Orthostatic hypotension should not deter intensive BP treatment among patients with hypertension

Considering this, a recent study published in the Journal of the American Medical Association (JAMA) sought to determine if the effect of intensive BP treatment on all-cause mortality or cardiovascular disease (CVD) differs based on the presence or absence of standing hypotension.

Stephen P. Juraschek, Harvard Medical School, Boston, Massachusetts, and colleagues found that asymptomatic orthostatic hypotension or standing hypotension among hypertension patients should not be a deterrent to more intensive hypertension treatment.

"The individual data meta-analysis involving more than 29,000 participants in 9 hypertension trials showed that more intensive BP treatment lowered the risk of all-cause mortality or CVD irrespective of whether participants had orthostatic hypotension," the researchers reported. "The effects did not differ by the absence or presence of standing hypotension."

For the research, the investigators conducted an individual participant data meta-analysis based on a systematic review of online databases through May 13, 2022. Randomized trials of blood pressure pharmacologic treatment (more intensive BP goal or active agent) with orthostatic hypotension assessments were selected.

They extracted individual participant data meta-analysis following PRISMA guidelines. Effects were determined using Cox proportional hazard models using a single-stage approach.

The main outcomes of the study were all-cause mortality or CVD. Orthostatic hypotension was defined as a reduction in systolic BP of at least 20 mm Hg and/or diastolic BP of at least 10 mm Hg after changing position from sitting to standing. Standing hypotension was defined as a standing systolic BP of 110 mm Hg or less or a standing diastolic BP of 60 mm Hg or less.

The researchers reported the following findings:

• The 9 trials included 29 235 participants followed up for a median of 4 years (mean age, 69.0 years; 48% women). There were 9% with orthostatic hypotension and 5% with standing hypotension at baseline.
• More intensive BP treatment or active therapy reduced the risk of CVD or all-cause mortality among those without baseline orthostatic hypotension (hazard ratio [HR], 0.81) similar to those with baseline orthostatic hypotension (HR, 0.83).
• More intensive BP treatment or active therapy lowered the risk of CVD or all-cause mortality among those without baseline standing hypotension (HR, 0.80), and nonsignificantly among those with baseline standing hypotension (HR, 0.94). Effects did not differ by baseline standing hypotension.

"In this population of hypertension trial participants, intensive therapy lowered the risk of CVD or all-cause mortality irrespective of orthostatic hypotension without evidence for different effects among those with standing hypotension," the researchers concluded.

The findings should "reassure clinicians that patients with orthostatic 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 blood pressure goals, albeit with less certainty."

Reference:

Juraschek SP, Hu J, Cluett JL, et al. Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis. JAMA. 2023;330(15):1459–1471. doi:10.1001/jama.2023.18497