In an individual meta-analysis of clinical trials of participants with hypertension, intensive blood pressure lowering reduced the risk of cardiovascular disease (CVD) or all-cause mortality regardless of whether patients also had orthostatic hypotension or standing hypotension.
These results allayed “ongoing concerns about the benefits of intensive vs standard blood pressure (BP) treatment among adults with orthostatic hypotension or standing hypotension,” the authors write.”The 9 trials included 29,235 participants followed up for a median of 4 years (mean age, 69.0 [SD, 10.9] years; 48% women). There were 9% with orthostatic hypotension and 5% with standing hypotension at baseline. More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline orthostatic hypotension (hazard ratio [HR], 0.81; 95% CI, 0.76-0.86) similarly to those with baseline orthostatic hypotension (HR, 0.83; 95% CI, 0.70-1.00; P = .68 for interaction of treatment with baseline orthostatic hypotension). More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline standing hypotension (HR, 0.80; 95% CI, 0.75-0.85), and nonsignificantly among those with baseline standing hypotension (HR, 0.94; 95% CI, 0.75-1.18). Effects did not differ by baseline standing hypotension (P = .16 for interaction of treatment with baseline standing hypotension).”
Editorial: “What this study does not enlighten is whether baseline [orthostatic hypotension (OH)] (symptomatic or not) is a clinically useful predictor of heightened treatment risks,” editorialists write. “As clinical hypertension experts, we must disclose our philosophical predisposition to treat high BP early and aggressively. Yet we must also acknowledge that hypertension treatment, especially to lower goals, comes with significant risks (ie, acute kidney injury, hyperkalemia, syncope), even without preexisting OH. Serious adverse events often outnumber by a factor of 2 or more the count of primary end points prevented in clinical trials. Often overlooked is that greater BP reduction is also associated with higher rates of treatment discontinuation, which rises disproportionately faster than outcome prevention. It is thus not wise to dismiss these and other potential harms (anxiety, missed work, medical costs) as the simple price of tight BP control.…”