Deprescribing antihypertensive medications in older people: a systematic review and a meta-analysis

INTRODUCTION: Hypertension is highly prevalent among older people, and the balance of benefit and harm of antihypertensive therapy may shift with age. In certain cases, reducing or discontinuing antihypertensive treatment (deprescribing) may be appropriate. This systematic review and meta-analysis aimed to summarize available evidence on deprescribing antihypertensive medications in older adults aged 65 years and older. METHODS: We searched MEDLINE, Embase, CINAHL, the Cochrane Library, the Web of Science Core Collection, ClinicalTrials.gov, ICTRP and Epistemonikos from inception to July 2024. We included randomized controlled trials (RCTs) and comparative observational studies (OS) comparing deprescribing versus continuation of antihypertensive medications in adults ≥ 65 years. The primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction, heart failure, stroke, major adverse cardiovascular events (MACE), orthostatic hypotension and falls. Where possible, data were synthesized using meta-analysis to estimate odds ratios (ORs) and 95% Confidence Intervals (CI). We assessed the risk of bias in the RCTs in Covidence basing on the Cochrane Risk Of Bias (Rob 2) tool. For the observational studies we used the Newcastle Ottawa Scale for comparative observational studies. RESULTS: We included 17 studies. Results from the observational studies are only reported as narrative summary. The pooled OR for all-cause mortality was 1.11 (95% CI 0.82-1.50; 6 RCTs). For secondary outcomes, pooled ORs were 1.32 (95% CI 0.30-5.92) for myocardial infarction (3 RCTs), 3.16 (95% CI 1.53-6.55) for heart failure (3 RCTs), and 3.08 (95% CI 0.73-13.00) for stroke (4 RCTs). CONCLUSION: The effects of deprescribing antihypertensive medications in older adults remain uncertain. The limited and low-event-rate evidence on key cardiovascular outcomes for older individuals highlights the need for individualized decision-making, especially in frail and multimorbid populations. This review provides a foundation for future research to address gaps and guide safer deprescribing practices in older adults in routine clinical practice.