Department of Neurobiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
Exp Gerontol. 2024 Aug;193:112461. doi: 10.1016/j.exger.2024.112461. Epub 2024 May 25.
Orthostatic hypotension (OH) is common in older adults with hypertension. Antihypertensive treatment (AHT) prevents cardio- and cerebrovascular events. However, physicians are concerned to cause OH, making them hesitant to initiate or augment AHT in older adults with hypertension.
We systematically researched electronic databases for trials with older participants (≥65 years) with hypertension and OH assessment after initiating, discontinuing, or augmenting AHT. Study quality was assessed using the ROBINS-I tool. Meta-analyses on OH prevalence and postural blood pressure (BP) drop were performed.
Twenty-five studies (26,695 participants) met inclusion criteria, of which fifteen could be included in the meta-analyses. OH prevalence decreased after AHT initiation or augmentation (risk ratio 0.39 (95 % CI = 0.21-0.72; I = 47 %; p < 0.01), n = 6 studies), but also after AHT discontinuation (risk ratio 0.39 (95 % CI = 0.28-0.55; I = 0 %; p < 0.01), n = 2 studies). Postural BP drop did not change after initiation or augmentation of AHT (mean difference 1.07 (95 % CI = -0.49-2.64; I = 92 %; p = 0.18), n = 11 studies). The main reason for ten studies not to be included in the meta-analyses was absence of baseline OH data. Most of these studies reported OH incidences between 0 and 2 %. Studies were heterogeneous in OH assessment methods (postural change, timing of BP measurements, and OH definition). Risk of bias was moderate to serious in twenty studies.
Results suggest that AHT initiation or augmentation decreases OH prevalence, implying that the risk of inducing OH may be overestimated in current AHT decision-making in older adults. However, the overall low level of evidence and the finding that AHT discontinuation reduces OH prevalence limit firm conclusions at present and highlight an important research gap. Future AHT trials in older adults should measure OH in a standardized protocol, adhering to consensus guidelines to overcome these limitations.
体位性低血压（OH）在高血压老年患者中很常见。抗高血压治疗（AHT）可预防心脑血管事件。然而，医生担心会引起 OH，导致他们在高血压老年患者中不愿启动或增加 AHT。
我们系统地检索了电子数据库，以寻找接受过 AHT 启动、停止或增加治疗的老年（≥65 岁）参与者的高血压和 OH 评估的试验。使用 ROBINS-I 工具评估研究质量。对 OH 发生率和体位性血压（BP）下降进行了荟萃分析。
25 项研究（26695 名参与者）符合纳入标准，其中 15 项可纳入荟萃分析。AHT 启动或增加后 OH 发生率降低（风险比 0.39（95%CI=0.21-0.72；I=47%；p<0.01），n=6 项研究），AHT 停止后也降低（风险比 0.39（95%CI=0.28-0.55；I=0%；p<0.01），n=2 项研究）。AHT 启动或增加后体位性 BP 下降无变化（平均差异 1.07（95%CI=-0.49-2.64；I=92%；p=0.18），n=11 项研究）。十个研究未纳入荟萃分析的主要原因是缺乏基线 OH 数据。这些研究大多数报告的 OH 发生率在 0%到 2%之间。在 OH 评估方法（体位变化、BP 测量时间和 OH 定义）方面，研究存在异质性。20 项研究的偏倚风险为中度至严重。
结果表明，AHT 启动或增加可降低 OH 发生率，这意味着当前在老年患者中启动或增加 AHT 时，诱导 OH 的风险可能被高估。然而，由于证据总体水平较低，且 AHT 停止也会降低 OH 发生率，因此目前尚不能得出明确结论，这突出了一个重要的研究空白。未来在老年患者中进行的 AHT 试验应采用标准化方案测量 OH，遵循共识指南以克服这些局限性。
