Isolated systolic hypertension in Evans county--I. Prevalence and screening considerations

Trajectories of body mass index and risk of incident hypertension among a normal body mass index population: A prospective cohort study

It is unclear whether there are different body mass index (BMI) trajectories among a population with normal BMI levels, and the association between BMI patterns and incident hypertension is not well characterized. This prospective cohort study includes surveys conducted at baseline and three follow‐ups. 3939 participants who are free of hypertension at baseline or first two follow‐ups were enrolled. At baseline, the age of participants ranged from 35 to 82 years and the mean age was 45.9 years. The BMI trajectories were identified using latent mixture modeling with data from the baseline and first two follow‐ups. The effects of different BMI trajectories on the development of hypertension were analyzed using a Cox proportional hazard model. Four distinct BMI trajectories were identified over the study period (2004‐2010): normal‐stable (n = 1456), normal‐increasing (n = 2159), normal‐fluctuated (n = 166), and normal‐sharp‐increasing (n = 158). Relative to the normal‐stable BMI group, the hazard ratios (HRs) and 95% confidence intervals (CIs) after adjustment for confounding factors of the normal‐increasing, normal‐fluctuated, and normal‐sharp‐increasing groups were 1.244 (1.103‐1.402), 1.331 (1.008‐1.756), and 1.641 (1.257‐2.142), respectively. Additionally, subgroup analysis showed that the normal‐fluctuated BMI trajectory was associated with a significantly higher risk of hypertension only in women (HR = 1.362; 95% CI = 1.151‐1.611). The BMI trajectories were significant predictors of hypertension incidence, and increasing BMI trajectories within the currently designated normal range were associated with an increased hypertension risk, especially in women.

Is Peri-Operative Isolated Systolic Hypertension (ISH) a Cardiac Risk Factor?

We are presenting a review of Isolated Systolic Hypertension (ISH) as a cardiovascular risk factor with emphasis on the perioperative period.

Isolated systolic hypertension is associated with aging and is the most frequent subtype (65%) among patients with uncontrolled hypertension. ISH is strongly associated with increased risks of cardiac and cerebrovascular events exceeding those in comparably aged individuals with diastolic hypertension. Patients with ISH show an increase in left ventricular (LV) mass and an increase in the prevalence of left ventricular hypertrophy (LVH). These LV changes increase cardiovascular events and frequently lead to diastolic dysfunction (DD). Treatment to reduce elevated systolic blood pressure has been shown to reduce the risk of cardiovascular events.

In the perioperative setting, essential hypertension has not been found to be a significant risk factor for cardiac complications. Most of the studies were based on the definition of essential hypertension and underpowered in sample size. The significance of perioperative ISH, however, is not well studied, partly due to its recognition only fairly recently as a cardiovascular risk factor in the non-surgical setting, and partly due to the evolving definition of ISH.

Perioperative cardiac complications remain a significant problem to the healthcare system and to the patient. Although the incidence of perioperative cardiac complications is prominent in high-risk patients as defined by the Revised Cardiac Risk Index (RCRI), the bulk of the cardiac complications actually occur in low-risk group. Currently, little understanding exists on the occurrence of perioperative cardiac complications in low- risk patients. A factor such as ISH, with its known pathophysiological changes, is a potential perioperative risk factor.

We believe ISH is an under-recognized perioperative risk factor and deserves further studying. Our research group has recently been funded by the Heart Stroke Foundation (HSF) to examine ISH as a perioperative risk factor (PROMISE Study).

The Camerano study on hypertension: the problem of arterial hypertension in the elderly

The Camerano study on arterial hypertension (AH) was a cross-sectional study, carried out on a large population sample in a small town in central Italy. The main goal was to reveal both the prevalence and certain characteristics of AH in the population examined. The main results, can be summarized as follows: (i) The occurrence of AH in the old (65-74 years) and very old (> or = 75 years) groups was 43.3 and 57.4%, respectively. (ii) isolated systolic hypertension (ISH) was found in 1.7, 23.6 and 3.9% in the adult, old and very old subjects, respectively. (iii) The association of AH with some of the more common cardiovascular risk factors (dyslipidemia, hyperglycemia, obesity, etc.) was significant for all the risk factors in the adult group, while in the old group there was a significant association only with the body mass index. (iv) Blood pressure (BP) values during the medical visits were evaluated, and adult versus old subjects were compared, but no significant differences were found.

Isolated systolic hypertension: data on a cohort of young subjects from a French working population (IHPAF)

Elderly patients with isolated systolic hypertension (ISH)--systolic blood pressure (SBP) > or =140 mmHg and diastolic blood pressure (DBP) <90 mmHg--have increased mortality and morbidity. The aim was to study the incidence of ISH in a younger population of between 15 and 60 years of age, and to measure pulse pressure (PP), mean arterial pressure (MAP) and heart rate (HR) in these subjects. The study population consisted of 27 783 subjects, aged 15-60 years, untreated for hypertension (HT) from a cohort of employees formed to study the incidence of HT in the French working population (AIHFP). BP and HR were measured with a validated, automatic device after 5, 6 and 7 min at rest. The prevalence of ISH was 6.9% in men, 2.3% in women. This prevalence was over 5% in young men and increased at 40-44 years; it was negligible in young women, but increased at 50-54 years to about 10% (ie to the same level as in men of the same age): PP in subjects with ISH (46.9 mmHg) was significantly higher than in the normotensive group (NT-40.9 mmHg); it was comparable in both young men (65.5 mmHg) and older men (66 mmHg); it was higher in men (63.1 mmHg) than in women (61.5 mmHg). HR was higher in ISH than in NT and it was higher in women ( approximately 5 bpm) in whom it decreased with age. The prevalence of ISH is not negligible in HT (30% men, 25% women), with a high prevalence in young subjects and elevated PP, MAP and HR values. These data should be taken into account as elevated ISH, PP and HR are considered as cardio-vascular risk factors.

Management of isolated systolic hypertension

Isolated systolic hypertension (ISH) [systolic blood pressure (SBP) > or = l60mm Hg with diastolic blood pressure (DBP) <90mm Hg] is the commonest form of hypertension in the elderly, and accounts for about 60% of all hypertensive conditions in the population aged over 65 years. It is associated with a significantly increased risk of cardiovascular and cerebrovascular morbidity and mortality. The landmark Systolic Hypertension in the Elderly Program (SHEP) study, published in 1991, has shown that lowering the SBP in elderly patients with ISH results in a significant reduction in cardiovascular events. These results have had a major impact on clinical practice in hypertension. On theoretical grounds, considering the pathophysiological mechanisms of ISH in the elderly, any drug which lowers total peripheral resistance and/or arterial stiffness should reduce SBP effectively in these patients. This effect has been observed in outcome studies and short term clinical trials using a variety of drugs from the 4 major antihypertensive classes: diuretics, beta(1)-blockers, calcium channel antagonists and ACE inhibitors. Other drugs, including alpha antagonists, may also be effective. In general, there is compelling evidence to support active treatment of any individual with an SBP > or = 160mm Hg. As in essential hypertension, the maximum benefit is gained by aggressive treatment of those individuals at highest risk because of coexisting cardiovascular risk factors. In these people, an SBP of 140 to 159mm Hg should be considered to be an indication for active management. Initial management should be by manipulation of lifestyle factors such as bodyweight, salt and alcohol intake and aerobic exercise. Drug therapy, generally well tolerated in low doses, should be considered if SBP remains > or = 160mm Hg, or > or = 140mm Hg in the presence of multiple risk factors. The choice of initial drug therapy should be influenced by the particular clinical situation. If there are no coexisting contraindications or co-indications for particular drugs, it is reasonable to begin treatment with a low dose of a thiazide-like diuretic, as used in the SHEP study. However, in short term treatment trials calcium channel antagonists and ACE inhibitors have been shown to lower SBP effectively and can be used in the appropriate clinical context. Beta-blockers appear to be less effective as monotherapy in ISH. Combination therapy is frequently required and can be effective and well tolerated if carefully chosen.

Epidemiologic aspects of isolated systolic hypertension and implications for future research

Isolated systolic hypertension represents an important public health issue in the 1990s because of its prevalence in the elderly and its importance as a risk factor for cardiovascular morbidity and mortality. Methodologic differences may account for the wide variation between prevalence rates in studies reported. With the advent of newer methods of blood pressure (BP) assessment, such as noninvasive ambulatory BP monitoring, it may be possible to define more accurately the true population at risk. Recent data from the Systolic Hypertension in the Elderly Program has indicated a clear benefit of treatment with a reduction in total stroke of 36%, and a reduction of 25 and 32% in the combined end points of coronary heart disease and cardiovascular disease, respectively. Further studies are now required to elucidate what treatment regimens are most effective in preferentially reducing both systolic BP, without producing undesirable effects such as diastolic hypotension, and fatal and nonfatal events. One such trial is underway in Europe using a drug regimen different from that in the Systolic Hypertension in the Elderly Program. The cost implications associated with treating the population at risk are potentially large but these are now based on firm scientific evidence.

Syst-Eur. A multicentre trial on the treatment of isolated systolic hypertension in the elderly: objectives, protocol, and organization

The Syst-Eur Trial is a concerted action of the European Community's Medical and Health Research Programme. The trial is carried out in consultation with the World Health Organization, the International Society of Hypertension, the European Society of Hypertension and the World Hypertension League. This article describes the objectives and the protocol of Syst-Eur, a multicentre trial designed by the European Working Party on High Blood Pressure in the Elderly (EWPHE), to test the hypothesis that antihypertensive treatment of elderly patients with isolated systolic hypertension results in a significant change in stroke morbidity and mortality. Secondary endpoints include cardiovascular events, such as myocardial infarction and congestive heart failure. To be eligible patients must be at least 60 years old and have a systolic blood pressure averaging 160-219 mmHg with a diastolic pressure less than 95 mmHg. Patients must give their informed consent and be free of major cardiovascular and non-cardiovascular diseases at entry. The patients are randomized to active treatment or placebo. Active treatment consists of nitrendipine (10-40 mg/day), combined with enalapril (5-20 mg/day) and hydrochlorothiazide (12.5-25 mg/day), as necessary. The patients of the control group receive matching placebos. The drugs (or matching placebos) are stepwise titrated and combined in order to reduce systolic blood pressure by 20 mmHg at least to a level below 150 mmHg. Morbidity and mortality are monitored to enable an intention-to-treat and per-protocol comparison of the outcome in the 2 treatment groups. A one-year pilot trial (1989) showed that the protocol is practicable. The Ethics Committee therefore decided to start the definite study (1990), in which randomized patients will be followed for 5 years. Recruitment of new centres and of the required 3,000 patients will last 3 years (until 1993).

Epidemiology, pathophysiology, and management of isolated systolic hypertension in the elderly

Isolated systolic hypertension (ISH) is a common disorder in the elderly, carrying with it a high risk of cardiovascular morbidity and mortality. Environmental and age-related factors believed to contribute to ISH include obesity, declining physical activity, stress, and such dietary changes as increased salt intake and decreased intake of calcium and potassium. Increased rigidity of the aorta resulting in reduced compliance is an important hemodynamic feature, but factors that increase peripheral resistance also appear to play a role. Antihypertensive drugs have been shown to effectively and safely lower the systolic blood pressure elevations characteristic of ISH. To date, use of low drug doses and careful titration of dosage have avoided significant orthostatic hypotension and undue lowering of the diastolic pressure. Studies of relatively small groups of patients suggest that antihypertensive drugs can lower the risk of cardiovascular morbidity/mortality associated with ISH but the definitive answer awaits results of the ongoing large-scale Systolic Hypertension in the Elderly Program trial. In the interim, management should begin with conservative measures such as weight loss, salt restriction and, possibly, calcium supplementation. If this fails, drug therapy should be considered in patients with systolic blood pressures above 180 mm Hg and in those with systolic readings between 160 and 180 mm Hg who have concomitant cardiovascular risk factors. To date, no controlled trials of sufficient size have demonstrated that one drug class is more effective than another in treating ISH. Drug therapy should be tailored to the individual patient, starting with a low dose of a single drug and, if necessary, slowly increasing dosage until a systolic blood pressure under 160 mm Hg is attained.

Isolated systolic hypertension in the elderly: an epidemiologic review

Isolated systolic hypertension (ISH) is usually defined as a systolic blood pressure greater than or equal to 160 mm Hg and diastolic blood pressure less than 90 or 95 mm Hg. Systolic blood pressure has been found to increase with age in most populations studied and thus the prevalence of ISH can be expected to increase with age. ISH is more prevalent in elderly women than in elderly men. Estimates of the prevalence of ISH vary according to its definition and the number of blood pressure measurements. There is evidence that the prevalence of ISH is decreasing. Results of a survey of the prevalence of ISH in 11 countries are presented; the estimates among men aged 60 to 69 years ranged from 1% in Israel to 24% in Norway. Only a prospective standardized survey conducted in several countries will reveal the true prevalence of ISH.

Hypertension in the aged: a pathophysiologic basis for treatment

According to major surveys, hypertension is found in over half the population aged 65 years or over. In this age group, systolic blood pressure is at least as important as diastolic blood pressure as a predictor of cardiovascular morbidity and mortality. Overall, the presence of hypertension is associated with approximately a threefold increase in the likelihood of major events. Differing factors contribute to the hypertension. Loss of proximal arterial compliance, affecting the larger conduit vessels, occurs often with aging and explains the tendency for systolic pressure to increase while diastolic pressure remains constant or even decreases. A loss of baroreceptor sensitivity also may contribute to hypertension. There is an increase in responsiveness of the sympathetic nervous system and an enhanced sensitivity to its effects in the elderly, perhaps reflecting a decline in the buffering activity of peripheral vascular beta receptors. It is possible, too, that sodium retention may contribute to hypertension in some older patients. Although diuretics traditionally have been the mainstay of treatment in these patients, it is now recognized that other classes of antihypertensive agents may be equally as effective yet less prone to metabolic or symptomatic adverse events. Sympatholytic drugs, calcium channel blockers and angiotensin-converting enzyme inhibitors, either as monotherapy or in combination with low-dose diuretics, have been shown to be efficacious in the elderly. These agents also can produce regression of left ventricular hypertrophy, an additional property that may contribute to a reduction in serious cardiac complications.

Awareness, treatment, and control of hypertension in the elderly in a general practice experience. Study Group on Hypertension in the Elderly

In 3858 ambulatory elderly people (age greater than or equal to 65 years) prevalence of hypertension was 67.8%. The hypertensive status was unknown to both the doctor and the patient in 21.4% of cases. More than 90% of known hypertensives were treated, but hypertension could be considered as controlled in less than 30% of them.

Clinical experience and rationale for angiotensin-converting enzyme inhibition with lisinopril as the initial treatment for hypertension in older patients

Hypertension is a major health problem for patients over 65 years of age. Control of elevated blood pressure reduces cardiovascular morbidity and mortality rates among older hypertensive patients. Increased total peripheral vascular resistance is the primary hemodynamic abnormality in these patients. Initially, diuretics were used alone to lower total peripheral vascular resistance, and thus blood pressure, in older patients. The antihypertensive efficacy of angiotensin-converting enzyme inhibitors has been questioned in this age group, in which low-renin hypertension is common. The latter condition might be thought to favor blood pressure control with diuretics and impair the response to angiotensin-converting enzyme inhibitor therapy. However, recent studies with lisinopril, a new long-acting, nonsulfhydryl angiotensin-converting enzyme inhibitor, indicate that reductions in systolic and diastolic blood pressure in older hypertensive patients receiving either angiotensin-converting enzyme inhibitor or hydrochlorothiazide monotherapy were not significantly different. These data demonstrate that angiotensin-converting enzyme inhibitor monotherapy can effectively lower blood pressure in older hypertensive patients.

Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial

The large cohort of white men (317,871) 35 to 57 years old at initial screening for possible enrollment into the Multiple Risk Factor Intervention Trial (MRFIT) was examined with regard to initial blood pressure levels and subsequent coronary heart disease (CHD), stroke, and all-cause mortality. The overall prevalence of isolated systolic hypertension (ISH), defined as systolic blood pressure (SBP) greater than or equal to 160 mm Hg and diastolic blood pressure (DBP) less than 90 mm Hg, was 0.67% among white men screened for MRFIT and increased with age (0.31% among 35- to 39-year-olds to 1.7% among 55- to 57-year-olds). The 6 year CHD and all-cause mortality rates in men over 50 were highest in those with ISH compared with both subjects with diastolic hypertension and those with normal pressure. The relative risk of death from stroke in those with ISH, compared with that in those with SBP less than 160 mm Hg and those with DBP less than 90 mm Hg, was 3.0 (95% confidence interval 1.3 to 6.8). In addition, at any level of DBP, the level of SBP appeared to be the major determinant of all-cause and CHD mortality. The determinants of ISH in individuals under 60 years of age as well as the possible efficacy of its treatment should be evaluated further.

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.

Isolated systolic hypertension: declining prevalence in the elderly

Isolated systolic hypertension is a prevalent condition among elderly U.S. residents of all age, sex, and race groups. In a population-based survey conducted on 4,672 adult residents of Georgia in 1981, prevalence rates were considerably below those noted in earlier surveys, such as Baldwin County, Georgia (1962), National Health Examination Series I (1960-1962), Evans County, Georgia (1967-1969), National Health and Nutrition Examination Survey I (1971-1974) and/or II (1976-1980). The lower 1981 prevalence of isolated systolic hypertension in Georgia was observed in association with a much greater likelihood of anti-hypertensive therapy in adult and elderly patients. The overall trend for early and more aggressive therapy of diastolic hypertension might account for less arterial rigidity and occurrence of isolated systolic hypertension in later life.

Myths about hypertension in the elderly

Many of the traditional concepts concerning hypertension in the elderly have turned out to be myths. Large randomized clinical trials have shown that antihypertensive therapy reduces the risk of cardiovascular mortality for elderly patients with diastolic hypertension. Elderly patients adhere well to prescribed regimens and they tolerate antihypertensive drugs as well as younger patients do. An oral diuretic is the agent of choice to initiate treatment for elderly patients with either diastolic or isolated systolic hypertension.

Prevalence of chronic disease and health practices in a retirement community

The prevalence of chronic disease based on a mailed questionnaire was estimated as part of a continuing epidemiological study of a retirement community. The prevalence of eight chronic diseases (high blood pressure, angina, myocardial infarction, stroke, diabetes, rheumatoid arthritis, glaucoma, and cancer) was determined across all age and sex groups. The relationships between these diseases and several health related life-style practices were assessed. A health index summarizing five practices (smoking, alcohol consumption, exercise, sleep and obesity) was clearly related to the prevalence of disease.

Systolic Hypertension in the Elderly Program (SHEP): antihypertensive efficacy of chlorthalidone

The Systolic Hypertension in the Elderly Program (SHEP) is a randomized, blinded test of the efficacy of antihypertensive drug treatment. In a large feasibility trial, 551 men and women who had isolated systolic hypertension and were at least 60 years old received chlorthalidone (25 to 50 mg/day) or matching placebo as the step I drug. After 1 year, 83% of the chlorthalidone group and 80% of the placebo group were still taking SHEP medications. Of those still taking chlorthalidone, 88% had reached goal blood pressure (BP) without requiring a step II drug, and most had responded to the lower dose (25 mg/day). The BP response was similar in all age, sex and race subgroups, with an overall mean difference between randomized groups of 17 mm Hg for systolic BP (p less than 0.001) and 6 mm Hg for diastolic BP (p less than 0.001). The only common adverse effects were asymptomatic changes in the serum levels of potassium (0.5 mEq/liter lower in the chlorthalidone group, p less than 0.001), uric acid (0.9 mg/dl higher, p less than 0.001) and creatinine (0.08 mg/dl higher, p = 0.02). This study indicates that chlorthalidone is effective for lowering BP in elderly patients with systolic hypertension and sets the stage for a larger trial of the effects of such treatment on the incidence of cardiovascular disease.

Comparison of the effects of diuretic therapy and low sodium intake in isolated systolic hypertension

Of 103 patients with isolated systolic hypertension, 71 were treated with diuretics and another 32 with low-sodium diet. In the 71 who were treated with diuretics, body weight decreased from 69.48 +/- 1.47 to 68.60 +/- 1.45 kg (p less than 0.0005) and systolic blood pressure from 178 +/- to 152 +/- 2 mm Hg (p less than 0.0005). Plasma renin activity increased from 1.78 +/- 0.30 to 7.32 +/- 1.78 ng/ml per hour (p less than 0.005) and urinary aldosterone from 10 +/- 1 to 23 +/- 4 micrograms per 24 hours (p less than 0.005). The greatest decrease in systolic blood pressure occurred in patients in the low-renin group (-32 +/- 2 mm Hg), whereas it decreased by 24 +/- 2 mm Hg (p less than 0.04) in the normal-renin group; however, blood pressure did not change significantly in the high-renin group. In the 32 patients who were treated with low-sodium diet, the 24-hour urinary sodium excretion decreased from 143 +/- 10 to 48 +/- 5 meq (p less than 0.005), body weight decreased from 71.18 +/- 2.50 to 70.17 +/- 2.47 kg (p less than 0.005), systolic blood pressure decreased from 174 +/- 2 to 156 +/- 3 mm Hg (p less than 0.0005), and diastolic blood pressure decreased from 90 +/- 1 to 87 +/- 1 mm Hg (p less than 0.01). Plasma renin activity increased from 2.25 +/- 0.33 to 4.27 +/- 0.43 ng/ml per hour (p less than 0.005) and urinary aldosterone from 9 +/- 1 to 15 +/- 2 micrograms per 24 hours (p less than 0.005). The decrease in the systolic blood pressure was related to the pretreatment 24-hour urinary sodium excretion (r = 0.40, p less than 0.05). The smallest decrease in systolic blood pressure occurred in the patients with high renin values (-1 +/- 9 mm Hg, n = 5), whereas the decrease in systolic blood pressure in the low-renin (n = 12) and normal-renin groups (n = 15) was similar, -22 +/- 2 mm Hg and -21 +/- 3 mm Hg, respectively (p less than 0.005 compared with the high-renin group). These results indicate that both diuretic therapy and low-sodium diet are effective antihypertensive means in most patients with isolated systolic hypertension and low or normal plasma renin activity.

Effects of diuretic therapy in low-, normal- and high-renin isolated systolic systemic hypertension

In 30 patients with isolated systolic systemic hypertension, diuretic therapy decreased body weight from 71.33 +/- 2.67 to 70.37 +/- 2.65 kg (p less than 0.0005) and the systolic blood pressure from 174 +/- 3 to 156 +/- 3 mm Hg (p less than 0.0005). Diastolic blood pressure and heart rate did not change significantly. Plasma renin activity increased from 2.25 +/- 0.33 to 4.27 +/- 0.43 ng/ml/hour (p less than 0.0005) and urinary aldosterone from 9 +/- 1 to 16 +/- 2 micrograms/24 hours (p less than 0.005). The antihypertensive effect of diuretics was significantly related only to the pretreatment plasma renin activity (r = -0.50, n = 30, p less than 0.05), and therefore the greatest decrease in systolic blood pressure occurred in the low-renin group, whereas the smallest occurred in the high-renin group (-22 +/- 2 vs -3 +/- 9 mm Hg, p less than 0.005). The diastolic blood pressure was significantly decreased only in the low-renin group (-7 +/- 2 mm Hg, p less than 0.005). There were no significant changes in blood pressure in 11 untreated control patients. These results indicate that diuretics are effective antihypertensive agents in most patients with low- and normal-renin isolated systolic systemic hypertension.

The contribution of hypertension to mortality in the US: 1968, 1977

The contribution of hypertension to total mortality in the United States in 1968 and 1977 is assessed through multiple cause death rates for all mentions of hypertension and the death certificate prevalence of hypertension. Age-adjusted declines in the hypertension death rates were 32.8 per cent for non-White females, 30.4 per cent for non-White males, 30.3 per cent for White females, and 25.2 per cent for White males. Declines for younger non-Whites were the greatest, about 50 per cent, although their rates were more than twice the White rates in both years. Death certificate prevalence also declined for all four groups with the greatest (16.5 per cent) for non-White males and the least (10.4 per cent) for White males, who only showed declines at older ages. The age trajectory of death certificate prevalence reached a peak at ages 50-69 for non-Whites and ages 60-79 for Whites, with lower prevalence at the most advanced ages. Large declines in the contribution of hypertension to mortality observed in death certificate data are particularly striking in light of the probability that any bias would be toward better detection and reporting over the 10 years.