Systolic hypertension

In medicine, systolic hypertension is defined as an elevated systolic blood pressure (SBP). If the systolic blood pressure is elevated (>140) with a normal (<90) diastolic blood pressure (DBP), it is called "isolated systolic hypertension".[1]

Systolic hypertension
SpecialtyCardiology

Causes

Systolic hypertension may be due to reduced compliance of the aorta with increasing age.[2] This increases the load on the ventricle and compromises coronary blood flow, eventually resulting in left ventricular hypertrophy, coronary ischemia, and heart failure.[3]

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.

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. Lifestyle interventions are a crucial element of successful treatment, including a diet low in sodium (salt) and rich in whole grains, fruits, and vegetables. Clinical trials have also documented the beneficial effects of weight loss, increased physical activity, and limiting alcohol consumption.[3]

In addition to lifestyle changes, medication can also be used to reduce systolic hypertension to safe levels.[4][5]

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. Corroborating this, a reanalysis of the SHEP data suggests allowing the diastolic to go below 70 may increase adverse effects.[6]

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.[7] The authors concluded "poor health conditions leading to low blood pressure and an increased risk for death probably explain the J-shaped curve".[7] Interpreting the meta-analysis is difficult, but avoiding a diastolic blood pressure below 68–70 mm Hg seems reasonable because:

  • The low value of 85 mm Hg for treated hypertensives in the meta-analysis is higher than the value of 68–70 mm Hg that is suggested by the two major randomized controlled trials of isolated systolic hypertension
  • The two largest trials in the meta-analysis, Hypertension Detection and Follow-up Program (HDFP)[8] and Medical Research Council trial in mild hypertension (MRC1)[9] were predominantly middle-aged subjects, all of whom had diastolic hypertension before treatment.
  • The independent contributions of diseases and factors other than hypertension versus effects of treatment are not clear in the meta-analysis.

A more contemporary meta-analysis by the Cochrane Hypertension group found no benefits in terms of reduced mortality or morbidity from treating patients to lower diastolic targets than 90–100 mmHg.[10]

References
  1. "Guideline for the diagnosis and management of hypertension in adults" (PDF). Australian Heart Foundation. 2016. p. 12. Archived from the original (PDF) on 14 January 2017. Retrieved 20 July 2017.
  2. Smulyan H, Safar ME (February 2000). "The diastolic blood pressure in systolic hypertension". Ann. Intern. Med. 132 (3): 233–37. doi:10.7326/0003-4819-132-3-200002010-00010. PMID 10651605. S2CID 12914966.
  3. DeLoach, SS; Townsend, RR (March 2008). "Systolic Hypertension: A Guide to Optimal Therapy". Consultant. 48 (3). Archived from the original on 2013-01-19.CS1 maint: bot: original URL status unknown (link)
  4. Musini, Vijaya M; Tejani, Aaron M; Bassett, Ken; Puil, Lorri; Wright, James M (2019-06-05). "Pharmacotherapy for hypertension in adults 60 years or older". The Cochrane Database of Systematic Reviews. 2019 (6). doi:10.1002/14651858.CD000028.pub3. ISSN 1469-493X. PMC 6550717. PMID 31167038.
  5. Musini, Vijaya M; Gueyffier, Francois; Puil, Lorri; Salzwedel, Douglas M; Wright, James M (2017-08-16). "Pharmacotherapy for hypertension in adults aged 18 to 59 years". The Cochrane Database of Systematic Reviews. 2017 (8). doi:10.1002/14651858.CD008276.pub2. ISSN 1469-493X. PMC 6483466. PMID 28813123.
  6. Somes GW, Pahor M, Shorr RI, Cushman WC, Applegate WB (September 1999). "The role of diastolic blood pressure when treating isolated systolic hypertension". Arch. Intern. Med. 159 (17): 2004–09. doi:10.1001/archinte.159.17.2004. PMID 10510985.
  7. Boutitie F, Gueyffier F, Pocock S, Fagard R, Boissel JP (2002). "J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data". Ann. Intern. Med. 136 (6): 438–48. doi:10.7326/0003-4819-136-6-200203190-00007. PMID 11900496. S2CID 38738695.
  8. "Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Hypertension Detection and Follow-up Program Cooperative Group". JAMA. 242 (23): 2562–71. 1979. doi:10.1001/jama.242.23.2562. PMID 490882.
  9. "MRC trial of treatment of mild hypertension: principal results. Medical Research Council Working Party". British Medical Journal (Clinical Research Ed.). 291 (6488): 97–104. 1985. doi:10.1136/bmj.291.6488.97. PMC 1416260. PMID 2861880.
  10. Arguedas JA, Perez MI, Wright JM. Treatment blood pressure targets for hypertension. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004349. DOI: 10.1002/14651858.CD004349.pub2.
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