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If blood pressure rises upon standing, so may risk for heart attack – American Heart Association

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Research Highlights:
Embargoed until 4 a.m. CT/5 a.m. ET Thursday, March 17, 2022
DALLAS, March 17, 2022 — Among young and middle-aged adults with high blood pressure, a substantial rise in blood pressure upon standing may identify those with a higher risk of serious cardiovascular events, such as heart attack and stroke, according to new research published today in the American Heart Association’s peer-reviewed journal Hypertension.
“This finding may warrant starting blood-pressure-lowering treatment including medicines earlier in patients with exaggerated blood pressure response to standing,” said Paolo Palatini, M.D., lead author of the study and a professor of internal medicine at the University of Padova in Padova, Italy.
Nearly half of Americans and about 40% of people worldwide have high blood pressure, considered to be the world’s leading preventable cause of death. According to the American Heart Association’s 2022 heart disease statistics, people with hypertension in mid-life are five times more likely to have impaired cognitive function and twice as likely to experience reduced executive function, dementia and Alzheimer’s disease.
Typically, systolic (top number) blood pressure falls slightly upon standing up. In this study, researchers assessed whether the opposite response – a significant rise in systolic blood pressure upon standing – is a risk factor for heart attack and other serious cardiovascular events.
The investigators evaluated 1,207 people who were part of the HARVEST study, a prospective study that began in Italy in 1990 and included adults ages 18-45 years old with untreated stage 1 hypertension. Stage 1 hypertension was defined as systolic blood pressure of 140-159 mm Hg and/or diastolic BP 90-100 mm Hg. None had taken blood pressure-lowering medication prior to the study, and all were initially estimated at low risk for major cardiovascular events based on their lifestyle and medical history (no diabetes, renal impairment or other cardiovascular diseases). At enrollment, participants were an average age of 33 years, 72% were men, and all were white.
At enrollment, six blood pressure measurements for each participant were taken in various physical positions, including when lying down and after standing up. The 120 participants with the highest rise (top 10%) in blood pressure upon standing averaged an 11.4 mm Hg increase; all increases in this group were greater than 6.5 mm Hg. The remaining participants averaged a 3.8 mm Hg fall in systolic blood pressure upon standing.
The researchers compared heart disease risk factors, laboratory measures and the occurrence of major cardiovascular events (heart attack, heart-related chest pain, stroke, aneurysm of the aortic artery, clogged peripheral arteries) and chronic kidney disease among participants in the two groups. In some analyses, the development of atrial fibrillation, an arrhythmia that is a major risk factor for stroke, was also noted. Results were adjusted for age, gender, parental history of heart disease, and several lifestyle factors and measurements taken during study enrollment.
During an average 17-year follow-up 105 major cardiovascular events occurred. The most common were heart attack, heart-related chest pain and stroke.
People in the group with top 10% rise in blood pressure:
After adjusting for average blood pressure taken over 24 hours, an exaggerated blood pressure response to standing remained an independent predictor of adverse heart events or stroke.
“The results of the study confirmed our initial hypothesis – a pronounced increase in blood pressure from lying to standing could be prognostically important in young people with high blood pressure. We were rather surprised that even a relatively small increase in standing blood pressure (6-7 mm Hg) was predictive of major cardiac events in the long run,” said Palatini.
In a subset of 630 participants who had stress hormones measured from 24-hour urine samples, the epinephrine/creatinine ratio was higher in the people with a rise in standing blood pressure compared to those whose standing blood pressure did not rise (118.4 nmol/mol vs. 77.0 nmol/mol, respectively).
“Epinephrine levels are an estimate of the global effect of stressful stimuli over the 24 hours. This suggests that those with the highest blood pressure when standing may have an increased sympathetic response [the fight-or-flight response] to stressors,” said Palatini. “Overall, this causes an increase in average blood pressure.”
“The findings suggest that blood pressure upon standing should be measured in order to tailor treatment for patients with high blood pressure, and potentially, a more aggressive approach to lifestyle changes and blood-pressure-lowering therapy may be considered for people with an elevated [hyperreactor] blood pressure response to standing,” he said.
Results from this study may not be generalizable to people from other ethnic or racial groups since all study participants reported white race/ethnicity. In addition, there were not enough women in the sample to analyze whether the association between rising standing blood pressure and adverse heart events was different among men and women. Because of the relatively small number of major adverse cardiac events in this sample of young people, the results need to be confirmed in larger studies.
Co-authors are Lucio Mos, M.D.; Francesca Saladini, M.D.; and Marcello Rattazzi, M.D. Authors’ disclosures are listed in the manuscript.  
The study was funded by the Association “18 Maggio 1370” in Italy.
Studies published in the American Heart Association’s scientific journals are peer-reviewed. The statements and conclusions in each manuscript are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here
Additional Resources:
About the American Heart Association
The American Heart Association is a relentless force for a world of longer, healthier lives. We are dedicated to ensuring equitable health in all communities. Through collaboration with numerous organizations, and powered by millions of volunteers, we fund innovative research, advocate for the public’s health and share lifesaving resources. The Dallas-based organization has been a leading source of health information for nearly a century. Connect with us on heart.org, Facebook, Twitter or by calling 1-800-AHA-USA1. 
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For Media Inquiries and AHA/ASA Expert Perspective: 214-706-1173
Karen Astle: 214-706-1392, Karen.Astle@heart.org
For Public Inquiries: 1-800-AHA-USA1 (242-8721)
heart.org and stroke.org
Blood Pressure Categories
(Transcription doc)
source: heart.org/hbp
copyright American Heart Associtation
Blood Pressure Categories
(Transcription doc)
source: heart.org/hbp
copyright American Heart Associtation
Please see AHA/ASA Multimedia Materials Usage Policy.
copyright American Heart Association
copyright American Heart Association
Please see AHA/ASA Multimedia Materials Usage Policy.
A high blood pressure reading.
copyright American Heart Association
A high blood pressure reading.
copyright American Heart Association
Please see AHA/ASA Multimedia Materials Usage Policy.
Nurse taking blood pressure of female patient at UTSW Medical Center in Dallas, Texas
copyright American Heart Association
Nurse taking blood pressure of female patient at UTSW Medical Center in Dallas, Texas
copyright American Heart Association
Please see AHA/ASA Multimedia Materials Usage Policy.

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