High blood pressure treatment linked to lower risk of orthostatic hypotension

Boston – Orthostatic hypotension, a condition characterized by an extreme drop in blood pressure upon standing, is an important risk factor for falls, fainting and death that is common among adults with hypertension and associated with multiple classes of antihypertensive medications. These associations with hypertension and its treatment have led to widespread concern that orthostatic hypotension is a complication of intensive blood pressure therapy, potentially causing faints or falls in vulnerable groups such as the elderly. Therefore, many physicians view orthostatic hypotension detected in the setting of blood pressure treatment as a reason to relax, avoid or de-escalate treatment.

In a new study published in Annals of Internal Medicine and presented at the virtual American Heart Association’s Hypertension 2020 Scientific Sessions, researchers at Beth Israel Deaconess Medical Center (BIDMC) found that treatment for lower high blood pressure did not increase – and may have in fact decreased – the risk of developing orthostatic hypotension. The authors conclude that orthostatic hypotension, prior to or in the setting of more intensive blood pressure treatment, should not be considered a reason to stop or reduce treatment for hypertension.

“Our findings should challenge the traditional teaching about blood pressure treatment causing orthostatic hypotension, reassuring clinicians about the safety of blood pressure treatment with regard to this condition,” said principal investigator Stephen Juraschek, MD, PhD, a clinician investigator in the Department of Medicine at BIDMC.

Investigators identified several studies in the medical literature that examined the effects of blood pressure medications on orthostatic hypotension. In a new analysis, researchers reviewed the health record assessments from nine large clinical trials of 31,043 adults with diagnosed hypertension. Nearly half of participants were women, one-fourth were over age 75 and one in five was African American.

“The study population was diverse, including older adults with a number of chronic conditions associated with cardiovascular disease, including diabetes,” said Juraschek. “Nevertheless, the findings were consistent across subgroups, including age, sex, race, hypertension, stroke, obesity, history of cardiovascular disease, and orthostatic hypotension detected prior to treatment.”

Across the studies, almost 50 percent of the patients were treated to either a lower blood pressure goal versus a higher blood pressure goal or with an active drug versus placebo.

Overall, the risk for low blood pressure upon standing decreased among participants taking medication to lower blood pressure, although the study did not look at what specific types of medication were taken. In contrast to conventional wisdom, the greatest decrease in risk occurred among those with the lowest blood pressure upon standing, compared to participants with higher blood pressure on standing. The second-greatest decrease in risk occurred among participants without diabetes compared to those with diabetes.

“Orthostatic hypotension identified in the setting of intensive blood pressure treatment should not be viewed as a reason to decrease or discontinue blood pressure treatment,” said Juraschek. “In fact, the finding that more aggressive blood pressure treatment lowered orthostatic hypotension was relatively consistent across the studies.”

Co-authors included Jennifer Cluett, MD, Lewis Lipsitz, MD, Kenneth Mukamal, MD, MPH, MA, of BIDMC; Anthony Ishak, PharmD, of Beth Israel Lahey Health; Jiun-Ruey Hu, MD, MPH, of Vanderbilt University Medical Center; Carol Mita, MLIS, of Harvard University; Lawrence Appel, MD, MPH, Edgar Miller 3^rd, MD, PhD, of Johns Hopkins University; Nigel Beckett MB, ChB, of Guy's and St Thomas' NHS Foundation Trust; Ruth Coleman, MSc, and Rury Holman, MB, ChB, of University of Oxford; William Cushman, MD, of University of Tennessee Health Science Center; Barry Davis, MD, PhD, The University of Texas School of Public Health; Greg Grandits, MS, of University of Minnesota; Ruth Peters, PhD, MSc, of University of New South Wales; Jan Staessen, MD, PhD, and Lutgarde Thijs, MSc, of University of Leuven; Addison Taylor, MD, PhD, of VA Medical Center and Baylor College of Medicine; and Jackson Wright Jr., MD, PhD, of University Hospitals Cleveland Medical Center.

This work was funded by the National Institutes of Health (7K23HL135273). The authors declare that there is no conflict of interest associated with this manuscript.