Isolated systolic hypertension in the elderly: lessons from clinical trials and future directions.
Systolic blood pressure (SBP) is a more reliable predictor of cardiovascular disease (CVD) events than is diastolic blood pressure (DBP). Perhaps the reduction of SBP should be more of the imperative of treatment than the reduction of DBP. Although two recent guidelines (WHO/ISH and JNC-VI) have recommended treating SBP to goal, there seems to be a reluctance in the medical community to embrace this paradigm shift and revise treatment plans. The deleterious effects of ignoring these findings are especially damaging to those with isolated systolic hypertension (ISH), which affects approximately two-thirds of hypertensive patients between the ages of 65 and 89 years. Two large clinical trials, the Systolic Hypertension in the Elderly Program (SHEP) and the Systolic Hypertension in Europe (Syst-EUR) trial have confirmed that reducing SBP in the elderly with stages 2 and 3 ISH (SBP > or = 160 mmHg with DBP < 90 mmHg in SHEP and SBP > 160 mmHg with DBP < 95 mmHg in Syst-EUR) reduced morbidity and mortality. Two SHEP sub-studies found that lowering SBP in subjects with non-insulin-dependent diabetes mellitus (NIDDM) and those with a history of myocardial infarction (MI) reduced the incidence of stroke and heart failure, as well as several other endpoints. The beneficial effects were corroborated in Syst-EUR where stroke (fatal and nonfatal), CVD endpoints and mortality were all significantly reduced when SBP was lowered 20 mmHg in subjects > 60 years of age. Despite these findings, however, recent analysis suggests that most hypertension treatment decisions continue to be based on DBP measurements instead of SBP. To combat this treatment gap, we must disseminate this information and motivate physicians and other providers to include reduction of SBP in their treatment plans. We must also encourage the development of antihypertensive drugs that lower SBP more effectively than those that are currently available.
Black
H R
HR
Department of Preventive Medicine, Rush-Presbyterian-St.Luke's Medical Center, Chicago IL 60612, USA. hblack@rush.edu
D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001794:Blood Pressure / Q000187:drug effects; D002986:Clinical Trials as Topic; D004232:Diuretics / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D006801:Humans; D006973:Hypertension / Q000150:complications* / Q000188:drug therapy / Q000503:physiopathology; D009200:Myocardial Contraction / Q000187:drug effects; D011379:Prognosis
D000959:Antihypertensive Agents; D004232:Diuretics