Skip to main content

Postural changes in blood pressure among patients with diabetes attending a referral hospital in southwestern Uganda: a cross-sectional study

Abstract

Background

Orthostatic hypotension (OH) and orthostatic hypertension (OHT) are often unrecognized in clinical care for diabetic individuals, yet they are associated with increased risk for adverse cardiovascular outcomes. We aimed to determine the prevalence of the abnormal orthostatic blood pressure (BP) responses, and associated factors among diabetic individuals in ambulatory care for diabetes in southwestern Uganda.

Methods

We conducted a cross-sectional study among diabetic individuals aged 18–65 years at Mbarara Regional Referral Hospital, southwestern Uganda from November 2018 to April 2019. We obtained demographic and clinical data including a detailed medical history, and glycemic profile. BP measurements were taken in supine position and within 3 min of standing. We defined OH in participants with either ≥ 20 mmHg drop in systolic BP (SBP) or ≥ 10 mmHg drop in diastolic BP (DBP) after assuming an upright position. OHT was defined in participants with either a ≥ 20 mmHg rise in SBP, or ≥ 10 mmHg rise in DBP after assuming an upright position. Multivariate logistic regression was used to identify factors associated with OH and OHT.

Results

We enrolled 299 participants, with a mean age of 50 years (SD ± 9.8), and mean HbA1c of 9.7% (SD ± 2.6); 70% were female. Of the 299 participants, 52 (17.4%; 95% CI 13.3–22.2%) met the definition of OH and 43 (14.4%; 95% CI 10.6–18.9%) were classified as having OHT. In multivariable models, factors associated with diabetic OH were older age (OR = 2.40 for 51–65 years vs 18–50 years, 95% CI 1.02–5.67, P = 0.046), diabetic retinopathy (OR = 2.51; 95% CI 1.14–5.53, P = 0.022), higher resting SBP ≥ 140 mmHg (OR = 3.14; 95% CI 1.31–8.7.56, P = 0.011), and history of palpitations (OR = 2.31; 95% CI 1.08–4.92, P = 0.031). Self-report of palpitations (OR = 3.14; 95% CI 1.42–6.95, P = 0.005), and higher resting SBP ≥ 140 mmHg (OR = 22.01; 95% CI 1.10–4.42, P = 0.043) were associated with OHT.

Conclusion

OH and OHT are common among diabetic individuals in ambulatory diabetes care in southwestern Uganda. Orthostatic BP measurements should be considered as part of routine physical examination to improve detection of OH and OHT, especially among older diabetics with complications of the disease. Future studies to assess the health and prognostic implications of OH and OHT among diabetics in the region are warranted.

Peer Review reports

Introduction

Orthostatic hypotension (OH) is a hemodynamic disorder that is characterized by a sustained drop in blood pressure (BP) from supine position to standing [1]. Orthostatic hypertension (OHT), on the other hand is a reverse phenomenon, characterized by an exaggerated sustained rise in BP from supine to standing position [2]. The primary pathophysiological mechanism involved in both OH and OHT is believed to be autonomic nervous system dysfunction [3]. Unlike OHT, OH has been well studied in different populations outside sub-Saharan Africa. The prevalence of OH is age-dependent, and higher in individuals with diabetes mellitus (DM) compared to non-diabetics [4, 5]; prevalence rates ranging from 7 to 64%, have been reported in diabetic populations [6]. Among diabetic individuals, several factors have been found to be associated with OH including age, smoking, duration of diabetes, obesity, hyperlipidemia, hypertension, glycemic control, and coexistence of other microvascular complications of DM [6,7,8].

OH is recognized as the among most disabling features of autonomic dysfunction [9], and is associated with adverse cardiovascular outcomes, including cardiac failure, stroke, myocardial infarction, and all-cause mortality [10,11,12]. Patients with OH are prone to syncope, falls, and cognitive impairment due to the resultant cerebral hypo-perfusion [9, 13,14,15]. Nonetheless, some with abnormal postural blood pressure abnormalities remain asymptomatic because of cerebral blood flow auto-regulatory mechanisms [16]. The concomitant presence of DM and abnormal orthostatic BP responses, has previously been referred to as a “dangerous combination”, because these conditions may portend a much poorer prognosis of cardiovascular complications [6, 17, 18]. Despite being serious and frequent complications, abnormal postural changes in BP are often unrecognized [2, 19].

In addition, some complications such as supine hypertension, usually observed in more than half of diabetics with OH, are challenging to manage and often require expertise of a cardiovascular specialist [20, 21]. Furthermore, there is mounting evidence to suggest that OHT is associated circadian BP abnormalities including labile hypertension during daytime, and extreme dipping at night; the circadian BP abnormalities accelerate hypertensive target organ damage [2].

However, there are very few data on the epidemiology of OH and OHT outside of resource-rich settings. Given the growing evidence of deleterious cardiovascular outcomes for individuals with abnormal orthostatic BP responses and DM [18, 21], it is crucial, that the epidemiology of OH and OHT among those with DM is better understood in more diverse global populations such that complications of these conditions can be considered, to minimize possible cardiovascular risk and improve the quality of life in this patient population [20].

Most earlier studies on abnormal postural changes in BP in diabetic populations have mainly focused on elderly individuals ≥ 70 years, and have taken place outside sub-Saharan Africa (SSA). Data on the burden and correlates of abnormal postural changes in BP in diabetic populations in SSA are limited. We aimed to respond to this gap in the literature by characterizing the prevalence of abnormal orthostatic BP responses, both OH and OHT, and to identify factors associated with these conditions in a relatively younger population of diabetic individuals (18–65 years) in ambulatory DM care in Uganda.

Methods

Study population and design

This was a cross-sectional study, conducted at the Diabetes and Endocrinology Clinic of Mbarara Regional Referral Hospital (MRRH) from November 2018 to April 2019. The detailed methods for the parent study that assessed the overall burden of cardiovascular autonomic neuropathy among individuals with diabetes in ambulatory care, and a detailed description of the study population at inclusion, have been published previously [22]. In brief, we included individuals with diabetes aged 18–65 years. We excluded patients with known underlying hepatic, renal, or cardiac diseases. We also excluded patients with known ECG or electrolyte abnormalities, those with acute febrile illnesses, and those actively taking antihypertensive medications such as calcium channel blockers, beta blockers and diuretics in the previous 24 h.

Study definitions and procedures

We collected clinical and demographic data, using an interviewer administered structured questionnaire. Waist circumference was measured at the level of umbilicus with inelastic tapeline (to the nearest 0.1 cm), at the end of normal expiration. Height and weight of study participants were measured to the nearest 0.1 cm and 0.1 kg respectively. We calculated body mass index as the weight (kg) divided by the square of height (m2). Measurements for glycosylated hemoglobin (HbA1c) were performed using an automated high performance liquid chromatography analyzer (Cobas Integra 400, Roche diagnostics, Basel, Switzerland), at Lancet laboratories. Measurements of fasting blood glucose were obtained under aseptic technique, using a Freestyle Glucometer (Abbott Diabetes Care Inc., Maidenhead, UK) after at least 8 h of fasting, by means of capillary blood obtained by finger prick. Diabetes was defined in participants with fasting capillary glucose of ≥ 7.0 mmol/L or those who were already on medication for diabetes mellitus, as per recognized criteria [23]. Diabetic retinopathy was diagnosed using direct ophthalmoscopy and classified as non-proliferative or proliferative diabetic retinopathy, by an ophthalmologist.

We performed resting 12 lead ECG recordings using a portable ECG machine (Edan Instruments, Inc., Hessen, Germany) on study participants, and measured the QT interval from the beginning of the earliest onset of the QRS complex to the end of the T wave, where it crosses the isoelectric line. We used the Bazette’s formula to calculate a heart rate–corrected QT (QTc) [24]. We consider a cut-off value of the QTc interval > 440 ms to be elevated [25].

Blood pressure measurements and assessment of orthostatic hypotension

All BP recordings were done using an automatic sphygmomanometer in the upper arm (Omron HEM 705 LP, Omron Healthcare, Inc., Bannockburn, IL, USA). The protocol for assessment of OH and OHT included supine BP and standing BP measurements. Supine BP was recorded after 5 min of rest. Standing BP was measured within 3 min of assuming upright standing position. We defined OH in participants with either a ≥ 20 mmHg drop in systolic BP (SBP) or ≥ 10 mmHg drop in diastolic BP (DBP) when assuming an upright position [26]. To define OHT, we considered the cut-off for abnormal systolic orthostatic blood pressure responses of ≥ 20 mmHg, which has been previously proposed for hypertensive orthostatic BP responses [1]. We thus defined systolic OHT in participants with a rise in SBP ≥ 20 mmHg, with or without an accompanying DBP rise; systolic OH was defined in participants with a drop of SBP ≥ 20 mmHg, with or without an accompanying DBP drop. To define diastolic orthostatic hypotensive responses, we considered the cut-off was ≥ 10 mmHg [1] and applied this cut-off for diastolic OHT, since there is no consensus for the numerical threshold for this entity [18]. Thus, we defined diastolic OHT in participants with an increase in diastolic BP ≥ 10 mmHg, with or without an accompanying SBP increase, and diastolic OH in participants with a drop in diastolic BP ≥ 10 mmHg, with or without an accompanying drop in SBP Accordingly, a normal diastolic orthostatic BP response was defined in participants with a change of DBP within the range of − 9 to + 9 mmHg, whereas a normal systolic orthostatic BP response was defined in participants with a change of SBP within the range of − 19 to + 19 mmHg.

Conventional BP measurements were done with participants in sitting positions. We defined hypertension in participants whose BP values were ≥ 140/90 mmHg or who were already on medications for high BP [27]. We calculated pulse pressure as the difference between systolic and diastolic BP measurements. Although there is no widely recognized cut-off for defining high pulse pressure, we adopted the previously suggested threshold of ≥ 65 mm Hg [28].

Sample size and statistical analyses

For the parent study, which was designed to estimate the prevalence of autonomic neuropathy, we estimated a sample size of 296 participants around a prevalence estimate of cardiovascular autonomic neuropathy (CAN) of 20% [29], with a 5% precision at a 95% level of confidence, after inflation for 10% non-response rate, using Epi Info (version 7.1.4.0, CDC, Atlanta, US). Study data were entered data into EpiData3. (EpiData, Odense, Denmark). We used Stata, version 13 (StataCorp, College Station, Texas, USA) for all statistical analyses.

Our primary outcomes were OH and OHT. First, we determined the prevalence of OH and OHT, as the proportion of participants that met their definitions. Next, we compared differences in clinical and demographic characteristics between participants with OH and OHT and those without. Continuous normally distributed data (presented as mean ± standard deviation) were compared using a two-tailed independent t-test; while continuous non-normally distributed data (presented as median ± inter-quartile range) were compared using Wilcoxon rank-sum test. We compared categorical variables using the chi-squared test. Finally, we performed univariate and multivariate logistic regression analyses to identify factors associated with OH and OHT. All variables with a P-value less than 0.1, were included in the multivariate models and adjusted for sex, age, BMI, HbA1c, QTc interval, and duration of diabetes, based on biological plausibility. Pulse pressure—derived from SBP and DPB— and history of hypertension, were eliminated from the final multivariate model because of collinearity. We considered statistical significance at a threshold of P < 0.05.

Results

Characteristics of study participants

The clinical and demographic characteristics of the total cohort have been described previously [22]. In brief, we enrolled a total of 299 participants, with a mean age of 50 years (SD ± 9.8), mean duration of diabetes of 5.8 (SD ± 5.9) years, and mean HbA1c of 9.7% (SD ± 2.6); 70% were female.

Overall, abnormal postural changes in BP were detected in 66 participants (22.1%). Of the 299 participants assessed orthostatic BP responses, 52 (17.4%; 95% CI 13.3–22.2%) met the definition of OH; 43 (14.4%; 95% CI 10.6–18.9%) were classified as having OHT (Table 1).

Table 1 Orthostatic blood pressure responses among 299 participants with diabetes aged 18–65 years, southwestern Uganda

Diastolic hypertension was found in 38 participants (12.7%), systolic hypotension in 23 participants (7.7%), while diastolic hypotension and systolic hypertension were found in 10 participants (3.3%) each. The differences between blood pressures from supine to standing followed a normal distribution pattern for both systolic and diastolic BP measurements are shown in Fig. 1. The mean (SD) change for the systolic BP was 3 (± 13) mmHg; for the DBP, the mean change (SD) was -4 (± 8) mmHg.

Fig. 1
figure 1

Distribution of systolic (a) and diastolic (b) orthostatic blood pressure changes among 299 study participants with diabetes aged 18–65 years, southwestern Uganda

We found crude differences in the mean age (P = 0.002), history of hypertension (P = 0.002), history of palpitations (P = 0.002), diabetic retinopathy (P < 0.001), mean QTc interval (P = 0.006) and median duration of diabetes (P = 0.031) between those with and without OH. Participants with OH also had significantly higher mean resting systolic BP (P < 0.001), higher mean resting diastolic BP (P = 0.004) and higher mean pulse pressure (P < 0.001) compared with their counterparts with no OH.

The proportion of female participants (P = 0.011) and those who reported history of palpitations (P < 0.001) was significantly higher in the OHT group than in the group without OHT, as shown in Table 2.

Table 2 Characteristics of 299 study participants with diabetes aged 18–65 years, by presence of orthostatic hypotension and orthostatic hypertension, southwestern Uganda

Participants with OHT had significantly higher mean BMI (P = 0.015), higher mean waist circumference (P = 0.019), higher mean pulse pressure (P < 0.001), higher mean resting systolic BP (P = 0.001), and higher mean QTc (P = 0.049) than their counterparts (Table 2).

Correlates of orthostatic hypotension and orthostatic hypertension

In multivariate analysis (Table 3), the factors associated with diagnosis of diabetic OH were older age of 51–65 years (OR = 2.40; 95% CI 1.02–5.67, P = 0.046), presence of diabetic retinopathy (OR = 2.51; 95% CI 1.14–5.53, P = 0.022), history of palpitations (OR = 2.31; 95% CI 1.08–4.92, P = 0.031), and higher resting systolic BP of ≥ 140 mmHg (OR = 3.14; 95% CI 1.31–8.7.56, P = 0.011).

Table 3 Univariate and multivariate logistic regression analyses for factors associated with orthostatic hypotension, and orthostatic hypertension among 299 participants with diabetes aged 18–65 years, southwestern Uganda

Having history of palpitations (OR = 3.14; 95% CI 1.42–6.95, P = 0.005) and higher resting SBP ≥ 140 mmHg (OR = 2.01; 95% CI 1.10–4.42, P = 0.043) were associated with presence of OHT in the multivariate analysis (Table 3).

Discussion

We detected a high prevalence of abnormal postural changes in BP among persons in ambulatory care for DM in Uganda: approximately 17% had OH and 14% had OHT. Notably, risk factors for falls and other comorbidities, including older age, high SBP, palpitations, and retinopathy were significantly associated with OH; high SBP and history of palpitations were each significantly associated with OHT. On balance, our data suggest a need to systematically and routinely detect these abnormal orthostatic responses in BP, so as to improve quality of life in this patient population, particularly in older diabetics with other complications.

With no published data currently available for comparison from sub-Saharan Africa, the prevalence of abnormal postural changes in BP in this study population is similar to previously reported findings from studies among individuals with type 1 diabetes and longstanding disease in USA [30] and older-aged type 2 diabetic individuals in Sweden, Brazil and Japan [18, 31, 32]. A population-based study among adult persons in Japan reported a similar prevalence of OH of 16%; in the same study, however, the prevalence of OHT was very low (1.1%) [33]. Nonetheless, even higher prevalence rates of OH than ours have been reported in elderly individuals with diabetes in France and China [34, 35]. However, it is challenging to compare prevalence rates of OH and OHT because of the different definitions for these clinical entities used across different studies. Some earlier studies used SBP cut-offs of 10 mmHg [31], or a change of DBP from < 90 to ≥ 90 mmHg or an increase of SBP from < 140 to ≥ 140 mmHg after standing from supine position [30, 32]. Nevertheless, our findings highlight that abnormal orthostatic BP reactions (both OH and OHT) are common and unrecognized complications among individuals with diabetes in Uganda.

We found that individuals with higher resting SBP (≥ 140 mmHg) had higher odds of OH, and OHT. This is in agreement with previous studies that have reported association between resting SBP and abnormal orthostatic BP responses [33, 34, 36,37,38,39,40]. Although the pathophysiological mechanisms involved in OHT and OH are largely unclear, both are believed to share similar pathophysiological pathways with autonomic nervous system dysfunction recognized as the primary pathophysiological disturbance in both disorders [3]. In individuals with diabetes and hypertension, the risk for developing OHT may be amplified because both diabetes and hypertension enhance activation of the autonomic nervous system [3]. Moreover, it has been hypothesized that OHT may be a form of masked hypertension or prehypertension among non-hypertensive individuals [40]. Thus, normotensive individuals with diabetes with OHT should be followed up for possible development of hypertension.

Although the precise mechanism of OH is not well studied in this population, we postulate that OH may be a manifestation of autonomic neuropathy, given the high prevalence of cardiovascular autonomic dysfunction detected in this same population [22]. This hypothesis is further supported by the association between increasing age and other microvascular complications (e.g., retinopathy) that are known to be more frequent in neurogenic type of OH [33, 38], probably due to age-related autonomic dysfunction and metabolic insults resulting from chronic hyperglycemia.

Current guidelines for care and management of diabetes in Uganda and other developing countries in sub-Saharan Africa do not routinely recommend screening for orthostatic BP abnormalities among individuals with diabetes in ambulatory care. Because routine measurement of BP is a non-invasive and low-cost procedure to identify individuals with abnormal orthostatic BP changes, our data suggest that routine comprehensive physical examinations in diabetic individuals could serve as a scalable mechanism to improve detection of OH and OHT. Future work should focus on how detection of OH and OHT with subsequent optimization of hemodynamics may improve quality of life and reduce the risk for excess cardiovascular morbidity and mortality associated with these complications.

Limitations

The findings from this study should be interpreted in consideration of our study limitations. First, our study population lacked individuals older than 65 years, based on the exclusion criteria of the parent study which assessed the overall burden of cardiovascular autonomic neuropathy among individuals with diabetes in ambulatory care. This may have led to underestimation of the prevalence of the OH and OHT, and biased our associations towards the null. Generalizability should be restricted similarly to those with diabetes and in ambulatory care in similar peri-urban African settings. Second, the cross-sectional study design limited us from assigning time causal directionally between our exposures and outcomes. Third, we did not comprehensively assess complications of OH and OHT including orthostatic intolerance and associated falls. Thus, we cannot evaluate the clinical implications of these abnormal orthostatic BP responses in the study population. Further studies are required to assess the prognostic and clinical implications of these orthostatic abnormalities in this patient population in the region. Despite these limitations, our study is among the first studies to provide useful epidemiological data on OH and OHT among diabetic individuals in sub-Saharan African region.

Conclusions

OH and OHT are common among individuals with diabetes in ambulatory care in southwestern Uganda. Higher SBP, history of palpitations, coexistence of diabetic retinopathy, and older age were key correlates of the orthostatic BP abnormalities. Future work should elucidate how these conditions impact the health and quality of life of those with DM in this region. Given the ease and low cost of performing orthostatic BP measurements in clinical settings, we recommend that clinical guidelines for care of persons with diabetes consider including screening for orthostatic abnormalities in BP into routine physical examinations to improve detection and management of OH and OHT in the region, especially among diabetics with hypertension, older age, and coexisting microvascular complications. Timely management of OH and OHT may potentially minimize future adverse cardiovascular events in this patient population, given that co-existing DM and orthostatic abnormalities in BP portent a much poorer prognosis.

Availability of data and materials

The datasets generated and analyzed during the study are available from the corresponding author on request.

Abbreviations

aOR:

Adjusted odds ratio

BMI:

Body mass index

BP:

Blood pressure

DBP:

Diastolic blood pressure

CAN:

Cardiovascular autonomic neuropathy

CVD:

Cardiovascular disease

CI:

Confidence interval

ECG:

Electrocardiogram

HbA1c:

Glycosylated hemoglobin

IQR:

Inter-quartile range, Mbarara Regional Referral Hospital

OH:

Orthostatic hypotension

OHT:

Orthostatic hypertension

OR:

Odds ratio

QTc:

Heart rate corrected QT interval

SBP:

Systolic blood pressure

SD:

Standard deviation

References

  1. Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69–72.

    Article  Google Scholar 

  2. Jordan J, Ricci F, Hoffmann F, Hamrefors V, Fedorowski A. Orthostatic hypertension: critical appraisal of an overlooked condition. Hypertension. 2020;75(5):1151–8.

    CAS  Article  Google Scholar 

  3. Magkas N, Tsioufis C, Thomopoulos C, Dilaveris P, Georgiopoulos G, Doumas M, et al. Orthostatic hypertension: from pathophysiology to clinical applications and therapeutic considerations. J Clin Hypert. 2019;21(3):426–33.

    Article  Google Scholar 

  4. Wu J-S, Yang Y-C, Lu F-H, Wu C-H, Wang R-H, Chang C-J. Population-based study on the prevalence and risk factors of orthostatic hypotension in subjects with pre-diabetes and diabetes. Diabetes Care. 2009;32(1):69–74.

    Article  Google Scholar 

  5. Saedon NI, Pin Tan M, Frith J. The prevalence of orthostatic hypotension: a systematic review and meta-analysis. J Gerontol Ser A. 2020;75(1):117–22.

    Article  Google Scholar 

  6. Zhou Y, Ke S-J, Qiu X-P, Liu L-B. Prevalence, risk factors, and prognosis of orthostatic hypotension in diabetic patients: a systematic review and meta-analysis. Medicine. 2017;96:36.

    Google Scholar 

  7. Low PA, Benrud-Larson LM, Sletten DM, Opfer-Gehrking TL, Weigand SD, O’Brien PC, et al. Autonomic symptoms and diabetic neuropathy: a population-based study. Diabetes Care. 2004;27(12):2942–7.

    Article  Google Scholar 

  8. Budyono C, Setiati S, Purnamasari D, Rumende CM. The proportion of orthostatic hypotension and its relationship with HbA1c levels in elderly patients with diabetes. Acta Med Indones. 2016;48(2):122–8.

    PubMed  Google Scholar 

  9. Freeman R, Abuzinadah AR, Gibbons C, Jones P, Miglis MG, Sinn DI. Orthostatic hypotension: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72(11):1294–309.

    Article  Google Scholar 

  10. Verwoert GC, Mattace-Raso FU, Hofman A, Heeringa J, Stricker BH, Breteler MM, et al. Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study. J Am Geriatr Soc. 2008;56(10):1816–20.

    Article  Google Scholar 

  11. Ricci F, Fedorowski A, Radico F, Romanello M, Tatasciore A, Di Nicola M, et al. Cardiovascular morbidity and mortality related to orthostatic hypotension: a meta-analysis of prospective observational studies. Eur Heart J. 2015;36(25):1609–17.

    Article  Google Scholar 

  12. Xin W, Mi S, Lin Z, Wang H, Wei W. Orthostatic hypotension and the risk of incidental cardiovascular diseases: a meta-analysis of prospective cohort studies. Prev Med. 2016;85:90–7.

    Article  Google Scholar 

  13. Gibbons CH, Centi J, Vernino S, Freeman R. Autoimmune autonomic ganglionopathy with reversible cognitive impairment. Arch Neurol. 2012;69(4):461–6.

    Article  Google Scholar 

  14. Maurer MS, Burcham J, Cheng H. Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility. J Gerontol A Biol Sci Med Sci. 2005;60(9):1157–62.

    Article  Google Scholar 

  15. Angelousi A, Girerd N, Benetos A, Frimat L, Gautier S, Weryha G, et al. Association between orthostatic hypotension and cardiovascular risk, cerebrovascular risk, cognitive decline and falls as well as overall mortality: a systematic review and meta-analysis. J Hypertens. 2014;32(8):1562–71.

    CAS  Article  Google Scholar 

  16. Novak V, Novak P, Spies JM, Low PA. Autoregulation of cerebral blood flow in orthostatic hypotension. Stroke. 1998;29(1):104–11.

    CAS  Article  Google Scholar 

  17. Fedorowski A, Gibbons C. Orthostatic hypotension and diabetes are dangerous companions. J Diabetes Complications. 2016;30(1):5.

    Article  Google Scholar 

  18. Wijkman M, Länne T, Östgren CJ, Nystrom FH. Diastolic orthostatic hypertension and cardiovascular prognosis in type 2 diabetes: a prospective cohort study. Cardiovasc Diabetol. 2016;15(1):83.

    Article  Google Scholar 

  19. Feldstein C, Weder AB. Orthostatic hypotension: a common, serious and underrecognized problem in hospitalized patients. J Am Soc Hypertens. 2012;6(1):27–39.

    Article  Google Scholar 

  20. Mar PL, Raj SR. Orthostatic hypotension for the cardiologist. Curr Opin Cardiol. 2018;33(1):66.

    Article  Google Scholar 

  21. Biaggioni I. The pharmacology of autonomic failure: from hypotension to hypertension. Pharmacol Rev. 2017;69(1):53–62.

    CAS  Article  Google Scholar 

  22. Migisha R, Agaba DC, Katamba G, Kwaga T, Tumwesigye R, Miranda SL, et al. Prevalence and correlates of cardiovascular autonomic neuropathy among patients with diabetes in Uganda: a hospital-based cross-sectional study. Glob Heart. 2020;15:1.

    Article  Google Scholar 

  23. Organization WH. Definition and diagnosis of diabetes mellitus and intermediate hyperglycaemia: report of a WHO/IDF consultation. 2006.

  24. Ahnve S. Correction of the QT interval for heart rate: review of different formulas and the use of Bazett’s formula in myocardial infarction. Am Heart J. 1985;109(3):568–74.

    CAS  Article  Google Scholar 

  25. Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. 2005;28(4):956–62.

    Article  Google Scholar 

  26. Gibbons CH, Schmidt P, Biaggioni I, Frazier-Mills C, Freeman R, Isaacson S, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017;264(8):1567–82.

    Article  Google Scholar 

  27. National CEPN. Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143.

    Article  Google Scholar 

  28. Gu Y-M, Thijs L, Li Y, Asayama K, Boggia J, Hansen TW, et al. Outcome-driven thresholds for ambulatory pulse pressure in 9938 participants recruited from 11 populations. Hypertension. 2014;63(2):229–37.

    CAS  Article  Google Scholar 

  29. Kuehl M, Stevens MJ. Cardiovascular autonomic neuropathies as complications of diabetes mellitus. Nat Rev Endocrinol. 2012;8(7):405.

    CAS  Article  Google Scholar 

  30. Hirai FE, Moss SE, Klein BE, Klein R. Postural blood pressure changes and associated factors in long-term Type 1 diabetes: Wisconsin Epidemiologic Study of Diabetic Retinopathy. J Diabetes Complic. 2009;23(2):83–8.

    Article  Google Scholar 

  31. Mesquita P, Queiroz D, Lamartine de Lima Silva V, Texeira VdC, Vilaça de Lima YR, Júnior ERF, et al. Prevalence of orthostatic hypertension in elderly patients with type 2 diabetes. Int J Endocrinol. 2015;2015.

  32. Yoshinari M, Wakisaka M, Nakamura U, Yoshioka M, Uchizono Y, Iwase M. Orthostatic hypertension in patients with type 2 diabetes. Diabetes Care. 2001;24(10):1783–6.

    CAS  Article  Google Scholar 

  33. Wu J-S, Yang Y-C, Lu F-H, Wu C-H, Chang C-J. Population-based study on the prevalence and correlates of orthostatic hypotension/hypertension and orthostatic dizziness. Hypertens Res. 2008;31(5):897–904.

    Article  Google Scholar 

  34. Bouhanick B, Meliani S, Doucet J, Bauduceau B, Verny C, Chamontin B, et al., editors. Orthostatic hypotension is associated with more severe hypertension in elderly autonomous diabetic patients from the French Gerodiab study at inclusion. Ann Cardiol d'Angéiol; 2014: Elsevier.

  35. Wu J-S, Lu F-H, Yang Y-C, Chang C-J. Postural hypotension and postural dizziness in patients with non-insulin-dependent diabetes. Arch Intern Med. 1999;159(12):1350–6.

    CAS  Article  Google Scholar 

  36. Fleg JL, Evans GW, Margolis KL, Barzilay J, Basile JN, Bigger JT, et al. Orthostatic hypotension in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) blood pressure trial: prevalence, incidence, and prognostic significance. Hypertension. 2016;68(4):888–95.

    CAS  Article  Google Scholar 

  37. Rahman S, Ahmad R, Aamir A. Prevalence of orthostatic hypotension among diabetic patients in a community hospital of Peshawar. Pak J Physiol. 2010;6(2):37–9.

    Google Scholar 

  38. Finucane C, O’Connell MD, Fan CW, Savva GM, Soraghan CJ, Nolan H, et al. Age-related normative changes in phasic orthostatic blood pressure in a large population study: findings from The Irish Longitudinal Study on Ageing (TILDA). Circulation. 2014;130(20):1780–9.

    Article  Google Scholar 

  39. Applegate WB, Davis BR, Black HR, Smith WM, Miller ST, Burlando AJ. Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) cohort. J Am Geriatr Soc. 1991;39(11):1057–64.

    CAS  Article  Google Scholar 

  40. Nibouche-Hattab W, Lanasri N, Zeraoulia F, Chibane A, Biad A, editors. Orthostatic hypertension in normotensive type 2 diabetics: What characteristics? Annales de Cardiologie et d'Angéiologie; 2017: Elsevier.

Download references

Acknowledgements

We thank the study participants, the staff and management of Mbarara Regional Referral Hospital who contributed in several ways towards the success of this study. We are very thankful to members of the Technical Advisory Committee (TAC) of Mbarara University Research Training Initiative (MURTI) for their technical input into the study. We also acknowledge Dr. Sam Ruvuma and Dr. Kwagga Teddy of the Ophthalmology Department of Mbarara University of Science and Technology for their technical support.

Funding

This research was supported by the Fogarty International Center and co-founding partners (NIH Common Fund, Office of Strategic Coordination, Office of the Director (OD/OSC/CF/NIH); Office of AIDS Research, Office of the Director (OAR/NIH); National Institute of Mental Health (NIMH/NIH); and National Institute of Neurological Disorders and Stroke (NINDS/NIH)) of the National Institutes of Health under Award Number D43TW010128. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author information

Authors and Affiliations

Authors

Contributions

RM, AM, DCA, and MS conceived the study, contributed to discussion, and reviewed, edited and wrote the manuscript. GK and DCA reviewed ECG recordings. RM analyzed the data. JM, AM, and MS contributed to interpretation of findings, review of the paper to ensure intellectual content and scientific integrity. RM is the guarantor of this research work and, as such, has full access to all the data for the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Richard Migisha.

Ethics declarations

Ethics approval and consent to participate

The study got approval from the institutional ethics review board of Mbarara University of Science and Technology (MUST-REC). We also received approval for the study from the Uganda National Council of Science and Technology (UNCST) and from the Research Secretariat in the Office of the President of Uganda, in accordance with the national guidelines. All study participants provided written informed consent before participation. Participants who could not write gave consent with a thumbprint.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests in regard to this work.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Migisha, R., Agaba, D.C., Katamba, G. et al. Postural changes in blood pressure among patients with diabetes attending a referral hospital in southwestern Uganda: a cross-sectional study. BMC Cardiovasc Disord 21, 213 (2021). https://doi.org/10.1186/s12872-021-02022-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12872-021-02022-5

Keywords

  • Orthostatic hypotension
  • Orthostatic hypertension
  • Diabetes
  • Uganda