Intensive Hypertension Treatment Lowers Orthostatic Hypotension

Megan Brooks

September 10, 2020

For most patients with hypertension, more aggressive blood pressure (BP) lowering does not increase risk for orthostatic hypotension (OH); on the contrary, it appears to lower the risk, a new meta-analysis suggests.

In addition, OH prior to treatment was not associated with more OH from aggressive treatment, principal investigator Stephen Juraschek, MD, PhD, of Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, told theheart.org | Medscape Cardiology.

"Our study does not support recommendations to screen for OH prior to and in the context of BP treatment," Juraschek said.

The study was presented at the virtual American Heart Association (AHA) Hypertension 2020 Scientific Sessions and simultaneously published online today in Annals of Internal Medicine.

"Major Analysis"

Commenting on the study for theheart.org | Medscape Cardiology, Vivek Bhalla, MD, director, Stanford Hypertension Center, Stanford University School of Medicine, California, said this is a "major analysis of an important consequence of drugs used to treat hypertension and addresses a potential barrier to implementation of newer, more intensive blood pressure guidelines."

"A meta-analysis allows one to have increased statistical power to detect effects that may not be possible in individual trials with smaller numbers of patients," said Bhalla, who was not involved in the study.

"This work provides further statistical evidence that orthostatic hypotension is not a reason to avoid intensive treatment to reduce blood pressure."

Intensive BP treatment reduces the risk of cardiovascular disease, but there are ongoing concerns that it might raise the risk for OH, an important risk factor for falls, fracture, syncope, dementia, stroke, and death. However, individual trials have been inconclusive.

Dr Stephen Juraschek

Juraschek and colleagues searched three large medical databases for randomized trials that examined the effects of BP medications on OH, defined as a drop in systolic blood pressure (SBP) ≥20 mm Hg or diastolic blood pressure (DBP) ≥10 mm Hg after changing from a seated to a standing position.

The primary analysis included individual patient data from five trials (AASK, ACCORD, SPRINT, SPS3 and UKPDS) with 18,466 participants (mean age, 64.5 years; 39% women) and 127,998 follow-up visits.

The intensive BP goal varied in the trials; two trials targeted an SBP <120 mm Hg (vs <140 mm Hg), one trial targeted an SBP <130 mm Hg (vs 130 to 149 mm Hg), one trial targeted a mean arterial pressure of 92 mm Hg or less (vs 102 to 107 mm Hg), and one trial targeted an SBP <150 mm Hg and DBP <85 mm Hg (vs <180/<105 mm Hg). 

All trials comparing the different BP treatment goals showed reductions in the odds of OH with treatment, with SPRINT demonstrating the strongest relationship (odds ratio [OR], 0.89; 95% CI, 0.80 - 0.98).

In the pooled analysis of the five trials, assignment to a more intensive (vs standard) BP goal also lowered the odds of OH (OR, 0.93; 95% CI, 0.86 - 0.99).

The odds of OH with intensive BP treatment were even lower in adults without diabetes (OR, 0.90 vs 1.10; P-interaction = .015) and in adults with low standing SBP before treatment (OR, 0.66 for <110 mm Hg vs 0.96 for ≥110 mm Hg; P-interaction = .02) but were not significantly altered by age, sex, or Black race.

The findings (overall and for subgroups) were unchanged in sensitivity analyses that included four additional placebo-controlled trials.

No Barrier to Intensive BP Lowering

"Our study, incorporating a diverse range of treatment agents and goals and a large population older than 75 years, strongly affirms that more intensive BP treatment usually does not induce OH even among older adults," the authors write.

In addition, the study suggests that intensive BP treatment may potentially improve postural regulation of BP upon standing, particularly among adults with lower standing BP before treatment, they add.

"We know that more intensive BP control, particularly in older individuals with higher cardiovascular risk, is associated with better outcomes," Bhalla told theheart.org | Medscape Cardiology. "Of course, those patients are conventionally thought to be more at risk of OH. That risk may make patients and clinicians more wary of intensive treatment."

"Perhaps the most important message is that in the setting of clinical trials, where patients are well supervised, orthostatic hypotension is not a major factor in the use of more intensive BP management," Bhalla emphasized.

"It is noteworthy, that in a real-life setting, we may see more episodes of orthostatic hypotension with intensive treatment, when patients are not seen as often and not supervised as closely as those patients that are participating in a clinical trial.

"However, with appropriate supervision, careful follow-up, and patient education, in an effort to reduce cardiovascular risk and improve patient outcomes, orthostatic hypotension does not have to be a barrier to more intensive blood pressure management," he added.

The study was supported by the NIH National Heart, Lung, and Blood Institute Juraschek and Bhalla have disclosed no relevant financial relationships.

Ann Intern Med. Published online September 10, 2020. Abstract

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