Time for a check-up on high blood pressure management

April 19, 2001

DALLAS, April 20 - Doctors need to re-think their approach to dealing with high blood pressure, a prominent hypertension specialist asserts in an editorial in the April issue of Hypertension: Journal of the American Heart Association.

Historically, physicians have emphasized lowering the diastolic pressure (the bottom number in a blood pressure reading) when it is 90 millimeters of mercury (mmHg) or greater. Yet half the people in the United States with hypertension have a normal diastolic pressure and only their systolic pressure (top number) is high. These people are usually older than age 50.

A blood pressure reading includes two numbers: the top number, which represents the blood pressure when the heart contracts, and the bottom number, the blood pressure when the heart relaxes. The difference between the two numbers is known as pulse pressure.

"If you look at all the analyses done in hypertension, you get a bigger bang for the buck with regard to heart attacks, strokes, heart failure and kidney failure by lowering the systolic pressure than by treating diastolic pressure," says Joseph L. Izzo, Jr., M.D., professor of medicine and pharmacology and vice chair for research in the department of medicine at the State University of New York in Buffalo. Izzo was also the lead author on a clinical advisory statement on systolic hypertension published in the May 2000 issue of Hypertension: Journal of the American Heart Association.

Current guidelines suggest initiating blood pressure treatment when either systolic is 140 mmHg or greater, or diastolic is 90 mmHg or higher. However, a recent survey found that 43 percent of primary care physicians do not treat a systolic pressure below 160 mmHg. "Doctors do not recognize that systolic hypertension by itself is a high-risk condition," Izzo says.

The third National Health and Nutrition Examination Survey (NHANES III) found that among Americans with high blood pressure, only one in four had both their systolic and diastolic pressure under control. Fifty percent had systolic hypertension alone, 10 percent had diastolic hypertension alone, and 16 percent had systolic and diastolic hypertension.

"That means that at any given time, 66 percent of people with hypertension have an elevated systolic blood pressure," Izzo says. "Our focus has to shift to systolic pressure because of the prevalence of the condition."

Systolic hypertension results from the stiffening of the large arteries, primarily a consequence of biological aging, Izzo says. "With hypertension, the large arteries become stiffer at an earlier age."

Although a number of epidemiological studies indicate that a high pulse pressure increases the risk of heart attack or stroke, Izzo argues against using it as a guide to treating patients.

"There are no scientific studies to guide a physician on appropriate pulse pressure," he says. "Anytime you lower systolic blood pressure, you will almost automatically lower pulse pressure."
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