Orthostatic Hypotension in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) Blood Pressure Trial

Abstract

Orthostatic hypotension (OH) is associated with hypertension and diabetes mellitus. However, in populations with both hypertension and diabetes, its prevalence, the effect of intensive versus standard systolic blood pressure (BP) targets on incident OH, and its prognostic significance are unclear. In 4266 participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) BP trial, seated BP was measured 3 times, followed by readings every minute for 3 minutes after standing. Orthostatic BP change, calculated as the minimum standing minus the mean seated systolic BP and diastolic BP, was assessed at baseline,12, and 48 months. The relationship between OH and clinical outcomes (total and cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, heart failure hospitalization or death and the primary composite outcome of non-fatal myocardial infarction, non-fatal stroke and cardiovascular death) was assessed using proportional hazards analysis. Consensus OH, defined by orthostatic decline in systolic BP ≥20 mm Hg and/or diastolic BP ≥10 mm Hg, occurred at ≥1 time point in 20% of participants. Neither age nor systolic BP treatment target (intensive, <120 mm Hg versus standard, <140 mm Hg) was related to OH incidence. Over a median follow-up of 46.9 months, OH was associated with increased risk of total death (HR=1.61, 95% CI 1.11–2.36) and heart failure death/hospitalization (HR=1.85, 95% CI 1.17–2.93), but not with the primary outcome or other prespecified outcomes. In patients with type 2 diabetes and hypertension, OH was common, not associated with intensive versus standard BP treatment goals, and predicted increased mortality and heart failure events.

Orthostatic Hypotension and Risk of Clinical and Subclinical Cardiovascular Disease in Middle‐Aged Adults

“…Along these lines, in a secondary analysis of the ACCORD, Fleg and colleagues 11 demonstrated that OH was not associated with CVD events. In addition, they showed that treatment of risk factors associated with both OH and CVD (namely, hyperglycemia and hypertension) had no impact on OH 11. In contrast, our study demonstrates prospective, concurrent, and intermediate‐term relationships between OH and both subclinical and clinical CVD outcomes.…”

“…Several prospective studies reported no association between OH and coronary heart disease (CHD)7, 8, 9 or CVD mortality 10. Similarly, a recent secondary study of ACCORD (Action to Control Cardiovascular Risk in Diabetes Blood Pressure Trial), a trial of blood pressure (BP) reduction in a population with diabetes mellitus, found that although OH was associated with death and heart failure (HF), it was not associated with atherosclerotic events 11. In contrast, many studies have shown that OH is associated with CVD events12, 13, 14, 15, 16, 17 and CVD mortality 14, 18…”

Orthostatic Hypotension and Risk of Incident Dementia

“…However, recent data suggest that symptomatic hypotension makes up <10% of OH and does not have a stronger association with occurrence of cardiovascular event than asymptomatic OH. 34 These limitations could partially explain the relatively weak prevalence of OH of ≈13% compared with other studies. However, this does not question the strength of the association between OH and dementia, which is probably underestimated as a result of these limitations.…”

Hypertension highlights during 2016

“…The persons in this trial were a randomized to treatment with antihypertensive drugs to lower the SBP to <120 mmHg or to <140 mmHg. After 1 year, the SBP was 119.3 mmHg with intensive blood pressure control versus 133.5 mmHg with standard antihypertensive drug treatment (9).…”

“…The Orthostatic Hypotension in Diabetics in the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial investigated the prevalence, incidence, and prognostic significance of orthostatic hypotension in the ACCORD BP trial (9,10). The participants in this trial were at high risk for having orthostatic hypotension because they had type 2 diabetes, had hypertension, and were treated with antihypertensive drugs.…”