Stephen P Juraschek1, Jiun-Ruey Hu2, Jennifer L Cluett1, Anthony Ishak3, Carol Mita4, Lewis A Lipsitz5, Lawrence J Appel6, Nigel S Beckett7, Ruth L Coleman8, William C Cushman9, Barry R Davis10, Greg Grandits11, Rury R Holman8, Edgar R Miller6, Ruth Peters12, Jan A Staessen13, Addison A Taylor14, Lutgarde Thijs15, Jackson T Wright16, Kenneth J Mukamal1. 1. Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.). 2. Vanderbilt University Medical Center, Nashville, Tennessee (J.H.). 3. Healthcare Associates, Beth Israel-Lahey Health System, Boston, Massachusetts (A.I.). 4. Countway Library, Harvard University, Boston, Massachusetts (C.M.). 5. Beth Israel Deaconess Medical Center, Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Harvard Medical School, Boston, Massachusetts (L.A.L.). 6. Johns Hopkins University, Baltimore, Maryland (L.J.A., E.R.M.). 7. Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (N.S.B.). 8. Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.). 9. University of Tennessee Health Science Center, Memphis, Tennessee (W.C.C.). 10. Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas (B.R.D.). 11. School of Public Health, University of Minnesota, Minneapolis, Minnesota (G.G.). 12. University of New South Wales, Sydney, and Neuroscience Research Australia, Randwick, New South Wales, Australia (R.P.). 13. Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, and NPA Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (J.A.S.). 14. Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas (A.A.T.). 15. Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, Belgium (L.T.). 16. Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio (J.T.W.).
Abstract
BACKGROUND: Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH). PURPOSE: To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults. DATA SOURCES: MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions. STUDY SELECTION: Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing. DATA EXTRACTION: 2 investigators independently abstracted articles and rated risk of bias. DATA SYNTHESIS: 5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged. LIMITATIONS: Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available. CONCLUSION: Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).
BACKGROUND: Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH). PURPOSE: To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults. DATA SOURCES: MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions. STUDY SELECTION: Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing. DATA EXTRACTION: 2 investigators independently abstracted articles and rated risk of bias. DATA SYNTHESIS: 5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged. LIMITATIONS: Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available. CONCLUSION: Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).
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