Association between antihypertensive treatment and adverse events: systematic review and meta-analysis
Authors: Albasri Ali , Hattle Miriam , Koshiaris Constantinos , Dunnigan Anna , Paxton Ben , Fox Sarah Emma , Smith Margaret , Archer Lucinda , Levis Brooke , Payne Rupert A , Riley Richard D , Roberts Nia , Snell Kym I E , Lay-Flurrie Sarah , Usher-Smith Juliet , Stevens Richard , Hobbs F D Richard , McManus Richard J , Sheppard James P 
Published: February 2021

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 (τ
2
).

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, τ
2
=0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ
2
=0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ
2
=0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ
2
=0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ
2
=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.