Association between antihypertensive treatment and adverse events: systematic review and meta-analysis

Abstract

Objective: To examine the association between antihypertensive treatment and specific adverse events.

Design: Systematic review and meta-analysis.

Eligibility criteria: Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up.

Information sources: Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020.

Main outcome measures: The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ²).

Results: Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ²=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ²=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ²=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ²=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ²=0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction.

Conclusions: This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function.

Registration: PROSPERO CRD42018116860.

Fig 1

Selection of studies for inclusion in review. *Hand searches of reference lists of included studies and recent meta-analyses of blood pressure lowering trials

Fig 2

Summary of risk of bias assessment across all included randomised controlled trials

Fig 3

Random effects meta-analysis of randomised controlled trials examining the association between antihypertensive treatment and falls

Fig 4

Random effects meta-analysis of randomised controlled trials examining the association between antihypertensive treatment and acute kidney injury

Fig 5

Random effects meta-analysis of randomised controlled trials examining the association between antihypertensive treatment and cardiovascular death