Intensive Blood Pressure Goals Pose No Risk for Orthostatic Hypotension

Caroline Helwick

September 13, 2019

NEW ORLEANS — For patients with prior stroke, a lower systolic blood pressure (SBP) goal actually reduced the occurrence of orthostatic hypotension and did not lead to more dizziness or lightheadedness compared to standard goals, an analysis 3000 patients shows.

"In this at-risk population, the key take-away is that orthostatic hypotension detection in the setting of intensive blood pressure treatment does not appear to be a reason to deescalate blood pressure therapy," said Stephen P. Juraschek, MD, PhD, of Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Their findings were presented here at the American Heart Association's Hypertension 2019 Scientific Sessions.

"Orthostatic hypotension (the difference between standing and seated blood pressures) is an important predictor of dizziness, falls, dementia, cardiovascular disease (including stroke) and premature death," he said. "Because of these associations, people have been worried that more intensive blood pressure treatment strategies could cause orthostatic hypertension and contribute to these long-term effects."

Prior studies in different populations have suggested that lower SBP treatment goals can reduce the risk for orthostatic hypotension, but whether this also reduces orthostatic symptoms, including dizziness and lightheadedness, has not been clear.

This was the question examined by Juraschek and his colleagues in the Secondary Prevention of Small Subcortical Strokes – Blood Pressure trial (SPS3-BP).

Three Prior Trials

Three large prior trials — AASK, in African Americans with chronic kidney disease; ACCORD, in persons with diabetes; and SPRINT, in individuals without stroke or diabetes — evaluated lower blood pressure goals and the occurrence of orthostatic hypotension. "Contrary to what was expected," he said, AASK and ACCORD showed a trend for less orthostatic hypotension with more intensive goals, and SPRINT demonstrated a statistically significant 12% reduction in risk.

"More intensive therapy was not creating more orthostatic hypotension or a greater difference between seated and standing blood pressures," he said.

The current study examined the effect of an intensive blood pressure goal on orthostatic hypotension in SPS3-BP, an open-label, randomized trial in which 3020 adults who had recently undergone a stroke (<6 months) were assigned to either the standard SBP goal of 130 – 149 mmHg or the more intensive goal of <130 mmHg. This study differed from the other three in that it studied the particularly vulnerable population of patients who had recently had strokes.

During follow-up, blood pressure was measured three times in a seated position and once after 2 minutes of standing. Orthostatic hypotension was defined as a drop in SBP of ≥20 mmHg or in diastolic blood pressure (DBP) of ≥10 mmHg. The researchers also assessed extreme standing blood pressure (SBP ≥190 mmHg or ≤90 mmHg; DBP ≥110mm Hg or ≤40 mmHg).

Participants were asked about dizziness and lightheadedness in the process of standing up. In each treatment arm, patients underwent approximately 18,000 different assessments for orthostatic hypotension; the average number was 15 per patient.

Orthostatic hypotension was present in 7.6% of visits in the standard goal group and in 6.7% of visits in the intensive-goal group. Similarly, dizziness was present in 3.8% and 3.5% of visits, respectively, and lightheadedness in 2.7% and 2.5%, respectively, Juraschek reported.

Mean Blood Pressure by Assignment

Mean blood pressures were lower in the intensive-goal group, but seated blood pressures and standing blood pressures did not differ greatly. The intensive group actually had an increase in blood pressure levels, not a decrease, upon standing.

Table. Mean Blood Pressures by Assignment

Assessment Standard Goal (n = 1444) Intensive Goal (n = 1432)
Seated SBP (mmHg) 137.2 125.9
Standing SBP (mmHg) 140.8 130.0
Difference (mmHg) 3.5 4.1
     
Seated DBP (mmHg) 75.4 69.4
Standing DBP (mmHg) 78.5 72.5
Difference (mmHg) 3.1 3.2

 

A lower SBP goal (compared to standard) was associated with a lower risk for orthostatic hypotension, a higher risk for SBP ≤90 mmHg or DBP ≤40 mm Hg, and a lower risk for SBP ≥190 mmHg or DBP ≥110 mmHg, with odds ratios (ORs) as follows:

  • Occurrence of orthostatic hypotension, OR = 0.86 (P = .03)

  • Standing SBP ≤90 mmHg, OR = 3.79 (P < .001)

  • Standing SBP ≥190 mmHg, OR = 0.40 (P = .001)

  • Standing DBP ≤40 mmHg, OR = 2.42 (P = .001)

  • Standing DBP ≥110 mmHg, OR = 0.31 (P < .001)

Although the intensive goal was significantly associated with extreme blood pressure levels, these shifts had no effect on dizziness or lightheadedness, Juraschek said.

"Putting these findings in context with the other trials, this was a different population, a slightly different goal, slightly different orthostatic hypotension assessment, but a very similar effect on orthostatic hypotension, suggesting there is consistency across trials for this finding," he concluded. "These findings support recent observations that more intensive SBP treatment does not increase risk of falls."

Reassuring to Clinicians

Session moderators Sandra J. Taler, MD, professor of medicine at the Mayo Clinic, Rochester, Minnesota, and Eric Judd, MD, assistant professor of medicine at the University of Alabama, Birmingham, said the findings are reassuring in that intensive blood pressure goals do not put patients at risk for falls.

"Dr Juraschek showed three studies that looked at drops in blood pressure. This is the fourth one, and it's nice because it's in stroke patients. Stroke patients are the ones we really worry about," said Taler. "His study confirmed the findings from the other trials that were not in stroke patients, showing that treatment intensity actually reduces the frequency of orthostatic hypotension."

"Importantly, this was not associated with changes in symptoms," Judd added. "Especially with the new guidelines, we are intensifying our blood pressure regimens, and this has worried physicians and patients — the potential for dizziness and lightheadedness. These data argue that intensive treatment won't, in fact, increase this risk, and you may actually reduce orthostatic hypotension."

Juraschek, Judd, and Taler have disclosed no relevant financial relationships.

Hypertension 2019 Scientific Sessions: Abstract 103, presented September 7, 2019.

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