Intensive BP-lowering Treatment May Reduce the Risk for Orthostatic Hypotension

Intensive blood pressure-lowering treatment may reduce the risk for orthostatic hypertension.

Intensive blood pressure (BP)-lowering treatment may reduce the risk for orthostatic hypertension (OH), according to the results of a systematic review and meta-analysis published in the Annals of Internal Medicine.

Investigators searched publication databases through October of 2019 for randomized trials in which hypertension and BP treatments were examined. Studies were included if they enrolled ≥500 participants, had a minimum duration of 6 months, and assessed participants for OH at the trial conclusion. A total of 5 trials (n=18,466; mean age, 64.5±9.9 years; 61.1% men; baseline mean seated systolic and diastolic BP: 141.4±17.6 mmHg and 79.1±12.2 mmHg, respectively) were selected for review.

Most of the studies (n=4) had placebo-controlled designs. Patients were stratified on the basis of systolic BP (n=3), diastolic and systolic BP (n=1), or atrial pressure. The investigators detected little heterogeneity among included studies (I2, 0.0%; P =.84).

At the conclusions of the studies, patients receiving standard BP treatment (n=63,630) had a mean increase in systolic BP of 1.82 mmHg (95% CI, 1.65-2.00 mmHg), and those assigned to an intense BP treatment (n=64,252) had a mean reduction in systolic BP of 1.84 mmHg (95% CI, 1.67-2.01 mmHg).

Among the placebo-controlled trials, BP treatment was not found to have an impact on the risk for OH (odds ratio [OR], 0.95; 95% CI, 0.88-1.02; P =.13). However, when these data were pooled with the 5 studies in which BP treatments were examined, intensive BP therapy was associated with a lower risk for OH (OR, 0.93; 95% CI, 0.89-0.98).

Patients without comorbid diabetes receiving intensive vs standard BP treatment were found to have a lower risk for OH (OR, 0.90; 95% CI, 0.83-0.98; P =0.015). Individuals with a standing systolic BP <110 mmHg at baseline lower risk for OH (OR, 0.66; 95% CI, 0.48-0.91; P =.02).

The effects of intensive vs standard BP treatment were comparable in patients with: seated systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg, a history of stroke or of cardiovascular disease, estimated glomerular filtration rate < 60 mL/min per 1.73 m2, or obesity.

Study limitations include the fact that data from trials with differing designs (ie, in stratification, intervention, and treatment frequency and duration) were combined.

“[I]n this large, individual participant–level synthesis of data from BP treatment trials, more intensive BP treatment did not increase risk for OH, regardless of age, and may even improve BP regulation in adults with standing hypotension,” concluded the study authors. “Although individual patients may have unique reactions to specific agents requiring changes in therapy, our aggregate findings support the growing body of evidence that OH identified in the setting of intensive BP treatment should not be viewed as a reason to downtitrate or discontinue BP treatment.”


Juraschek S P, Hu J-R, Cluett J L, et al. Effects of intensive blood pressure treatment on orthostatic hypotension: A systematic review and individual participant–based meta-analysis. [published online September 10, 2020] Ann Intern Med. doi:10.7326/M20-4298