Intensive hypertension treatment associated with lower risk for orthostatic hypotension

Orthostatic hypotension should not be viewed as a reason to avoid or de-escalate hypertension treatments, according to the authors of a new systematic review of hypertension treatment trials.

Hypertension treatment lowers the risk for orthostatic hypotension, a systematic review found.

Researchers reviewed trials for adults with hypertension in which sitting and standing blood pressure was measured to identify orthostatic hypotension. Randomized trials of hypertension treatments that involved more than 500 adults with hypertension or elevated blood pressure and lasted six months or more were included. The primary outcome was orthostatic hypotension, defined as a decrease of 20 mm Hg or more in systolic blood pressure or 10 mm Hg or more in diastolic blood pressure after standing. Individual-patient data were also analyzed to determine demographic characteristics or related comorbidities. Results were published Sept. 10 by Annals of Internal Medicine and were presented at the American Heart Association (AHA) Hypertension Scientific Sessions 2020.

Five trials compared higher and lower blood pressure treatment goals and included 18,466 participants with 127,882 follow-up visits. The systematic review found lower risk for orthostatic hypotension with intensive treatment (odds ratio, 0.93; 95% CI, 0.86 to 0.99). Overall and subgroup findings did not change in sensitivity analyses that included four additional placebo-controlled trials. Lower blood pressure targets were associated with lower risk for orthostatic hypotension regardless of age, standing hypotension status, or orthostatic hypotension before treatment. The review found that intensive treatment may even improve blood pressure regulation in adults with standing hypotension, the authors said.

They added that these findings are important because current American Heart Association/American College of Cardiology blood pressure management guidelines recommend screening for orthostatic hypotension before hypertension treatment or in treated adults, especially older adults. This study suggests that neither screening nor medication adjustment is necessary before treating hypertension. Although individual patients may have unique reactions to some drugs, requiring changes in therapy, the findings support a growing body of evidence that orthostatic hypotension should not be a reason to titrate or stop blood pressure treatment, the authors said.

“Our findings may seem at odds with clinical experience because many clinicians have observed hypotension, syncope, and falls while treating their hypertensive patients,” they wrote. “This observation may be due to the acute effects of antihypertensive therapy before baroreflex sensitivity, vascular stiffness, ventricular diastolic filling, and other blood pressure regulatory mechanisms have had a chance to adapt. The long-term treatment of hypertension has been shown to improve many of these mechanisms, which may explain the beneficial effect of treatment shown here.”