Deprescribing of blood pressure-lowering medications in patients with hypotensive syncope

To assess the efficacy of deprescribing blood pressure-lowering medications in hypertensive patients suffering from severe hypotensive syncope.

Multicentre, prospective, pragmatic, non-randomized uncontrolled, study. Deprescribing (withdrawal or dose reduction of antihypertensive and psychoactive medications with blood pressure lowering effects) was guided by clinical experience and supported by two 24-hour ambulatory blood pressure monitoring (ABPM) assessments-one before (ABPM 1) and one after (ABPM 2) drug optimization. Primary endpoint was the reduction of the burden of syncope.

In a cohort of 92 patients (mean age 76.6 ± 12.1 years, 53% female), the total number of hypotensive medications decreased from 218 (2.4 ± 1.1 per patient) before deprescribing to 123 (1.3 ± 1.0 per patient) after the intervention. The 24-hour systolic blood pressure increased from 118.8 ± 10.8 mmHg at ABPM 1 to 127.5 ± 11.6 at ABPM 2 (p = 0.0001). The number of daytime SBP drops <90 mmHg and <100 mmHg decreased by 52%, (from 208 to 100) and 53% (from 601 to 280), respectively (p = 0.0001 for both). During the mean follow-up of 12.6 ± 3.8 months (range 2 to 21 months), 28 patients (30.4%) had syncopal recurrences. Excluding the index episode, patients experienced 111 episodes in the year before enrolment and 41 during the overall follow-up. The syncope burden dropped by 66%, from 0.08 (IQR 0-0.17) to 0 (IQR 0-0.07) episodes per month (p = 0.0001).

In patients with hypertension and hypotensive syncope deprescribing of blood pressure lowering medications reduced hypotensive episodes and syncopal recurrences. However, the findings preclude firm causal inferences.