Blood Pressure and Dizziness Revisited

As you may noticed in the last few blog posts, I am going back to some earlier topics and seeing if the evidence, or general consensus, has changed over the two or three years since the posts were written. I did a series on Blood Pressure and Dizziness about three years ago. The gist of that series was that many patients taking medications for hypertension experience transient lightheadedness and loss of balance when they first stand up. Although this is an issue I see in my office almost daily, checking for orthostatic changes in blood pressure is not a standard part of a medical exam on hypertensive patients. A little lightheadedness isn’t going to hurt anyone, but orthostatic hypotension has long been considered a significant fall risk.

A recent article in the journal Hypertension addresses this, sort of. The authors followed a group of “500 healthy, elderly seniors “ who were taking medications for hypertension, and did not find a higher incidence of falling.
According to the study’s lead author, Dr. Lewis A Lipsitz (Harvard Medical School):

“In the treatment of hypertension in older people, it is important to prevent adverse events and it’s appropriate to think of adverse effects of the drugs themselves. But when it comes to falls in people who are on chronic use of antihypertensive medication, we need not worry much about precipitating falls, and with ACE inhibitors and calcium-channel blockers, we may actually reduce that risk. The general thinking is that hypertension should be treated, but the most recent guidelines suggest clinicians should be less aggressive and treat to 150/90 mm Hg and below; treating to 120/80 mm Hg is not considered safe, because with lower blood pressure there is lower blood flow to the brain. However, we looked at that and found that calcium-channel blockers actually improved [cerebral blood flow],”

I have two concerns about this article, particularly the line, “we need not worry much about precipitating falls.” One is the fact that these were “healthy, elderly seniors.” Studies on risk of falls have shown that the vast majority of fallers have more than one risk factor, more typically four or five risk factors. If the study participants were otherwise healthy, it is not surprising that the incidence of falls was as low as reported.

The second concern is that this is an observational study, which is good, but there is no mention of whether these patients were monitored for orthostatic changes in blood pressure. Trust me, I am not criticizing the authors about how to manage blood pressure. That would be similar to a third grader offering tips to Stephen Curry on how to shoot a three-point shot (basketball fans will get this). I just wish there were more awareness and more checking for orthostatic changes at the Primary Care and Internal Medicine level.

On the flip side, it is very clear that the authors have a lot of experience in the frustrations of studying fall prevention. They note, and I wholeheartedly agree, that people’s behavior plays the biggest role in risk of falls.  Dr. Lipsitz explains:

“There is a U-shaped relationship: the frailest people tend to fall and the most active people tend to fall—for different reasons. Indoor falls tend to occur in people who are frailer and don’t go out much and get caught on furniture or slippery floors or other hazards, whereas outdoor falls tend to occur in very active people. If you lump them all together you sometimes lose information about what is really going on.”

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About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.