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Targets for deprescribing in patients with hypertension and reflex syncope
Antonella Groppelli1, Giulia Rivasi2, Artur Fedorowski3
1IRCCS Istituto Auxologico Italiano, Faint and Fall Research Centre, Department of Cardiology, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy.
Insights
To prevent blood pressure drops in hypertensive patients with reflex syncope, aim for a 12 mmHg increase in 24-hour systolic blood pressure (SBP) to reach 134 mmHg. Drug withdrawal is more effective than dose reduction for achieving this target.
Area of Science:
- Cardiology
- Geriatrics
- Clinical Pharmacology
Background:
- Hypertension management in elderly patients with reflex syncope is complex.
- Systolic blood pressure (SBP) drops can lead to syncope, necessitating treatment adjustments.
- Identifying optimal blood pressure targets for deprescribing is crucial.
Purpose of the Study:
- To determine the target 24-hour SBP increase for maximal reduction of SBP drops in hypertensive patients with reflex syncope.
- To evaluate the effectiveness of drug withdrawal versus dose reduction in preventing SBP drops.
Main Methods:
- Forty hypertensive patients (mean age 73.6 years) with reflex syncope and SBP drops underwent ambulatory blood pressure monitoring (ABPM).
- Patients were advised to withdraw or reduce antihypertensive therapy.
- A second ABPM was performed within 3 months to assess SBP drops <90 mmHg and <100 mmHg.
Main Results:
- A 24-hour SBP increase of 12 mmHg (to 134 mmHg) was associated with the disappearance of daytime SBP drops <100 mmHg in 50% of patients.
- Patients achieving this target had a greater reduction in hypotensive drugs (67% vs. 19%) and higher withdrawal rates (62% vs. 29%).
- Drug withdrawal was more common (44/98 drugs) than dose reduction (16/98 drugs).
Conclusions:
- An increase in 24-hour SBP to 134 mmHg, representing a 12 mmHg rise, is an optimal target for preventing SBP drops in this population.
- Complete drug withdrawal is generally more effective than dose reduction for achieving target SBP goals.
- These findings guide deprescribing strategies in hypertensive elderly patients with reflex syncope.
Background:
We aimed to identify the target of deprescribing, i.e. the 24-hour SBP increase needed to achieve the greatest reduction of SBP drops.
Method:
Forty hypertensive patients (mean age 73.6 ± 9.3 years, 26 females) with reflex syncope and SBP drops on a screening ABPM were advised to withdraw or to reduce their therapy. The study objective was the reduction of SBP drops <90 mmHg and <100 mmHg on a second ABPM performed within 3 months.
Results:
Out of a total of 98 drugs taken during ABPM 1, 44 were withdrawn, 16 had a dose reduction and 38 remained unchanged at the time of ABPM 2. 24-hour SBP increased from 119.7 ± 10.1 mmHg to 129.4 ± 13.2 mmHg during ABPM2. Total disappearance of daytime SBP drops <100 mmHg was achieved in 20 (50 %) patients who had 24-hour SBP of 134±13 mmHg and an increase from ABPM 1 of 12 (IQR 5-20) mmHg. Compared with the 20 patients who had persistence of drops, these patients had a greater reduction of the number of hypotensive drugs (67 % versus 19 %, p = 0.002) and a greater rate of withdrawals (62 % versus 29 %, p = 0.003).
Conclusion:
In hypertensive patients with reflex syncope, an increase of 12 mmHg and an absolute value of 24-hour SBP of 134 mmHg appear to represent the optimal goals aimed to prevent SBP drops. Drugs withdrawal, rather than simply dose reduction, is mostly required to achieve the above target.
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