2023-11-20 15:50:08
Patients with chronic high blood pressure, but also asymptomatic orthostatic hypotension (OH), benefit just as much from more intensive blood pressure therapy as patients without a drop in blood pressure when standing up. This is shown by a meta-analysis of 9 randomized studies, the results of which are now in JAMA were published [1].
Dr. Lucas Lauder
Source: Armin Schweitzer
“About 10% of patients with hypertension have orthostatic hypotension,” says Dr. Lucas Lauder from the Clinic for Internal Medicine III – Cardiology, Angiology and Internal Intensive Care Medicine at Saarland University Hospital. “Often these are patients who are older and frailer and have comorbidities such as diabetes or chronic kidney disease, but also those whose high blood pressure is not well controlled.”
Concern regarding worsening hypotension has led to recommendations once morest more intensive blood pressure therapy, particularly in the elderly. Dr. Stephen P. Juraschek
Older and frail patients in particular are often underrepresented in studies, adds Lauder, which raises the question of whether they can be treated like younger patients. The study authors led by Dr. Stephen P. Juraschek from the Division of General Medicine at Beth Israel Deaconess Medical Center in Boston, USA, report: “Concern regarding worsening hypotension has led to recommendations once morest more intensive blood pressure therapy, particularly in the elderly. In fact, discontinuing antihypertensive medication is recommended as the first measure for orthostatic hypotension.”
More intensive blood pressure therapy may reduce the risk of orthostatic hypotension
The research group has already demonstrated in one that this might be the worst possible measure previous meta-analysis: This not only showed no association between intensive blood pressure therapy and OH. There was also strong evidence that more intensive blood pressure therapy reduced the risk of OH.
But does OH affect what benefit patients receive from blood pressure therapy in terms of cardiovascular events and death? Juraschek and his colleagues investigated this with a meta-analysis of individual patient data from 29,235 patients from 9 studies. They were followed up for a median of 4 years.
The participants were on average 69 years old at the start of the study, 9% of them had orthostatic hypotension and 5% had hypotension when standing. The researchers defined OH as a drop in blood pressure when standing up of at least 20 mmHg systolic or at least 10 mmHg diastolic (blood pressure when standing minus blood pressure when sitting). They assumed hypotension while standing if the systolic blood pressure while standing was below 110 mmHg and diastolic below 60 mmHg – regardless of the blood pressure while sitting.
The vast majority of OH cases are asymptomatic, with only regarding 10% of patients showing symptoms such as dizziness or syncope. Dr. Stephen P. Juraschek
Most OH patients had no symptoms. “The vast majority of OH cases are asymptomatic, with only regarding 10% of patients showing symptoms such as dizziness or syncope,” says Lauder.
Any blood pressure therapy is better than none
The studies either compared intensive blood pressure therapy with standard blood pressure therapy or active therapy with a placebo. Juraschek and his colleagues report that there was no difference between patients with or without OH. Blood pressure therapy reduced the risk of cardiovascular disease or death in those with OH (hazard ratio: 0.83; 95% confidence interval: 0.70-1.00) as much as in those without OH (HR: 0.81; 95% CI: 0.76-0.86).
Only in standing hypotension was there a small difference: blood pressure therapy significantly reduced the risk of cardiovascular disease or death only in the patients without standing hypotension (HR 0.80; 95% CI 0.75-0.85) . Although a risk reduction was also observed in those with hypotension when standing, it did not reach statistical significance in this case (HR: 0.94; 95% CI 0.75-1.18).
Juraschek’s group of authors concludes that “physicians should not let asymptomatic orthostatic hypotension or standing hypotension prevent them from initiating more intensive blood pressure therapy in adult patients with hypertension.”
Not transferrable to patients with symptomatic OH
The distinction between OH patients with and without symptoms is of greater importance for Lauder because: “Most studies in this meta-analysis excluded patients with symptomatic OH and very frail patients, so the results and conclusions are not generalizable to these patient groups.”
According to the cardiology resident, the focus in the management of patients with symptomatic orthostatic hypotension is on identifying remediable causes. “For example, there are various medications that can promote OH, such as alpha receptor blockers such as tamsulosin, antidepressants such as amitriptyline, loop diuretics or beta blockers. A change in medication may make sense here.”
In addition, there are non-pharmacological measures that can help with OH: eating smaller meals, avoiding alcohol, reducing orthostatic stress through slow position changes, using isometric countermaneuvers, drinking water and wearing compression stockings.
“In patients with persistent symptoms – despite these measures – and in very frail patients, the antihypertensive therapy should be reduced,” recommends Lauder.
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