Related Experiment Videos
Prevalence and implications of uncontrolled systolic hypertension
1National Heart, Lung and Blood Institutes Framingham Study and Boston University School of Medicine, Framingham, Massachusetts 01702-5827, USA. kannel@fram.nhlbi.nih.gov
Insights
Elevated blood pressure, even high-normal, significantly increases cardiovascular disease (CVD) risk. Systolic blood pressure is a key driver, and managing isolated systolic hypertension (ISH) is crucial for reducing CVD events.
Area of Science:
- Cardiology
- Hypertension Research
- Public Health
Background:
- Cardiovascular disease (CVD) risk escalates with blood pressure, including high-normal ranges.
- Hypertension contributes significantly to CVD, with many events occurring in individuals with high-normal or mild hypertension.
- A substantial portion of CVD events in the elderly, even those treated for hypertension, are linked to elevated blood pressure levels.
Purpose of the Study:
- To highlight the critical role of systolic blood pressure (SBP) in determining cardiovascular disease (CVD) risk.
- To emphasize the importance of isolated systolic hypertension (ISH) and pulse pressure in CVD risk assessment.
- To advocate for improved clinical translation of evidence regarding systolic pressure's dominance in CVD risk.
Main Methods:
- Analysis of data from large-scale studies like the Framingham Study to assess blood pressure and CVD event relationships.
- Review of clinical trial data to evaluate the impact of treating hypertension, particularly ISH.
- Examination of risk factor burden in conjunction with hypertension for global risk assessment.
Main Results:
- Systolic blood pressure is a primary determinant of CVD risk, with modest average SBP levels associated with coronary heart disease.
- Isolated systolic hypertension (ISH) constitutes a significant proportion of hypertension in the elderly, and pulse pressure directly correlates with CVD risk.
- A considerable percentage of CVD events occur in individuals with high-normal blood pressure and mild hypertension, including those receiving treatment.
Conclusions:
- Systolic blood pressure, especially ISH, is a crucial factor in CVD risk that requires greater clinical attention.
- Global risk assessment, considering accompanying risk factors, is essential for managing hypertension and determining treatment urgency.
- While evidence supports treating ISH with SBP >160 mm Hg, further research is needed for lesser elevations, though many with mild ISH warrant treatment due to combined risk factors.
Abstract:
Risk of cardiovascular disease (CVD) increases incrementally with blood pressure, even within the high-normal range. In the general population, 27% of CVD in women and 37% in men is attributable to hypertension. A high percentage of these hypertension-related events occur in those with high-normal blood pressure and mild hypertension; about one-fourth of CVD events in elderly women and one-third in elderly men in the Framingham Study occurred in persons who had blood pressures of 140-159 mm Hg systolic and/or 90-95 mm Hg diastolic. The average systolic blood pressure (SBP) at which coronary heart disease occurs is rather modest (141 mm Hg), as is the pulse pressure (59-63 mm Hg). Of the CVD events in elderly participants in the Framingham Study, 24% in men and 36% in women occurred in persons receiving treatment for hypertension. There is a growing recognition of the importance of the systolic component of blood pressure. About 65% of hypertension in the elderly is isolated systolic hypertension (ISH), and CVD risk increases with pulse pressure. Pulse pressure is not simply a marker for stiff diseased arteries; treatment of ISH in trials promptly reduces the CVD risk, indicating that the pulse pressure generated by the stiff artery is the culprit. Analysis of data from clinical trials indicates that greater reliance should be placed on systolic pressure in evaluating the CVD potential of hypertension. Hypertension, including ISH, seldom occurs in isolation from other risk factors and overt CVD. Risk varies widely depending on the burden of accompanying risk factors. This makes global risk assessment mandatory for evaluating risk and the urgency and nature of treatment required. Evidence incriminating systolic pressure as the dominant blood pressure determinant of CVD has not been translated into clinical practice. Most of the uncontrolled hypertension observed in the Framingham Study is concentrated in those with ISH. This also extends to African-Americans, people with diabetes mellitus and the elderly. When should SBP be considered controlled? Substantial evidence supports the value of treating ISH with SBP exceeding 160 mm Hg. Trial data are not yet available to support recommendations to treat lesser elevations of ISH or pulse pressure per se, but since one-half of patients with mild ISH have two or more additional risk factors, most are candidates for treatment. In such patients, ISH should be considered controlled when their global CVD risk is reduced to below the average for their age.