5MinuteConsult Journal Club
Intensive Blood Pressure Lowering and Hypotension
Juraschek SP, Hu JR, Cluett JL, et al. Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension: A Systematic Review and Individual Participant-based Meta-analysis [published online ahead of print, 2020 Sep 10]. Ann Intern Med. 2021 Jan;174(1):58-68. doi: 10.7326/M20-4298. PMID: 32909814
This systematic review and meta-analysis set out to determine if aggressive blood pressure lowering increased the rate of orthostatic hypotension in patients with elevated blood pressure. It included 5 open label trials. Orthostatic BPs were measured from the sitting (not supine) to standing position and the BP was taken 1 minute after standing. The meta-analysis found intensive blood pressure lowering lowered the odds of orthostatic hypotension (odds ratio, 0.93, 95% CI 0.86-0.99).
In this small meta-analysis, intensive BP lowering did not induce orthostatic hypotension when measured 1 minute after moving from sitting to standing.
This study made medical headlines, and caught our attention, because inducing iatrogenic orthostatic hypotension is certainly one of our fears.
Unfortunately, this study reports data, but not patient-oriented outcomes, the information we need to make decisions. It does not tell us anything about what happens when our patients stand from the supine position (like getting out of bed). It does not tell us how their BP changes immediately upon changing position, but rather how it changes a minute later. Lastly and most curiously, it does not tell us about falls after standing. This last point is the patient-oriented outcome we need to know—if aggressive lowering HURTS patients.
Based upon these missing pieces of data, I still will take a cautious approach to aggressive BP lowering. Remind patients to go from supine to sitting and WAIT before standing, and to report any light-headedness or falls after standing immediately.
And for patients with known ASCVD, a “lower” blood pressure goal has yet to be found to be beneficial. This from a 2020 Cochrane systematic review found “probably little to no difference in total mortality and cardiovascular mortality between people with hypertension and cardiovascular disease treated to a lower compared to a standard blood pressure target…At present, evidence is insufficient to justify lower blood pressure targets (135/85 mmHg or less) in people with hypertension and established cardiovascular disease.”
Bottom line: use BPS of <140 and BPD of <90 as your blood pressure goal.
Disease-oriented evidence refers to intermediate outcomes; these are measures that sometimes act (often inappropriately) as surrogates for important outcomes (ex: LDL cholesterol vs. MI or death). Patient-oriented outcomes are measures that effect patient quality of life, morbidity, or mortality. This study chose to focus on disease-oriented outcomes. Rather than looking immediately at BP changes upon rising from supine, they chose to have patients rise from sitting and wait a minute to measure their blood pressure.
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Contributed by Frank J. Domino, MD, March 24, 2021