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Orthostatic hypotension does not confer CVD event risk, regardless of BP goal
Orthostatic hypotension during treatment for hypertension was not found to be associated with risk for CVD events, syncope, electrolyte abnormalities, injurious falls or acute renal failure, regardless of systolic BP treatment goal, according to research published in Hypertension.
Using data from the SPRINT trial, researchers determined that orthostatic hypotension, defined as a drop in systolic BP of at least 20 mm Hg or in diastolic BP of at least 10 mm Hg 1 minute after standing from a seated position, was not associated with an increased risk for CVD events (HR = 1.06; 95% CI, 0.78-1.44) at 3 years. They also found the prevalence of orthostatic hypotension was slightly less in those assigned a systolic BP treatment goal of less than 120 mm Hg (5%) than in those assigned a goal of less than 140 mm Hg (5.7%) during the study period.
Moreover, orthostatic hypotension did not confer any increase in prevalence of syncope (HR = 1.38; 95% CI, 0.86-2.23), electrolyte abnormality (HR = 0.99; 95% CI, 0.6-1.62), injurious fall (HR = 1.2; 95% CI, 0.88-1.63) or acute kidney injury or acute renal failure (HR = 1.14; 95% CI, 0.72-1.81).
However, orthostatic hypotension was found to be associated with hypotension-related hospitalizations or ED visits (HR = 1.77; 95% CI, 1.11-2.82) and bradycardia (HR = 1.94; 95% CI, 1.19-3.15). According to the study, these associations did not differ by BP treatment goal.
Researchers stated that symptomless orthostatic hypotension at the time of treatment for hypertension should not be viewed as a reason to down-titrate therapy, regardless of BP goal.
“There was no evidence that orthostatic hypotension in the setting of intensive therapy was more strongly related to the majority of outcomes and adverse events examined,” Stephen P. Juraschek, MD, PhD, assistant professor of medicine at Harvard Medical School and clinician investigator at Beth Israel Deaconess Medical Center, and colleagues wrote. “Although further research is needed to examine the association orthostatic hypotension and non-MI ACS, given the primary survival benefits from more aggressive hypertension treatment among older adults, the detection of orthostatic hypotension does not represent a clear contraindication for treatment.”
SPRINT was a prospective, randomized controlled and open-label outcome trial funded by the NIH to compare the hypertension treatment goal of less than 120 mm Hg with the standard treatment target of less than 140 mm Hg. For the present analysis, researchers assessed 8,156 patients from SPRINT (mean age, 68 years; 35% women; 31% black) with the aim of determining the association between orthostatic hypertension and adverse CV outcomes.
“There are concerns that more aggressive BP treatment goals result in orthostatic hypotension and increase risk of falls in older adults,” Juraschek told Healio. “This secondary analysis of data from the SPRINT trial do not support these concerns. However, it should be noted that OH was performed from seated to standing positions (vs. supine) and adults with standing BP < 110 mm Hg were excluded from SPRINT.”
Future research
More research in this area is forthcoming, Juraschek told Healio.
“We are examining the effects of BP treatment on orthostatic symptoms in additional trials (such as SPS3) and pooling trials together via an individual meta-analysis,” he said. “We are examining the relationship between different approaches to measuring orthostatic hypotension (supine vs. seated) and relevant clinical outcomes such as falls. We are looking at the association of subclinical cardiovascular disease and change in physical function over time in aging adults.”
Considerations for orthostatic hypotension
“If a symptomatic patient’s hypertension is well controlled, it is often easy to slightly down-titrate antihypertensive therapy,” Teemu J. Niiranen, MD, PhD, of the department of medicine at the University of Turku at Turku University Hospital and the Finnish Institute for Health and Welfare in Turku, Finland, wrote in a related editorial. “However, treatment decisions for symptomatic, poorly controlled patients or asymptomatic patients with severe orthostatic hypotension have been more complex.
“Although the results of the current study may not be generalizable to all (symptomatic) patients, the article demonstrates that more-intensive antihypertensive therapy does not lead to increased incidence of orthostatic hypotension or complications of orthostatic hypotension in asymptomatic patients,” Niiranen wrote. “The major clinical implication of the study is that symptomless orthostatic hypotension should not be considered a cause for down-titrating therapy, even in the setting of intensive antihypertensive therapy.” – by Scott Buzby
Disclosures: The authors report no relevant financial disclosures.
Perspective
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The take-home message for clinical cardiologists is that in the absence of symptoms, asymptomatic orthostatic hypotension measured in the office is not a reason to de-intensify BP treatment targets. We know that older adults are more likely to have orthostatic hypotension, however this analysis demonstrated that rates of orthostatic hypotension in both standard and aggressive BP-lowering arms were similar.
This group’s findings stand in contrast to/conflict with prior data that observed that orthostatic hypotension was a predictor of CV events. These data suggest that the presence of orthostatic hypotension is not associated with higher risk for CVD events, be it in patients with aggressive or standard BP goals. Similarly, the presence of orthostatic hypotension did not lead to more falls or syncope compared with patients without orthostatic vital signs. Patients with orthostatic hypotension did have more episodes of bradycardia and overall hypotension, though.
Possible reasons for the discrepancy between prior observational studies and this SPRINT analysis may be the exclusion of patients with baseline standing systolic BPs of less than 110 mm Hg. Also, the SPRINT trial overall did not enroll patients with a prior stroke or with diabetes, so may not be representative of patients with those conditions.