Intensive antihypertensive treatment provides the same benefit with regard to cardiovascular disease (CVD) and all-cause mortality regardless of the presence or absence of orthostatic or standing hypotension, new research shows.
In response to ongoing concern about the benefits of intensive vs standard blood pressure (BP) treatment for adults with orthostatic hypotension (OH), researchers conducted a meta-analysis of individual patient data from nine randomized clinical trials to see whether the benefit of antihypertensive treatment was diminished for patients who had OH at baseline. Benefit was defined as a reduction in nonfatal CVD events and all-cause mortality.
The included trials assessed BP pharmacologic treatment (more intensive BP goal or active agent) and had data on OH.
The nine trials included 29,235 participants (mean age, 69 years; 48% women) who were followed for a median of 4 years; 9% had OH, and 5% had standing hypotension at baseline.
Having OH at baseline was significantly associated with the composite of CVD or all-cause mortality (hazard ratio [HR], 1.14; 95% CI, 1.04 – 1.26) and with all-cause mortality (HR, 1.24; 95% CI, 1.09 – 1.41). The same was true for baseline standing hypotension (composite outcome: HR, 1.39; 95% CI, 1.24 – 1.57; all-cause mortality: HR, 1.38; 95% CI, 1.14 – 1.66).
More intensive BP treatment or active therapy significantly and similarly lowered risk of CVD or all-cause mortality among adults who did not have OH at baseline (HR, 0.81; 95% CI, 0.76 – 0.86) as well as those with OH at baseline (HR, 0.83; 95% CI, 0.70 – 1.00).
More intensive BP treatment or active therapy also significantly lowered risk of CVD or all-cause mortality among those without baseline standing hypotension (HR, 0.80; 95% CI, 0.75 – 0.85) and nonsignificantly lowered the risk among those with baseline standing hypotension (HR, 0.94; 95% CI, 0.75 – 1.18).
“These findings suggest that orthostatic hypotension alone (ie, without symptoms) and standing hypotension measured prior to intensification of BP treatment should not deter adoption of more intensive BP treatment in adults with hypertension,” the authors conclude.
The findings should “reassure clinicians that patients with OH (and perhaps standing hypotension) will derive the full expected benefits from antihypertensive therapy,” add the authors of an accompanying editorial. “This also applies to patients treated to lower BP goals, albeit with less certainty.”
The study, with first author Stephen Juraschek, MD, PhD, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, and the accompanying editorial were published online October 17 in JAMA.
In the hypertension trials that were included in the analysis, the study populations differed, as did BP measurement procedures, interventions, duration, and CVD outcome ascertainment processes and definitions. Some trials excluded adults with low standing systolic BP, limiting the number of participants with standing hypotension. OH was determined on the basis of a seated-to-standing protocol; supine-to-standing protocols are more sensitive and may not be interchangeable. Medications used in the trials may not reflect current medicine practice, or the trials may not have included agents thought to be more likely to affect OH and falls.
The study had no specific fuding. Juraschek has disclosed no relevant financial relationships.
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