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期刊来源：JAMA

文献发表时间：2023-10-17

原文链接：https://jamanetwork.com/journals/jama/article-abstract/2810698

关键点内容如下：

问题

强化血压治疗对心血管疾病或全因死亡率的影响是否因是否存在直立性或立位性低血压而不同？

调查结果

在这项对9项高血压试验的29000多名参与者进行的个体数据荟萃分析中，无论参与者是否患有直立性低血压，更多的强化血压治疗降低了心血管疾病或全因死亡率的风险。此外，效果并不因是否存在站立低血压而不同。

意义

在成人高血压患者中，无症状的直立性低血压或站立低血压不应成为更多强化高血压治疗的障碍。

摘要内容如下：

重要性

在患有直立性低血压或站立低血压的成人中，强化治疗与标准血压（BP）治疗的益处一直备受关注。

意义

确定较低血压治疗目标或积极治疗与标准血压治疗目标或安慰剂相比，对心血管疾病（CVD）或基线直立性低血压或基线站立低血压的全因死亡率的影响。

数据来源

基于MEDLINE、EMBASE和中央数据库的系统综述的个体参与者数据荟萃分析，截至2022年5月13日。

研究选择

血压药物治疗（强化血压目标或活性药物）与直立性低血压评估的随机试验。根据PRISMA指南提取的个体参与者数据荟萃分析。使用单阶段方法的Cox比例风险模型确定效应。

主要结局和措施

主要结局是心血管疾病或全因死亡率。直立性低血压定义为从坐位改为站立位后，收缩压下降至少20 mm Hg和/或舒张压下降至少10 mm Hg。立位低血压定义为立位收缩压≤110 mm Hg或立位舒张压≤60 mm Hg。

结果

9项试验包括29235名参与者，随访时间中位数为4年，（平均年龄69.0[SD，10.9]岁；48%的妇女）。基线时有9%的患者出现直立性低血压，5%的患者出现站立低血压。在没有基线直立性低血压的患者中，更多的强化BP治疗或积极治疗降低了CVD或全因死亡率的风险（风险比[HR]，0.81；95%CI，0.76-0.86）与基线直立性低血压相似（HR，0.83；95%可信区间为0.70~1.00；治疗与基线直立性低血压）的相互作用P=0.68。在没有基线站立低血压的患者中，更多的强化BP治疗或积极治疗降低了CVD或全因死亡率的风险（HR，0.80；95%CI，0.75-0.85），而在基线站立低血压患者中无显著性（HR，0.94；95%CI，0.75-1.18）。效果不因基线站立低血压而不同（治疗与基线站立低血压的相互作用P=0.16）。

结论和相关性

在该高血压试验参与者人群中，无论是否存在直立性低血压，强化治疗均降低了心血管疾病或全因死亡率的风险，但没有证据表明在站立低血压患者中存在不同的影响。

英文原文如下：

Key Points

Question  Does the effect of intensive blood pressure treatment on cardiovascular disease or all-cause mortality differ based on the presence or absence of orthostatic or standing hypotension?

Findings  In this individual data meta-analysis of more than 29 000 participants in 9 hypertension trials, more intensive blood pressure treatment lowered risk of cardiovascular disease or all-cause mortality regardless of whether participants had orthostatic hypotension. Moreover, effects did not differ by the presence or absence of standing hypotension.

Meaning  Asymptomatic orthostatic hypotension or standing hypotension among adults with hypertension should not be a deterrent to more intensive hypertension treatment.

Abstract

Importance  There are ongoing concerns about the benefits of intensive vs standard blood pressure (BP) treatment among adults with orthostatic hypotension or standing hypotension.

Objective  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.

Data Sources  Individual participant data meta-analysis based on a systematic review of MEDLINE, EMBASE, and CENTRAL databases through May 13, 2022.

Study Selection  Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) with orthostatic hypotension assessments.

Data Extraction and Synthesis  Individual participant data meta-analysis extracted following PRISMA guidelines. Effects were determined using Cox proportional hazard models using a single-stage approach.

Main Outcomes and Measures  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.

Results  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).

Conclusions and Relevance  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.

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