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Published on: March 21, 2013
Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension : A Systematic Review and Individual
Stephen P Juraschek1, Jiun-Ruey Hu2, Jennifer L Cluett1
1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.).
Insights
Intensive blood pressure (BP) lowering treatment reduces the risk of orthostatic hypotension (OH) in adults with hypertension. This finding suggests that OH should not prevent or reduce the intensity of BP-lowering therapy.
Area of Science:
- Cardiology
- Clinical Pharmacology
- Hypertension Management
Background:
- Intensive blood pressure (BP)-lowering treatment is associated with reduced cardiovascular disease risk.
- Concerns exist regarding the potential for intensive BP treatment to induce orthostatic hypotension (OH).
Purpose of the Study:
- To evaluate the impact of intensive BP-lowering treatment on the occurrence of OH in adults diagnosed with hypertension.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted.
- Included trials involved over 500 hypertensive adults, with treatment durations of at least 6 months.
- OH was defined as a significant drop in BP upon standing; data were extracted from MEDLINE, EMBASE, and Cochrane CENTRAL.
Main Results:
- Five trials focused on BP treatment goals and four on active agents versus placebo.
- Intensive BP treatment was associated with a reduced risk of OH (odds ratio, 0.93; 95% CI, 0.86 to 0.99).
- No significant differences in effect were observed based on pre-existing OH or in sensitivity analyses.
Conclusions:
- Intensive BP-lowering treatment effectively decreases the risk of developing orthostatic hypotension.
- Orthostatic hypotension should not be a deterrent for initiating or continuing intensive BP management in hypertensive patients.
Background:
Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH).
Purpose:
To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults.
Data Sources:
MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions.
Study Selection:
Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing.
Data Extraction:
2 investigators independently abstracted articles and rated risk of bias.
Data Synthesis:
5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged.
Limitations:
Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available.
Conclusion:
Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension.
Primary Funding Source:
National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).
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Monitoring Both Arms:
Monitoring BP in both arms during the initial assessment is advisable, as the systolic value may differ by five to ten mm Hg between arms. For subsequent BP assessments, use the arm with the higher reading.