Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut.
JAMA. 2023 Oct 17;330(15):1459-1471. doi: 10.1001/jama.2023.18497.
There are ongoing concerns about the benefits of intensive vs standard blood pressure (BP) treatment among adults with orthostatic hypotension or standing hypotension.
To determine the effect of a lower BP treatment goal or active therapy vs a standard BP treatment goal or placebo on cardiovascular disease (CVD) or all-cause mortality in strata of baseline orthostatic hypotension or baseline standing hypotension.
Individual participant data meta-analysis based on a systematic review of MEDLINE, EMBASE, and CENTRAL databases through May 13, 2022.
Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) with orthostatic hypotension assessments.
Individual participant data meta-analysis extracted following PRISMA guidelines. Effects were determined using Cox proportional hazard models using a single-stage approach.
Main outcomes were CVD or all-cause mortality. Orthostatic hypotension was defined as a decrease in systolic BP of at least 20 mm Hg and/or diastolic BP of at least 10 mm Hg after changing position from sitting to standing. Standing hypotension was defined as a standing systolic BP of 110 mm Hg or less or standing diastolic BP of 60 mm Hg or less.
The 9 trials included 29 235 participants followed up for a median of 4 years (mean age, 69.0 [SD, 10.9] years; 48% women). There were 9% with orthostatic hypotension and 5% with standing hypotension at baseline. More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline orthostatic hypotension (hazard ratio [HR], 0.81; 95% CI, 0.76-0.86) similarly to those with baseline orthostatic hypotension (HR, 0.83; 95% CI, 0.70-1.00; P = .68 for interaction of treatment with baseline orthostatic hypotension). More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline standing hypotension (HR, 0.80; 95% CI, 0.75-0.85), and nonsignificantly among those with baseline standing hypotension (HR, 0.94; 95% CI, 0.75-1.18). Effects did not differ by baseline standing hypotension (P = .16 for interaction of treatment with baseline standing hypotension).
In this population of hypertension trial participants, intensive therapy reduced risk of CVD or all-cause mortality regardless of orthostatic hypotension without evidence for different effects among those with standing hypotension.
对于患有直立性低血压或站立性低血压的成年人，强化与标准血压（BP）治疗的益处仍存在争议。
确定较低的 BP 治疗目标或积极治疗与标准 BP 治疗目标或安慰剂相比，在基线直立性低血压或基线站立性低血压分层中对心血管疾病（CVD）或全因死亡率的影响。
基于对 MEDLINE、EMBASE 和 CENTRAL 数据库的系统评价的个体参与者数据荟萃分析，检索时间截至 2022 年 5 月 13 日。
对 BP 药物治疗（更强化的 BP 目标或活性药物）进行随机试验，并评估直立性低血压情况。
按照 PRISMA 指南提取个体参与者数据荟萃分析。使用 Cox 比例风险模型，采用单阶段方法确定效果。
主要结局为 CVD 或全因死亡率。直立性低血压定义为从坐姿变为站立位后收缩压至少下降 20mmHg 和/或舒张压至少下降 10mmHg。站立性低血压定义为站立时收缩压为 110mmHg 或更低，或站立时舒张压为 60mmHg 或更低。
9 项试验共纳入 29235 名参与者，中位随访时间为 4 年（平均年龄为 69.0[标准差为 10.9]岁；48%为女性）。基线时，9%的患者存在直立性低血压，5%的患者存在站立性低血压。与标准 BP 治疗相比，更强化的 BP 治疗或积极治疗降低了无基线直立性低血压患者的 CVD 或全因死亡率风险（风险比[HR]，0.81；95%CI，0.76-0.86），与基线直立性低血压患者的结果相似（HR，0.83；95%CI，0.70-1.00；P=0.68 用于治疗与基线直立性低血压的交互作用）。与标准 BP 治疗相比，更强化的 BP 治疗或积极治疗降低了无基线站立性低血压患者的 CVD 或全因死亡率风险（HR，0.80；95%CI，0.75-0.85），而在基线站立性低血压患者中无显著差异（HR，0.94；95%CI，0.75-1.18）。治疗与基线站立性低血压之间的交互作用无显著差异（P=0.16）。
在这项高血压试验参与者的研究中，强化治疗降低了 CVD 或全因死亡率的风险，无论是否存在直立性低血压，而在有站立性低血压的患者中，没有证据表明存在不同的治疗效果。
