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Dear Editor,  With interest we have read the article by Fedorowski et al. [1], which provides valuable information about cause-specific mortality in middle-aged subjects with orthostatic hypotension. In their study orthostatic hypotension (defined as a decrease in systolic blood pressure ≥20 mmHg and/or decrease in diastolic blood pressure ≥10 mmHg within 3 min of standing) was associated with mortality through injuries and neurologic diseases. Our major comment is that the article lacks data on the postural diastolic pressure response, both in describing the whole group with orthostatic hypotension, and the analyses of all cause and cause-specific mortality.  Surprisingly, orthostatic hypotension and postural systolic blood pressure decline was not associated with cardiovascular mortality, although there was such an association in a smaller rescreened subsample. In other studies orthostatic hypotension was associated with myocardial infarction in middle-aged adults [2] and home dwelling elderly [3]. Unfortunately Fedorowski et al. [1] did not study the influence of postural diastolic blood pressure decline on cause-specific mortality. There might be a crucial role of diastolic blood flow on myocardial perfusion and subsequently myocardial infarction and cardiovascular mortality [3]. Postural diastolic, but not systolic blood pressure decline, seems to be associated with an increased risk of myocardial infarction [3]. Moreover in the same study population of the Malmo Preventive Project already the association was found that postural diastolic, but not systolic blood pressure decline predicts coronary events [4].  In conclusion, Fedorowski et al. [1] added very valuable information to the current knowledge of orthostatic hypotension through information on cause-specific mortality. However we miss in their study specific data on cause-specific mortality in relation to postural diastolic blood pressure decline and especially regarding cardiovascular mortality.  References    Fedorowski A, Hedblad B, Melander O. Early postural blood pressure response and cause-specific mortality among middle-aged adults. Eur J Epidemiol 2011.   Rose KM, Tyroler HA, Nardo CJ, Arnett DK, Light KC, Rosamond W et al. Orthostatic hypotension and the incidence of coronary heart disease: the Atherosclerosis Risk in Communities study. Am J Hypertens 2000; 13(6 Pt 1): 571–8.   Luukinen H, Koski K, Laippala P, Airaksinen KE. Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly. J Intern Med 2004; 255(4): 486–93.   Fedorowski A, Stavenow L, Hedblad B, Berglund G, Nilsson PM, Melander O. Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project). Eur Heart J 2010; 31(1): 85–91.

Early postural blood pressure response and cause-specific mortality among middle-aged adults: what is the role of diastolic blood pressure?