Comment on: Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms

To the Editor: Orthostatic hypotension (OH) develops in several conditions and with healthy aging. OH is defined as a drop in systolic blood pressure (BP) ≥20 mmHg, or diastolic drop of ≥10 mmHg within 3 min of standing or head-up tilt from a supine position. OH can be severe, recurrent, associated with reduced quality of life, and is an independent risk factor for falls.3–5 In the latest issue of Journal of the American Geriatric Society, Juraschek et al. report on orthostatic vital signs in 534 community-dwelling older adults, and performed a paired comparison of orthostatic BP changes during a supine-to-stand vs. sit-to-stand maneuver. Using the standard BP criteria for OH (≥20 mmHg/10 mmHg), the prevalence of OH was 15.0% when using a supine-tostand assessment, but only 2.1% with a sit-to-stand assessment (p < 0.001). Juraschek et al. concluded that in clinical practice, a seated OH protocol should not be considered a substitute for a supine OH protocol. Juraschek et al. should be congratulated for performing this large study in community-dwelling older adults focused on this important issue. However, we are not persuaded that we should dismiss the seated OH protocol so quickly. It is established that the sit-to-stand maneuver elicits a smaller BP drop in comparison to both head-up tilt testing and supine-to-stand maneuvers. To address this difference Shaw et al. identified optimal BP cutoffs in response to a sit-to-stand maneuver, and reported that a BP cutoff of ≥15/7 mmHg when performing a sit-to-stand maneuver yielded sensitivities, specificities, and positive and negative predictive values all above 80% for both systolic and diastolic BPs. Casiglia and Jordan independently validated these cutoffs within an epidemiological setting. In their unselected cohort of 2940 participants, they found no appreciable difference in OH prevalence between the supine-to-stand ≥20/10 mmHg criteria vs. the sit-to-stand ≥15/7 mmHg threshold (16.9% vs. 17.3%; p = 0.7). While the supine-to-stand maneuver is the gold standard, it cannot always be performed. OH afflicts a large number of older aged community-dwelling adults, and individuals in geriatric wards and nursing homes many of whom have comorbidities that can impact mobility. A sit-tostand maneuver offers a safer and more feasible test for patients without risking an acute fall or syncopal episode. Further, a sit-to-stand test simply requires a chair as opposed to a bed or tilt table. It may therefore be a more practical option to assess orthostatic vital signs in a variety of clinical environments (e.g., outpatient clinics) where it might currently not be done due to logistical difficulties. A sit-to-stand test, with adjusted BP cutoffs, could be used to screen patients for OH and determine the need for a gold standard supine-to-stand test, or even further autonomic testing via head-up-tilt with beat-to-beat hemodynamic monitoring. In conclusion, the study by Juraschek et al. provides interesting data in a large cohort. While a sit-to-stand test should not replace the gold standard head-up tilt or supineto-stand tests, when used with the appropriate BP reduction cutoffs, the sit-to-stand test does offer a safe, validated, and accessible means to screen for OH in a variety of clinical settings. This has important clinical implications for improving care for patients at risk of OH.