Practice IN, USA e VA HSR&D Stroke Quality Enhancement Research Initiative (QUERI), IN, USA f Indiana University School of Health and Rehabilitation, Department of Occupational Therapy, IN, USA g Indiana University, Center for Aging Research, IN, USA h Stanford University, Division of Cardiology, Falk Cardiovascular Research Center, Stanford, CA, USA i Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA j Department of Neurology, Indiana University School of Medicine, IN, USA k Department of Internal Medicine, Indiana University School of Medicine, IN, USA l Regenstrief Institute, Indianapolis, IN, USA abstract article info Article history: Received 5 August 2011 Received in revised form 19 October 2011 Accepted 26 October 2011 Available online 17 November 2011 Keywords: Hypotension Orthostatic Stroke Accidental falls Risk factors Background: The treatment of hypertension is an essential component of stroke prevention; however, the clinical management of patients with cerebrovascular disease is complicated by orthostatic hypotension (OH). The primary objectives were to: determine the prevalence of OH in a stroke outpatient clinic; describe categories of OH; and identify factors independently associated with the presence of OH. Methods: Veterans with stroke, cared for in a multidisciplinary stroke clinic, were included. OH was defined as a ≥20 mm Hg fall in systolic blood pressure (BP), a ≥10 mm Hg fall in diastolic BP, or a ≥10 mm Hg fall in systolic BP with symptoms. Multivariable logistic regression was used to identify factors associated with OH including demographics, comorbidites, stroke severity, and baseline BP. Results: Among 60 patients with stroke, 16 (27%) patients had OH. Among those with OH, half were hypertensive, seven were normotensive, and one was hypotensive. A history of coronary artery disease was independently associated with the presence of OH. Conclusions: Orthostatic hypotension is present in about one quarter of outpatients with stroke, and coronary artery disease appears to be a risk factor. Stroke patients should be screened for OH given that the presence of positional BP changes may alter clinical management. Published by Elsevier B.V. 1. Introduction Approximately 795,000 strokes occur each year in the United States[1]. A key component of stroke prevention is hypertension management[2,3]. Hypertension management has been associated with a 30–40% stroke risk reduction[3]. Given that approximately three-quarters of patients with stroke or transient ischemic attack (TIA) have hypertension[4], the majority of patients with cerebrovas- cular disease are eligible for hypertension management as a means of reducing their risk of recurrent vascular events. The management of hypertension can be complicated by the presence of orthostatic hypotension (OH), defined as a fall in blood pressure when changing position from sitting or supine to standing [5]. OH can occur in patients who are normotensive, hypotensive, or hypertensive. OH is a known risk factor for recurrent stroke in outpa- tients[6,7], and may be an additional risk factor for falls among pa- tients with prior stroke or transient ischemic attack (TIA)[8,9]. The prevalence of OH among older community-dwelling adults ranges from 15% to 26%, and the prevalence increases with older age[10]. In the general population, diabetes and coronary artery dis- ease have been associated with the presence of OH[10]. Previous studies have examined the prevalence of OH post-stroke in acute [11,12] and rehabilitation [13] settings, but have not focused on the outpatient setting, where most blood pressure management occurs. To our knowledge, no studies have assessed the fall risk associated with OH in stroke patients. The factors that have been associated with the presence of OH among stroke patients in the inpatient reha- bilitation setting include older age, lower functional status, and more severe hemiparesis; [13] no particular factor has been associated with OH in the acute setting[12]. Journal of the Neurological Sciences 314 (2012) 62–65 ⁎ Corresponding author at: VA Connecticut Healthcare System, 950 Campbell Ave, 11-ACSLG West Haven, CT 06516, USA. E-mail address: michael.phipps@yale.edu (M.S. Phipps). 0022-510X/$ – see front matter. Published by Elsevier B.V. doi:10.1016/j.jns.2011.10.031 Contents lists available at SciVerse ScienceDirect Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns