The paradigm has shifted to systolic blood pressure

Abstract

Since the middle of the 20th century, most physicians and epidemiologists assessed the risks associated with hypertension based on the level of diastolic blood pressure (DBP). In a classic paper in 1971, the Framingham Heart Study clearly showed that systolic BP more accurately described the risk of all the complications we attribute to hypertension. It took 22 years until JNC V in 1993 also used systolic blood pressure (SBP) to define hypertension in US national guidelines. Since then, the paradigm has shifted dramatically. In JNC VI (1997) and JNC VII (2003), SBP has become the primary focus of risk stratification and treatment goals. This shift is a result of the Framingham results being confirmed by many others analyses, the most compelling of which is the recently published report of the Prospective Collaborative Study Group, which pooled 61 observational studies in more than 1 million volunteers with a collective experience of more than 12 million personyears. This group showed that the SBP level at baseline was a significantly more informative reading than DBP for predicting strokes and coronary heart disease (CHD). Furthermore, three trials of older individuals with isolated systolic hypertension, SHEP, SYST-Eur, and SYST-China, unambiguously demonstrated that effective antihypertensive therapy lowered the rate of strokes, heart failure, CHD, and even all-cause mortality. Finally, the World Health Organization (WHO)/International Society of Hypertension (ISH) Hypertension Trialists also showed that the level of SBP achieved in clinical trials comparing different antihypertensives with placebo and with each other was the strongest determinant of how effectively strokes and CHD events were reduced, although a similar relationship was not evident for heart failure. A recent metaregression analysis using new trials, many of which were used by the Trialists, and older studies not included in their analysis also showed that small differences in SBP can have a dramatic impact on cardiovascular outcomes. If there is one thing we have learned in the recent past, it is the need for us to focus on lowering SBP and getting it down to a reasonable goal. We have also learned that to do so, we will need to combine a variety of lifestyle and pharmacological approaches, always with combinations of drugs that will usually contain a low-dose thiazidetype diuretic with other antihypertensives. Reverend Stephen Hales first measured blood pressure (BP) by inserting a glass tube in the carotid artery of a restrained horse. BP measurements in humans began in the late 19th century when RivaRocci developed the technology to measure BP noninvasively. In 1906, Korotkoff described the still-used K-sounds, by which indirect measurements could be easily performed. Over the next several decades, systolic blood pressure (SBP) was used to define hypertension and describe the risks associated with having an elevated BP and stratifying risk by the degree of that elevation. Diastolic blood pressure (DBP) elevations were notable but not co...

Macro and microvasculature in hypertension: therapeutic aspects

“…This aspect is important to consider because, during chronic treatment, it is difficult to normalize SBP (o140 mm Hg) and much easier to control adequately diastolic blood pressure (DBP) (o90 mm Hg). 3 This aspect is important to consider because, in the absence of treatment, two kinds of hypertension are usually defined: systolic (X140 mm Hg)-diastolic (X90 mm Hg) hypertension in the middle age; systolic (X140 mm Hg) hypertension in older subjects, particularly in subjects with low (p90 mm Hg) DBP. International guidelines consider that the normalisation of SBP is nowadays a priority of anti-hypertensive drug therapy.…”

Treatment of systolic hypertension: spotlight on recent studies with angiotensin II antagonists

“…[1][2][3][4][5][6] The presence of systolic hypertension amplifies the impact of other risk factors such as diabetes and hypercholesterolemia on occurrence of cardiovascular (CV) events. 2,7,8 Prevention, detection, and control of SBP is therefore a major goal in hypertension management, as reflected by the prominence of SBP in the most recent hypertension management guidelines.…”

Efficacy of indapamide 1.5 mg, sustained release, in the lowering of systolic blood pressure

“…Nevertheless, many cross-sectional studies have shown that end-organ damage in hypertensive people is more strongly associated to SBP. Furthermore, recent prospective epidemiological studies 3,4 have directed attention to SBP as a better guide than DBP to evaluate cardiovascular and all-cause mortality. A metaanalysis of outcome trials has confirmed the overwhelming importance of SBP as a determinant of risk.…”

“…5 Studies have shown that drug treatment of hypertension frequently results in an adequate control of DBP (p90 mmHg), whereas the ability to control SBP (p140 mmHg) is achieved to a significantly smaller extent. [4][5][6][7] Such studies have focused attention on the factors that determine the level of SBP and cardiovascular risk in hypertensive individuals, and on therapeutic interventions preferably reducing SBP. Several therapeutic trials have confirmed that SBP increases markedly with age while DBP [8][9][10] becomes stable and even tends to fall spontaneously after the age of 50-60 years.…”

“…Nevertheless, as already stated previously, an adequate control is frequently achieved on DBP and to a significantly smaller extent on SBP. [4][5][6][7] In the case of ISH, the therapeutic goal is to obtain a preferential decrease in SBP while maintaining unchanged DBP. In patients with essential hypertension, the International guidelines recommend the use of thiazidetype diuretics in monotherapy or in combination; they also highlight the need to select the lowest dosages.…”