High blood pressure treatment linked to less risk for drop in blood pressure upon standing

Research Highlights:

• Treatment to lower blood pressure did not increase and may decrease the risk of extreme drops in blood pressure upon standing from a sitting position.
• These findings suggest that orthostatic hypotension, a type of low blood pressure that occurs when moving from sitting or lying down to standing, should not be a reason to stop or reduce hypertension treatment.

Embargoed until 9 a.m. CT/10 a.m. ET Thursday, Sept. 10, 2020

DALLAS, Sept. 10, 2020 — Treatment to lower high blood pressure did not increase and may have decreased the risk of developing a condition characterized by an extreme drop in blood pressure upon standing, according to new research to be presented Sept. 10-13, 2020, at the virtual American Heart Association’s Hypertension 2020 Scientific Sessions. The meeting is a premier global exchange for clinical and basic researchers focusing on recent advances in hypertension research.

A type of low blood pressure, known as orthostatic hypotension, occurs when standing from sitting or lying down. Symptoms include feelings of dizziness or light-headedness and sometimes even fainting. The condition is more common among older adults, however, other factors also can increase the risk, including other conditions, such as heart disease and diabetes, and some medications.

Previously, medications to lower blood pressure were thought to increase the risk for extreme drops in blood pressure upon standing. Individual studies, however, were unable to definitively prove cause and effect. In this study, researchers assessed the results of nine separate studies as a meta-analysis, which can provide more information when analyzed collectively.

“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 P. Juraschek, M.D., Ph.D., a clinician investigator at Beth Israel Deaconess Medical Center-Harvard Medical School in Boston.

Investigators reviewed three large medical databases — MEDLINE, EMBASE and CENTRAL —through October 7, 2019, to identify studies that examined the effects of blood pressure medications on orthostatic hypotension. For this 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 were African American.

“The study population was diverse, including older adults with a number of chronic conditions associated with cardiovascular disease, like diabetes,” Juraschek said. “Nevertheless, the findings were consistent across subgroups.”

Almost 50% of the patients were treated more aggressively, either to a lower 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. 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,” Juraschek said. “In fact, the finding that more aggressive blood pressure treatment lowered orthostatic hypotension was relatively consistent across the studies.”

Several limitations could have affected the study’s results. First, inconsistent information was available about symptoms and adverse effects, such as falls or fainting, from low blood pressure upon standing. Another limitation is that some cases of low blood pressure could have been missed, since most measurements occurred after one minute, instead of within the first minute of standing. In addition, measurements occurred only after standing from sitting, not from lying down to standing. Finally, the study did not include information about the classes of blood pressure medication used by participants.

This study is publishing simultaneously in the scientific journal, Annals of Internal Medicine.

Co-authors are Jiun-Ruey Hu, M.D., M.P.H.; Jennifer Cluett, M.D.; Anthony Ishak, Pharm.D.; Carol Mita, M.L.I.S.; Lewis Lipsitz, M.D.; Lawrence J. Appel, M.D., M.P.H.; Nigel Beckett, M.B., Ch.B.; Ruth L. Coleman, M.Sc.; William Cushman, M.D.; Barry R. Davis, M.D., Ph.D.; Greg Grandits, M.S.;  Rury R. Holman, F.R.C.P.; Edgar R. Miller III, M.D., Ph.D.; Ruth Peters, Ph.D., M.Sc.; Jan A. Staessen, M.D., Ph.D.; Addison A. Taylor, M.D., Ph.D.; Lutgarde Thijs, M.Sc.; Jackson T. Wright, Jr., M.D., Ph.D.; and Kenneth J. Mukamal, M.D,. M.P.H., M.A. The National Institutes of Health and the National Heart, Lung, and Blood Institute funded the study.

Additional Resources:

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