Systolic hypertension

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Systolic hypertension is defined as an elevated systolic blood pressure with a normal diastolic blood pressure. Systolic hypertension may be due to reduced compliance of the aorta with increasing age[1].

Treatment

Several randomized controlled trials have established the value of treating systolic hypertension[2][3][4][5].

SHEP study

This randomized controlled trial showed a reduction of three strokes per 100 patients treated for five years[2][6][7]

  • Patients: inclusion criteria were SBP greater than 160 to 219 mm Hg and DBP less than 90 mm Hg. Exclusion criteria included "history of stroke with residual paresisor other neurological disability." Mean initial BP was 170/77.
  • Treatment goal: 20 mmHg reduction in systolic pressure or a systolic pressure of less than 160 mmHg, whichever was lower
  • Mean final blood pressure in the treatment group: 143/68

Syst-Eur Trial

This randomized controlled trial showed a reduction of 0.3 strokes per 100 patients treated for a median follow-up of two years[3].

  • Patients: inclusion criteria were systolic of 160-219 mm Hg and diastolic blood pressure lower than 95 mm Hg. Average was 174/86 mm HG.
  • Treatment goal: "We aimed to reduce the sitting systolic blood pressure by at least 20 mm Hg to less than 150 mm Hg"
  • Mean final blood pressure in the treatment group: 151/79. 44% of patients reached the target blood pressure goals.

HYVET Trial

Although not labeled a trial of systolic hypertension, the separate report of the subgroup of patients were 80 years old or older, on average had systolic hypertension with baseline mean blood pressure values of 173/91[4]

  • Patients: inclusion criteria were systolic of over 160 mm Hg. Average was 173/91 mm Hg.
  • Treatment goal: 150/80
  • Mean final blood pressure in the treatment group: not repeated. Only the differences between groups were reported.

SPRINT

Although not labeled a trial of systolic hypertension, the separate report of the subgroup of patients 75 years old or older, on average had systolic hypertension with baseline mean blood pressure values of 142/71[5].

  • Patients: inclusion criteria were 75 years or older with hypertension but without diabetes, SPRINT exclusion criteria included: history of stroke, "an SBP of less than 110 mm Hg following 1 minute of standing."
  • Treatment goal: "systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment)"
  • Mean final blood pressure in the treatment group: 123/63. Mean final blood pressure in the control group: 135/67.

The treatment goal

Based on these studies, treating to a systolic blood pressure of 140, as long as the diastolic blood pressure is 68 or more seems safe. Corroborating this, a re-analysis of the SHEP data suggest that allowing the diastolic to go below 70 may increase adverse effects.[7].

A meta-analysis of individual-patient data from randomized controlled trials found that the nadir diastolic blood pressure below which cardiovascular outcomes increase is 85 mm Hg for untreated hypertensives and 85 mm Hg for treated hypertensives.[8] The authors concluded "poor health conditions leading to low blood pressure and an increased risk for death probably explain the J-shaped curve".[8] Interpreting the meta-analysis is difficult, but avoiding a diastolic blood pressure below 68-70 mm Hg seems reasonable because:

  • The nadir value of 85 mm Hg for treated hypertensives in the meta-analysis is higher than the value of 68-70 mm Hg that is the nadir suggested by the two major randomized controlled trials of isolated systolic hypertension
  • The two largest trials in the meta-analysis, Hypertension Detection and Follow-up Program (HDFP)[9] and Medical Research Council trial in mild hypertension (MRC1)[10] were predominantly middle aged subjects, all of whom had diastolic hypertension before treatment.
  • The independent contributions of incidental comorbid diseases versus effects of treatment are not clear in the meta-analysis

More recent analyses that include the SPRINT trial, find conflicting results:

  • No relation to blood pressure treatment[11][12][13][14]
  • Avoid treating below 70[15]
  • No relationship unless in the setting of tight diabetic control[16]

Practice guidelines =

The 2018 ESC/ESH Guidelines include the statements[17]:

  • Among patients with coronary artery disease, treat to a DBP target of < 80, but not less than 70 mmHg
  • The 2017 ACC/AHA guidelines to not discuss low DBP[18]

References

  1. ↑ Smulyan H, Safar ME. The diastolic blood pressure in systolic hypertension. Ann Intern Med. 2000 Feb 1;132(3):233-7. PMID 10651605
  2. ↑ 2.0 2.1 "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). SHEP Cooperative Research Group". JAMA. 265 (24): 3255–64. 1991. PMID 2046107.
  3. ↑ 3.0 3.1 Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhäger WH; et al. (1997). "Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators". Lancet. 350 (9080): 757–64. doi:10.1016/s0140-6736(97)05381-6. PMID 9297994.
  4. ↑ 4.0 4.1 Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D; et al. (2008). "Treatment of hypertension in patients 80 years of age or older". N Engl J Med. 358 (18): 1887–98. doi:10.1056/NEJMoa0801369. PMID 18378519. Review in: J Fam Pract. 2008 Aug;57(8):506-7 Review in: ACP J Club. 2008 Aug 19;149(2):10 Review in: Evid Based Med. 2008 Oct;13(5):136
  5. ↑ 5.0 5.1 Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM | display-authors=etal (2016) Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA 315 (24):2673-82. DOI:10.1001/jama.2016.7050 PMID: 27195814
  6. ↑ Borhani NO, Applegate WB, Cutler JA, Davis BR, Furberg CD, Lakatos E; et al. (1991). "Systolic Hypertension in the Elderly Program (SHEP). Part 1: Rationale and design". Hypertension. 17 (3 Suppl): II2–15. doi:10.1161/01.hyp.17.3_suppl.ii2. PMID 1999373.
  7. ↑ 7.0 7.1 "Implications of the systolic hypertension in the elderly program. The Systolic Hypertension in the Elderly Program Cooperative Research Group". Hypertension. 21 (3): 335–43. 1993. PMID 8478043.
  8. ↑ 8.0 8.1 Boutitie F, Gueyffier F, Pocock S, Fagard R, Boissel JP (2002). "J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data". Ann. Intern. Med. 136 (6): 438–48. PMID 11900496.
  9. ↑ "Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-up Program Cooperative Group". JAMA. 242 (23): 2562–71. 1979. PMID 490882.
  10. ↑ "MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party". British medical journal (Clinical research ed.). 291 (6488): 97–104. 1985. PMID 2861880.
  11. ↑ Juraschek SP, Hu JR, Cluett JL, Ishak AM, Mita C, Lipsitz LA; et al. (2023). "Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis". JAMA. 330 (15): 1459–1471. doi:10.1001/jama.2023.18497. PMC 10582789 Check |pmc= value (help). PMID 37847274 Check |pmid= value (help).
  12. ↑ Sobieraj, Piotr; Lewandowski, Jacek; Siński, Maciej (21 April 2019). "Low on-treatment diastolic blood pressure is not independently associated with increased cardiovascular risk: an analysis of the SPRINT trial". European Heart Journal. 40 (25): 2094–2095. doi:10.1093/eurheartj/ehz225. eISSN 1522-9645. ISSN 0195-668X. PMID 31006014.
  13. ↑ Foy, Andrew J.; Filippone, Edward J.; Schaefer, Eric; Nudy, Matt; Ruzieh, Mohammed; Dyer, Anne-Marie; Chinchilli, Vernon M.; Naccarelli, Gerald V. (20 October 2021). "Association Between Baseline Diastolic Blood Pressure and the Efficacy of Intensive vs Standard Blood Pressure–Lowering Therapy". JAMA Network Open. 4 (10): e2128980. doi:10.1001/jamanetworkopen.2021.28980. eISSN 2574-3805. PMC 8529404 Check |pmc= value (help). PMID 34668944 Check |pmid= value (help).
  14. ↑ Wright, Jackson T.; Whelton, Paul K.; Johnson, Karen C.; Snyder, Joni K.; Reboussin, David M.; Cushman, William C.; Williamson, Jeff D.; Pajewski, Nicholas M.; Cheung, Alfred K.; Lewis, Cora E.; Oparil, Suzanne; Rocco, Michael V.; Beddhu, Srinivasan; Fine, Lawrence J.; Cutler, Jeffrey A.; Ambrosius, Walter T.; Rahman, Mahboob; Still, Carolyn H.; Chen, Zhengyi; Tatsuoka, Curtis (December 2021). "SPRINT Revisited: Updated Results and Implications". Hypertension. 78 (6): 1701–1710. doi:10.1161/HYPERTENSIONAHA.121.17682. eISSN 1524-4563. ISSN 0194-911X. PMC 8824314 Check |pmc= value (help). PMID 34757768 Check |pmid= value (help).
  15. ↑ Li, Jingen; Somers, Virend K.; Gao, Xiang; Chen, Zhuo; Ju, Jianqing; Lin, Qian; Mohamed, Essa A.; Karim, Shahid; Xu, Hao; Zhang, Lijing (17 February 2021). "Evaluation of Optimal Diastolic Blood Pressure Range Among Adults With Treated Systolic Blood Pressure Less Than 130 mm Hg". JAMA Network Open. 4 (2): e2037554. doi:10.1001/jamanetworkopen.2020.37554. eISSN 2574-3805. PMC 7890449 Check |pmc= value (help). PMID 33595663 Check |pmid= value (help).
  16. ↑ Hartsell, Sydney E.; Beddhu, Srinivasan (20 October 2021). "Diastolic Blood Pressure and the J-Curve—Causal Effect or Confounding?". JAMA Network Open. 4 (10): e2130031. doi:10.1001/jamanetworkopen.2021.30031. eISSN 2574-3805. PMC 8967343 Check |pmc= value (help). PMID 34668952 Check |pmid= value (help).
  17. ↑ Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M; et al. (2018). "2018 ESC/ESH Guidelines for the management of arterial hypertension". Eur Heart J. 39 (33): 3021–3104. doi:10.1093/eurheartj/ehy339. PMID 30165516.
  18. ↑ Whelton, Paul K.; Carey, Robert M.; Aronow, Wilbert S.; Casey, Donald E.; Collins, Karen J.; Dennison Himmelfarb, Cheryl; DePalma, Sondra M.; Gidding, Samuel; Jamerson, Kenneth A.; Jones, Daniel W.; MacLaughlin, Eric J.; Muntner, Paul; Ovbiagele, Bruce; Smith, Sidney C.; Spencer, Crystal C.; Stafford, Randall S.; Taler, Sandra J.; Thomas, Randal J.; Williams, Kim A.; Williamson, Jeff D.; Wright, Jackson T. (June 2018). "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Hypertension. 71 (6). doi:10.1161/HYP.0000000000000065. eISSN 1524-4563. ISSN 0194-911X. PMID 29133356.

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