Effects of intensive blood pressure treatment on orthostatic hypotension a systematic review and individual participant-based meta-analysis

Stephen P. Juraschek, Jiun Ruey Hu, Jennifer L. Cluett, Anthony Ishak, Carol Mita, Lewis A. Lipsitz, Lawrence J. Appel, Nigel S. Beckett, Ruth L. Coleman, William C. Cushman, Barry R. Davis, Greg Grandits, Rury R. Holman, Edgar R. Miller, Ruth Peters, Jan A. Staessen, Addison A. Taylor, Lutgarde Thijs, Jackson T. Wright, Kenneth J. Mukamal

Research output: Contribution to journalReview articlepeer-review

46 Scopus citations


Background: Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH). Purpose: To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults. Data Sources: MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions. Study Selection: Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20mmHg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing. Data Extraction: 2 investigators independently abstracted articles and rated risk of bias. Data Synthesis: 5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged. Limitations: Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available. Conclusion: Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension.

Original languageEnglish (US)
Pages (from-to)58-68
Number of pages11
JournalAnnals of internal medicine
Issue number1
StatePublished - Jan 1 2021

Bibliographical note

Funding Information:
Grant Support: By grant 7K23HL135273-02 from the National Heart, Lung, and Blood Institute, National Institutes of Health, to Dr. Juraschek. Dr. Holman is an Emeritus UK National Institute for Health Research Senior Investigator.

Funding Information:
This review and analysis was funded by the National Institutes of Health (grant 7K23HL135273). The funder did not play any role in the design, conduct, and analysis of the study or in the decision to submit the manuscript for publication.

Publisher Copyright:
© 2021 American College of Physicians. All rights reserved.


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