Treatment and blood pressure control in isolated systolic hypertension vs diastolic hypertension in primary care

Cross-sectional surveys on prevalence, treatment and control of hypertension could not satisfactorily distinguish between diastolic hypertension and isolated systolic hypertension because the definition of hypertension included patients under pharmacological treatment. We assessed the situation in the two types of hypertension in general practice in Belgium, based on current blood pressure (BP) measurements and on BP prior to the initiation of drug therapy. Participating physicians enrolled the first 15 at least 55-year-old men visiting the surgery, measured their BP and recorded data on medical history including pretreatment BP, drug utilization, cardiovascular risk factors and target organ damage. Diastolic hypertension was defined as diastolic BP> or =90 mmHg, irrespective of systolic BP, and isolated systolic hypertension as systolic BP > or =140 mmHg and diastolic BP < 90 mmHg. Among 3761 evaluable patients, 74% were hypertensive. Among the 1533 hypertensive patients in whom blood pressure was known prior to treatment (n=965) or who were untreated at the study visit (n=568), 1164 had diastolic hypertension and 369 isolated systolic hypertension. The prevalence of antihypertensive treatment was, respectively, 75 and 25% (P<0.001) in these two types of hypertension. The odds of being treated were independently determined by type of hypertension, severity of hypertension and level of risk (P<0.001). BP was controlled in 25% of all patients with diastolic hypertension and in 13% of all patients with isolated systolic hypertension (P<0.001). About half of the treated patients with systolic hypertension were on a diuretic and/or a calcium-channel blocker. In conclusion, isolated systolic hypertension is less frequently treated than diastolic hypertension, overall BP control is poor and actual drug therapy diverges from recommendations based on placebo-controlled intervention trials.     

The diastolic blood pressure in systolic hypertension

Because antihypertensive therapy is effective in elderly patients with isolated systolic hypertension, attention has been focused on the systolic blood pressure as a predictor of cardiovascular risk. However, it is a normal diastolic pressure that separates patients with isolated systolic hypertension from those with essential hypertension. The normal diastolic and elevated systolic pressures are largely due to age-related stiffening of the aorta. An indistensible aorta causes the pressure pulse to travel faster than normal, where it is quickly reflected off the peripheral resistance. The reflected wave then returns to the central aorta in systole rather than diastole. This augments the systolic pressure further, increasing cardiac work while reducing the diastolic pressure, on which coronary flow is dependent. The potential harm of further reducing the diastolic pressure with antihypertensive therapy, especially in patients with coronary heart disease, underlies the controversial "J curve." By decreasing the blood pressure, all antihypertensive agents improve aortic distensibility, but no agents do so directly; the nitrates come the closest. Such an agent would be useful because any therapeutic increase in aortic distensibility would decrease systolic pressure without greatly reducing diastolic pressure. The problem is complicated by the suspected inaccuracy of the cuff technique in predicting the aortic diastolic pressure. New noninvasive methods to predict the aortic diastolic pressure may help in the future. At present, the combination of a high systolic and normal diastolic pressure-a widened pulse pressure-seems to be the best predictor of cardiovascular risk in patients with hypertension or heart disease. Patients with isolated systolic hypertension should be treated, but marked diastolic hypotension should be avoided.     

Geriatric hypertension: chairman's comments on the NIH Working Group report

Of the more than 25,000,000 people in the United States older than 65 years, more than 60% have hypertension. Approximately 10% of the elderly people have isolated systolic hypertension (systolic blood pressure greater than or equal to 160 mm Hg, diastolic less than 90 mm Hg). Hypertension in the elderly, either systolic or diastolic, increases the risk of cardiovascular morbidity and mortality as much as it does for younger patients. Three large, controlled clinical trials have shown that diuretic-based stepped care therapy will reduce the risk of cardiovascular mortality for patients 60 years of age and older who have diastolic hypertension. In general, elderly patients tolerate antihypertensive drugs as well as younger patients do, and they are as compliant as younger patients. As yet, there is no evidence from controlled trials that drug treatment reduces the risk for patients with isolated systolic hypertension.     

Pathophysiology of hypertension in the elderly

Combined systolic and diastolic arterial hypertension and isolated systolic hypertension in the elderly are proven risk factors for stroke, sudden death, coronary artery disease, and congestive heart failure. Because hemodynamics, vascular and cardiac adaptations, fluid volume, and endocrine functions are distinctly altered in the elderly hypertensive patient compared with a younger patient, antihypertensive treatment should be individualized, and an unsophisticated regimen, such as a stepped-care approach, is too rigid to be as beneficial for elderly hypertensive patients as for young hypertensive patients.     

Systolische Hypertonie—Treat or Not to Treat?

HEMODYNAMICS: Elevated diastolic as well as elevated systolic blood pressure substantially contribute to the increase of cardiovascular risk. Conclusive results have proven that lowering diastolic and/or systolic blood pressure can reduce cardiovascular risk. There is evidence that not only the absolute values for diastolic and systolic blood pressure alone but also the pulse pressure as an additional indicator of cardiovascular risk have to be considered. The prevalence of isolated systolic hypertension increases with age. Remodeling of the arterial wall with increase of collagen and decrease of elastic fibers are leading to an impaired arterial compliance. Decreased compliance and acceleration of the pulse wave velocity can elevate systolic and lower diastolic blood pressure. In consequence cardiac stress and pulse pressure will rise. CONCLUSION: There is a strong correlation in elderly patients between cardiovascular mortality and morbidity and systolic blood pressure. Antihypertensive therapy is able to lower cardiovascular event rate in elderly patients with isolated systolic hypertension with a predominant risk reduction for stroke.     

Pathophysiologic considerations in the treatment of the elderly hypertensive patient

Changes that occur as a consequence of aging can influence the development of hypertension and its complications. Such changes may adversely affect cardiac function and tissue blood flow and the responsiveness of the circulation to antihypertensive therapy. The distribution and metabolism of antihypertensive drugs may also be influenced by aging. These factors can complicate the pharmacologic management of the elderly hypertensive patient and may lead to a higher incidence of side effects. A conservative approach to the treatment of isolated systolic hypertension is indicated because the merits of therapy remain uncertain. Although standard stepped-care treatment can be used, certain special precautions should be considered. Lower doses of medications are generally required in elderly than in young hypertensives. Hypokalemia and volume contraction are the more frequent and more clinically important complications of diuretic therapy, while sluggishness, sexual dysfunction, or decreased mentation are more commonly observed with sympatholytic agents. Complications from beta-adrenergic blockers also are relatively frequent in elderly persons. Calcium-channel blockers, although not approved in the United States for the treatment of hypertension, may be beneficial in these patients. When diastolic hypertension is also present, a vigorous approach to lowering blood pressure should be used because the benefits of such therapy have been well documented. However, similar precautions should be used in these patients as in those with systolic hypertension.     

Characteristics of hypertension subtypes and treatment outcome among elderly Korean hypertensives

There are limited data about characteristics of hypertension subtypes in Asian hypertensive patients and their impacts on treatment of hypertension. This prospective, multi-center, observational study evaluated 2439 hypertensive patients. (≥60 years) Inadequately controlled and drug-naïve patients were categorized into three hypertension subtypes (isolated systolic hypertension [ISH], combined systolic/diastolic hypertension [SDH], and isolated diastolic hypertension [IDH]), and proportions of each hypertension subtype were evaluated. After 6-month strict treatments, we compared the characteristics of patients who did not achieve target BP with those who did. In overall population, ISH was the most common subtype (53.2%; 1297/2439). However, in drug-naïve patients, SDH was the predominant hypertension subtype (59.6%; 260/436). Notably, the proportion of ISH was substantially lower than previously known data. Predictors associated with failure of reaching target BP were old age (>70 years), hypertension awareness, and baseline systolic blood pressure (≥160 mm Hg) for total patients. In drug naïve patients, hypertension awareness, ISH, and microalbuminuria were associated with treatment failure. These findings might have an impact on the evaluations and antihypertensive treatments of elderly Korean patients.     

Blood pressure lowering for the primary and secondary prevention of stroke: treatment of hypertension reduces the risk of stroke.

Hypertension is the most important risk factor in the development of stroke. It is also the risk factor most amenable to treatment. The results from 18 controlled trials show a reduction in relative risk of stroke of 25-47% among treated hypertensive patients. This reduction applies both to the elderly and to younger patients, but the absolute reductions are greater among the elderly and the number of patients with hypertension that need to be treated to prevent a stroke is lower in the elderly because they have a higher risk of stroke. The reductions in relative but not absolute risk appear to be similar for both isolated systolic hypertension and combined systolic and diastolic hypertension in the elderly. The case for antihypertensive treatment in the secondary prevention of stroke is less clear but the results of four clinical trials of antihypertensive treatment among patients with and without hypertension and a history of cerebrovascular disease point to a probable benefit. The results of the PROGRESS trial will elucidate this further.     

Prevalence of isolated uncontrolled systolic blood pressure among treated hypertensive patients in primary care in Belgium: results of the I-inSYST survey

OBJECTIVE: To evaluate the prevalence of isolated uncontrolled systolic blood pressure (on-treatment isolated systolic hypertension) in treated hypertensive patients and identify the characteristics and treatment strategy in these patients. METHODS: Prospective cross-sectional survey in primary care. Participating physicians enrolled more than 13 consecutive treated hypertensive patients. Patients were considered to have isolated systolic hypertension when systolic blood pressure was at least 140 mmHg and diastolic blood pressure was less than 90 mmHg. RESULTS: On-treatment isolated systolic hypertension occurred in 28% of evaluable patients (n = 11562) and in 36% of uncontrolled patients (n = 9080). Among the isolated systolic hypertension and among other uncontrolled patients, 53% and 47%, respectively, used more than one antihypertensive drug class. beta-Blockers were the most frequently prescribed antihypertensive drugs. Patients with isolated uncontrolled systolic blood pressure were more frequently treated with diuretics (43 vs. 39%) and angiotensin II receptor antagonists (23 vs. 17%). Despite blood pressure being under control in only 21% of the patients, hypertension treatment was not changed in 46% of patients with isolated uncontrolled systolic blood presssure vs. 14% of patients with both uncontrolled systolic and diastolic blood pressure. CONCLUSION: In Belgium, the prevalence of on-treatment isolated systolic hypertension in treated hypertensive patients, was 28%. The goal blood pressure was likely not reached in most patients due to inadequate treatment. The overall control rate was worse for systolic than for diastolic blood pressure. Furthermore, antihypertensive treatment was less frequently adapted in patients with isolated uncontrolled systolic blood pressure than in those patients with both uncontrolled systolic and diastolic blood pressure.     

Effect of combination therapy of benidipine hydrochloride and candesartan cilexetil on serum lipid metabolism and blood pressure in elderly hypertensive patients with type 2 diabetes mellitus

The effects of combination therapy of angiotensin II receptor blockers (ARBs) and a calcium antagonist, benidipine hydrochloride, on glucose and lipid metabolism and pulse pressure were studied in elderly hypertensive patients with type 2 diabetes mellitus. Twenty-five hypertensive diabetic patients aged 65 years or older, who had been receiving candesartan cilexetil, were administered benidipine hydrochloride (4 mg/day) and followed for 4 months. After 4 months, systolic and diastolic blood pressure decreased significantly from 154/91 mmHg to 139/78 mmHg (p<0.01 versus before benidipine hydrochloride administration). Body mass index (BMI) and glycosylated hemoglobin (HbA1c) were apparently reduced but the changes were not statistically significant. The serum lipid profile showed no significant changes in serum total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). Serum lipoprotein lipase mass levels (preheparin LPL mass) increased significantly from 51 to 59 ng/dl (p<0.01 versus before benidipine hydrochloride administration), and the LDL/HDL motility ratio calculated from PAG disc electrophoresis decreased significantly (p<0.05 versus before benidipine hydrochloride administration). When patients were divided into a systolic hypertension group (systolic blood pressure > or =140 mmHg and diastolic blood pressure <90 mmHg) and non-systolic hypertension group (others), preheparin LPL mass was significantly lower in the systolic hypertension group, and the decrease in pulse pressure and increase in preheparin LPL mass were significantly greater in the systolic hypertension group. Stepwise regression analysis showed that low preheparin LPL mass at baseline was associated with a decrease in pulse pressure. Add-on benidipine hydrochloride therapy in elderly hypertensive patients with type 2 diabetes mellitus significantly decreases the LDL/HDL motility ratio and pulse pressure, and significantly increases preheparin LPL mass, in addition to improving blood pressure control. These findings suggest that combination therapy with benidipine hydrochloride and candesartan cilexetil may contribute to the suppression of arteriosclerosis and may be useful for elderly hypertensive patients with diabetes mellitus.     

我国部分地区高血压登记调查及治疗达标研究

目的通过对我国不同地区高血压人群的基线资料调查,了解我国高血压患者相关危险因素、靶器官损害及并存疾病（心、脑、糖尿病及。肾病）的发生率以及不同危险分层和不同高血压类型的分布状态,并观察4周、12周经药物治疗后总体人群和不同危险分层及不同高血压类型患者的高血压治疗达标情况。方法前瞻性高血压基线调查,然后由医师根据日常医疗实践常规,自主选用不同药物及剂量进行4周、12周高血压治疗达标观察。共观察26655例。结果26655例患者中相关危险因素中缺乏体力活动、吸烟、体重指数增高、血脂紊乱分别占52．2％、34．4％、31．8％、24．5％;靶器官损害及伴随疾病中微量白蛋白尿、左室肥厚、临床诊断冠心病及糖尿病分别占21．0％、23．6％、20．1％、26．7％;平均收缩压（158±14）mmHg（1mmHg=0．133kPa）,舒张压（94±11）mmHg,其中1、2、3级高血压分别为42．1％、43．2％、15．6％;危险分层中低危、中危、高危及重度高危分别为3．2％、22．2％、21．1％及53．3％;男性平均危险程度高于女性;高血压类型以混合性高血压最多,占77．2％,单纯收缩及舒张性高血压分别为20．4％、2．4％。4周、12周药物治疗达标率分别为50．2％及56．7％。随危险分层增高,达标率依次下降。糖尿病、肾病患者达标率显著低于平均水平。收缩压达标率显著低于舒张压。不论4周或12周,达标患者平均每人用药均在1．5种以上,60％患者需用2种或3种药物才能治疗达标。结论国人高血压合并相关危险因素、靶器官损害及伴同疾病发生率高,除积极降压达标外,加强综合治疗十分重要。在日常医疗模式下,通过加强对患者的登记随访、联合用药及督促指导在毪国宴瑚高向乐榨制率的昂著椹高县切空可行的．     

Geriatric hypertension: antihypertensive therapy in coronary artery disease

Systemic hypertension is a common clinical problem in the elderly. There is emerging evidence to suggest that with careful utilization of antihypertensive drugs, blood pressure can be lowered in the elderly population. Whether isolated systolic hypertension should be treated aggressively remains an unanswered question despite the evidence that systolic hypertension can cause certain cardiovascular complications. An elderly patient with hypertension and concomitant coronary artery disease merits proper blood pressure control with appropriate drugs to prevent progression of coronary disease. The therapeutic objective is not only to lower the blood pressure but to accomplish this goal with drugs which are likely to have a favorable effect on coronary artery disease. Changing trends in the drug therapy of hypertension indicate that calcium antagonists and beta-blocking drugs offer a therapeutic advantage in elderly hypertensive patients with coronary artery diseases.     

Aging and the cardiovascular system.

With advancing age blood pressure rises in most populations with the exception of some isolated tribes. In western countries 30 to 40% of the people above the age of 60 years have casual blood pressure levels greater than or equal to 160/95 mm Hg. Advancing age per se produces a number of physiological changes related to blood pressure, such as a decrease in cardiac output, an increase in peripheral vascular resistance and a decrease in plasma renin-angiotensin-aldosterone levels. The mechanism causing the elevation in pressure with age are unknown though increased rigidity of the great vessels contributes to the rise in systolic pressure. There is a decline in the sensitivity of the baroreceptor reflex, but the contribution of this to the elevation of pressure has not be elucidated. Elderly patients with uncomplicated essential hypertension have a low cardiac output and high peripheral vascular resistance. The rise in blood pressure is associated with an increased cardiovascular morbidity and mortality even in the elderly hypertensives. The available data on the efficacy of hypotensive treatment in the elderly is scanty. There are no data proving that hypotensive therapy prolongs life. Controlled studies on the prevention of organ damage especially cerebrovascular accidents are inconclusive, showing either a significant decrease or no effect. Isolated reports illustrate, however, that drastic blood pressure reduction can provoke serious side effects, thus decreasing the quality of life. Hypotensive treatment is indicated in elderly hypertensive patients with hypertensive retinopathy grade III or IV, congestive heart failure or cerebral haemorrhage, in elderly patients with a markedly elevated diastolic blood pressure (greater than or equal to 120 mm Hg) and a trial of hypotensive therapy should be offered in milder forms of hypertension when it is accompanied by certain specific symptoms such as angina, headache and dyspnoe. The management of elderly hypertensive patients is more difficult than in the young. General measures are often not well accepted. The dose adjustment of the hypotensive agent is more critical and volume depletion or orthostatic hypotension are more likely to occur.     

"Diastolic" heart failure and pulsed pressure

Cardiac failure is the leading cause of hospital admission after 65 years of age. Several studies have confirmed the frequency of cardiac failure with normal systolic function ("diastolic" cardiac failure) in the elderly (nearly half the cases). The cause is commonly isolated systolic hypertension. The pulsed pressure depends on ventricular ejection, arterial rigidity and the precocity of reflected pulse waves. In the elderly, the pulse pressure is a powerful predictive factor for mortality and adverse cardiovascular events (acute coronary syndromes, cardiac failure and cerebrovascular accidents). Patients with isolated systolic hypertension or an increased pulsed pressure usually have left ventricular hypertrophy or concentric remodelling, abnormal relaxation, alteration of hypertrophied myocytes with increased myocardial oxygen consumption and subendocardial ischaemia, especially when the coronary reserve is reduced. The decrease of the diastolic blood pressure reduces the presence of coronary perfusion. Moreover, an increase in the pulsed pressure predisposes to coronary atherosclerosis. These patients are very symptomatic on exercise because they do not have a reserve of preload and easily develop acute pulmonary oedema after a volume overload (increased salt intake, postoperative rehydratation). A recent study showed that the left ventricular ejection fraction was preserved during acute pulmonary oedema of hypertensive patients. The diagnosis of "diastolic" cardiac failure is often suspected by elimination (clinical signs of cardiac failure with a normal left ventricular ejection fraction), and echographers have proposed many criteria to detect abnormal relaxation, filling or distensibility of the left ventricle. Mortality would seem to be half that of systolic cardiac failure. Treatment should normalise the hypertension, ischaemia, tachycardia, and maintain or reestablish sinus rhythm, but it remains empirical.     

Hypertension in the elderly: a review of the importance of systolic blood pressure elevation

The elderly, those 65 years of age and older, will account for 20% of the population by the year 2040. Hypertension affects more than one half of the elderly and its prevalence continues to increase with age. The presence of hypertension confers an increased risk of stroke, congestive heart failure, coronary heart disease, end-stage renal disease, and death. Although both diastolic and systolic blood pressure elevations are independently associated with increased cardiovascular risk in the younger individual, as vascular compliance becomes reduced at age 60, an increasing systolic blood pressure and lower diastolic blood pressure (or wider pulse pressure) increase cardiovascular risk in the elderly. Isolated systolic hypertension is the most common form of hypertension seen in the elderly. Lifestyle modification, including weight loss and salt restriction, reduces blood pressure, and may decrease the need for pharmacologic therapy. When the systolic blood pressure is 160 mm Hg or more and the diastolic blood pressure is <90 mm Hg, the initial use of a diureticbased or calcium channel blocker-based regimen improves outcome. Alpha blocker therapy should not be used as initial monotherapy. Most elderly hypertensives will require two to three drugs to achieve the present blood pressure goal of <140 mm Hg. Caution should be exercised when lowering diastolic pressure to <55 mm Hg in those with isolated systolic hypertension. Although side effects of therapy are no more likely to occur in the elderly than in the younger individual with hypertension, blood pressure reduction should be accomplished gradually.     

Treatment of the older hypertensive: Paradigms,practices, and proofs

Summary Recent outcome trials in patients above age 60 with systolo-diastolic hypertension are reviewed. The metaanalysis suggests that antihypertensive drug therapy can decrease cardiovascular and coronary mortality in selected patients. Based on these studies it is suggested that antihypertensive drug therapy is indicated in patients between age 60 and 75 when the diastolic pressure remains above 95 mmHg after repeated measurements. A target for systolic b.p. is not definitely established but a pressure of 150 mmHg may serve as a temporary proposal. Whether uncomplicated isolated systolic hypertension in symptomless patients should be treated is still under investigation.     

Treatment of arterial hypertension with diuretics, beta- and calcium channel blockers in old patients

Hypertension increases in prevalence with age. Population based studies suggest that more than 50% of people over the age of 65 years may have chronic hypertension. Hypertension, especially systolic hypertension, is the single most common, powerful, however, treatable risk factor for cardiovascular morbidity and mortality in the elderly. In order to assess the effectiveness of antihypertensive drug therapy among the elderly, with diuretics, beta-blockers and calcium channel blockers, a literature search was performed at the Cochrane Library, Medline and Excerpta medica. The Cochrane Hypertension Group identified 14 randomised controlled trials of at least one year duration with 21,785 elderly subjects where diuretics, beta-blockers or calcium channel blockers were used in the treatment group as first line drugs. In their meta-analysis (including one small trial with a central acting antiadrenergic drug) there was a decrease in total mortality (111 vs 129 deaths) and cardiovascular morbidity and mortality (126 vs 177 events) within the treatment group. The three trials restricted to persons with isolated systolic hypertension indicated beneficial effects in the treatment group with regard to cardiovascular morbidity and mortality (104 vs 157 events). Trial data on adverse effects is limited. In three studies, where adverse effects were reported, no substantial differences between treatment and control groups in measures of physical, cognitive and emotional function were found. Cardiovascular benefits of treatment with low dose diuretics or beta-blockers are cleared for elderly subjects with either diastolic or isolated systolic hypertension. Treatment with a long-acting dihydropyridine calcium channel blocker shows beneficial effects in reducing cardiovascular morbidity and mortality for elderly people with isolated systolic hypertension. Due to inconsistent findings in a subgroup meta-analysis of antihypertensive drug treatment in very old people, the efficacy of antihypertensive treatment in these subjects still remains unclear.     

Arterial hypertension of the aged patient in general medicine. French national survey]

The aim of the study was to assess the management of elderly hypertensives in general practice. A sample of 2,727 general practitioners filled a specially designed questionnaire between February and March 1998 in France. Areas covered by the questionnaire included risk of hypertension, blood pressure measurement and treatment. Most respondents (97%) considered that hypertension remains a cardiovascular risk factor in elderly but 4% thought that hypertension is usefull by improving target organ perfusion. Fifty-five percent recorded both standing and supine measurement, 34% reported measuring blood pressure with patient supine only. All respondents reported that they would start antihypertensive treatment on the basis of blood pressure level. A minimum systolic level of 160 and 180 mmHg was given by 65% and 27% practitioners respectively while 2% required a minimum level ranging from 139 to 149 mmHg. Among the respondents who considered that isolated systolic hypertension is pathological (74%), 73% and 19% used 160 and 180 mmHg as cut-off, respectively. Among those who considered that isolated systolic hypertension is physiological (23%), 43% and 46% initiated treatment above 160 and 180 mmHg, respectively. A minimum diastolic level of 90 mmHg was reported by many respondents (61%) while 34% required a cut-off level of 100 mmHg. Comparison of systolic and diastolic levels showed that 49% practitioners started antihypertensive therapy above 160/90 mmHg and 16% above 180/100 mmHg. Less than 1% reported a threshold level of 140/90 mmHg. Most practitioners 5%) treated hypertensive patients regardless of their age. The others treated patients younger than 65 years old (3%), 70 (2%), 80 (5%) and 90 (4%). All respondents reported that they would treat their patients to prevent vascular complications, mainly cerebrovascular (96%), cardiac (89%) and kidney (75%) disease. In conclusion, for all general practitioners, hypertension remains a cardiovascular risk factor in elderly and hypertensive therapy is beneficial to prevent cardiovascular complications. This study reveals some inter-physician variability in blood pressure measurement and treatment. The risk of standing blood pressure fall is not taken into account by 66% of respondents. Variability in age threshold is in accordance with the lack of published data on benefice of hypertensive treatment in the very old. The risk of isolated systolic hypertension is under-estimated by 27% of physicians who reported a minimum systolic blood pressure level of 180 mmHg to initiate therapy.     

The use of olmesartan medoxomil as monotherapy or in combination with other antihypertensive agents in elderly hypertensive patients in Japan

The efficacy and safety of the angiotensin receptor blocker olmesartan medoxomil (OLM) was assessed in 550 elderly Japanese hypertensive patients who were followed for 24 weeks in daily clinical practice. Patients were given OLM alone or in combination with other antihypertensive drugs at the discretion of the investigators. After 24 weeks of treatment, systolic and diastolic blood pressure (BP) significantly decreased from baseline (P<.0001). When patients were classified as either young-old (65-74 years) or older-old (75 years and older), with either isolated systolic hypertension (ISH) or systolic-diastolic hypertension (SDH), the reduction of diastolic BP in ISH patients was significantly smaller than that in SDH patients (5.0 vs 15.2 mm Hg; P<.0001), indicating that OLM did not cause excessive reduction of diastolic BP in ISH patients. Treatment was well tolerated in all groups. In conclusion, the medication was safe and effective in reducing BP levels in ISH patients aged 75 years and older, as well as in other elderly hypertensive patients.     

Systolic hypertension: occurrence and treatment in a defined community.

Systolic hypertension, a disorder occurring predominantly in the elderly, is associated with an increased incidence of stroke and coronary artery disease. Based on the supposition that it is a risk factor, many authorities have urged that it be treated. This report concerns an experience in treating systolic hypertension in a defined ambulatory population of 898 hypertensive subjects in a work-site program. The systolic hypertension group (N = 39) was compared with a matched diastolic hypertension group and with a matched systolic/diastolic hypertension group (N = 39 each). The patients with systolic hypertension responded to standard treatment (chiefly with diuretics), but less satisfactorily than did the patients with diastolic hypertension. Side effects or toxicity were uncommon and did not interfere with the therapeutic regimen. However, the ultimate value of such therapy in the prevention of vascular complications remains to be determined.