Systolic hypertension explained

Specialty:cardiology

In medicine, systolic hypertension is defined as an elevated systolic blood pressure (SBP).[1] If the systolic blood pressure is elevated (>140) with a normal (<90) diastolic blood pressure (DBP), it is called isolated systolic hypertension.[2] Eighty percent of people with systolic hypertension are over the age of 65 years old.[3] Isolated systolic hypertension is a specific type of widened (or high) pulse pressure.

Causes

Systolic hypertension may be due to reduced compliance of the aorta with increasing age.[4] This increases the load on the ventricle and compromises coronary blood flow, eventually resulting in left ventricular hypertrophy, coronary ischemia, and heart failure.[5]

Contemporary science shows an immersed boundary method of computational illustration of a single heartbeat. Applied to physiologic models, immersed boundary theory sees the heart as a great folded semisolid sail fielding and retrieving a viscous blood mass. The sail, likened to Windkessel effect physiology, gives and receives a load under time-ordered phases. Decreasing compliance of the sail heralds the onset of systolic hypertension.[6]

Treatment

The goal of treating systolic hypertension is to delay and reduce the extent of damage to the heart, the cerebrovascular system, and the kidneys. This also decreases the risk of cardiovascular disease and morbidity. Lifestyle interventions are alternative solutions to treating systolic hypertension. Examples include a diet low in sodium (salt) and rich in whole grains, fruits, and vegetables.

A low sodium diet should contain a maximum sodium intake of 2.0 grams (approximately 5.0 grams of salt). Additional salt and processed foods should also be avoided.

Clinical trials have also documented the beneficial effects of weight loss, increased physical activity, and limiting alcohol consumption. For hypertensive men, alcoholic drinks should be reduced to 14 units per week. For hypertensive women, alcoholic drinks should be reduced to 8 units per week. (1 unit corresponds to 1/8 liter of wine or 1/4 liter of beer).[7]

In addition to lifestyle changes, medication can also be used to reduce systolic hypertension to safe levels.[8] [9]

Common medications used to treat systolic hypertension include a thiazide-type diuretic (TTD) or calcium channel blockers (CCB), or a combination of the two.[10]

Goal

Based on these studies, treating to a systolic blood pressure of 140, as long as the diastolic blood pressure is 68 or more, seems safe.[11] Corroborating this, a reanalysis of the SHEP data suggests allowing the diastolic to go below 70 may increase adverse effects.[12]

A meta-analysis of individual patient data from randomized controlled trials found the lowest diastolic blood pressure for which cardiovascular outcomes improve is 85 mm Hg for untreated hypertensives and 80 mm Hg for treated hypertensives.[13] The authors concluded "poor health conditions leading to low blood pressure and an increased risk for death probably explain the J-shaped curve".[13] Interpreting the meta-analysis is difficult, but avoiding a diastolic blood pressure below 68–70 mm Hg seems reasonable because:

An updated 2020 Cochrane review found that in the general population of individuals with elevated blood pressure interventions to achieve a lower blood pressure target beyond a standard (≤ 140/90 mm Hg) create more harms than no intervention.[16] Further research is needed, the results of this review were applicable mainly to older individuals with moderate to high cardiovascular risk.

In 2019, a systematic review of anti-hypertensive treatment trials in elderly patients with isolated systolic hypertension demonstrated results with the intensive decrease of SBP to <140 mm Hg. All cause mortality was diminished for 24% and cardiovascular mortality for 39%[17]

Notes and References

  1. Angeli F, Verdecchia P, Masnaghetti S, Vaudo G, Reboldi G . Treatment strategies for isolated systolic hypertension in elderly patients . Expert Opinion on Pharmacotherapy . 21 . 14 . 1713–1723 . October 2020 . 32584617 . 10.1080/14656566.2020.1781092 . 220078261 .
  2. Web site: Guideline for the diagnosis and management of hypertension in adults. 2016. Australian Heart Foundation. 12. https://web.archive.org/web/20170114101220/https://heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf. 14 January 2017. 20 July 2017.
  3. Angeli F, Verdecchia P, Masnaghetti S, Vaudo G, Reboldi G . Treatment strategies for isolated systolic hypertension in elderly patients . Expert Opinion on Pharmacotherapy . 21 . 14 . 1713–1723 . October 2020 . 32584617 . 10.1080/14656566.2020.1781092 . 220078261 .
  4. Smulyan H, Safar ME . The diastolic blood pressure in systolic hypertension . Annals of Internal Medicine . 132 . 3 . 233–237 . February 2000 . 10651605 . 10.7326/0003-4819-132-3-200002010-00010 . 12914966 .
  5. DeLoach SS, Townsend RR . Systolic Hypertension: A Guide to Optimal Therapy. Consultant. 48. 3. March 2008 . dead . https://archive.today/20130119184513/. 2013-01-19 .
  6. Reymond P, Westerhof N, Stergiopulos N . Systolic hypertension mechanisms: effect of global and local proximal aorta stiffening on pulse pressure . Annals of Biomedical Engineering . 40 . 3 . 742–749 . March 2012 . 22016326 . 10.1007/s10439-011-0443-x . 254185822 .
  7. Bergler-Klein J . What's new in the ESC 2018 guidelines for arterial hypertension : The ten most important messages . Wiener Klinische Wochenschrift . 131 . 7–8 . 180–185 . April 2019 . 30715608 . 6459798 . 10.1007/s00508-018-1435-8 .
  8. Musini VM, Tejani AM, Bassett K, Puil L, Wright JM . Pharmacotherapy for hypertension in adults 60 years or older . The Cochrane Database of Systematic Reviews . 6 . 6 . CD000028 . June 2019 . 31167038 . 6550717 . 10.1002/14651858.CD000028.pub3 .
  9. Musini VM, Gueyffier F, Puil L, Salzwedel DM, Wright JM . Pharmacotherapy for hypertension in adults aged 18 to 59 years . The Cochrane Database of Systematic Reviews . 2017 . 8 . CD008276 . August 2017 . 28813123 . 6483466 . 10.1002/14651858.CD008276.pub2 .
  10. Egan BM, Yang J, Rakotz MK, Sutherland SE, Jamerson KA, Wright JT, Ferdinand KC, Wozniak GD . 6 . Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines . Hypertension . 79 . 2 . 338–348 . February 2022 . 34784722 . 10.1161/HYPERTENSIONAHA.121.17102 . 244375750 . free .
  11. Commodore-Mensah Y, Loustalot F, Himmelfarb CD, Desvigne-Nickens P, Sachdev V, Bibbins-Domingo K, Clauser SB, Cohen DJ, Egan BM, Fendrick AM, Ferdinand KC, Goodman C, Graham GN, Jaffe MG, Krumholz HM, Levy PD, Mays GP, McNellis R, Muntner P, Ogedegbe G, Milani RV, Polgreen LA, Reisman L, Sanchez EJ, Sperling LS, Wall HK, Whitten L, Wright JT, Wright JS, Fine LJ . 6 . Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension . American Journal of Hypertension . 35 . 3 . 232–243 . March 2022 . 35259237 . 8903890 . 10.1093/ajh/hpab182 .
  12. Somes GW, Pahor M, Shorr RI, Cushman WC, Applegate WB . The role of diastolic blood pressure when treating isolated systolic hypertension . Archives of Internal Medicine . 159 . 17 . 2004–2009 . September 1999 . 10510985 . 10.1001/archinte.159.17.2004 . free .
  13. Boutitie F, Gueyffier F, Pocock S, Fagard R, Boissel JP . J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data . Annals of Internal Medicine . 136 . 6 . 438–448 . March 2002 . 11900496 . 10.7326/0003-4819-136-6-200203190-00007 . 38738695 .
  14. ((Hypertension Detection and Follow-up Program Cooperative Group)) . Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. . JAMA . 242 . 23 . 2562–2571 . December 1979 . 490882 . 10.1001/jama.242.23.2562 .
  15. MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party . British Medical Journal . 291 . 6488 . 97–104 . July 1985 . 2861880 . 1416260 . 10.1136/bmj.291.6488.97 .
  16. Arguedas . Jose Agustin . Leiva . Viriam . Wright . James M. . 2020-12-17 . Blood pressure targets in adults with hypertension . The Cochrane Database of Systematic Reviews . 2020 . 12 . CD004349 . 10.1002/14651858.CD004349.pub3 . 1469-493X . 8094587 . 33332584.
  17. Koracevic G, Stojanovic M, Kostic T, Lovic D, Tomasevic M, Jankovic-Tomasevic R . Unsolved Problem: (Isolated) Systolic Hypertension with Diastolic Blood Pressure below the Safety Margin . Medical Principles and Practice . 29 . 4 . 301–309 . 2020 . 32380500 . 7445659 . 10.1159/000508462 .

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