A British Medical Association Lecture on THE SIGNIFICANCE OF A RAISED BLOOD PRESSURE

Overview of the Evolution of Hypertension: From Ancient Chinese Emperors to Today

Hypertension is one of the most commonly treated conditions in modern medical practice, but despite its long history, it was largely ignored until the midpoint of the 20th century. This article will review the origins of elevated blood pressure from when it was first appreciated in 2600 BC to its most recent emerging treatments. Awareness of sustained elevations in blood pressure goes back to the Chinese Yellow Emperor's Classic of Internal Medicine (2600 BC); even then, salt was appreciated as a contributor to elevated pressure. Early treatments included acupuncture, venesection, and bleeding by leeches. About 1000 years later, the association between the palpated pulse and the development of heart and brain diseases was described by Ebers Papyrus (1550 BC). But really, it has only been since well after World War II that hypertension has finally been appreciated as the cause of so much heart, stroke, and kidney disease. We review the development of effective treatments for hypertension while acknowledging that so many people with hypertension in need of treatment have unacceptably poor blood pressure control. We explore why, despite our considerable and growing knowledge of hypertension, it remains a significant public health problem globally.

Prevalence of Hypertension in Indian Tribal Population: a Systematic Review and Meta-analysis

Hypertension is a serious condition that significantly increases the risks of several cardiovascular diseases. An estimated 1.28 billion adults aged 30-79 years worldwide have hypertension, and two-thirds of them live in low- and middle-income countries. Indigenous (tribal) populations are not exceptional to the threat of hypertension. Hence, there is a need to highlight the rising prevalence of hypertension among Indian tribes and to bring them under health care programmes. This paper reports the systematic review and meta-analysis of the literature on the prevalence of hypertension among Indian tribes by following the PRISMA guidelines. Three databases, viz. PubMed/Medline, Google Scholar and Scopus, were included. The gender-wise pooled prevalences were calculated, and forest plots were depicted. Other analyses were performed, including heterogeneity test, meta-regression and sub-group analysis. Of the 1010 studies obtained, 42 were included in this review. These studies covered tribal populations in different regions of India. The pooled prevalence of hypertension among men, women and combined were 23.66% (95% confidence interval (CI): 23.25 to 24.07%), 23.37% (95% CI: 22.99 to 23.75%) and 16.68% (95% CI: 16.10 to 17.28%) respectively. Considerable heterogeneity was found among these studies. The situation of increasing prevalence, as evident from this review, is worrisome as the hypertension epidemic will affect the poor tribal communities that cannot afford to pay for treatment expenses. Therefore, people's access to public health services must be improved. This review discusses the recent initiatives to reduce the burden of hypertension and other noncommunicable diseases in India and highlights the need of implementation research to strengthen these initiatives.

The debate over the optimal blood pressure treatment target of less than 130/80 mmHg

OBJECTIVES

The objective of this study was to analyze the controversy regarding the optimal blood pressure (BP) target of <130/80 mmHg as proposed by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) across all age groups. Hypertension is a major risk factor for cardiovascular disease (CVD), stroke, and chronic kidney disease (CKD), and its optimal control is associated with lessening or preventing these complications. A recent study has argued that this BP level is universally accepted as an optimal and safe BP level. However, this argument is not accepted by other investigators, arguing that higher BP levels are as effective and safe.

METHODS

In order to investigate the current status of this level of BP control, a Medline search of the English literature was conducted between 2017 and February 2022, and 25 pertinent papers were selected.

RESULTS

The analysis of data from these studies indicates that these BP are effective in lowering the BP and preventing cardiovascular disease, heart failure, and chronic kidney disease, and they are indeed universally accepted.

CONCLUSION

Based on the current evidence, the current proposed by the 2017 ACC/AHA treatment guidelines are effective in lowering the BP and decreasing its cardiovascular complications and should followed, till perhaps, new data come out to the contrary.

Deprescribing Antihypertensive Medications in Older People: A Narrative Review, Part 1

The problem of polypharmacy is complex, pervasive, and expanding. Appropriate prescribing of antihypertensive therapy for older people might help reduce medication burden, but it begins with a better understanding of what the evidence offers and where the evidence is quiet.In the first of this three-part series on antihypertensive medications for older people, we will trace the history of treating blood pressure with medication, from the expert opinion opposing treatment, to the observational data that led to paradigm shifts. We will follow the trail of evidence to randomized controlled trials (RCT) demonstrating the clear benefit of better control of blood pressure for all adults, regardless of age.RCT first evaluated any treatment against placebo, then began comparing one medication with another, and finally, more intensive control compared with less intensive control. Eventually professional societies bundled the evidence into guidelines to help busy prescribers and pharmacists wisely advise the consumers at the coal-face.In this first part of this series, we will present the evidence that favors intensive therapy in older people, that lower is better. In the second part, we will present evidence that highlights the dangers of going too low, and that stopping blood pressure-lowering medication might help. In the third part, we will discuss the evidence, new and old, that shows what happens when you stop.

Establishing target systolic and diastolic blood pressure in diabetic patients with hypertension: what do we need to consider?

INTRODUCTION

The optimum target for systolic and diastolic blood pressure remains divisive. In particular, the conflicting outcomes of the SPRINT and ACCORD trials have led to a divergence of guideline-recommended blood pressure targets for adults with diabetes.

AREAS COVERED

Here, we review the existing recommendations for blood pressure targets in diabetes, discussing the evidence base behind them and their limitations. We start by outlining the risks and benefits of lower systolic blood pressure targets among diabetics. We then follow with a separate appraisal of diastolic blood pressure targets, which necessitates examination of the 'J curve' and isolated diastolic hypertension.

EXPERT OPINION

Current and emerging evidence supports, on balance, a blood pressure therapeutic target of < 130/90 mmHg in adults at increased risk for cardiovascular disease, including diabetics. Whether certain diabetics with systolic BPs of 120-130 and/or diastolic BPs 80-90 mmHg require drug treatment to a target of <120/80 mmHg is less clear and requires more research.

Acupuncture for Hypertension Using Traditional Chinese Medicine Concepts

Hypertension affects 25% of the adult population worldwide. Biomedical treatment involves various blockers and is associated with side-effects. Acupuncture was one of the earliest methods of treatment for "hard pulse disease" (now called hypertension); it is effective and is associated with no untoward effects. Various studies showing the effectiveness of acupuncture for addressing hypertension are presented, along with an illustrative case. Acupuncture is effective for reducing blood pressure. This modality can be used as a stand-alone therapy or along with antihypertensive medications-in which case the dosages of the medications can be reduced significantly-and this helps to reduce the side-effects of medications.

The Story of the Silent Killer : A History of Hypertension: Its Discovery, Diagnosis, Treatment, and Debates

Hypertension is the leading risk factor for death and disability-adjusted life-years lost globally. Despite this tremendous impact on health, blood pressure measurement and treatment are relatively new to medical practice, with widespread measurement beginning just over 100 years ago. How, in such a short time, did blood pressure become such an integral measurement in medical practice that it is now considered one of the vital signs? Key revelations through Stephen Hales and his horse experiment, Riva-Rocci's modern blood pressure cuff, Korotkoff sounds, and President Roosevelt's death set the stage for discovery. Landmark trials such as the VA Cooperative studies of the 1960s through the recent Systolic Blood Pressure Intervention Trial and Prevention with Mediterranean Diet trials provide the foundation for modern clinical practice. An understanding of the history of hypertension can directly affect current clinical practice and offers unique insights into how the medical community has approached the management of one of the deadliest medical conditions in history.

Blood pressure medication should be routinely dosed at bedtime. An internist's critical appraisal of the editorial by Rainhold Kreutz et al. (2020). Blood pressure medication should not be routinely dosed at bedtime. We must disregard the data from the HYGIA project. Blood Pressure. 29 (3):135-136

The history of hypertension the past hundred years is a successful story of the fall of myths, beliefs, and assumptions under the weight of evidence. The recent editorial by Kreutz et al. (2020),"Blood pressure medication should not be routinely dosed at bedtime. We must disregard the data from the HYGIA project", published in Blood Pressure, conveys unjustified concerns founded on baseless doubts and suspicions about the Hygia Chronotherapy Trial. The physicians of Portugal are beginning to incorporate into routine clinical practice the proven methods of the Hygia Chronotherapy Trial - 48-hour ambulatory blood pressure monitoring and bedtime hypertension chronotherapy - to improve in a cost-effective matter the diagnosis and management of hypertension and to reduce the overwhelming burden of cardiovascular morbidity and mortality in our country.

The clinical significance of isolated diastolic hypertension

The prevalence of isolated diastolic hypertension (IDH) has been increased in hypertensive subjects with the new 2017 ACC/AHA blood pressure treatment guidelines to 6.5% from 1.3% by the JNC-7 guidelines. However, its clinical significance as a cause of adverse cardiovascular (CV) events especially in older subjects has been debated by several investigators, who have demonstrated no adverse CV effects of untreated IDH, but not by others. It is also more common in the young subjects who are at low CV risk and quite rare in the older subjects, who are at increased CV risk. Treatment of IDH in the older subjects could increase the CV complications due to a J-curve effect and, in addition, could increase the incidence of stroke from further lowering the normal systolic blood pressure (SBP). Very low SBP and DBP cannot be sustained by the cerebral blood flow autoregulation and could lead to cerebral ischemia. In order to get a better perspective of the current status of the treatment of IDH, a review of the English language literature of the available studies was conducted and 12 papers with pertinent information were retrieved. The analysis of results from these studies suggests that IDH is associated with adverse CV events in younger persons and it should be treated. In contrast, the prevalence of IDH is low in older subjects and is not associated with adverse CV events in the majority of cases. Thus, its further lowering should be avoided to prevent further decrease in normal SBP and prevent the onset of adverse CV events. However, the decision to treat IDH in older subjects should be individualized.

Evolution of Blood Pressure Clinical Practice Guidelines: A Personal Perspective

Before the second half of the 20th century, most clinical decision making was based on expert opinion. By the 1960s, experience in actuarial and research cohort studies had provided strong evidence that blood pressure was an important risk factor for cardiovascular disease. The landmark 1967 and 1970 Veterans Administration Cooperative Study trials confirmed the value of antihypertensive drug therapy in preventing stroke, myocardial infarction, and heart failure in adults with high levels of diastolic blood pressure. They also provided an impetus to develop the first blood-pressure-related clinical practice guideline in 1977. In subsequent years, more structured and comprehensive blood-pressure guidelines have evolved to become a major resource in clinical and public health practice. Despite some limitations, these guidelines provide useful evidence-based guidance for diagnosis and management of high blood pressure. The core advice in most of the current comprehensive blood pressure guidelines is more similar than different. Modelling studies suggest that better adherence to guideline recommendations would result in a lower average blood pressure and substantial improvement in public health.

Management of "Hypertension" Based on Blood Pressure Level Versus an Absolute Cardiovascular Risk Approach

PURPOSE OF REVIEW

To address the tension between guideline recommendations and the evidence from clinical trials supporting them and clinician concerns of overtreatment of elevated blood pressure.

RECENT FINDINGS

Systolic Blood Pressure Intervention trial (SPRINT) demonstrated lower blood pressure targets provided robust clinical benefit (reduced all-cause mortality) but also expected adverse events due to hypotension. Treatment thresholds for systolic blood pressure in the latest US guidelines have been lowered to 130 mmHg, although this has not been adopted elsewhere. These guidelines specify that treatment in the 130 s should be considered in the setting of absolute risk, i.e. treatment should be directed to those at high risk. This review argues that this hybrid approach, treatment thresholds in the 130 s based on absolute risk and above 140 mmHg on blood pressure level alone is a compromise, and that risk stratification should be the basis of drug treatment decision-making unless blood pressure is very high. Who receives blood pressure lowering medication is best determined by who is most likely to have a heart attack or stroke in the intermediate period rather than medicalising individuals who have a mildly elevated blood pressure.

Blood pressure and cardiovascular outcomes in patients with diabetes and high cardiovascular risk

Aims

Optimal blood pressure for prevention of cardiovascular (CV) events in patients with Type 2 diabetes mellitus (T2DM) remains uncertain and there is concern for increased risk with low diastolic blood pressure (DBP). This study analysed the association between blood pressure and CV outcomes in high-risk patients with T2DM.

Methods and results

Patients with T2DM and elevated CV risk were enrolled in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus-Thrombolysis in Myocardial Infarction 53 trial. Cardiovascular outcomes were compared in the biomarker subgroup (n = 12 175) after stratification by baseline systolic blood pressure (SBP) and DBP. Adjusted risk was calculated by blood pressure stratum using clinical covariates plus N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin-T (hsTnT). Trends were tested using linear and quadratic models. Adjusted risk of the composite endpoint of CV death, myocardial infarction (MI), or ischaemic stroke showed U-shaped relationships with baseline SBP and DBP (Pquadratic ≤ 0.01) with nadirs at SBP 130-140 or DBP 80-90 mmHg. Diastolic blood pressure <60 mmHg was associated with increased risk of MI (adjusted hazard ratio 2.30; 95% confidence interval 1.50-3.53) relative to DBP 80-90 mmHg. Adjusted odds of hsTnT concentration ≥14 ng/L showed U-shaped relationships with SBP and DBP (Pquadratic ≤ 0.01). The relationships between low DBP, elevated hsTnT, and increased MI remained after exclusion of patients with prior heart failure or NT-proBNP >median, suggesting that the relationship was not due to confounding from diagnosed or undiagnosed heart failure.

Conclusions

In patients with diabetes and elevated CV risk, even after extensive adjustment for underlying disease burden, there was a persistent association for low DBP with subclinical myocardial injury and risk of MI.

Diastolic Blood Pressure, Subclinical Myocardial Damage, and Cardiac Events: Implications for Blood Pressure Control

BACKGROUND

The optimal systolic blood pressure (SBP) treatment goal is in question, with SPRINT (Systolic Blood Pressure Intervention Trial) suggesting benefit for 120 mm Hg. However, achieving an SBP this low may reduce diastolic blood pressure (DBP) to levels that could compromise myocardial perfusion.

OBJECTIVES

This study sought to examine the independent association of DBP with myocardial damage (using high-sensitivity cardiac troponin-T [hs-cTnT]) and with coronary heart disease (CHD), stroke, or death over 21 years.

METHODS

The authors studied 11,565 adults from the ARIC (Atherosclerosis Risk In Communities) cohort, analyzing DBP and hs-cTnT associations as well as prospective associations between DBP and events.

RESULTS

Mean baseline age was 57 years, 57% of patients were female, and 25% were black. Compared with persons who had DBP between 80 to 89 mm Hg at baseline (ARIC visit 2), the adjusted odds ratio of having hs-cTnT ≥14 ng/l at that visit was 2.2 and 1.5 in those with DBP <60 mm Hg and 60 to 69 mm Hg, respectively. Low DBP at baseline was also independently associated with progressive myocardial damage on the basis of estimated annual change in hs-cTnT over the 6 years between ARIC visits 2 and 4. In addition, compared with a DBP of 80 to 89 mm Hg, a DBP <60 mm Hg was associated with incident CHD and mortality, but not with stroke. The DBP and incident CHD association was strongest with baseline hs-cTnT ≥14 ng/l (p value for interaction <0.001). Associations of low DBP with prevalent hs-cTnT and incident CHD were most pronounced among patients with baseline SBP ≥120 mm Hg.

CONCLUSIONS

Particularly among adults with an SBP ≥120 mm Hg, and thus elevated pulse pressure, low DBP was associated with subclinical myocardial damage and CHD events. When titrating treatment to SBP <140 mm Hg, it may be prudent to ensure that DBP levels do not fall below 70 mm Hg, and particularly not below 60 mm Hg.

Prevalence of hypertension and prehypertension in a community-based primary health care program villages at central India

OBJECTIVE

The objective of this study is to evaluate the effects of a community-based effort in a rural area of central India to decrease the prevalence of hypertension among the middle-aged and older population by using multiple blood pressure measurements.

METHODS

With a prevalence of 16.8% (error of 3.36, and 95% confidence interval) from a recent study in a nearby district, the sample size required for this study was 495 subjects. A proportionally stratified random sample design was used. With maps of ten villages, where in a community-based health project had been in place for many years, 20 households and 20 backups were randomly selected from a list of all households. Multiple BP measurements were obtained and categorized and one-month period prevalence was calculated. Statistical analyses of frequency and percentage were performed.

RESULTS

Approximately one-fifth of the population above 40 years of age in central India where a community-based approach is in place was hypertensive. This is significantly lower than the previously documented prevalence rate of one-third or even more prevalence rate in India. The attribute of caste and religion, a specific rural Indian characteristic did not have any significant bearing on the above results. The prevalence tended to increase progressively with age until 70 years, after which it declined. Multiple blood pressure measurements may yield an accurate prevalence of hypertension.

CONCLUSION

With the documented evidences from India, the current reduced prevalence of hypertension could have been influenced by the community-based interventions in this population.

The discovery of hypertension: evolving views on the role of the kidneys, and current hot topics

Primary hypertension is increasingly common and is associated with significant morbidity. Here, we review the history of its discovery and rise during the last century with an emphasis on studies trying to identify its cause. Early studies identified a defect in sodium excretion by the kidney as being central to the pathogenesis. Recent studies have focused on a variety of genetic, congenital (fetal programming), and acquired mechanisms for causing the defect in natriuresis. Certain risk factors are apparent, including genetic polymorphisms that regulate sodium excretion, a congenital reduction in nephron number, obesity and hyperleptinemia, an elevated sympathetic nervous system, diet (salt and fructose), and metabolic (hyperuricemia) mechanisms. The kidney shows evidence for renal arteriolar vasoconstriction, an intrarenal inflammatory response, local oxidative stress, and intrarenal activation of the renin-angiotensin system. Recent studies suggest that intrarenal T cells have an important role in causing hypertension to be persistent, likely due to the induction of a local autoimmune response to neoantigens such as heat shock protein 70 and protein aggregates formed by isoketals resulting from lipid peroxidation. Salt retention due to impairment in pressure-diuresis leads to the release of cardiotonic steroids and central nervous system effects that cause systemic vasoconstriction and a rise in blood pressure. Some recent studies suggest that salt may increase blood pressure not simply by effects on extracellular volume but rather as a consequence of hyperosmolarity. These new insights could lead to new approaches for the prevention and treatment of this important disease.

Prevalence of hypertension in Indian tribes: a systematic review and meta-analysis of observational studies

INTRODUCTION

In India there is an increasing trend in hypertension prevalence among the general population. Studies have shown that tribal populations in India are also experiencing this burden.

OBJECTIVE

The aim was to estimate the pooled prevalence of primary hypertension among adult tribal populations of India.

METHODS

A systematic search was conducted in MEDLINE, IndMed, Web of Science, Google Scholar and major journals for studies published between 1981 and 2011. Two authors independently reviewed the studies, did quality assessment and extracted data in pre-coded spread-sheets. Pooled estimates of prevalence of hypertension were calculated using DerSimonian-Laird random effects model. Subgroup and sensitivity analyses and meta-regression were performed.

RESULTS

Twenty studies or 53 subpopulations with 64 674 subjects were included in final review. The pooled estimate of hypertension prevalence was 16.1% (95% CI: 13.5, 19.2). There was significant heterogeneity among the studies (I2 = 99% and Q = 4624.0, df  = 53, p<0.001). Subgroup analyses showed that year of study, acculturation status, special features, and BP measurement techniques significantly influenced prevalence, but after meta-regression analyses, 'decade of study' remained the only covariate that significantly and independently influenced prevalence (R2 = 0.57, Q = 119.2, df  = 49, p value <0.001).

CONCLUSION

An increasing trend was found in the prevalence of hypertension in adult tribal populations across three decades. Although acculturation was probably the underlying agent that caused this increase, other unmeasured factors that need further research were also important. Concerned policy makers should focus on the changing health needs of tribal communities.

Renal denervation for treatment-resistant hypertension

Hypertension is a major public health concern that is increasing in prevalence. Lifestyle and pharmacological management are not always sufficient to control blood pressure and treatment-resistant hypertension is a recognized clinical challenge. Renal sympathetic denervation (RSD) represents a new frontier in the treatment of resistant hypertension.

RESULTS

from the Symplicity HTN-1 and HTN-2 trials have demonstrated evidence that suggests RSD can safely reduce blood pressure in patients with this condition. More research is needed to verify these data, clarify unanswered questions and assess future applications of RSD. This review provides a detailed overview on the history of hypertension, treatment-resistant hypertension, the rationale behind RSD, current evidence and potential future applications of RSD. An overview of current and upcoming RSD devices is also included.

Regulatory approval of cancer risk-reducing (chemopreventive) drugs: moving what we have learned into the clinic

This article endeavors to clarify the current requirements and status of regulatory approval for chemoprevention (risk reduction) drugs and discusses possible improvements to the regulatory pathway for chemoprevention. Covering a wide range of topics in as much depth as space allows, this report is written in a style to facilitate the understanding of nonscientists and to serve as a framework for informing the directions of experts engaged more deeply with this issue. Key topics we cover here are as follows: a history of definitive cancer chemoprevention trials and their influence on the evolution of regulatory assessments; a brief review of the long-standing success of pharmacologic risk reduction of cardiovascular diseases and its relevance to approval for cancer risk reduction drugs; the use and limitations of biomarkers for developing and the approval of cancer risk reduction drugs; the identification of individuals at a high(er) risk for cancer and who are appropriate candidates for risk reduction drugs; business models that should incentivize pharmaceutical industry investment in cancer risk reduction; a summary of scientific and institutional barriers to development of cancer risk reduction drugs; and a summary of major recommendations that should help facilitate the pathway to regulatory approval for pharmacologic cancer risk reduction drugs.

Current status of aggressive blood pressure control

The concept of treatment of hypertension has gone through wide swings over the years. From ignoring blood pressure (BP) treatment initially, to aggressive BP control recently. As newer and more effective drugs were developed, it was possible to lower BP to very low levels. However, recent studies have shown that aggressive BP control might not be in the best interest of the patient. Low levels of diastolic BP (DBP) have been associated with increased cardiovascular events, a situation known as the J-curve effect. This has been seen mostly with low DBP, since the coronary arteries are perfused during the diastolic phase of the cardiac cycle. Due to an autoregulatory mechanism, the heart is protected against wide fluctuations of BP. However, the presence of coronary heart disease, hypertension, especially with left ventricular hypertrophy, shift the curve to higher BP levels and makes the heart more liable to DBP fluctuations. The J-Curve effect has been reported by most investigators, but not by others. Recently, a J-Curve effect has been observed with systolic BP (SBP), as well. In contrast to the heart, the brain is very infrequently subjected to J-curve effect, and in contrast to the heart, the brain's blood flow autoregulation depends mostly on the SBP. A Medline search of the English literature on this subject was conducted between 1992 and 2010 and 11 pertinent articles were selected. These articles with collateral literature will be discussed in this concise review.

Historical perspectives on the management of hypertension

As late as the 1950s, elevated blood pressure was considered by many expert physicians to be necessary for the adequate perfusion of vital organs. Although the morbidity and mortality risks of hypertension were known at that time to insurance companies, which often refused life insurance policies to people with high blood pressure, there was a lag in the recognition of the dangers of hypertension in the medical community. Following the pioneering efforts of researchers who began to treat patients with malignant hypertension, the results of clinical trials and population studies, and the availability of effective antihypertensive agents, hypertension management improved rapidly. This review traces the history of hypertension management from the 1940s, when President Franklin Delano Roosevelt died of a cerebrovascular accident-a result of uncontrolled hypertension-to today, when a large number of patients, even those with less severe hypertension, are being treated successfully, with a resulting dramatic decrease in hypertension-related vascular disease.

Key Articles and Guidelines in the Management of Hypertension

Hypertension is a key risk factor for cardiovascular disease. Current management of hypertension, both pharmacologic and nonpharmacologic, is based on an extensive amount of published literature. We present a list of publications, clinical trials, meta-analyses, and clinical practice guidelines that we believe are essential in defining the current practice standards in the management of hypertension.

Historic perspectives on the relative contributions of diastolic and systolic blood pressure elevation to cardiovascular risk profile

The aim of this review was to examine the relative contributions of systolic and diastolic blood pressures to the risk of cardiovascular disease on the basis of epidemiologic evidence from the Framingham Heart Study and the change in attitudes toward systolic blood pressure that occurred during the course of the study. Historic texts were evaluated in comparison with data from the Framingham Heart Study, a prospective longitudinal analysis of the relation between blood pressure and occurrence of subsequent cardiovascular morbidity and mortality rates in a fixed cohort. Historically, systolic hypertension has been considered an innocent accompaniment to arterial stiffening, occurring as a compensatory phenomenon in the elderly. Epidemiologic data show that the development of hypertension is neither inevitable nor beneficial. The data also provide evidence that systolic pressure is more important than diastolic pressure as a determinant of cardiovascular sequelae. Mild or moderate elevations of systolic blood pressure, even when unaccompanied by diastolic pressure elevations, are associated with an increased risk of cardiovascular disease. Risk is increased further by the added presence of related metabolic disturbances such as dyslipidemia, glucose intolerance, insulin resistance, cardiac hypertrophy, and obesity. Over-reliance on diastolic blood pressure in assessing the risk of hypertension can be misleading. Systolic pressure constitutes a powerful predictor of cardiovascular disease and a valuable tool when incorporated within multivariate risk formulas for estimating the conditional probability of coronary and stroke events.

Isolated systolic hypertension in the elderly: pathophysiology and treatment

Isolated systolic hypertension (ISH) is a common clinical finding in the elderly population and appears to be a risk factor for cardiovascular morbidity and mortality. It appears feasible and safe to treat patients with various antihypertensive drugs; however, the morbidity and mortality benefits still need to be determined.