Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group

Implications of the Systolic Hypertension in China trial

In 1988, the Systolic Hypertension in China (Syst-China) Collaborative Group started to investigate whether active treatment could reduce the incidence of stroke and other cardiovascular complications of isolated systolic hypertension. After stratification for center, sex and previous cardiovascular complications, alternate patients (n = 1253) were assigned nitrendipine 10-40 mg daily, with the possible addition of captopril 12.5-50.0 mg daily, or hydrochlorothiazide 12.5-50.0 mg daily, or both drugs. In 1141 control patients, matching placebos were employed similarly. At entry, sitting blood pressure averaged 170 mm Hg systolic and 86 mm Hg diastolic, age averaged 66 years, and total serum cholesterol was 5.1 mmol/L. At 2 years, the between-group differences were 9.1 mm Hg systolic (95% confidence interval: 7.6-10.7 mm Hg) and 3.2 mm Hg diastolic (2.4-4.0). Active treatment reduced total stroke by 38% (p=0.01), all-cause mortality by 39% (p=0.003), cardiovascular mortality by 39% (p=0.03), stroke mortality by 58% (p=0.02) and all fatal and nonfatal cardiovascular endpoints by 37% (p=0.004). In conclusion, antihypertensive treatment prevents stroke and other cardiovascular complications in older Chinese patients with isolated systolic hypertension. Treatment of 1000 Chinese patients for 5 years could prevent 55 deaths, 39 strokes, or 59 major cardiovascular endpoints.

Treatment of diabetic patients with hypertension

This review attempts to highlight the potential of calcium-channel blockers in the prevention of sequelae of diabetes mellitus and hypertension in patients who have both disorders. Evidence-based medicine is driven by the results of randomized, clinical trials. Major contributions were therefore derived from post hoc analyses of the diabetic patients enrolled in placebo-controlled trials, such as Systolic Hypertension in the Elderly Program (SHEP), Systolic Hypertension in Europe (Syst-Eur), and Systolic Hypertension in China (Syst-China), and stepped-care blood-pressure-oriented trials, such as the Hypertension Optimal Treatment (HOT) and United Kingdom Prospective Diabetes Study (UKPDS). Several studies, such as the Fosiniprl; versus Amlodipine Cardiovascular Events Trial (FACET) and Appropriate Blood Pressure Control in Diabetes (ABCD) Trial, have compared the relative merits of angiotensin-converting enzyme and calcium-channel blockers in preserving renal function and metabolic balance in diabetic patients with hypertension, but their publications focused on cardiovascular disorders, which were only secondary end points. On balance, the articles reviewed prove that dihydropyridine calcium-channel blockers score particularly well in the prevention of cardiovascular complications in diabetic patients with hypertension.

Isolated systolic hypertension: an important cardiovascular risk factor

Hypertension is an established risk factor for cardiovascular disease morbidity and mortality. Randomized trials of antihypertensive therapy have demonstrated the benefits of treating diastolic blood pressure, and recently the value of treating isolated systolic blood pressure has also been established. There is an excess risk of cardiovascular disease in subjects with borderline isolated systolic hypertension. In fact, data from men screened for the Multiple Risk Factor Intervention Trial show that the great majority of excess deaths are in those with high-normal systolic blood pressure or with stage 1 hypertension, i.e., systolic blood pressure 130 to 159 mmHg. Similarly, data from the Framingham Heart Study and the Physicians' Health Study emphasize the importance of mild elevations of systolic blood pressure. As age increases the hemodynamic patterns of blood pressure change due to an increase in large artery stiffness, and borderline isolated systolic hypertension becomes the dominant form of hypertension. These facts make the prevention and control of borderline isolated systolic hypertension a key strategic challenge in the effort to prevent excess mortality attributable to blood pressure levels above normal.