New issues in the treatment of isolated systolic hypertension

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The newest hot issue in the field of hypertension relates to the oldest—isolated systolic hypertension (ISH) in the elderly. The article by Fagard et al1 in this issue of Circulation provides important evidence about the response of ISH to antihypertensive therapy. Moreover, the implications of the evidence extend to the management of hypertension of any nature at any age.Before commenting on the findings in this article, I will provide a bit of background. ISH is the most common form of hypertension in those older than 65 years.2 Because this segment of the population is expanding so rapidly, ISH will soon be the most prevalent form of hypertension.Over the last few years, a paradigm shift has occurred, away from the prior concern over an elevation of diastolic pressure to our current awareness that an elevation of systolic pressure and, to an even greater extent, the combination of higher systolic and lowered diastolic pressures (ie, a widening of the pulse pressure) are the major determinants of cardiovascular risk in the elderly.3 This should come as no surprise because the widening pulse pressure reflects atherosclerotic stiffening of the aorta and large capacitance vessels.4 This provides a smaller, rigid reservoir wherein systolic inflow raises pressure and diastolic emptying lowers pressure to a greater degree than occurs with more compliant, elastic vessels. In addition, pulse-wave velocity is faster through stiff vessels, so that the usual reflection of the pressure wave back from the periphery occurs in midsystole rather than diastole, augmenting the already elevated systolic pressure and removing a major support of diastolic pressure. Therefore, the widened pulse pressure so typically found in the elderly reflects both a rise in systolic levels and a fall in diastolic levels.The dangers of high systolic pressure are well known, and unequivocal …




Kaplan, N. M. (2000, September 5). New issues in the treatment of isolated systolic hypertension. Circulation, 102(10), 1079–1081.

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