Baroreflex sensitivity as a target for nonpharmacological interventions in elderly patients with supine hypertension and orthostatic hypotension

Q: What are the key findings of this study?

Concurrent supine hypertension and systolic orthostatic hypotension reduced adrenergic (11.2 vs 18.9 mmHg/s) and vagal (2.6 vs 3.5 ms/mmHg) baroreflex sensitivity compared to controls (p<0.05).

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Systolic orthostatic hypotension and supine hypertension (n=273). Intervention: Concurrent supine hypertension and systolic orthostatic hypotension (SH/sOH) vs. No supine hypertension and no systolic orthostatic hypotension (No SH/No sOH). Primary outcome: Adrenergic baroreflex sensitivity (BRSa, mmHg/s) during the Valsalva maneuver (p=<0.05).

Q: What does this research mean for the field?

Concurrent supine hypertension and systolic orthostatic hypotension in elderly patients are associated with marked impairments in both adrenergic and vagal baroreflex sensitivity. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To determine the relationship between heart rate variability autonomic biomarkers and impaired baroreflex responses in elderly patients with systolic orthostatic hypotension, supine hypertension, or both.

José R. Criado; Richard Gevirtz; Mary A. Kalafut

doi:10.21203/rs.3.rs-11222315/v1

October 14, 2026Open Access

Baroreflex sensitivity as a target for nonpharmacological interventions in elderly patients with supine hypertension and orthostatic hypotension

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Key result

Concurrent supine hypertension and orthostatic hypotension are linked to ~41% lower adrenergic baroreflex sensitivity.

P<0.05
n=273

Why the study?

Pharmacological interventions do not restore normal baroreflex control in elderly patients with orthostatic hypotension and supine hypertension, creating a need to define the relationship between impaired baroreflex responses and autonomic biomarkers targeted by heart rate variability biofeedback.

What is the relationship between heart rate variability biomarkers (SDNN and LF-HRV) and impaired adrenergic and vagal baroreflex responses during the Valsalva maneuver and head-up tilt in elderly patients with systolic orthostatic hypotension and/or supine hypertension?

Key Points

To determine the relationship between heart rate variability autonomic biomarkers and impaired baroreflex responses in elderly patients with systolic orthostatic hypotension, supine hypertension, or both.
Conducted a retrospective analysis of 273 elderly patients (144 women; aged 65–94 years) evaluated via the Autonomic Reflex Screen from 2015 to 2022.
Assessed time- and frequency-domain heart rate variability metrics during supine rest and head-up tilt, alongside adrenergic and vagal baroreflex sensitivity and hemodynamic phases during the Valsalva maneuver.
Systolic orthostatic hypotension was associated with reduced head-up tilt heart rate variability and reduced adrenergic baroreflex sensitivity (10.1 mmHg/s in No SH/sOH and 11.2 mmHg/s in SH/sOH vs. 18.9 mmHg/s in controls), independent of supine hypertension.
Supine hypertension was associated with an increased early Phase II pressure drop during the Valsalva maneuver and lower vagal baroreflex sensitivity (2.4 ms/mmHg in SH/No sOH and 2.6 ms/mmHg in SH/sOH vs. 3.5 ms/mmHg in controls), independent of orthostatic hypotension.
Deficits in late Phase II were observed exclusively in patients with concurrent supine hypertension and systolic orthostatic hypotension (5.7 mmHg vs. 11.3 mmHg in controls), while SDNN and LF-HRV significantly correlated with baroreflex recovery parameters.

Study Design

Type

Observational (n=273)

Multicenter

No

Structured PICO

What is the relationship between heart rate variability biomarkers (SDNN and LF-HRV) and impaired adrenergic and vagal baroreflex responses during the Valsalva maneuver and head-up tilt in elderly patients with systolic orthostatic hypotension and/or supine hypertension?

P

Population

273 elderly patients (mean age 74.9 years, 53% female) undergoing autonomic reflex screening for systolic orthostatic hypotension and/or supine hypertension, excluding those with pacemakers or vasoactive medications.

E

Exposure

Standardized Autonomic Reflex Screen testing protocol including Valsalva maneuver (VM; maintaining expiratory pressure at 30-40 mmHg for 15 s) and 5-minute Head-up Tilt (HUT) testing to evaluate autonomic biomarkers and baroreflex sensitivity.

C

Comparator

Comparison across four patient groups stratified by presence of supine systolic hypertension (SH, supine SBP ≥140 mmHg) and systolic orthostatic hypotension (sOH, sustained SBP drop ≥20 mmHg or ≥30 mmHg in those with SH within 3 minutes of HUT): No SH/No sOH (n=109) vs SH/No sOH (n=86) vs No SH/sOH (n=33) vs SH/sOH (n=45).

O

Outcome

Heart rate variability (HRV) indices (SDNN, RMSSD, LF-HRV, HF-HRV during supine and HUT) and adrenergic (BRSa) and vagal (BRSv) baroreflex responses and beat-to-beat BP phases (Phase IIE, Phase IIL, Phase IV, blood pressure recovery time [PRT]) during the Valsalva maneuver.surrogate

Main Result

Absolute Event Rate: 11.2% vs 18.9%

p-value: p=<0.05

This study demonstrates that in elderly patients, heart rate variability biomarkers (SDNN and LF-HRV) strongly correlate with distinct adrenergic and vagal baroreflex deficits underlying systolic orthostatic hypotension and supine hypertension, supporting their utility as physiological targets for nonpharmacological HRV biofeedback interventions.

Limitations

Retrospective data from patients referred to an Autonomic Laboratory without an age-matched healthy control group, which may limit representativeness.
Patients with systolic orthostatic hypotension included both those with and without neurogenic orthostatic hypotension without separate subgroup stratification.
Did not evaluate patients with delayed orthostatic hypotension (occurring after 3 minutes of standing).

Implication

SH with sOH linked to reduced baroreflex sensitivity; hypothesis-generating and should not yet change practice.

Abstract

Orthostatic hypotension (OH) and supine hypertension (SH) are physiological indicators of autonomic dysfunction that are associated with an increased risk of major cerebrocardiovascular events. Since pharmacological interventions do not restore normal baroreflex control, improving the efficacy of nonpharmacological interventions that are suitable for these at-risk populations is needed. Heart rate variability (HRV) biofeedback (HRVB) intervention is a safe option to effectively target cardiovascular autonomic regulation and the baroreflex in this patient population. The objective of this study was to determine in elderly patients the relationship between autonomic biomarkers known to be increased by HRVB and impaired baroreflex responses in patients with systolic OH (sOH) and/or SH. This is a retrospective study of 273 patients (144 women; Age: 65–94 yrs) evaluated with a standardized testing protocol of the Autonomic Reflex Screen from 2015 to 2022. Analyses were performed to determine HRV indices and adrenal (BRS a ) and vagal (BRS v ) baroreflex responses during the Valsalva maneuver (VM). The study demonstrated that sOH was associated with a reduction in HRV metrics and the BRS a , independent of SH. This study also demonstrated that SH was associated with a significant increase in Phase II E of the VM and a reduction in the BRS v , independent of sOH. Our results also showed that deficits in Phase II L of the VM were only observed in patients with sOH and concurrent SH. These findings suggest a significant relationship between biomarkers known to improve with HRVB (SDNN and LF-HRV) and deficits in hemodynamic fluctuations in VM contributing to sOH and SH.

Discussion

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Cite This Study

Criado et al. (2026) conducted an observational in Systolic orthostatic hypotension and supine hypertension (n=273). Concurrent supine hypertension and systolic orthostatic hypotension (SH/sOH) vs. No supine hypertension and no systolic orthostatic hypotension (No SH/No sOH) was evaluated on Adrenergic baroreflex sensitivity (BRSa, mmHg/s) during the Valsalva maneuver (p=<0.05). Concurrent supine hypertension and systolic orthostatic hypotension reduced adrenergic (11.2 vs 18.9 mmHg/s) and vagal (2.6 vs 3.5 ms/mmHg) baroreflex sensitivity compared to controls (p<0.05).

synapsesocial.com/papers/6ae28f40cbadf70daf6c446b https://doi.org/10.21203/rs.3.rs-11222315/v1

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Baroreflex sensitivity as a target for nonpharmacological interventions in elderly patients with supine hypertension and orthostatic hypotension

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Baroreflex sensitivity as a target for nonpharmacological interventions in elderly patients with supine hypertension and orthostatic hypotension

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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