Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis

SPS commentary:

There was also no significant difference in the reduction in CVD or all-cause mortality for more intensive vs standard BP treatment among those with and without baseline standing hypotension (HRs 0.94 and 0.80, p=0.16 for interaction).

A related commentary notes that regardless of exact thresholds, the presence of orthostatic hypotension (OH) is important to uncover because it can be both a marker and a mediator of increased morbidity and mortality. It is also common, affecting between 5% and 30% of adults depending on a number of factors, notably age. Hypertension guidelines have thus conventionally recommended obtaining orthostatic readings prior to initiating medications and for follow-up safety monitoring. The theoretical goal is to identify at-risk patients and prevent falls and syncope. However, the merits of this logic hinge on the balance between 2 sides of an issue that remain controversial despite decades of research. The first is whether patients with preexisting OH derive the expected benefits from antihypertensive therapy. The second is whether they experience an excess burden of adverse consequences. It concludes that altogether, the findings of this new study should reassure clinicians that patients with OH (and perhaps standing hypotension) will derive the full expected benefits from antihypertensive therapy. However, it is important to highlight that the meta-analysis was designed to address treatment benefits. There remains an unknown but real possibility for excess harm (e.g. syncope) from antihypertensive therapy in patients with preexisting OH.