Treatment of Isolated Systolic Hypertension is Beneficial
Abstract & Commentary
Source: Staessen JA, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: Meta-analysis of outcome trials. Lancet 2000;355:865-872.
In order to evaluate the risks associated with isolated systolic hypertension in older patients, Staessen and colleagues performed a meta-analysis of eight published trials. Patients were 60 years old or older, systolic blood pressure (BP) was 160 mmHg or greater, and diastolic BP was less than 95 mmHg. More than 15,000 patients with isolated systolic hypertension were followed for a median time of 3.8 years. Untreated systolic BP was a more accurate predictor of mortality and cardiovascular complications than diastolic BP. A 10 mmHg increase in systolic BP was significantly and independently correlated with increases of nearly 10% for total mortality (Relative Hazard Rate [RHR] 1.3; P = 0.0001) and stroke (RHR 1.2; P = 0.02), but not for coronary events (RHR 1.1; P = 0.37). Diastolic BP, in contrast, was inversely correlated with total and cardiovascular mortality. At any given level of systolic BP, the risk of death rose with lower diastolic BP and therefore also with greater pulse pressure.
Active treatment of hypertension reduced total mortality by 13%, stroke by 30%, and coronary events by 23%. The number of patients to treat for five years to prevent one major cardiovascular event was lower in men (18 vs 38), at age 70 or older (17 vs 39), and in patients with previous cardiovascular complications (16 vs 37).
Commentary
Isolated systolic hypertension refers to a rise in systolic BP with increasing age due to decreased elasticity of the large arteries and is not necessarily accompanied by a rise in mean arterial BP or in peripheral resistance. The prevalence of isolated systolic hypertension averages 8% in individuals between 60 and 70 years of age and exceeds 25% in those aged 80 years or older (Staessen J, et al. J Hypertens 1990;8:393-405). Nevertheless, systolic hypertension is not a benign aging change. Rather, it is one of the stroke risk factors that is reversible with treatment.
Staessen et al found treatment of systolic hypertension had a greater absolute benefit in men, older patients, those with previous cardiovascular complications, or those with a higher pulse pressure. Why antihypertensive treatment apparently provided less protection against coronary complications than against stroke is unclear. As Staessen et al state, it may be among other reasons that the association between systolic BP and coronary artery disease weakens with increasing age. In summary, the evidence justifies drug treatment of isolated systolic hypertension in the elderly. —jjc
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