A Review of Clinical Trial and Meta-Analyses of BP Treatment Strategies for Patients with Orthostatic Hypotension: Blood Pressure Management in Patients with Hypertension and Orthostatic Hypotension.

PURPOSE OF REVIEW: To review clinical trial and meta-analysis data on the effects of blood pressure (BP) pharmacologic treatment for hypertension on orthostatic hypotension (OH) to identify BP goals for patients with these concomitant conditions. FINDINGS: Hypertension and OH are commonly found together. The autonomic reflex that prevents hypotension upon standing also prevents hypertension when supine. OH, a fixed difference in systolic BP (≥ 20 mmHg) or diastolic BP (≥ 10 mmHg) between supine (or seated) and standing positions, can thus be associated with adverse outcomes related to low BP (e.g., syncopal events and falls) or high BP (e.g., coronary heart disease and stroke). While all OH stems from some degree of autonomic dysfunction, the type and extent of deficit has implications on the severity and reproducibility of the OH. Treatment strategies, moreover, differ based on predominant risks as well as OH etiology, specifically: neurologic, acute, pharmacologic, or hypertensive (cardiovascular). Hypertensive (cardiovascular) OH has been viewed traditionally through the lens of hypotensive event prevention, but emerging evidence suggests that more intensive therapy may reduce OH and prevent CVD disease with minimal effects on hypotensive events. Careful medication selection, however, is essential to reduce supine or seated hypertension, improve orthostatic BP regulation, and prevent hypotensive complications of treatment in these complex patients. Mounting evidence does not consider OH a deterrent for hypertension management; however, careful phenotyping of OH etiology and patient risks are essential for more precise patient care.