A Rise in Blood Pressure Upon Standing May Signal Future Heart Attack, Stroke Risk

Blood pressure normally dips when a person stands up—but an unusual rise may indicate a higher risk of cardiovascular events later in life.

Doctor checking blood pressure of patient
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A rise in blood pressure upon standing in some people may indicate an increased risk of heart problems later in life, new research shows. The findings may help health care providers better determine a person's future cardiovascular risk and treatment options.

The study, published in the American Heart Association's journal Hypertension, found that among people ages 18 to 45 years old with hypertension (high blood pressure), a rise in blood pressure upon standing indicated an increased risk of future major cardiovascular events, like heart attack, heart-related chest pain, and stroke.

"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 blood pressure response to standing," Paolo Palatini, MD, lead study author and professor of internal medicine at the University of Padova in Italy, said in a press release.

Among this population specifically, many aren't even aware that they have high blood pressure: A 2020 JAMA study found that 67% of people aged 18 to 44 were not aware that they had hypertension. And even among those who knew about their high blood pressure, fewer 18­­- to 44-year-olds managed their hypertension through medication, as compared to people ages 45 and older. The new research shows that management among this population plays an important role in future cardiovascular health.

Standing Blood Pressure and Cardiovascular Event Risk

For the new study, researchers from the University of Padova evaluated data from 1,207 people ages 18 to 45 with untreated stage 1 hypertension (a systolic blood pressure of 140­-159 mm HG and/or a diastolic blood pressure of 90-100 hh mg). None of the study participants had taken any blood pressure-lowering medication, and they were all considered at low risk for major cardiovascular events.

At the time of their enrollment in the study, patients had six blood pressure readings done in different positions, including while lying down and after standing up. Of all participants, 120 (10%) saw the highest rise of more than a 6.5 mm Hg increase in systolic blood pressure upon standing. The other participants averaged a 3.8 mm Hg fall in systolic blood pressure.

Researchers followed up with the patients after an average of 17 years, discovering 105 major cardiovascular events among study participants, including heart attacks, heart-related chest pain, and stroke. Those with the highest blood pressure rise were nearly twice as likely as others to experience a major cardiovascular event—even if they did not have a higher overall risk profile.

The change in blood pressure is not only significant due to the increased risk of cardiovascular events attached to it, but also because it's the opposite of what normally happens upon standing. According to researchers, systolic blood pressure falls slightly when people stand up.

"Upon standing, more blood pools in our legs and relatively less blood is supplised to the upper parts of our body," Aeshita Dwivedi, MD, a cardiologist at Lenox Hill Hospital who was not involved in the study, told Health.com. "The body…has internal mechanisms to counteract the change in position and typically the blood pressure goes back to normal within seconds."

"This study identifies a group of patients whose compensatory mechanisms are hyperactive to this positional change," said Dr. Dwivedi. "Additionally, since these are young patients, early detection and aggressive blood pressure control can help to potentially improve long-term outcomes."

Though the study findings were significant, there were still limitations. All study participants were white, and the large majority (72%) were men, so the results may not be generalizable to people of other racial or ethnic groups, or genders. More research needs to be done to confirm these findings across various populations.

A New Approach to Blood Pressure Measurements?

Health care providers don't typically measure blood pressure upon standing, according to Dr. Palatini—but the study findings suggest it may be beneficial.

"The correct approach would be to measure blood pressure in all young subjects on standing focusing especially on systolic blood pressure," Dr. Palatini said. "If the lying to standing blood pressure difference exceeds 6-7 mmHg and orthostatic blood pressure is in the hypertensive range, using the same cut off as for sitting blood pressure, drug treatments should be started."

As of right now, however, blood pressure-measuring practices won't see any changes. "While this study is not practice changing, it does call for larger scale studies to further study if this group of patients may benefit from more aggressive blood pressure management," Dr. Dwivedi said.

In the meantime, it is important to seek regular preventive medical care—that includes annual checkups with health care providers that include blood pressure readings. People of all ages should continue to focus on a healthy, sustainable lifestyle to avoid long-term cardiovascular complications.

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