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Intensive hypertension treatment lowers risk of orthostatic hypotension

Annals of Internal Medicine
AHA Hypertension 2020
Reuters Health - 10/09/2020 - Orthostatic hypotension is not necessarily a reason to avoid or de-escalate treatment for hypertension, researchers reported Thursday at the American Heart Association's Hypertension 2020 Scientific Sessions.

In fact, lower blood pressure targets were associated with a lower risk for orthostatic hypotension, particularly among adults without diabetes and adults with lower standing systolic blood pressure, a meta-analysis of randomized trials suggests.

Researchers examined data from five trials with a total of 18,466 hypertensive adults that examined BP treatment goals, including four trials that compared active agents to placebo.

At baseline, mean seated systolic blood pressure was 141.4 mm HG and mean diastolic blood pressure was 79.1 mm Hg. Among 14,846 participants with orthostatic hypotension measurements in the visit before randomization, 8.5% had 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 changing from a seated to standing position.

The mean postural change in systolic blood pressure was 1.82 mm Hg among people assigned standard blood pressure goals, and 1.84 mm Hg among those assigned intensive blood pressure treatment goals. In the pooled analysis, a more-intensive blood pressure goal lowered the odds of orthostatic hypotension more than a standard blood pressure goal (odds ratio 0.93).

"These results suggest that orthostatic hypotension does not seem to result from more aggressive blood pressure treatment," said lead study author Dr. Stephen Juraschek, an assistant professor of medicine at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

"We ultimately showed that hypertension treatment lowered risk of orthostatic hypotension, and this was observed regardless of age, standing hypotension status, or orthostatic hypotension prior to treatment," Dr. Juraschek said by email.

These findings are important because current ACC/AHA blood pressure management guidelines recommend screening for orthostatic hypotension prior to hypertension treatment or in treated adults, especially older adults, Dr. Juraschek said.

"Our findings do not support this practice nor the belief that asymptomatic orthostatic hypotension in the setting of treatment be viewed as a reason to stop or down-titrate hypertension medications," Dr. Juraschek concluded.

Adults without diabetes had a lower risk of orthostatic hypotension with intensive blood pressure treatment (OR 0.90), as did adults who had standing systolic blood pressure below 110 mm Hg at baseline (OR 0.66).

Compared to less-aggressive blood pressure management, more-intensive treatment targets were not associated with statistically significant differences in postural change in blood pressure, systolic orthostatic hypotension, or diastolic orthostatic hypotension. But more-intensive treatment did increase the risk for low standing blood pressure and decrease the risk for high standing blood pressure.

Across the five trials in the analysis, participants' mean age was 64.5 years, 38.9% were women, and over a median trial duration of 3.3 to 8.4 years in the individual studies, participants made a total of 127,882 follow-up visits.

One limitation of the study is that orthostatic hypotension wasn't measured from lying to standing position. Another drawback is that many measurements of orthostatic hypotension were delayed more than one minute after standing, which could underestimate the occurrence of this condition among the study participants.

Additionally, the study lacked information on falls and syncope.

It's also possible that results from controlled clinical trials might not reflect what would happen among the general population in the community, the researchers noted in their study report, published in the Annals of Internal Medicine to coincide with their presentation at the meeting.

"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," said Dr. Vivek Bhalla, director of the hypertension center at Stanford University School of Medicine in California.

"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," Dr. Bhalla, who wasn't involved in the study, said by email.

By Lisa Rapaport

SOURCE: https://bit.ly/3m2lZ8G Annals of Internal Medicine, online September 10, 2020.

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