Targets for deprescribing in patients with hypertension and reflex syncope

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.