Systolic hypertension and cardiovascular risk reduction: A clinical review

Conclusion  In conclusion, SBP and pulse pressure are stronger predictors of cardiovascular risk than is DBP in older individuals, and reduction in events has been more impressive in SBP treatment trials. Because of older morbidity trials that primarily used DBP entry criteria, however, treatment decisions should still include DBP goals. Nevertheless, clinicians should be more attentive to treating SBP, especially in patients older than 60 years. Although guidelines recommend SBP goals of < 140 mm Hg for most hypertensive patients and < 130 mm Hg for those with diabetes, clinical trial data are consistent with systolic blood pressure goals of < 150 and 140 mm Hg, respectively. Achieving these latter goals should be the first priority in the management of hypertension; the lower goals recommended by guidelines may then be considered. Several classes of antihypertensive agents have reduced events in morbidity trials, but an a-blocker (doxazosin) was inferior to a diuretic as initial therapy. Other clinical trials comparing newer classes to older classes are ongoing, and should clarify how much it matters which class of drugs is used as initial therapy. These trials are making it clear, however, that several agents in combination are usually necessary to reach modern treatment goals. Thus, convenience and tolerance, as well as efficacy in lowering SBP, are likely to be important properties of agents that are selected for a multidrug regimen. The angiotensin II receptor blockers may have a particular advantage in such regimens because of their ability to lower blood pressure, including SBP, with almost no symptomatic adverse effects.