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Arterial Hypotension: Prevalence of Low Blood Pressure in the General Population Using Ambulatory Blood Pressure Monitoring

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Arterial Hypotension: Prevalence of Low Blood Pressure in the General Population Using Ambulatory Blood Pressure Monitoring Journal of Human Hypertension (2000) 14, 243–247 2000 Macmillan Publishers Ltd All rights reserved 0950-9240/00 $15.00 www.nature.com/jhh ORIGINAL ARTICLE Arterial hypotension: prevalence of low blood pressure in the general population using ambulatory blood pressure monitoring PE Owens, SP Lyons and ET O’Brien Blood Pressure Unit, Beaumont Hospital, Dublin, Ireland Background: Chronic constitutional hypotension has diary. Blood was drawn for serum electrolyte estimation. been described in a proportion of the population, and Results: A total of 254 subjects were included, 49% of has a symptom complex ascribed to it. The true preva- whom demonstrated hypotensive events. Hypotensive lence of low blood pressure in the normal population means and individual hypotensive values were more fre- has not been defined. quently found in women, and occurred in a group of Aim of study: This study was undertaken to determine individuals with a distinct body habitus, specifically thin the prevalence of low blood pressure states, as meas- subjects, with a lower creatinine suggesting a smaller ured using ambulatory blood pressure monitoring, in a muscle mass. Hypotensive events in these subjects general population cohort, and to determine the associ- were associated with a low risk cardiovascular profile, ation between low blood pressure and clinical and in that subjects who displayed these events had a lower demographic variables. blood pressure, a lower weight and were less likely to Patient population: The population enrolled were a have a positive family history of hypertension or vascu- cohort of mainly urban dwelling Irish subjects, either lar disease. employees or spouses of employees of a major national Conclusion: Hypotension is common in the general bank. population and is associated with a distinct body hab- Methods: Subjects had an ambulatory blood pressure itus. It carries a generally benign cardiovascular risk monitor fitted between 09.00 and 12.00 and wore the factor profile. monitor for 24 hours. The subjects also filled out a Journal of Human Hypertension (2000) 14, 243–247 detailed lifestyle questionnaire, and kept an activity Keywords: hypotension; ambulatory blood pressure monitoring; prevalence Introduction nificant advantages in the investigation of low blood pressure.4 It is relatively free of the white coat effect, Arterial hypotension is most widely recognized in and therefore more likely to give a true reflection of the elderly, or in patients with significant impair- 1 ambient blood pressure for a given individual dur- ment of autonomic reflexes. A significant body of ing the course of the day and night. Furthermore, it scientific work exists on the topic of orthostatic allows an assessment of blood pressure that is hypotension and some drug and non-drug treat- closely allied to an individuals behaviour, and ments exist for its management.2 Less well under- which can be closely monitored using an accurately stood however is the concept of chronic consti- kept symptom diary. Finally, it gives information on tutional hypotension, and there is a paucity of scientific work on the subject. Nevertheless, it is a night-time blood pressure, when blood pressure is frequently diagnosed complaint in the minds of the at its lowest. lay public, and symptoms of fatigue, anergy and diz- To provide a framework for further study of this ziness are not infrequently attributed to hypoten- neglected aspect of blood pressure research, we sion. Physicians in some European countries do undertook to examine the prevalence of chronic view chronic low blood pressure as a disease entity, constitutional hypotension in a large general popu- and drug treatments do exist.3 However, it remains lation, using the technique of ambulatory blood a poorly explored subject. pressure monitoring. Specifically we examined the Ambulatory blood pressure monitoring has sig- distribution of low blood pressure means for day- time and night-time periods, and examined the prevalence and associated variables of hypotensive Correspondence: PE Owens, Blood Pressure Unit, Beaumont Hos- events in these subjects. pital, PO Box 1297, Beaumont Road, Dublin, Ireland Received 13 August 1999; revised and accepted 23 November 1999 Hypotension and ambulatory monitoring PE Owens et al 244 Subjects and methods the diet was defined as the addition of salt to food at table. Alcohol consumption was quantified as units Study population consumption per week. Smokers were coded accord- The study population comprised subjects enrolled ing to current or non-smoking status. into the Allied Irish Bank (AIB) phase two study. This is a study of blood pressure in an Irish, largely Statistical analysis urban population, drawing on the staff and families of a national bank. The first AIB study5 helped to The analysis was approached in two steps. First, the set the upper limits of normal for ambulatory blood blood pressure of the population as a whole was pressure in the general population. The original assessed, and, in the absence of a recognized lower study cohort of 815 subjects were contacted an aver- limit of normal, the lower limit of normal was taken age of 5 years later, and asked to participate in a as the fifth percentile of blood pressure appropriate follow-up study. Patients agreeing to re-participate for sex and time of day. Clinical variables in subjects underwent repeat ambulatory blood pressure moni- exhibiting hypotensive mean pressures were com- toring and blood testing for biochemical parameters. pared to identify associations with low-pressure Subjects also filled out a detailed lifestyle question- states. Secondly, hypotensive events were exam- naire. All subjects attending for repeat monitoring ined. Hypotensive events were defined as two or were enrolled into this study; the only specific more consecutive systolic or diastolic readings exclusion criteria for participation in this study was below the fifth percentile for sex and time of day. concomitant use of blood pressure lowering drug Clinical variables were then examined to determine therapy. Untreated hypertensives were included in categorical associations with the occurrence of the analysis. hypotensive events. Categorical associations were examined using the ␹2 test, or Fishers exact test (FET) where appropriate. Continuous variables were Ambulatory blood pressure monitoring (ABPM) examined using Student’s t-test. ABPM was performed using the SpaceLabs 90207 ambulatory blood pressure monitor (Redmond, WA, Results USA).6 This was fitted to the non-dominant arm A total population of 245 subjects was available for after arm measurement for appropriate cuff size, and study, representing 30% of the original AIB cohort. the monitor was programmed for measurement at Only four patients were excluded from the follow- 30-min intervals day and night. The subject was up study, for concomitant use of blood pressure low- instructed to continue life as normal between read- ering medications. Males comprised 62.9% of the ings, but to rest the arm at heart level during read- population, and the mean age for the population as ings. Subjects were also asked to keep an accurate a whole was 47.4 (10.2) (males 48.9 (9.0), females symptom diary, reporting activity at each measure- 44.8 (11.6)). ment. They were also asked to note down the time of retiring and time of rising. The initial, daytime and night-time systolic, diastolic and mean blood Ambulatory blood pressure means pressures were calculated. The daytime and night- The 5th, 10th, 50th, 90th, and 95th percentiles of time periods were calculated on the basis of the ris- blood pressure in the population are given in Table ing and retiring times noted in the symptom diary. 1, for the population as a whole and for the sexes Subjects were asked to comment on the quality of individually. Using the fifth percentile as the stat- the night-time sleep. The monitor was removed the istical lower limit of normal gives the lower limit of next day, and the data was retrieved from the ABPM, normal as 115/70 mm Hg and 97/56 mm Hg for male and immediately loaded into a specialized software subjects for daytime and night-time respectively, database (DABL).7 All recorded measurements not and 105/65 mm Hg and 92/52 mm Hg for female edited by the monitor software were included in subjects for daytime and night-time respectively. the results.8 In females, a daytime systolic hypotensive mean pressure was significantly associated with a daytime Blood testing diastolic hypotensive mean pressure, and vice versa (P = 0.009, FET), but neither were associated with When the subjects attended for examination and low nocturnal pressures. Nocturnal systolic or dias- monitor fitting, they had fasting blood drawn for tolic hypotensive means were not significantly asso- urea, electrolyte and creatinine estimation. ciated with either each other, or diurnal hypoten- sive means. Questionnaire Clinical variables between females showing hypo- tensive means during the day or night were com- Subjects completed a lifestyle questionnaire, which pared (Table 2). Weight was significantly lower in asked in detail about smoking and alcohol habits, the hypotensive group. There was also a nonsignifi- activity during the course of a normal day, as well cant trend towards a negative family history of as regular exercise, if any. Subjects completed a self- hypertension. A logistic regression model was fitted assessment scoring questionnaire for physical to the data to identify significant predictors of hypo- activity graded on a scale from 1 to 10, from
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