Editor's Note: Commentary based on Juraschek SP, Hu J-R, Cluett JL, et al. Effects of intensive blood pressure treatment on orthostatic hypotension: a systematic review and individual participant-based meta-analysis. Ann Intern Med 2020;Sep 10:[Epub ahead of print].¹

Geriatric Cardiology Take Home Points

• Concern about orthostatic hypotension (OH) and its implications for fall risk is one of the most common reasons for less intensive blood pressure treatment in older adults.
• Prior studies have shown that among older adults, the highest risk for OH is in individuals with uncontrolled systolic hypertension.²
• The current report, using data from nine prospective randomized trials involving more than 18,000 participants, confirms that more intensive blood pressure reduction is associated with less OH than standard blood pressure management.
• Results were similar in patients younger or older than age 75, although those over 75 comprised only 15.7% of participants in the trials, which is a limitation of the analysis.
• The mechanisms for this seemingly paradoxical observation are unclear but may include favorable effects of improved blood pressure control on autonomic function, baroreceptor function, and/or arterial stiffness.
• In light of the substantial benefits of more intensive blood pressure reduction in older adults demonstrated in SPRINT and other studies, including among patients ≥75 years of age with or without frailty, undue concern about OH should not be used to justify a less aggressive approach to blood pressure management.

Study Questions

The 2017 guidelines published by the American Heart Association and American College of Cardiology now recommend a blood pressure (BP) target of below 130/80.³ This new recommendation is largely based on the evidence provided by the SPRINT Trial which showed that treating to a target systolic BP <120mmHg reduced rates of heart attack, heart failure, stroke, and death.⁴ Some experts have expressed concern that intensive BP treatment goals might increase risk of orthostatic hypotension (OH), which is important because it is a risk factor for falls, syncope, and death.¹ The researchers of this study aimed to conduct a systematic review and participant-based meta-analysis to understand whether intensive BP treatment goals causes increased rates of OH compared to less-intensive BP treatment goals in adults with hypertension.

Methods

In this systematic review and participant based meta-analysis, two investigators independently abstracted published articles using Embase, Central, and Medline, and selected randomized trials of intensive BP treatment goals; the authors included studies where the comparator was less intensive BP treatment goals and studies where the comparator was placebo.

Key criteria for study inclusion:

• Population: Sample of at least 500 non-pregnant adults over the age of 18.
• Intervention: BP control of at least 6 months duration.
• Comparison: Either less intensive BP treatment goal or placebo.
• Outcome: OH measured during post-randomization study visits, defined as a decrease of at least 20mmHg in systolic BP or at least 10mmHg in diastolic BP upon a change in position from seated to standing.

Data from all trials and all pre-randomization and post-randomization follow-up visits were combined into a single analytic data set before a pooled analysis was performed. Clinical trials comparing intensive versus less intensive BP treatment goals were pooled and analyzed; clinical trials comparing intensive BP treatment goals versus placebo were pooled and analyzed; finally, all studies regardless of comparator were pooled and analyzed.

Results

A total of nine randomized control trials of 18,466 participants were selected. Data was reported separately according to comparator.

• Among clinical trials comparing intensive versus less intensive BP treatment (five studies), odds of OH were lower among the intensive BP treatment group (OR .93 [CI 95%, .86 to .99]).
• Among clinical trials comparing intensive BP treatment versus placebo (four studies), odds of OH were similar (OR, .95 [CI 95%, .88 to 1.02]).
• When pooling all nine studies together, the odds for OH was lower among the intensive BP treatment group (OR, .93 [CI 95%, .89 to .98]).
• The odds of OH for intensive BP treatment did not differ according to age, sex, black race, reduced eGFR (<60), obesity, or pre-existing cardiovascular disease.

Conclusion

This systematic review and individual participant-based meta-analysis found that intensive BP treatment goals in adults with hypertension does not increase the odds for OH. Based on these findings, the authors suggest that OH identified in the setting of intensive BP control should not be viewed as a reason to opt for less intensive blood pressure treatment goals.

References

1. Juraschek SP, Hu J-R, Cluett JL, et al. Effects of intensive blood pressure treatment on orthostatic hypotension: a systematic review and individual participant-based meta-analysis. Ann Intern Med 2020;Sep 10:[Epub ahead of print].
2. Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 2011;59:383-89.
3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the  American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127–e248.
4. Systolic Blood Pressure Intervention Trial (SPRINT) Study (NHLBI/NIH website). 2018. Available at: https://www.nhlbi.nih.gov/science/systolic-blood-pressure-intervention-trial-sprint-study. Accessed 11/06/2020.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Acute Heart Failure, Hypertension

Keywords: Geriatrics, Blood Pressure, Hypotension, Orthostatic, Vascular Stiffness, American Heart Association, Pressoreceptors, Cardiovascular Diseases, Accidental Falls, African Americans, Follow-Up Studies, Prospective Studies, Random Allocation, Hypertension, Risk Factors, Stroke, Myocardial Infarction, Heart Failure, Syncope, Cardiology, Obesity, Reference Standards

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