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Published on: March 21, 2013
Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis
Stephen P Juraschek1, Jiun-Ruey Hu2, Jennifer L Cluett1
1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Insights
Intensive blood pressure treatment effectively reduces cardiovascular disease and all-cause mortality risk in adults, irrespective of whether they have orthostatic hypotension. This benefit was observed consistently across different blood pressure (BP) management strategies.
Area of Science:
- Cardiology
- Hypertension Management
- Clinical Trials
Background:
- Concerns exist regarding intensive versus standard blood pressure (BP) treatment benefits for adults with orthostatic hypotension.
- Orthostatic hypotension and standing hypotension are common conditions affecting BP regulation upon standing.
Purpose of the Study:
- To evaluate the impact of lower BP treatment goals or active therapy versus standard goals or placebo on cardiovascular disease (CVD) and all-cause mortality.
- To analyze these effects across different baseline levels of orthostatic hypotension and standing hypotension.
Main Methods:
- Individual participant data meta-analysis of 9 randomized trials including 29,235 participants.
- Systematic review of MEDLINE, EMBASE, and CENTRAL databases.
- Cox proportional hazard models were used to determine effects on CVD or all-cause mortality.
Main Results:
- Intensive BP treatment reduced CVD or all-cause mortality risk similarly in participants with and without baseline orthostatic hypotension (HR, 0.81-0.83).
- A similar risk reduction was observed in those without baseline standing hypotension (HR, 0.80), with a non-significant trend in those with it (HR, 0.94).
- No significant interaction was found between treatment effects and baseline orthostatic or standing hypotension.
Conclusions:
- Intensive BP treatment lowers CVD or all-cause mortality risk in hypertension trial participants.
- This benefit is consistent regardless of the presence of orthostatic hypotension.
- The study found no evidence of differing effects based on baseline standing hypotension.
Importance:
There are ongoing concerns about the benefits of intensive vs standard blood pressure (BP) treatment among adults with orthostatic hypotension or standing hypotension.
Objective:
To determine the effect of a lower BP treatment goal or active therapy vs a standard BP treatment goal or placebo on cardiovascular disease (CVD) or all-cause mortality in strata of baseline orthostatic hypotension or baseline standing hypotension.
Data Sources:
Individual participant data meta-analysis based on a systematic review of MEDLINE, EMBASE, and CENTRAL databases through May 13, 2022.
Study Selection:
Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) with orthostatic hypotension assessments.
Data Extraction And Synthesis:
Individual participant data meta-analysis extracted following PRISMA guidelines. Effects were determined using Cox proportional hazard models using a single-stage approach.
Main Outcomes And Measures:
Main outcomes were CVD or all-cause mortality. Orthostatic hypotension was defined as a decrease in systolic BP of at least 20 mm Hg and/or diastolic BP of at least 10 mm Hg after changing position from sitting to standing. Standing hypotension was defined as a standing systolic BP of 110 mm Hg or less or standing diastolic BP of 60 mm Hg or less.
Results:
The 9 trials included 29 235 participants followed up for a median of 4 years (mean age, 69.0 [SD, 10.9] years; 48% women). There were 9% with orthostatic hypotension and 5% with standing hypotension at baseline. More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline orthostatic hypotension (hazard ratio [HR], 0.81; 95% CI, 0.76-0.86) similarly to those with baseline orthostatic hypotension (HR, 0.83; 95% CI, 0.70-1.00; P = .68 for interaction of treatment with baseline orthostatic hypotension). More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline standing hypotension (HR, 0.80; 95% CI, 0.75-0.85), and nonsignificantly among those with baseline standing hypotension (HR, 0.94; 95% CI, 0.75-1.18). Effects did not differ by baseline standing hypotension (P = .16 for interaction of treatment with baseline standing hypotension).
Conclusions And Relevance:
In this population of hypertension trial participants, intensive therapy reduced risk of CVD or all-cause mortality regardless of orthostatic hypotension without evidence for different effects among those with standing hypotension.
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