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Isolated systolic hypertension in the elderly: lessons from clinical trials and future directions
1Department of Preventive Medicine, Rush-Presbyterian-St.Luke's Medical Center, Chicago IL 60612, USA. hblack@rush.edu
Insights
Focusing on systolic blood pressure (SBP) reduction is crucial for treating hypertension and preventing cardiovascular disease (CVD) events. Clinical trials demonstrate SBP lowering significantly reduces morbidity and mortality, especially in older adults with isolated systolic hypertension (ISH).
Area of Science:
- Cardiology
- Geriatrics
- Public Health
Background:
- Systolic blood pressure (SBP) is a more reliable predictor of cardiovascular disease (CVD) events than diastolic blood pressure (DBP).
- Despite guidelines recommending SBP treatment goals, a reluctance exists in the medical community to shift focus from DBP.
- Isolated systolic hypertension (ISH) significantly impacts hypertensive patients aged 65-89, affecting approximately two-thirds of this demographic.
Purpose of the Study:
- To highlight the importance of SBP reduction in hypertension management.
- To address the gap in clinical practice regarding SBP-focused treatment strategies.
- To advocate for prioritizing SBP reduction in treatment plans and drug development.
Main Methods:
- Analysis of data from large clinical trials, including the Systolic Hypertension in the Elderly Program (SHEP) and Systolic Hypertension in Europe (Syst-EUR).
- Examination of sub-studies focusing on specific patient groups, such as those with non-insulin-dependent diabetes mellitus (NIDDM) and a history of myocardial infarction (MI).
Main Results:
- Both SHEP and Syst-EUR trials confirmed that reducing SBP in the elderly with ISH significantly lowered morbidity and mortality.
- SHEP sub-studies showed SBP reduction decreased stroke and heart failure incidence in patients with NIDDM and prior MI.
- Syst-EUR demonstrated a significant reduction in stroke, CVD events, and mortality with a 20 mmHg SBP decrease in individuals over 60.
Conclusions:
- Reducing SBP is a critical imperative for effective hypertension management and CVD prevention.
- Clinical evidence strongly supports prioritizing SBP reduction, particularly for elderly patients with ISH.
- A paradigm shift in medical practice and antihypertensive drug development is needed to effectively lower SBP.
Abstract:
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.