Systolic hypertension (SH), defined as systolic blood pressure (SBP) of at least 140 mm Hg and diastolic blood pressure (DBP) of less than 90 mm Hg, is a major public health issue that predominantly affects older individuals, according to background information in the article. A major message of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) is that in older persons (those aged 60 years and older), SH is a much more important cardiovascular disease risk factor than diastolic hypertension, and consequently, the control of SBP should be the focus of treatment in this population. Despite this recommendation, poor control of SH is increasing. A recent study examining trends in hypertension control found that isolated elevation of SBP was the most common finding among patients being treated for hypertension (high blood pressure), occurring in 76 percent of patients in 1999 compared with 57 percent in 1990-1995.
Sarwat I. Chaudhry, M.D., of the West Haven Veterans Affairs Medical Center, West Haven, Conn., and colleagues examined the evidence on the clinical management of SH in older persons by reviewing previous studies. The researchers performed a MEDLINE search for relevant reports from 1966-2004 and identified 1,064 studies, of which 36 articles met criteria they established for inclusion in their review.
In analyzing the studies, the researchers found: "There is strong evidence from clinical trials to support the treatment of SH in older persons with SBP of at least 160 mm Hg. Large-scale trials to assess the value of antihypertensive therapy for older patients with SBP of 140 to 159 mm Hg have not been performed, and recommendations to treat these patients are based on observational studies that show a graded relationship of cardiovascular risk with increasing SBP. The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy to treat SH."
" … recent work demonstrates the long-term (11-14 years) effectiveness of treating SH in reducing cardiovascular events. Despite this effectiveness, poor control of SH among patients seeking treatment for hypertension is increasing," the authors write.
"Many questions remain unresolved in the treatment of SH in older persons, leaving patients and clinicians uncertain about how best to balance risks and benefits. In addition, in this age group, decisions about treatment invariably involve tradeoffs of substantial risk," they write. "Given the scope of the problem and the growing size of the elderly population, there remains an acute need for more study."
(JAMA. 2004; 292:1074-1080. Available post-embargo at JAMA.com)
Editor's Note: Co-author Dr. Foody is supported by a National Institutes of Health/National Institute on Aging (NIA) Career Development Award and an NIA/Hartford Foundation Fellowship in Geriatrics.
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JAMA