New Study Shows Intensive Blood-Pressure Treatment Effective Regardless of Hypotension

A groundbreaking study published in JAMA titled “Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis” provides new understanding regarding the effectiveness of intensive blood-pressure treatment, offering important insights for health care providers and individuals living with hypertension (high blood pressure).

The study, led by Stephen P. Juraschek, M.D., PhD, Section for Research, Division of General Medicine, Beth Israel Deaconess Medical Center, sought to answer a pivotal question: Does the effect of intensive blood-pressure treatment on cardiovascular disease or all-cause mortality differ based on the presence or absence of orthostatic hypotension. Orthostatic hypotension, also known as postural hypotension, is an excessive drop in blood pressure when standing up from a seated or lying down position. The findings have the potential to reshape clinical approaches to blood-pressure management.

Key findings from this meta-analysis, which involved over 29,000 participants from nine hypertension trials, indicate that more intensive blood-pressure treatment is associated with a lower risk of cardiovascular disease or all-cause mortality, regardless of whether participants had orthostatic hypotension. Moreover, the study found that the effects did not significantly differ based on the presence or absence of orthostatic hypotension.

Orthostatic hypotension is defined by a significant decrease in systolic blood pressure (at least 20 mm Hg) and/or diastolic blood pressure (at least 10 mm Hg) after changing position from sitting to standing. Orthostatic hypotension may also be present if a standing systolic blood pressure is 110 mm Hg or less or a standing diastolic blood pressure is 60 mm Hg or less.

In the nine trials included in the analysis, participants were followed for a median of four years, with a mean age of 69.0 years, and 48% were women. At baseline, 9% of the participants had orthostatic hypotension.

The results showed that more intensive blood-pressure treatment lowered the risk of cardiovascular disease or all-cause mortality among those without baseline orthostatic hypotension, similarly to those with baseline orthostatic hypotension. Additionally, more intensive blood-pressure treatment lowered the risk of cardiovascular disease or all-cause mortality among those without baseline orthostatic hypotension

This study’s conclusions have significant clinical implications. According to Lewis A. Lipsitz, M.D., director, Hebrew SeniorLife Marcus Institute for Aging Research and Hebrew SeniorLife’s chief academic officer, “Asymptomatic orthostatic hypotension should not deter adults with hypertension from pursuing more intensive hypertension treatment, as long as patients are carefully monitored for hypotension while treatment is being increased. In many older adults, the slow, judicious treatment of hypertension may actually reduce the occurrence of orthostatic hypotension. The findings underscore the potential benefits and safety of intensive blood-pressure management in preventing cardiovascular disease and improving overall patient outcomes, irrespective of baseline orthostatic hypotension.”

Co-authors include: 

• Jiun-Ruey Hu, M.D., MPH, clinical fellow, Yale School of Medicine 
• Jennifer L. Cluett, M.D., clinical specialist in hypertension, Internal Medicine, Primary Care, Beth Israel Deaconess Medical Center
• Anthony M. Ishak, PharmD, ambulatory care clinical pharmacist, Beth Israel Deaconess Medical Center; 
• Carol Mita, MLIS, research & education librarian, Harvard Medical School 
• Lewis A. Lipsitz, M.D., Irving and Edyth S. Usen and Family Chair in Medical Research, Hebrew SeniorLife, professor of medicine, Harvard Medical School and chief, Division of Gerontology, Beth Israel Deaconess Medical Center
• Lawrence J. Appel, M.D., MPH, director of the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health
• Nigel S. Beckett, MB ChB, consultant physician in ageing and health, Guy’s and St, Thomas’ NHS Foundation Trust, London
• Ruth L. Coleman, MSc, head of Statistics and Modelling Group, Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford
• William C. Cushman, M.D., medical director, Department of Preventive Medicine, and professor of preventive medicine, medicine, and physiology at the University of Tennessee Health Science Center
• Barry R. Davis, M.D., PhD, professor emeritus of biostatistics & public health, Coordinating Center, University of Texas School of Public Health
• Greg Grandits, M.S., senior research fellow, Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota
• Rury R. Holman, MB ChB, emeritus professor of diabetic medicine, Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford
• Edgar R. Miller 3rd, M.D., PhD, deputy director, Johns Hopkins Institute for Clinical and Translational Science; 
• Ruth Peters, PhD, MSc, program lead for dementia, Global Brain Health Initiative, the George Institute for Global Health 
• Jan A. Staessen, M.D., PhD, emeritus professor of medicine, Head Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, Sint-Franciscus College, Addison A. Taylor, M.D., PhD, professor of medicine-hypertension, Michael E. DeBakey VA Medical Center and Baylor College of Medicine
• Lutgarde Thijs, MSc, Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, Sint-Franciscuscollege, Heusden-Zolder
• Jackson T. Wright Jr, M.D., PhD, program director of the William T. Dahms M.D. Clinical Research Unit, Case Western Reserve University, University Hospitals Cleveland Medical Center
• Kenneth J. Mukamal, M.D., MPH, M.A., department associate, Beth Israel Deaconess Medical Center.

This work was supported by the National Institutes of Health/NHLBI grant K23HL135273; UK National Institute for Health Research, National Institutes of Health/National Institute on Aging grant K24AG065525.

About Hebrew SeniorLife
Hebrew SeniorLife, an affiliate of Harvard Medical School, is a national senior services leader uniquely dedicated to rethinking, researching, and redefining the possibilities of aging. Hebrew SeniorLife cares for more than 4,500 seniors a day across six campuses throughout Greater Boston. Locations include: Hebrew Rehabilitation Center-Boston and Hebrew Rehabilitation Center-NewBridge in Dedham; NewBridge on the Charles, Dedham; Orchard Cove, Canton; Simon C. Fireman Community, Randolph; Center Communities of Brookline, Brookline; and Jack Satter House, Revere. Founded in 1903, Hebrew SeniorLife also conducts influential research into aging at the Hinda and Arthur Marcus Institute for Aging Research, which has a portfolio of more than $85 million, making it one of the largest gerontological research facilities in the U.S. in a clinical setting. It also trains more than 1,000 geriatric care providers each year. For more information about Hebrew SeniorLife, visit our website or follow us on our blog, Facebook, Instagram, Twitter, and LinkedIn.