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| |  CCS: Most Doctors Still Overlook Systolic Blood Pressure In Hypertensives VANCOUVER, B.C. -- November 1, 2000 -- It appears that many doctors are still not treating elevated systolic blood pressure despite the overwhelming evidence showing that it is an important marker of cardiovascular risk. Up until the 1980s, 160 mm Hg was still regarded as normal blood pressure in the elderly population," according to George Carruthers, MD, professor of medicine at the University of Western Ontario, in London, Canada. Dr. Carruthers spoke today at the annual meeting of the Canadian Cardiovascular Society (CCS) being held in Vancouver, Canada. "It took two landmark trials - SHEP (Systolic Hypertension in the Elderly Program) and Syst-EUR (Systolic Hypertension in Europe) to show that, if we took people with so-called normal blood pressure and lowered their systolic, that you had a major impact on stroke and cardiovascular disease." Those trials involved patients with diastolic pressure less than 90-95 mm Hg and systolic pressure greater than 160 mm Hg. Both trials were landmarks in terms of showing that elevated systolic created an additional risk for the patients, and that lowering systolic meant lowering their risk. "The evidence of SHEP and Systolic-Europe trials is unequivocal. These are two different trials, two different countries, two different drugs, and they both show clearly that if systolic pressure is above 160 mm Hg, there is benefit in reducing it further." Even today, many doctors mistakenly believe they can sacrifice higher systolic pressure if they maintain lower diastolic pressure, Dr. Carruthers said. This stems, in part, from the long-held belief that diastolic hypertension is a serious health risk -- which is generally true in patients under the age of 50. Beyond the age of 50, systolic hypertension should be given just as much consideration. Until fairly recently, less than ten years, in fact, doctors often relied on a rule of thumb that "normal" blood pressure for an elderly person would be their age, plus 100. Thus, it was not uncommon to have people with blood pressures in the order of 180 mm Hg or more. However, the STOP-I trial (Swedish Trial in Old Patients With Hypertension) showed that a blood pressure reduction of 19.5 mm Hg systolic and 8.1 mm Hg diastolic was associated with a 40 percent reduction in all cardiovascular mortality and 47 percent reduction in stroke-related morbidity and mortality. Dr. Carruthers said one of the reasons systolic blood pressure has been overlooked is that most doctors received their training in an era when the Framingham Heart Study evidence reported increased cardiovascular risk for people with elevated diastolic pressure. However, many felt that by treating systolic blood pressure, they would bring down diastolic blood pressure as well, and that there was a risk of what is known as a J-curve, in which patients’ risk for cardiovascular events would increase if diastolic pressure dropped too low. It is not the diastolic pressure per se that leads to more cardiovascular events, but the higher systolic pressure in the presence of low or near-normal diastolic pressure which results in a greater pulse pressure (the difference between systolic and diastolic) - and, therefore, more risk of cardiovascular events, he explained. "The bottom line is that we have a strong resistance to the concept of diastolic blood pressure being the most important," Dr. Carruthers added. "We know that in practice, doctors tend to ignore the systolic pressure and we know that there’s a lot of work to be done to convince people that systolic pressure and pulse pressure have to be looked at." "I have no doubt that diastolic blood pressure is important, but it’s only important for people under the age of 50 and it’s important in association with systolic blood pressure. Our continued inability to address systolic blood pressure and to bring it down effectively remains a major public health issue."
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