Perspectives on Isolated Systolic Hypertension in Elderly Patients

Abstract

Until the mid-20th century, clinicians' concern was directed mainly to the systolic component of blood pressure. Later, however, when systolic blood pressure was found to be elevated with advancing age and decreased compliance of the arterial wall, it began to be considered an inevitable consequence of aging. Based on this belief, physicians often concluded that only the diastolic blood pressure elevation, which reflected peripheral vascular resistance, was harmful, while systolic hypertension was innocuous. Therapeutic intervention was practiced mainly for diastolic hypertension, and research protocols were based on the levels of diastolic blood pressure alone. In the 1950s, even when life insurance companies' actuarial data revealed that systolic and diastolic blood pressure elevations were hazardous to health, few clinicians took heed. In 1962, the World Health Organization also defined hypertension as a blood pressure level of 165/95 mm Hg or higher for intervention purposes. However, until the 1991 Systolic Hypertension in the Elderly Program (SHEP) trial, many physicians were reluctant to pay credence to the need for therapy of elevated systolic blood pressure (vide infra).

Hypertension and peripheral arterial disease

“…1 ISH has previously been associated with heart failure, renal failure and stroke. 17 The ATTEST study has reported an association between form of hypertension and vascular territory, in particular the association between PAD and ISH. This may contribute to the understanding of the complex pathophysiological mechanisms associating cardiovascular outcome with vascular territory.…”

“…With age, increased arterial stiffness leads to increased SBP with a decrease in DBP, resulting in a higher pulse pressure. 17 In patients with increased arterial stiffness, increased SBP may disappear in the presence of reduced ventricular ejection fraction, 15 which may partly explain the lower prevalence of ISH in the CAD/CVD cohort. The use of antihypertensives may also partly explain the difference in ISH in the different cohorts of the ATTEST study.…”

Systolische Hypertonie?Treat or Not to Treat?

“…Weltweit wurde die Prävalenz der isolierten systolischen Hypertonie im Alter von 60 bis 69 Jahren unterschiedlich geschätzt. In Israel betrug die Prävalenz 1%, in Norwegen hingegen 24% [14]. Eine isolierte systolische Hypertonie liegt bei 60% der unbehandelten und bei 37% der behandelten Hypertoniker vor [15].…”

Systolic versus diastolic blood pressure versus pulse pressure

“…Isolated systolic hypertension (ISH), is a disorder typically defined when the systolic BP is greater than 140 mm Hg but with a diastolic BP below 90 mm Hg [2][3][4]. ISH is associated with increases in all forms of cardiovascular morbidity and mortality including stroke, coronary disease, cardiac and renal failure, and allcause mortality [5]. The issue of ISH is especially important in older people, as aging predisposes patients to develop arteriosclerosis and isolated systolic hypertension.…”