• 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, and Kenneth J Mukamal.
• Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.).
• Ann. Intern. Med. 2021 Jan 1; 174 (1): 58-68.

BackgroundAlthough intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH).PurposeTo examine the effects of intensive BP-lowering treatment on OH in hypertensive adults.Data SourcesMEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions.Study SelectionRandomized 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 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing.Data Extraction2 investigators independently abstracted articles and rated risk of bias.Data Synthesis5 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.LimitationsAssessments 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.ConclusionIntensive 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.Primary Funding SourceNational Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).

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