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.

Related Information: Controlling Your Blood Pressure


  1. Rumi Farhad Ara

    It is very difficult to treat severe hypertension in mid trimester pregnancy with medication available at now. That is a real challenge for obstetricians.

  2. Kevin Jorgensen

    This article ignores the significant side effects of all blood medications. Using multiple blood medications increases the risk of a serious side effect that can impact quality of life significanty

  3. Geoffrey

    Aggressive hypertension treatment does not lead to dangerous drops in blood pressure.This was happend to me.Now I understood ,thank you.

  4. Eva Pardee

    So what do you do if you have high blood pressure and you cannot take the appropriate dose of medication to control it because of severe side effects? Even after trying numerous medications. It seem this topic is never addressed. Side effects seem to be just swept under the rug by doctors even though they can be very severe.


    Aggressive hypertension treatment to bring the blood pressure to a desired level free of I’ll affects of even if there is postural hypotension should be evaluated with comorbidities and can not be as simple as an observation of a meta-analysis.
    Present contagion has raised horrifying issues in aged with Metabolic Syndrom where in postural hypotension is an important finding attributable to anti- hypertensive drugs, convalescence, Covad-19 induced dysautonomia, stress and multiple organ involvement challenging body homeostasis.

  6. Kittredge White, PA-C

    I read with great interest your blog post on aggressive lowering of blood pressure not leading to dangerous lowering of BP. Your article focused mostly on concerns for falls with too-aggressive lowering of BP.

    When working as a PA in a community clinic, I saw a 73 yo lady with BP of 200/# (I forget the diastolic, but was very concerned about that systolic). I went to my SP to discuss, and to ask him if we had anything in-house we could give her to bring her pressure down a bit. He gave me a very hard time, saying that dropping pressure too quickly could lead to lowered end-organ perfusion – which made sense to me – and he wanted me to give her an Rx and send her home, with instructions for f/u. He produced an Up-to-Date article supporting his POV.

    Because of my own concern and discomfort with sending her home, I sent her to the ED for care and monitoring.

    What do your resources say about the concern for diminished end-organ perfusion with aggressive intervention for hypertension?

  7. Donald E Morisky

    One of the most important confounders in clinical trial studies is medication-taking behavior (adherence). Many clinical trials fail to measure this very important behavior, which may result in a misdiagnosis of the blood pressure. All patients should be measured on their level of adherence to rule out any differences between the two groups. This baseline measure can be measured at different periods of the study. Measuring adherence allows the investigator to correlate the adherence measure with the physiological outcome, blood pressure control. Most studies find the higher the adherence the higher the proportion of patients having their BP under control. Patients in the treatment group may receive educational counseling and this may make a big difference in final outcome.

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