Current Hypertension Reports

, Volume 2, Issue 5, pp 433–440

The need to lower systolic blood pressure

  • Sanjay Shrivastava
  • Mahendr S. Kochar
Article
  • 20 Downloads

Abstract

Systolic hypertension is the most common form of hypertension, especially in individuals aged 60 years or older. Systolic hypertension is a reflection of decreasing compliance of large arteries and is a strong independent risk factor for all cardiovascular diseases. Despite proven benefits of therapy for systolic hypertension, only 25% of patients with this condition are adequately treated to attain target blood pressures. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure (JNC VI) recommends the use of diuretics and long-acting dihydropyridine calcium channel blockers as first-line therapy for isolated systolic hypertension. Therapy is also guided by comorbid conditions where certain drugs may have additional benefits. The goal of therapy should be a graded reduction in blood pressure to less than 140/90 mm Hg with lower blood pressure targets in patients with coexistent diabetes or renal failure.

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References and Recommended Reading

  1. 1.
    Joint National Committee on Prevention, Detection, Evaluation and Treatment of high blood pressure: The sixth report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure (JNC VI). Arch Intern Med 1997, 157:2413–2446. The JNC VI report, a comprehensive, evidence-and consensus-based document, provides guidance on the prevention, detection, evaluation, and treatment of hypertension.CrossRefGoogle Scholar
  2. 2.
    Lloyd-Jones DM, Evans JC, Larson MG, et al.: Differential impact of systolic and diastolic blood pressure level of JNC-VI blood pressure stage classification. Hypertension 1999, 34:381–385. The importance of systolic BP in determining the appropriate JNC VI BP stage, and hence eligibility, is demonstrated by this study. Systolic BP alone predicted appropriate JNC VI stage in 96% of subjects, and 77.7% of the patients were upstaged based on systolic BP compared with 9.3% based on diastolic BP.PubMedGoogle Scholar
  3. 3.
    O‘Donnell CJ, Ridker PM, Glynn RJ, et al.: Hypertension and borderline isolated hypertension increase risks of CVD and mortality in male physicians. Circulation 1997, 95:1132–1137.PubMedGoogle Scholar
  4. 4.
    Franklin SS, Khan SA, Wong ND, et al.: Is pulse pressure more important than systolic blood pressure in predicting coronary heart disease events? Circulation 1999, 100:354–360.PubMedGoogle Scholar
  5. 5.
    Franklin S: Aging and hypertension: the assessment of blood pressure indices in predicting coronary heart disease risk. J Hypertens 1999, 17(suppl 5):S29-S36.Google Scholar
  6. 6.
    Alli C, Avanzini F, Bertelli G, et al.: The long term prognostic significance of repeated blood pressure measurements in the elderly: SPAA (Studio sulla pressione artiosa nell anziano) 10 year follow-up. Arch Intern Med 1999, 159:1205–1212.PubMedCrossRefGoogle Scholar
  7. 7.
    SHEP cooperative research group: Prevention of stroke by antihypertensive drug treatment in older persons with systolic hypertension: final results of the systolic hypertension in the elderly program (SHEP). JAMA 1991, 256:3255–3264.Google Scholar
  8. 8.
    Black HR, Kuller LH, O‘Rourke MF, et al.: The first report of the systolic and pulse pressure (SYPP) working group. J Hypertens 1999, 17(suppl 5):S3-S14. This report summarizes the epidemiology, physiology, and treatment of systolic hypertension and highlights the importance of pulse pressure in predicting cardiovascular disease and stroke in the elderly. It also points out areas for future research in assessing arterial wall disease.Google Scholar
  9. 9.
    De Mey JG, Schiffers PM: Effects of the endothelium on growth responses in arteries. J Cardiovasc Pharmacol 1993, 21(suppl 1):S22-S25.PubMedGoogle Scholar
  10. 10.
    Benetos A, Gautier S, Ricard S, et al.: Influence of angiotensinconverting enzyme and angiotensine II type 1 receptor polymorphisms on aortic stiffness in normotensive and hypertensive patients. Circulation 1996, 94:698–703.PubMedGoogle Scholar
  11. 11.
    Staessen JA, Fagard R, Thijs L, et al.: Randomised double blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet 1997, 350:757–764. This study demonstrates the safety and efficacy of treating isolated systolic hypertension in the elderly population. Significant reductions in cardiovascular morbidity and mortality occurred with the use of a long acting calcium channel blocker to achieve a goal systolic BP of less than 150 mm Hg.PubMedCrossRefGoogle Scholar
  12. 12.
    Whelton PK, Appel LJ, Espeland MA, et al.: Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA 1998, 279:839–846.PubMedCrossRefGoogle Scholar
  13. 13.
    Hansson L, Lindholm LH, Ekbom T, et al.: for the STOP Hypertension-2 study group: Randomised trial of old and new antihypertensive drugs in the elderly patients: cardiovascular mortality and morbidity: the Swedish Trial on Old Patients with Hypertension-2 Study. Lancet 1999, 354:1751–1756. This study compares the effects of conventional antihypertensive drugs (diuretics and b-blockers) and newer drugs (ACE inhibitors and calcium channel blockers) on cardiovascular morbidity and mortality in an elderly population. Similar reduction in BP and incidence of cardiovascular disease was achieved in both groups with the diabetic subjects deriving additional benefit from ACE inhibitor therapy compared to treatment with calcium channel blockers.PubMedCrossRefGoogle Scholar
  14. 14.
    Yusuf S, Sleight P, Pogue J, et al.: Effects of an angiotensinconverting-enzyme inhibitor, ramipril, on cardiovascular events in high risk patients: The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000, 342:145–153. The HOPE study investigated the effects of an ACE inhibitor, ramipril, on cardiovascular morbidity and mortality in patients with vascular disease and an additional cardiovascular risk factor but without congestive heart failure. The study demonstrated a 22% reduction in cardiovascular endpoints with the use of ramipril in these high-risk subjects, with a normal ejection fraction.PubMedCrossRefGoogle Scholar
  15. 15.
    Lapeurta P, L‘Italien GJ: Awareness, treatment and control of systolic blood pressure in the United States. Am J Hypertens 1999, 12(part 2):92A.CrossRefGoogle Scholar
  16. 16.
    Hansson L, Zanchetti A, Carruthers SG, et al.: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet 1998, 351:1755–1762. This large, multicenter, prospective trial demonstrates the safety and beneficial effects of BP reduction on cardiovascular mortality. The lowest incidence of cardiovascular events occurred at a mean diastolic BP of 82.6 mm Hg. Diabetic subjects with diastolic BP control to less than 80 mm Hg had significantly fewer cardiovascular events compared with the study group, which had a target diastolic BP of less than 90 mm Hg.PubMedCrossRefGoogle Scholar
  17. 17.
    Coppola WG, Whincup PH, Walker M, Ebrahim S: Identification and management of stroke risk in older people: a national survey of current practice in primary care. J Hum Hypertens 1997, 11:185–191.PubMedCrossRefGoogle Scholar
  18. 18.
    Fries ED: Improving treatment effectiveness in hypertension. Arch Intern Med 1999, 159:2517–2521.CrossRefGoogle Scholar
  19. 19.
    Staesson JA, Thijs L, Fagard R, et al.: Predicting cardiovascular risk using conventional versus ambulatory blood pressure in older patients with systolic hypertension. JAMA 1999, 282:539–546.CrossRefGoogle Scholar
  20. 20.
    Verdecchia P, Schillaci G, Borgioni C, et al.: Ambulatory pulse pressure: a patient predictor of total cardiovascular risk in hypertension. Hypertension 1998, 32:983–988.PubMedGoogle Scholar
  21. 21.
    Verdecchia P, Porcellati C, Schillaci G, et al.: Ambulatory blood pressure: an independent predictor of prognosis in essential hypertension. Hypertension 1994, 24:793–801.PubMedGoogle Scholar
  22. 22.
    Curb JD, Pressel SL, Cutler JA, et al.: Effects of diuretic based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with systolic hypertension. JAMA 1996, 276:1886–1892.PubMedCrossRefGoogle Scholar
  23. 23.
    Ravid M, Lang R, Rachmani R, Lishner M: Long-term renoprotective effect of angiotensin-converting enzyme inhibition in non-insulin dependent diabetes mellitus: a 7 year follow-up study. Arch Intern Med 1996, 156:286–289.PubMedCrossRefGoogle Scholar
  24. 24.
    Bakris GL, Copley JB, Vicknair N, et al.: Calcium channel blockers versus antihypertensive therapies on progression of NIDDM associated nephropathy. Kidney Int 1996, 50:1641–1650.PubMedCrossRefGoogle Scholar
  25. 25.
    Lash JP, Bakris GL: Effects of ACE inhibitors and calcium antagonists alone or combined on progression of diabetic nephropathy. Nephrol Dial Transplant 1995, 10(suppl 9):56–62.PubMedGoogle Scholar
  26. 26.
    Perry HM Jr, Miller JP, Fornoff JR, et al.: Early predictors of 15 year endstage renal disease in hypertensive patients. Hypertension 1995, 25:587–594.PubMedGoogle Scholar
  27. 27.
    Klahr S, Levey AS, Beck GJ, et al.: The effects of dietary protein restriction and blood pressure control on the progression of chronic renal disease. N Engl J Med 1994, 330:877–884.PubMedCrossRefGoogle Scholar
  28. 28.
    Maschio G, Alberti D, Janin G, et al.: Effect of angiotensinconverting enzyme inhibitor benazepril on the progression of chronic renal insufficiency. N Engl J Med 1996, 334:939–945.PubMedCrossRefGoogle Scholar
  29. 29.
    Fernandez-Andrade C, Russo D, Iversen B, et al.: Comparison of losartan and amlodipine in renally impaired hypertensive patients. Kidney Int 1998, 68:S120-S124.Google Scholar
  30. 30.
    Maki DD, Jennie ZM, Louis TA, Kasiske BL: Long term effects of antihypertensive agents on proteinuria and renal function. Arch Intern Med 1995, 155:1073–1080.PubMedCrossRefGoogle Scholar
  31. 31.
    Neaton JD, Wentworth D: Serum cholesterol, blood pressure, cigarette smoking and death from heart disease: overall findings and difference by age for 316,099 white men: Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med 1992, 152:56–64.PubMedCrossRefGoogle Scholar
  32. 32.
    Flack JM, Neaton J, Grimm R Jr, et al.: Blood pressure and mortality among men with prior myocardial infarction: Multiple Risk Factor Intervention Trial Research Group. Circulation 1995, 92:2437–2445.PubMedGoogle Scholar
  33. 33.
    Fotherby MD, Panayiotou B: Antihypertensive therapy in the prevention of stroke: what, when and for whom? Drugs 1999, 58:663–674.PubMedCrossRefGoogle Scholar
  34. 34.
    Rodgers A, MacMahon S, Gamble G, et al.: Blood pressure and risk of stroke in patients with cerebrovascular disease: The United Kingdom Transient Ischaemic Attack Collaborative Group. BMJ 1996, 313:147.PubMedGoogle Scholar
  35. 35.
    PROGRESS Management Committee: Blood pressure lowering for the secondary prevention of stroke: rationale and design for PROGRESS. J Hypertens 1996, 14(suppl)2:S41-S46.Google Scholar
  36. 36.
    Somes GW, Pahor M, Shorr RI, et al.: The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999, 159:2004–2009.PubMedCrossRefGoogle Scholar
  37. 37.
    Staesson J, Bulpitt C, Clement D, et al.: Relation between mortality and treated blood pressure in elderly patients with hypertension: report of the European Working Party on High Blood Pressure in the Elderly. BMJ 1989, 298:1552–1556.CrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2000

Authors and Affiliations

  • Sanjay Shrivastava
    • 1
  • Mahendr S. Kochar
    • 2
  1. 1.Fort Hamilton HospitalHamiltonUSA
  2. 2.Medical College of WisconsinMilwaukeeUSA

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