Cutting use of antihypertensives may not affect mortality or cardiovascular outcomes, Cochrane review finds

Antihypertensive discontinuation in older people may have no effect on clinically important outcomes, such as mortality or cardiovascular events, a Cochrane review has concluded.

However, deprescribing may lead to an increase in blood pressure, requiring some patients to restart therapy, the review warned.

Six randomised controlled trials (RCTs), including 1,073 adults aged 50 years and over who were taking blood pressure medications for hypertension or for prevention of cardiovascular disease, were included in the review. Study duration and follow-up ranged from 4 to 56 weeks and in 3 of the studies, the dose of the antihypertensive was slowly lowered before stopping. The antihypertensives included diuretics, beta-blockers, calcium channel blockers, renin inhibitors, angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists.

In their meta-analysis, the reviewers compared stopping or reducing the dose of antihypertensive medications with continuing them, and rated the certainty of the evidence using four levels: very low, low, moderate, or high, depending on how confident they were in the results.

Overall, they found a low certainty of evidence that stopping antihypertensive medication increased blood pressure by a small amount, compared to continuation. 

They also found a low or very low certainty of evidence that stopping blood pressure medications did not increase the risk of having a heart attack, stroke, hospitalisation or death, and a very low certainty of evidence that stopping blood pressure medications did not increase the risk of adverse events and may resolve side effects.

None of the studies reported whether stopping blood pressure medications affected falls.

Overall, the authors concluded that there was “no evidence” of an effect of discontinuing, compared with continuing, antihypertensives used for hypertension or primary prevention of cardiovascular disease in older adults on all-cause mortality and myocardial infarction, suggesting it “may be” safe to stop the medication in this population.

They said that the findings of the review had “clinical implications” for the management of hypertension in older adults and could be “considered” in the next updates of international guidelines.

However, they added that future research should focus on populations with the greatest uncertainty of the benefit-risk ratio for use of antihypertensive medications, such as those with frailty, older age groups and those taking multiple medicines, as well as measure clinically important outcomes, such as falls, quality of life and adverse drug events.

Nina Barnett, consultant pharmacist in care of older people at Northwick Park Hospital, said that the conclusions were at odds with the 2008 HYVET trial, which suggested a benefit from antihypertensives in older people.

“My first thought [on the review] is that Cochrane defined older people as over 50 years old — that certainly wouldn’t be representative of clinical practice and even with this definition, they only included six RCTs. I’d be surprised if there was much data in the over-80s.

“The report states that there was low certainty of evidence and a number of biases, so, I am reminded of the phrase ‘absence of evidence is not evidence of absence’.”

Barnett highlighted that the decision to stop or continue medicines for hypertension in an older frail person was “always multifactorial and individualised”.

“Each person’s situation will be considered in relation to the evidence (often very little), their preferences and goals for treatment and our clinical judgement, which combines evidence, experience and preferences,” she said.