May 2024
Intensive vs standard blood pressure treatment in patients with orthostatic or standing hypotension

A meta-analysis provides reassurance that neither type of hypotension should deter from adopting more-intensive blood pressure management in patients with hypertension.

The 2017 American College of Cardiology/American Heart Associa­tion high blood pressure guidelines lowered the definition of hypertension to 130/80 mmHg, yet blood pressure control in the USA has worsened since that time, even by the old definition of 140/90mmHg. Some clinicians may have concerns about the lower threshold, particularly for people with baseline orthostatic hypotension. To address this issue, investigators conducted a participant-­level meta­-analysis of nine blood pressure trials that assessed the new blood pressure goals or an active agent and included assessments of orthostatic hypotension.

The nine trials included 29,235 partici­pants (mean age, 69 years; 48% women) followed for a median of four years. At baseline, 9% had orthostatic hypotension and 5% had standing hypotension. The researchers found that more-­intensive blood pressure goals or active treatment reduced risk for nonfatal CVD events or all-­cause mortality regardless of the pre­sence of orthostatic hypotension or stand­ing hypotension. Of note, orthostatic hypotension and standing hypotension were independently associated with higher risks for CVD or all­-cause mortal­ity and for all-­cause mortality alone. 

Comment: People with orthostatic hypo­tension or standing hypotension had a higher risk for adverse outcomes, but they experienced relative risk reductions in response to intensification of BP manage­ment that were not significantly different from those without these conditions. I agree with the authors when they state that orthostatic hypotension and standing hypotension should not deter us from adopting more-­intensive blood pressure treatment in those with hypertension.

Harlan M. Krumholz, MD, SM, Harold H. Hines, Jr. Professor of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, USA.

Juraschek SP, et al. Orthostatic hypotension, hypertension treatment, and cardiovascular disease: an individual participant meta-analysis. JAMA 2023; 330: 1459-1471.

This summary is taken from the following Journal Watch titles: Cardiology, Hospital Medicine.