Skip to main content
SpringerLink
Log in

Is there a preferred antihypertensive therapy for isolated systolic hypertension and reduced arterial compliance?

  • Published:
Current Hypertension Reports Aims and scope Submit manuscript

Abstract

Isolated systolic hypertension (ISH) is the most common type of hypertension and the most difficult type to control with antihypertensive therapy. ISH, by definition, is wide pulse pressure hypertension resulting largely from excessive large artery stiffness and representing an independent risk factor for cardiovascular disease in the older aged population. Two major intervention studies of ISH have shown significant benefit in reducing systolic blood pressure with active drug therapy, including thiazide diuretics and calcium receptor antagonists. The optimal treatment strategy is to maximize reduction in systolic blood pressure and to minimize reduction in diastolic blood pressure, thereby reducing pulse pressure. All classes of antihypertensive drugs reduce pulse pressure by means of lowering peripheral resistance, but certain drugs like nitrates, angiotensin converting enzyme inhibitors, and other drugs affecting the renin-angiotensin system have multiple actions that improve large artery stiffness and early wave reflection and are especially useful in treating ISH in the elderly.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997, 157:2413–2446.

  2. Guidelines Subcommittee: 1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. J Hypertens 1999, 17:151–183.

    Google Scholar 

  3. SHEP Cooperative Research Group: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 1991, 265:3255–3264.

    Article  Google Scholar 

  4. Staessen JA, Fagard R, Thijs L, et al.: Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet 1997, 350:757–764.

    Article  PubMed  CAS  Google Scholar 

  5. Burt VL, Whelton P, Roccella EJ, et al.: Prevalence of hypertension in the US adult Population. Results from the Third National Health and Nutrition Examination Survey, 1998–1991. Hypertension 1995, 25:305–313.

    PubMed  CAS  Google Scholar 

  6. Colhoun HM, Dong W, Poulter NR: Blood pressure screening, management and control in England: results from the health survey for England 1994. J Hypertens 1998, 16:747–752.

    Article  PubMed  CAS  Google Scholar 

  7. Marques-Vidal P, Tuomilehto J: Hypertension awareness, treatment and control in the community: is the "rule of halves" still valid? J Hum Hypertens 1997, 11:213–220.

    Article  PubMed  CAS  Google Scholar 

  8. Coppola WG, Whincup PH, Walker M, et al.: 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.

    Article  PubMed  CAS  Google Scholar 

  9. Berlowitz DR, Ash AS, Hickey EC, et al.: Inadequate management of high blood pressure in a hypertensive population. N Engl J Med 1998, 339:1957–1963.

    Article  PubMed  CAS  Google Scholar 

  10. Bakris GL: Maximizing cardiorenal benefit in the management of hypertension: achieving blood pressure goals. J Clin Hypertens 1999, 1:141–147.

    Google Scholar 

  11. Franklin SS, Gustin W, Wong ND, et al.: Hemodynamic pattern of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997, 96:308–315.

    PubMed  CAS  Google Scholar 

  12. Pannier B, Brunel P, Aroussy WE, et al.: Pulse pressure and echocardiographic findings in essential hypertension. J Hypertens 1989, 7:127–132.

    Article  PubMed  CAS  Google Scholar 

  13. Gardin JM, Arnold A, Gottdiener JS, et al.: Left ventricular mass in the elderly. The Cardiovascular Health Study. Hypertension 1997, 29:1095–1103.

    PubMed  CAS  Google Scholar 

  14. Salonen R, Salonen JT: Determinants of carotid intima-media thickness: a population-based ultrasonography study in eastern Finnish men. J Int Med 1991, 229:225–231.

    Article  CAS  Google Scholar 

  15. Psaty BM, Furberg CD, Kuller, et al.: Isolated systolic hypertension and subclinical cardiovascular disease in the elderly. Initial findings from the Cardiovascular Health Study. JAMA 1992, 268:1287–1291.

    Article  PubMed  CAS  Google Scholar 

  16. Bots ML, Hofman A, de Bruyn AM, et al.: Isolated systolic hypertension and vessel wall thickness of the carotid artery. Arterioscler Thromb 1993, 13:64–69.

    PubMed  CAS  Google Scholar 

  17. Sutton-Tyrrell K, Alcorm HG, Wolfson SK, et al.: Predictors of carotid stenosis in older adults with and without isolated systolic hypertension. Stroke 1993, 24:355–361.

    PubMed  CAS  Google Scholar 

  18. Franklin SS, Sutton-Tyrrell K, Belle SH, et al.: The importance of pulsatile components of hypertension in predicting carotid stenosis in older adults. J Hypertens 1997, 15:1143–1150.

    Article  PubMed  CAS  Google Scholar 

  19. Witteman JCM, Grobbee DE, Valkenburg HA, et al.: J-shaped relation between change in diastolic blood poressure and progression of aortic atherosclerosis. Lancet 1993, 343:504–507.

    Article  Google Scholar 

  20. Darne B, Girerd X, Safar M, et al.: Pulsatile versus steady component of blood pressure: a cross-sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension 1989, 13:392–400.

    PubMed  CAS  Google Scholar 

  21. Benetos A, Safar M, Rudnichi A, et al.: Pulse pressure, a predictor of long-term cardiovascular mortality in a French population. Hypertension 1997, 30:1410–1415.

    PubMed  CAS  Google Scholar 

  22. Franklin SS, Khan SA, Wong ND, et al.: Is pulse pressure useful in predicting risk for coronary Heart disease? The Framingham Heart Study. Circulation 1999, 100:354–360. This study focuses on the high collinearity of SBP and PP in predicting CHD risk. By holding one blood pressure component constant and exploring the range of other component, PP was superior to SBP in predicting CHD risk in this older age population.

    PubMed  CAS  Google Scholar 

  23. Madhavan S, Ooi WL, Cohen J, et al.: Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction. Hypertension 1994, 23:395–401.

    PubMed  CAS  Google Scholar 

  24. Fang J, Madhavan S, Cohen H, et al.: Measures of blood pressure and myocardial infarction in treated hypertensive patients. J Hypertens 1995, 13:413–419.

    Article  PubMed  CAS  Google Scholar 

  25. Mitchell GF, Moye LA, Braunwald E, et al.: Sphygmomanometrically determined pulse pressure is a powerful independent predictor of recurrent events after myocardial infarction in patients with impaired left ventricular function. Circulation 1997, 96:4254–4260.

    PubMed  CAS  Google Scholar 

  26. Domanski ML, Mitchell GF, Norman JE, et al.: Independent prognostic information provided by sphygmomanometrically determined pulse pressure and mean arterial pressure in patients with left ventricular dysfunction J Am Coll Cardiol 1999, 33:951–958.

    Article  PubMed  CAS  Google Scholar 

  27. Chae CU, Pfeffer MA, Glynn RJ, et al.: Increased pulse pressure and risk of heart failure in the elderly. JAMA 1999, 281:634–639. This is the first study to clearly show that PP, a measure of pulsatile hemodynamic load, is an independent predictor of heart failure risk.

    Article  PubMed  CAS  Google Scholar 

  28. Haider AW, Larson MG, Franklin SS, et al.: Pulse pressure predicts the new onset of overt heart failure in the community: The Framingham Heart Study [abstract]. Circulation 1998, 98:1.

    Google Scholar 

  29. Verdecchia P, Schillaci G, Borgioni C, et al.: Ambulatory pulse pressure. A potent predictor of total cardiovascular risk in hypertension. Hypertension 1998, 32:983–988. This is the first study of ambulatory blood pressure monitors to show that PP is the most sensitive blood pressure index for predicting cardiovascular events.

    PubMed  CAS  Google Scholar 

  30. Lee MT, Rosner BA, Weiss ST: Relationship of blood pressure to cardiovascular death: the effects of pulse pressure in the elderly. Ann Epidemiol 1999, 9:101–107.

    Article  PubMed  CAS  Google Scholar 

  31. Millar JA, Lever AF, Burke V: Pulse pressure as a risk factor for cardiovascular events in the MRC Mild Hypertension Trial. J Hypertens 1999, 17:1065–1072.

    Article  PubMed  CAS  Google Scholar 

  32. Scuteri A, Cacciafesta M, Di Gernardo MG, et al.: Pulsatile versus steady-state components to blood pressure in elderly females: an independent risk factor for cardiovascular disease. J Hypertens 1995, 13:185–191.

    PubMed  CAS  Google Scholar 

  33. Domanski MJ, Davis BR, Pfeffer MA, et al.: Isolated systolic hypertension prognostic information provided by pulse pressure. Hypertension 1999, 34:375–380. This is the first study to clearly show the value of PP as an independent predictor of stroke events.

    PubMed  CAS  Google Scholar 

  34. Selker HP, Beshansky J, Schmid CH: Presenting pulse pressure predicts thrombolytic therapy-related intracranial hemorrhage. Thrombolytic Predictive Instrument (TPI) Projects Results. Circulation 1994, 90:1657–1661.

    PubMed  CAS  Google Scholar 

  35. Perry HM Jr, Miller JP, Fornoff JR, et al.: Early predictors of 15 year end-stage renal disease in hypertensive patients. Hypertension 1995, 25:587–594.

    PubMed  Google Scholar 

  36. Blacher J, Guerin AP, Pannier B, et al.: Impact of aortic stiffness on survival in end-stage renal disease. Circulation 1999, 99:2434–2439. This study provides the first direct evidence in patients with end-stage renal disease that increased aortic stiffness, as determined by measurement of aortic pulse wave velocity, is a strong independent predictor of fatal cardiovascular events.

    PubMed  CAS  Google Scholar 

  37. Nichols WW, O’Roruke MF: McDonald"s Blood Flow in Arteries, edn 4. London: Arnodl, Hodder Headline Group; 1998.

    Google Scholar 

  38. Ohtsuka S, Kakihana M, Watanabe H, et al.: Alterations in left ventricular wall stress and coronary circulation in patients with isolated systolic hypertension. J Hypertens 1996, 14:1349–1355.

    Article  PubMed  CAS  Google Scholar 

  39. Zabalgoitia M, Rahman SNU, Haley WE, et al.: Role of left ventricular hypertrophy in diastolic dysfunction in aged hypertensive patients. J Hypertens 1997, 15:1175–1179.

    Article  PubMed  CAS  Google Scholar 

  40. Davis BR, Vogt T, Frost PH, et al.: Risk factors for stroke and type of stroke in persons with isolated systolic hypertension. Stroke 1998, 29:1333–1340.

    PubMed  CAS  Google Scholar 

  41. Castellani S, Ungar A, Cantini C, et al.: Impaired renal adaptation to stress in the elderly with isolated systolic hypertension. Hypertension 1999, 34:1106–1111.

    PubMed  CAS  Google Scholar 

  42. Sagie A, Larson MG, Levy D: The natural history of borderline isolated systolic hypertension. N Engl J Med 1993, 329:1912–1917.

    Article  PubMed  CAS  Google Scholar 

  43. Grassi G, Dell’Oro R, Bertinieri G, et al.: Sympathetic nerve traffic and baroreflex control of circulation in systodiastolic and isolated systolic hypertension of the elderly. J Hypertens 1999, 17: (suppl 3):S45-S46.

    Google Scholar 

  44. Hall JE, Brands MW, Shek EW: Central role of the kidney and abnormal fluid Volume control in hypertension. J Hum Hypertens 1996, 10:633–639.

    PubMed  CAS  Google Scholar 

  45. Rosenberg ME, Smith LJ, Correa-Rotter R, et al.: The paradox of the renin-angiotensin system in chronic renal disease. Kidney Int 1994, 45:404–410.

    Google Scholar 

  46. O’Rourke MF, Kelly RP: Wave reflection in the systemic circulation and its implictions in ventricular function. J Hypertens 1993, 11:327–337.

    Article  PubMed  CAS  Google Scholar 

  47. Schiffrin El, Deng LY, Larochelle P: Progressive improvement in the structure of resistance arteries of hypertensive patients after 2 years of treatment with an angiotensin l-converting enzyme inhibitor. Comparison with effects of a b blocker. Am J Hypertens 1995, 8:229–236.

    Article  PubMed  CAS  Google Scholar 

  48. Dzau VJ: Angiotensin converting enzyme inhibitors and the cardiovascular system. J Hypertens 1992, 10(suppl 3):S3-S10.

    CAS  Google Scholar 

  49. Koch-Weser J: Correlation of pathophysiology and pharmacotherapy in primary hypertension. Am J Cardiol 1973, 32:499–510.

    Article  Google Scholar 

  50. Franklin SS, Weber MA: Measuring hypertensive cardiovascular risk: the vascular overload concept. Am Heart J 1994, 128:793–803.

    Article  PubMed  CAS  Google Scholar 

  51. D’Agostino RB, Belanger AJ, Kannel WB, et al.: Relation of low diastolic blood pressure to coronary hear disease death in presence of myocardial infarction: the Framingham Study. BMJ 1991, 303:385–389.

    Article  PubMed  CAS  Google Scholar 

  52. Langer RD, Criqui MH, Barrett-Connor EL: Blood pressure change and survival after age 75. Hypertension 1993, 22:551–559.

    PubMed  CAS  Google Scholar 

  53. Cruickshank JM, Trorp JM, Zacharias FJ: Benefits and potential harm of low blood pressure. Lancet 1987, 1:581–584.

    Article  PubMed  CAS  Google Scholar 

  54. Weijenberg MP, Feskens EJM, Fromhout D: Blood pressure and isolated systolic hypertension and the risk of coronary heart disease and mortality in elderly men (the Zutphen Elderly Study). J Hypertens 1996, 14:1159–1166.

    Article  PubMed  CAS  Google Scholar 

  55. Collins R, Peto R, MacMahon S, et al.: Blood pressure, stroke, and coronary heart disease, Part 2. Short-term reductions in blood pressure: overview of randomized drug trials in their epidemiologic context. Lancet 1990, 355:827–838.

    Article  Google Scholar 

  56. Hansson L, Zanchetti A, Carruthers SG, et al.: on behalf of the HOT Study Group:Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principle results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998, 351:1755–1762.

    Article  PubMed  CAS  Google Scholar 

  57. Staessen JA, Gasowski J, Wang JI G, et al.: Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000, 355:865–872. This meta-analysis of eight outcome trials of ISH concluded that CHD risk is more accurately estimated when using both SBP and PP as risk markers.

    Article  PubMed  CAS  Google Scholar 

  58. 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.

    Article  PubMed  CAS  Google Scholar 

  59. Smulyan H, Mookherjee S, Warner RA: The effect of nitroglycerine on forearm arterial distensibility. Circulation 1986, 73:1254–1269.

    Google Scholar 

  60. Duchier J, Iannascoli, F, Safar M: Antihypertensive effect of sustained-release isosorbide dinitrate for isolated systolic systemic hypertension in the elderly. Am J Cardiol 1987, 60:99–102.

    Article  PubMed  CAS  Google Scholar 

  61. Starmans-Kool MJF, Kleinjans HAJ, Lustermans FAT, et al.: Treatment of elderly patients with isolated systolic hypertension with isosorbide dinitrate in an asymmetric dosing schedule. J Hum Hypertens 1998, 12:557–561.

    Article  PubMed  CAS  Google Scholar 

  62. Stokes GS, Ryan M, Brnabic A, et al.: A controlled study of the effects of isosorbide mononitrate on arterial blood pressure and pulse wave form in systolic hypertension. J Hypertens 1999, 17:1767–1773.

    Article  PubMed  CAS  Google Scholar 

  63. Watanabe H, Kakihana M, Ohtsuka S, et al.: Effects of enalapril during continuous nitrate therapy: analysis of diameter of coronary arteries and platelet cyclic guanosine monophosphate. Am Heart J 1997, 134:614–621.

    Article  PubMed  CAS  Google Scholar 

  64. Van Bortel LM, Spek JJ, Balkestein EJ, et al.: Is it possible to develop drugs that act more selectively on large arteries? J Hypertens 1999, 17:701–705.

    Article  PubMed  Google Scholar 

  65. Shimamoto H, Shimamoto Y: Lisinopril reverses left ventricular hypertrophy through improved aortic compliance. Hypertension 1996, 28:457–463.

    PubMed  CAS  Google Scholar 

  66. Rizzoni D, Muiesan ML, Porteri E, et al.: Effects of long-term antihypertensive treatment with lisinopril on resistance arteries in hypertensive patients with left ventricular hypertrophy. J Hypertens 1997, 15:197–204.

    Article  PubMed  CAS  Google Scholar 

  67. The Heart Outcomes Prevention Evaluation Study Investigators: Effects of an angiotensin-converting-enzyme inhibitor, Ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000, 342:145–153. This landmark trial clearly shows the value of ACE inhibitor therapy for secondary prevention of cardiovascular events in an elderly high-risk population. Since recorded blood pressure differences were small between the treated and placebo groups, this suggested that ACE inhibitor therapy had direct protective effects on both the vasculature and the myocardium.

    Article  Google Scholar 

  68. Kelly RP, Gibbs HH, O’Rourke MF, et al.: Nitroglycerin has more favorable effects on left ventricular afterload than apparent from measurement of pressure in a peripheral artery. Eur Heart J 1990, 11:138–144.

    PubMed  CAS  Google Scholar 

  69. Messerli FH, Grossman E, Goldbourt U: Are b-blockers efficacious as first-line therapy for hypertension in the elderly? JAMA 1998, 279:1903–1907.

    Article  PubMed  CAS  Google Scholar 

  70. Kelly R, Daley J, Avolio A, et al.: Arterial dilation and reduced wave reflection benefit of dilevalol in hypertension. Hypertension 1989, 14:14–21.

    PubMed  CAS  Google Scholar 

  71. Burnett JC Jr: Vasopeptidase inhibition: a new concept in blood pressure management. J Hypertens 1999, 17(suppl 1):S37-S43. This new antihypertensive class, possessing both ACE inhibitor and neutral endopeptidase inhibition activity, is very effective in lowering SBP and may also have direct beneficial effects on the vasculature and myocardium. Intervention trials on high risk subjects, ie, the elderly with ISH, will be followed with interest.

    CAS  Google Scholar 

  72. Corman B, Duriez M, Poitevin P, et al.: Aminoguanidine prevents age-related arterial stiffening and cardiac hypertrophy. Proc Natl Acad Sci 1998, 95:1301–1306.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. UCI Heart Disease Prevention Program, C240 Medical Sciences, University of California, 92697, Irvine, CA, USA

    Stanley S. Franklin MD

Authors
  1. Stanley S. Franklin MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Franklin, S.S. Is there a preferred antihypertensive therapy for isolated systolic hypertension and reduced arterial compliance?. Current Science Inc 2, 253–259 (2000). https://doi.org/10.1007/s11906-000-0008-0

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11906-000-0008-0

Keywords

Search

Navigation