Aggressive hypertension treatment does not lead to dangerous drops in blood pressure

Hypertension (high blood pressure) is a leading cause of death and disability worldwide. It is a primary risk factor for numerous medical conditions, including heart attacks, strokes, heart failure, kidney disease, atrial fibrillation, and dementia.

Blood pressure (BP) control is so critical that when the American Heart Association and the American College of Cardiology updated their treatment guidelines in 2017, they called for more aggressive blood pressure treatment. They lowered the definition of normal, or optimal, blood pressure to less than 120/80 mm Hg, and they recommended treatment for blood pressure higher than 130/80 mm Hg.

Doctors worry about treating high blood pressure too aggressively

Physicians have historically worked to optimize blood pressure, yet many doctors have been reluctant to be overly aggressive. This is likely based on our Hippocratic Oath of “first, do no harm.” There is concern that lowering blood pressure too aggressively might result in symptoms of weakness and fatigue, or lightheadedness and dizziness. These symptoms, especially in older patients, could result in a fall with the potential for injury or disability.

A reduction in blood pressure with a change in position is called orthostatic hypotension. It typically occurs when someone goes from sitting to standing. Most of us have experienced momentary symptoms, noting dark vision after getting up too quickly. This is typically a short-lived event, lasting only seconds and resolving quickly. But what if these symptoms were severe enough or lasted long enough to be dangerous?

Study finds intensive hypertension treatment does not cause dangerous drops in blood pressure

A recent meta-analysis published in Annals of Internal Medicine reviewed five trials to examine the effect of intensive blood pressure-lowering treatment, and to answer the question: does intensive blood pressure treatment cause a dangerous drop in blood pressure? The analysis included over 18,000 participants, and study quality was noted to be good, with minimal variation between trials.

This meta-analysis analyzed randomized studies in which patients were assigned to either intensive blood pressure control, less intensive blood pressure control, or a placebo, for at least six months. The studies documented both seated and standing blood pressure readings, and the standing blood pressure readings were taken after standing for at least one minute. Orthostatic hypotension was defined as a drop in seated to standing blood pressure of at least 20 mm Hg systolic blood pressure (the top number in a BP reading) and at least 10 or more mm Hg diastolic blood pressure (the bottom number).

The study results provide an important take-home message for both patients and their physicians: intensive blood pressure lowering was not associated with orthostatic hypotension, and in fact intensive treatment decreased the risk of orthostatic hypotension. These results should give physicians peace of mind when aiming for lower blood pressure goals.

One less worry when selecting blood pressure treatment

Given that Americans have a greater than 80% lifetime risk of hypertension, most individuals with a normal blood pressure are likely to eventually develop elevated blood pressure. Regular blood pressure measurements are essential to ensure prompt treatment.

Treatment should usually start with lifestyle changes such as weight loss, regular exercise, and a healthy diet, which means limiting processed foods and sodium, working on portion control, and limiting alcohol. These changes can have a significant impact on blood pressure, but they’re not always enough. If you do need medications, you and your doctor can select a treatment without worrying about orthostatic hypotension.