Abstract
Isolated systolic hypertension (ISH) is the dominant form of hypertension in the elderly. It is associated with increased arterial pulse pressure, to which an early-returning and magnified pulse-wave reflection makes an important contribution. Treatment of ISH with diuretics, calcium channel blockers (CCBs), and angiotensin II inhibitors is effective in reducing systolic blood pressure, preventing cardiovascular morbid events, and lowering mortality; these agents may have to be used in combination to achieve the systolic blood pressure goal of < 140 mm Hg. Treatment with β-blockers appears to be less effective. The relative efficacy of various classes of antihypertensive drugs for lowering pulse pressure and systolic blood pressure is determined in part by their differing abilities to reduce pulse-wave reflection. In patients with ISH that is refractory to dual or triple therapy, measurement of the reflected wave by applanation tonometry may be useful in determining which additional antihypertensive agent to use.
Similar content being viewed by others
References and Recommended Reading
Franklin SS, Jacobs MJ, Wong ND, et al.: Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives. Analysis based on National Health and Nutrition Examination Survey (NHANES) III. Hypertension 2001, 37:869–874.
Amery A, Birkenhager W, Brixko P, et al.: Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet 1985, 1:1349–1354.
SHEP Cooperative Research Group:Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991, 265:3255–3264.
Dahlof B, Lindholm LH, Hansson L, et al.: Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (Stop-Hypertension). Lancet 1991, 338:1281–1285.
Staessen JA, Thijs L, Fagard R, et al.: Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension: Systolic Hypertension in Europe Trial Investigators. JAMA 1999, 282:539–546.
Hyman DJ, Pavlik VN: Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. Arch Intern Med 2001, 160:2281–2286.
Staessen JA, Gasowski J, Wang JG, et al.: Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000, 355:865–872.
O’Rourke MF, Kelly RP: Wave reflection in the systemic circulation and its implications in ventricular function. J Hypertens 1993, 11:327–337.
Schiffrin EL: Vascular stiffening and arterial compliance. Implications for systolic blood pressure. Am J Hypertens 2004, 17:39S-48S. This review describes methods for the measurement of arterial stiffness, and examines the relationship between stiffness and other cardiovascular risk factors.
Wilkinson IB, Hall IR, MacCallum H, et al.: Pulse-wave analysis. Clinical evaluation of a non-invasive, widely applicable method for assessing endothelial function. Arterioscler Thromb Vasc Biol 2002, 22:147–152.
Cohn JN:. Vascular wall function as a risk marker for cardiovascular disease. J Hypertens 1999, 17(Suppl 5):S41-S44.
Stokes GS: Nitrates as adjunct hypertensive treatment. Curr Hypertens Rep 2006, 8:60–68.
Stokes GS, Barin ES, Gilfillan KL: Effects of isosorbide mononitrate and AII inhibition on pulse wave reflection in hypertension. Hypertension 2003, 41:297–301. Shows that isosorbide mononitrate is more effective than Ang II inhibitors in reducing pulse-wave reflection, and examines implications this has for understanding the mechanisms that cause the reflected wave.
Weinberger MH, Miller JZ, Luft FC, et al.: Definitions and characteristics of sodium sensitivity and blood pressure resistance. Hypertension 1986, 8:127–134.
Bagrov AY, Lakatta EG: The dietary sodium-blood pressure plot “stiffens.” Hypertension 2004, 44:22–24.
Pickering TG: Why don’t we use nitrates to treat older hypertensive patients? J Clin Hypertens 2005, 7:685–690.
Chen C-H, Ting C-T, Lin S-J, et al.: Different effects of fosinopril and atenolol on wave reflections in hypertensive patients. Hypertension 1995, 25:1034–1041.
Morgan TO, Lauri J, Bertram D, Anderson A: Effect of different antihypertensive drug classes on central aortic pressure. Am J Hypertens 2004, 17:118–123. The relationship between central aortic blood pressure, a key determinant of cardiac workload, and brachial artery blood pressure was found to vary between drugs of the four major antihypertensive drug classes.
Townsend MS, Fulgoni VL III, Stern JS, et al.: Low mineral intake is associated with high systolic blood pressure in the Third and Fourth National Health and Nutrition Examination Surveys. Could we all be right? Am J Hypertens 2005, 18:261–269.
He FJ, Markandu ND, MacGregor GA: Modest salt reduction lowers blood pressure in isolated systolic hypertension and combined hypertension. Hypertension 2005, 46:66–70.
Gates PE, Tanaka H, Hiatt WR, Seals DR: Dietary sodium restriction rapidly improves large elastic artery compliance in older adults with systolic hypertension. Hypertension 2004, 44:35–41. This study investigates the effect of low-sodium diet on stage I hypertensive subjects, and shows that improvements in central compliance appear to be key in the lowering of systolic blood pressure by sodium restriction.
Brennan P, Pescatello LS, Bohannon RW, et al.: Time spent moving is related to systolic blood pressure among older women. Prev Cardiol 2005, 8:160–164.
Ferrier KE, Waddell TK, Gatzka CD, et al.: Aerobic exercise training does not modify large-artery compliance in isolated systolic hypertension. Hypertension 2001, 38:222–226.
ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. The antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA 2002, 288:2981–2997.
London G, Schmieder R, Calvo C, Asmar R: Indapamide SR versus candesartan and amlodipine in Hypertension: the X-CELLENT Study. Am J Hypertens 2006, 19:113–121.
Kostis JB, Wilson AC, Freudenberger RS, et al.: Longterm effect of diuretic-based therapy on fatal outcomes in subjects with isolated systolic hypertension with and without diabetes. SHEP Collaborative Research Group. Am J Cardiol 2005, 95:29–35.
Chen GJ, Ferrucci L, Moran WP, Pahor M: A cost-minimization analysis of diuretic-based antihypertensive therapy reducing cardiovascular events in older adults with isolated systolic hypertension. Cost Eff Resour Alloc 2005, 3:2.
Xie F, Petitti DB, Handler J: Changes in the continuation of antihypertensive drug use after ALLHAT. J Clin Invest 2005, 7:649–653.
Black HR: The paradigm has shifted to systolic blood pressure. J Hum Hypertens 2004 18(Suppl 2):S3-S5.
Izzo JL, Levy D, Black HR: Importance of systolic blood pressure in older Americans. Hypertension 2000, 35:1021–1024. In regard to its acceptance of the blood pressure management goals of JNC VI for the elderly, the statement represents a milestone in the treatment of ISH.
Hansson L, Lindholm LH, Ekbom T, et al.: for the STOP-Hypertension-2 Study Group: Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Lancet 1999, 354:1751–1756.
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.
Turnbull F; Blood Pressure Treatment Trialists’ Collaboration: Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectivelydesigned overviews of randomized trials. Lancet 2003, 362:1527–1535.
Kjeldsen SE, Lyle PA, Kizer JR, et al.: The effects of losartan compared to atenolol on stroke in patients with isolated systolic hypertension and left ventricular hypertrophy. The LIFE study. J Clin Hypertens 2005, 7:152–158.
Dahlof B, Sever PS, Poulter NR, et al.: Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005, 366:895–906. This very large trial in patients 40 to 79 years of age showed that a CCB plus ACE inhibitor combination was more effective than a β-blocker plus diuretic combination in reducing cardiovascular morbidity.
Messerli FH, Grossman E, Goldbourt U: Are beta-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. JAMA 1998, 278:1903–1907.
Carlberg B, Samuelsson O, Lindholm LH: Atenolol in hypertension: Is it a wise choice? Lancet 2004, 364:1684–1689.
Lindholm LH, Carlberg B, Samuelsson O: Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005, 366:1545–1553. This meta-analysis of controlled treatment trials in hypertension concludes that the relative risk for stroke was 16% higher for β-blockers than for other antihypertensive drugs.
Beevers G: The end of beta-blockers for uncomplicated hypertension? Lancet 2005, 366:1510–1512.
Williams B, Lacy PS, Thom SM, et al.: The CAFE Investigators, for the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Investigators, CAFE Steering Committee and Writing Committee. Differential impact of blood pressure -lowering drugs on central aortic pressure and clinical outcomes: principal results of the conduit artery function evaluation (CAFE) study. Circulation 2006, 113:1213–1225. Different effects on central aortic blood pressure despite similar effects on brachial blood pressure may explain the different clinical outcomes between treatment arms of the ASCOT Trial 34.
Stokes GS, Bune AJ, Huon N, Barin ES: Long-term effectiveness of extended-release nitrate for the treatment of systolic hypertension. Hypertension 2005, 45:380–384.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Stokes, G.S. Treatment of isolated systolic hypertension. Current Science Inc 8, 377–383 (2006). https://doi.org/10.1007/s11906-006-0081-0
Issue Date:
DOI: https://doi.org/10.1007/s11906-006-0081-0