Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials

Staessen, Jan A.; Gąsowski, Jerzy; Wang, Ji G.; Thijs, Lutgarde; Hond, Elly Den; Boissel, Jean-Pièrre; Coope, John; Ekbom, Tord; Gueyffier, François; Liu, Lisheng; Kerlikowske, Karla; Pocock, Stuart J.; Fagard, Robert

doi:10.1016/s0140-6736(99)07330-4

Cited by 1,028 publications

(578 citation statements)

References 37 publications

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“…For many years, it was felt that isolated systolic hypertension was not only a natural condition of ageing but that treating older individuals with only elevated SBP would not reduce cardiovascular events and might even be harmful. However, three trials of older individuals with isolated systolic hypertension-the Systolic Hypertension in the Elderly Program (SHEP), SYSTolic hypertension in Europe (SYST-Eur) study, and SYSTolic hypertension in China (SYST-China)-unambiguously demonstrated that effective antihypertensive therapy lowered the rate of strokes, heart failure, coronary heart disease, and even all-cause mortality [17][18][19][20] ( Figure 4). The reduction in events in older persons with isolated systolic hypertension is comparable to the reductions seen in subjects of the same age with systolic and diastolic hypertension.…”

Section: Chd (%)mentioning

confidence: 99%

The paradigm has shifted to systolic blood pressure

Black

2004

J Hum Hypertens

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Since the middle of the 20th century, most physicians and epidemiologists assessed the risks associated with hypertension based on the level of diastolic blood pressure (DBP). In a classic paper in 1971, the Framingham Heart Study clearly showed that systolic BP more accurately described the risk of all the complications we attribute to hypertension. It took 22 years until JNC V in 1993 also used systolic blood pressure (SBP) to define hypertension in US national guidelines. Since then, the paradigm has shifted dramatically. In JNC VI (1997) and JNC VII (2003), SBP has become the primary focus of risk stratification and treatment goals. This shift is a result of the Framingham results being confirmed by many others analyses, the most compelling of which is the recently published report of the Prospective Collaborative Study Group, which pooled 61 observational studies in more than 1 million volunteers with a collective experience of more than 12 million personyears. This group showed that the SBP level at baseline was a significantly more informative reading than DBP for predicting strokes and coronary heart disease (CHD). Furthermore, three trials of older individuals with isolated systolic hypertension, SHEP, SYST-Eur, and SYST-China, unambiguously demonstrated that effective antihypertensive therapy lowered the rate of strokes, heart failure, CHD, and even all-cause mortality. Finally, the World Health Organization (WHO)/International Society of Hypertension (ISH) Hypertension Trialists also showed that the level of SBP achieved in clinical trials comparing different antihypertensives with placebo and with each other was the strongest determinant of how effectively strokes and CHD events were reduced, although a similar relationship was not evident for heart failure. A recent metaregression analysis using new trials, many of which were used by the Trialists, and older studies not included in their analysis also showed that small differences in SBP can have a dramatic impact on cardiovascular outcomes. If there is one thing we have learned in the recent past, it is the need for us to focus on lowering SBP and getting it down to a reasonable goal. We have also learned that to do so, we will need to combine a variety of lifestyle and pharmacological approaches, always with combinations of drugs that will usually contain a low-dose thiazidetype diuretic with other antihypertensives. Reverend Stephen Hales first measured blood pressure (BP) by inserting a glass tube in the carotid artery of a restrained horse. BP measurements in humans began in the late 19th century when RivaRocci developed the technology to measure BP noninvasively. In 1906, Korotkoff described the still-used K-sounds, by which indirect measurements could be easily performed. Over the next several decades, systolic blood pressure (SBP) was used to define hypertension and describe the risks associated with having an elevated BP and stratifying risk by the degree of that elevation. Diastolic blood pressure (DBP) elevations were notable but not co...

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Section: Chd (%)mentioning

confidence: 99%

The paradigm has shifted to systolic blood pressure

Black

2004

J Hum Hypertens

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“…8,9 In the elderly, some disagreement has surrounded the importance of monitoring and treating SBP, DBP, or both, as well as whether to treat isolated and/or borderline isolated systolic hypertension. 7,[10][11][12][13] Further, in the very elderly, older than 80 years, BP elevations have shown an association with better survival. [14][15][16] Despite these areas of controversy, treatment is commonly recommended for identified hypertension in the elderly and in middle-aged adults, as participants with stage 1 or 2 hypertension have shown that lowering systolic pressure by 10-12 mm Hg and diastolic pressure by 5-6 mm Hg reduces CVD event rates.…”

Section: Introductionmentioning

confidence: 97%

Blood pressure as a predictor of cardiovascular events in the elderly: the William Hale Research Program

2006

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This study evaluates the association between blood pressure (BP) and the risk of developing cardiovascular disease (CVD) events in the elderly. The Morton Plant Mease Foundation has followed 4008 elderly patients 464 years of age for at least 5 years. Systolic and diastolic blood pressure (SBP and DBP) was divided into categories. Cardiovascular disease events were classified as myocardial infarction, stroke, and CVDrelated deaths reported from the National Death Index. Cox proportional hazard ratios were used to assess the relationship between BP and CVD events and controlled for weight, gender, smoker, and alcohol use. Ages o75 and X75 years were assessed separately. After 11.1 years of follow-up, elevated SBP (P ¼ o0.0001) is strongly associated with developing a future CVD event; the relationship is linear and graded and holds for ages above and below 75 years. The frequency of CVD events was lowest in the SBP o120 mm Hg group. In subjects o75 years of age, DBP elevations were not a significant risk factor for CVD events. (relative risk (RR): DBP 70 to o80 mm Hg ¼ 0.92; DBP 80 to o90 mm Hg ¼ 0.88; DBP X90 mm Hg ¼ 1.02.) With subjects X75 years of age, a DBP between 80 and 90 is associated with the lowest significant risk for CVD (RR: DBP 70 to o80 mm Hg ¼ 0.74; DBP 80 to o90 mm Hg ¼ 0.59; DBP X90 ¼ 0.71). In conclusion, these findings support the Joint National Committee on Hypertension recommendations for SBP in the elderly. Further studies are warranted to identify optimal DBP for the elderly at various ages.

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“…12 Pooling the results of all the patients with ISH included in the SHEP and SYST-EUR studies as well as the other studies of the treatment of hypertension where some patients with ISH were included, demonstrates a significant reduction in total mortality, cardiovascular mortality, cardiovascular vents, fatal or nonfatal stroke and fatal or nonfatal coronary heart disease. 7 This overview analysis was the first to show convincingly that lowering blood pressure also reduces all-cause mortality.…”

Section: Introductionmentioning

confidence: 97%

“…A recent analysis of the placebo or control groups in these trials among hypertensive patients who received no treatment clearly demonstrates that for a given level of SBP the risk was greater when the DBP was low. 7 Thus, a blood pressure of 200/68 carried a greater risk of death than a blood pressure of 200/92.…”

Section: Introductionmentioning

confidence: 99%

Epidemiological, pathophysiological and clinical significance of systolic, diastolic and pulse pressure

Beevers

2004

J Hum Hypertens

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Long-term population surveys and studies of untreated hypertensive patients both strongly suggest that over the age of about 45, the height of the systolic blood pressure is a better predictor of cardiovascular outcome than the diastolic pressure. Research into echocardiographic left ventricular size, endothelial function and thromborheology also back up this supposition. In clinical practice, the treatment of isolated systolic hypertension has been shown to be very worthwhile. There remains some uncertainty as to the relative significance of diastolic blood pressure when it is frankly high, as in severe systo-diastolic hypertension. However some clinicians and epidemiologists have questioned whether diastolic pressure is still worth measuring, given the overwhelming importance of the height of the systolic blood pressure at predicting outcome.

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Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials

Cited by 1,028 publications

References 37 publications

The paradigm has shifted to systolic blood pressure

The paradigm has shifted to systolic blood pressure

Blood pressure as a predictor of cardiovascular events in the elderly: the William Hale Research Program

Epidemiological, pathophysiological and clinical significance of systolic, diastolic and pulse pressure

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