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Syncope and Hypotension Associated With Intensive Treatment of Hypertension
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Adults aged ≥50 years at high risk for cardiovascular disease with a systolic blood pressure (SBP) between 130 and 180 mm Hg were treated for hypertension and were randomized to a treatment goal of <120 mm Hg (intensive control) or <140 mm Hg to evaluate the predictors of syncope, hypotension, and falls. Syncope was seen in 1.8% of participants, while 1.6% had hypotension and 2.2% experienced falls. Intensive control was associated with a significantly increased risk of hypotension (P = .002) and possibly an increased risk of syncope (P = .07). Intensive treatment was not associated with the risk of falls. The risk of all three adverse events was highest among individuals with chronic kidney disease or frailty, and the risk of adverse events was not dependent on age.
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Adults aged ≥50 years at high risk for cardiovascular disease with a systolic blood pressure (SBP) between 130 and 180 mm Hg were treated for hypertension and were randomized to a treatment goal of <120 mm Hg (intensive control) or <140 mm Hg to evaluate the predictors of syncope, hypotension, and falls. Syncope was seen in 1.8% of participants, while 1.6% had hypotension and 2.2% experienced falls. Intensive control was associated with a significantly increased risk of hypotension (P = .002) and possibly an increased risk of syncope (P = .07). Intensive treatment was not associated with the risk of falls. The risk of all three adverse events was highest among individuals with chronic kidney disease or frailty, and the risk of adverse events was not dependent on age.
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
To determine predictors of serious adverse events (SAEs) involving syncope, hypotension, and falls, with particular attention to age, in the Systolic Blood Pressure Intervention Trial.
DESIGN
Randomized clinical trial.
SETTING
Academic and private practices across the United States (N = 102).
PARTICIPANTS
Adults aged 50 and older with a systolic blood pressure (SBP) of 130 to 180 mmHg at high risk of cardiovascular disease events, but without diabetes, history of stroke, symptomatic heart failure or ejection fraction less than 35%, dementia, or standing SBP less than 110 mmHg (N = 9,361).
INTERVENTION
Treatment of SBP to a goal of less than 120 mmHg or 140 mmHg.
MEASUREMENTS
Outcomes were SAEs involving syncope, hypotension, and falls. Predictors were treatment assignment, demographic characteristics, comorbidities, baseline measurements, and baseline use of cardiovascular medications.
RESULTS
One hundred seventy-two (1.8%) participants had SAEs involving syncope, 155 (1.6%) hypotension, and 203 (2.2%) falls. Randomization to intensive SBP control was associated with greater risk of an SAE involving hypotension (hazard ratio (HR) = 1.67, 95% confidence interval (CI) = 1.21-2.32, P = .002), and possibly syncope (HR = 1.32, 95% CI = 0.98-1.79, P = .07), but not falls (HR = 0.98, 95% CI = 0.75-1.29, P = .90). Risk of all three outcomes was higher for participants with chronic kidney disease or frailty. Older age was also associated with greater risk of syncope, hypotension, and falls, but there was no age-by-treatment interaction for any of the SAE outcomes.
CONCLUSIONS
Participants randomized to intensive SBP control had greater risk of hypotension and possibly syncope, but not falls. The greater risk of developing these events associated with intensive treatment did not vary according to age.
Additional Info
Syncope, Hypotension, and Falls in the Treatment of Hypertension: Results From the Randomized Clinical Systolic Blood Pressure Intervention Trial
J Am Geriatr Soc 2018 Mar 30;[EPub Ahead of Print], KM Sink, GW Evans, RI Shorr, JT Bates, D Berlowitz, MB Conroy, DM Felton, T Gure, KC Johnson, D Kitzman, MF Lyles, K Servilla, MA Supiano, J Whittle, A Wiggers, LJ FineFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) examined serious adverse events (SAEs) involving syncope, hypotension, and falls, with particular attention to age. Of the 9361 patients, 172 (1.8%) had syncope, 155 (1.6%) hypotension, and 203 (2.2%) experienced falls.
In the group with tighter systolic blood pressure (SBP) control <120 mm Hg compared with <140 mm Hg, more patients experienced hypotension (HR, 1.67; 95% CI, 1.21–2.32; P = .002) but not syncope (HR, 1.32; 95% CI, 0.98–1.79; P = .07) or falls (HR, 0.98; 95% CI, 0.75–1.29; P = .90). All SAEs were more common in older age, but there was no difference by blood pressure treatment. Unfortunately, patients with comorbidities (diabetes, stroke, ejection fraction <35%, dementia, or baseline standing SBP <110 mm Hg), which are often seen in our older adults, were excluded in SPRINT, limiting our ability to extrapolate.
Previous studies have shown that slower gait increases risk of tight blood pressure control, with a cutoff 0.8 m/s for community living and 0.5 m/s in facility-dwelling patients.1,2 In this study, in the older than 85 years group (average speed 0.9 m/s), slower gait was associated with more SAEs; however, specific cutoff was not mentioned and, due to small number of events in this age group, this may not be reliable.
Alpha blockers and beta blockers in the older than 85 years group in this analysis were associated with higher risk of SAEs, but small numbers of outcomes, again, limit reliability. Combining all age categories showed no differences. The MOBILIZE study showed lower risk of falls associated with ACE inhibitors, ARBs, and calcium channel blockers.3 Better blood pressure control may reduce the vascular damage that contributes to periventricular white matter changes that lead to falls.
This study showed no effect on falls when orthostasis was measured 1 minute after arising. The TILDA study showed a correlation with orthostatic hypotension and falls, but identified that the blood pressure nadir occurs at 15 seconds. Perhaps, the 1-minute interval used to measure the blood pressure in the SPRINT trial missed some orthostatic hypotension and therefore did not show a correlation with falls.
The authors concluded that treating individuals aged 75 and older to a SBP goal of <120 mm Hg does not increase risk for SAEs involving syncope, hypotension, or falls more than in individuals aged 50 to 74. This study reinforces that tight blood pressure control does not increase the risk of patient-oriented outcomes of syncope or falls.
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