Planned Antihypertensive Deprescribing in Long-Term Care Residents: A Systematic Review of Randomized Evidence

Background: Evidence supporting antihypertensive treatment in older adults is derived largely from populations that differ from long-term care residents, in whom frailty, dementia, multimorbidity, polypharmacy, and competing clinical priorities may alter the balance between preventive benefit and treatment burden. Objectives: The aim was to synthesize randomized evidence on planned antihypertensive deprescribing in institutional long-term care and determine whether clinically and methodologically comparable effects support a common treatment-effect estimate. Methods: Randomized or cluster-randomized studies of planned antihypertensive deprescribing in long-term care were systematically reviewed. MEDLINE/PubMed, Embase, CENTRAL, CINAHL Complete, Web of Science Core Collection, trial registries, and PROSPERO were searched from inception and updated to 20 August 2026. Meta-analysis was reserved for outcomes with at least two clinically and methodologically compatible estimates of a common, interpretable effect; otherwise, structured study-level synthesis was used. Result-specific risk of bias was assessed with the revised Cochrane risk-of-bias tool (RoB 2), and certainty with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Results: Three randomized long-term care studies involving 1548 residents were included. Their populations, deprescribing strategies, monitoring, restart criteria, and follow-up differed substantially, and no outcome was considered sufficiently clinically and methodologically comparable for meta-analysis. RETREAT-FRAIL reported an adjusted hazard ratio (HR) for all-cause mortality of 1.02 (95% confidence interval 0.86–1.21) over a median potential follow-up of 38.4 months, whereas DANTON reported an HR of 1.65 (0.95–2.85) to 32 weeks; Gulla/COSMOS had no cluster-adjusted comparative mortality estimate. At 16 weeks in DANTON, deprescribing increased systolic blood pressure by 11.0 mmHg (5.6–16.4), increased diastolic blood pressure by 4.6 mmHg (1.1–8.1), and reduced the number of antihypertensive drugs by 1.2 (1.0–1.4). Evidence for hospitalization, falls, cardiovascular events, cognition, function, and quality of life remained sparse, outcome-specific, or at risk of bias. Conclusions: Randomized evidence for antihypertensive deprescribing in long-term care remains sparse and clinically heterogeneous. Within individual trials, supervised deprescribing reduced antihypertensive exposure and raised blood pressure, but the magnitude and clinical consequences varied by strategy and follow-up. Current evidence does not establish a common effect on mortality, hospitalization, or other resident-important outcomes, making trial-specific estimates and deprescribing protocols more informative than a single pooled treatment effect. PROSPERO Registration: CRD420261370802.