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(Hypertension. 1999;34:386-387.)
© 1999 American Heart Association, Inc.

Scientific Contributions

The Paradigm Has Shifted, to Systolic Blood Pressure

Henry R. Black

From the Department of Preventive Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Ill.

Correspondence to Henry R. Black, MD, Charles J. and Margaret Roberts Professor and Chairman, Department of Preventive Medicine, Rush-Presbyterian-St. Luke's Medical Center, 1700 W Van Buren St, Room 400, Chicago, IL 60612. E-mail hblack{at}rush.edu

Key Words: Editorials • blood pressure, systolic • risk factors

	Introduction

Top Introduction References

 
In this issue of Hypertension,¹ Lloyd-Jones and colleagues from the Framingham Heart Study report on the results of their categorization of blood pressure stage by both systolic and diastolic blood pressure in 3656 subjects from both the original cohort and the Framingham Offspring cohort. They showed that systolic blood pressure was far more likely to correctly classify individuals as having hypertension, or a high-normal or normal blood pressure, than was diastolic blood pressure. Their data confirmed the value of using both systolic and diastolic blood pressure to determine blood pressure classification, a practice only recently suggested by expert committees.² Now both the Sixth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) in 1997 and the more recent World Health Organization/International Society of Hypertension (WHO/ISH) guidelines subcommittee agreed that both values should be used for classification and that the higher stage (in JNC VI) or grade (in WHO/ISH) should be considered to be the subgroup in which the subject belonged.^{3 4}

The importance of these staging systems and the resultant classification of our patients has never been and is especially not now a trivial issue. Both expert committees have recommended basing treatment recommendations for when to start therapy, especially when to start pharmacological treatment, on the blood pressure stage (or grade) and on the presence or absence of risk factors and target-organ damage. The level of blood pressure, which represents increasing relative risk as it rises, and the level of associated conditions or clinical disease, which represents increasing absolute risk if present, provide us with the opportunity to use our limited resources more cost-effectively. Those hypertensives (and probably all individuals we treat for anything) at highest relative and especially absolute risk benefit the most from treatment.

The importance of this article, as well as the one by Pogue et al⁵ published in this journal in 1996, is that it clearly points out that it is the level of systolic blood pressure, not diastolic blood pressure, that determines the appropriate classification of middle-aged and older persons and even of those undergoing treatment. We must view this information in light of what we know about cardiovascular risk and blood pressure. Kannel et al,⁶ also studying the Framingham Heart Study cohort, found in 1971 that systolic blood pressure is a better predictor of events than diastolic blood pressure. This finding has been confirmed by many since that time, including a recently published large, population-based study from Italy.⁷ Yet it took 22 years, until the fifth report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC V), for systolic blood pressure to be considered even equally important to diastolic blood pressure in defining individuals as hypertensive.²

The first demonstration that reduction of systolic blood pressure in older persons with stage 2 or 3 isolated systolic hypertension (systolic blood pressure 160 mm Hg and "normal" diastolic blood pressure [<90 mm Hg]) reduced morbidity and mortality was the Systolic Hypertension in the Elderly Program (SHEP), completed in 1991.⁸ Before the publication of this trial, many still felt that although systolic blood pressure was an indicator of increased risk, the value of treatment of these individuals had not been proven. Since SHEP, others have confirmed the benefit and made it impossible to ignore the "upper number."^{9 10} It is no longer permissible for us (or our colleagues or our patients) to think that a systolic blood pressure of "100 plus your age" is acceptable. Yet many still do not know this, and many have trouble giving up that antiquated idea.

Recent assessments of whether we in the United States and elsewhere in the world are controlling blood pressure have shown that we are doing a highly inadequate job. JNC VI showed that only 27% of hypertensive Americans aged 18 to 74 years had their blood pressure at goal (<140 mm Hg for systolic and <90 mm Hg for diastolic).³ The record in older individuals and in Europe is even worse.^{11 12 13}

Berlowitz et al¹⁴ recently analyzed treatment in 5 New England Veterans Affairs Hospitals and provided some important insight as to where we are falling short. This group showed that it was systolic blood pressure that was most often ignored unless coronary heart disease was present. These findings are particularly troublesome because individuals in the cohort were older (average age was 66 years), were seen frequently, and were cared for primarily by attending physicians. Clearly, the results of SHEP were not incorporated into those practices, and the subsequent recommendations of JNC V were not being implemented.

There are several ways we can address this problem. The first is with continued professional and public education. It is crucial that we inform our patients, especially our older patients, that they must ask about their systolic blood pressure and not be satisfied if it is above 140 mm Hg. We must be sure that we and our colleagues and our trainees take systolic blood pressure elevations very seriously.

Second, we have to prove that active treatment of those with stage 1 isolated systolic hypertension (systolic blood pressure 140 to 159 mm Hg and diastolic blood pressure <90 mm Hg) reduces morbidity and mortality. Sagie et al¹⁵ showed that this subgroup of hypertensives is very common and is the group most likely not to be treated in the current era. There are as yet no morbidity and mortality trials that have proven that these hypertensives benefit from treatment. Such data are essential before we can make this recommendation without reservation.

Next, we must be sure we have the tools to get systolic blood pressure to our goal. The Hypertension Optimal Treatment study (HOT) showed that practicing physicians, who made up the vast majority of HOT investigators, can successfully reduce diastolic blood pressure to <90 mm Hg more than 90% of the time.^{16 17} Systolic blood pressure, however, averaged >140 mm Hg, even when a modern 3-drug regimen was used and the goal for diastolic blood pressure was mandated by the protocol. Furthermore, in both the Antihypertensive Lipid Lowering Trial to Prevent Heart Attack (ALLHAT) and the Controlled Onset Verapamil Investigation of Cardiovascular Events (CONVINCE) trials, diastolic blood pressure control rates (percent of individuals with diastolic blood pressure <90 mm Hg) at 2 years approach 90%, but systolic blood pressure control rates (percent <140 mm Hg) are only 60%.^{18 19} These 3 studies (HOT, ALLHAT, and CONVINCE) show that practicing physicians in clinical trials can get diastolic blood pressure to goal in most subjects when forced titration is imposed. Doctors still, however, fall short of reaching the JNC VI and WHO/ISH goal for systolic blood pressure of <140 mm Hg in a large number of subjects.

So I feel also that we do need better drugs, ones that are particularly effective at lowering systolic blood pressure, or we need to discover better ways to use the ones we already have. We need the Food and Drug Administration and its sister agencies around the world to change their long-standing policy of assessing the efficacy of an antihypertensive drug only by its ability to lower diastolic blood pressure. Any drug that lowers diastolic blood pressure will also lower systolic blood pressure, but the benchmark a new drug should be tested for should be systolic blood pressure. Diastolic will follow.

Lloyd-Jones et al¹ have done us a great service by pointing out, in yet a different context, why the systolic blood pressure measurement is so important. In 1985, Fisher²⁰ suggested, perhaps whimsically and perhaps not, that we shouldn't even bother to measure diastolic blood pressure. It took time, and such measurement was often inaccurate by indirect sphygmomanometry, and systolic blood pressure was more important at predicting risk.²⁰ He may well be right, expect for one other important issue. It seems increasingly clear that in fact, pulse pressure, the difference between systolic and diastolic blood pressure, is an even better predictor of risk than systolic blood pressure, especially in older persons.^{21 22 23 24} We cannot calculate pulse pressure without knowing diastolic blood pressure, so for that reason alone, it is too soon to abandon its measurement.

	Footnotes

 
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.

	References

Top Introduction References

 
1. Lloyd-Jones DM, Evans JC, Larson MG, O'Donnell CJ, Levy D. Differential impact of systolic and diastolic blood pressure level on JNC-VI staging. Hypertension. 1999;34:381–385.[Abstract/Free Full Text]

2. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153:154–183.[Abstract/Free Full Text]

3. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:2413–2446.[Abstract/Free Full Text]

4. Guidelines Subcommittee. World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. J Hypertens. 1999;17:151–183.[Medline] [Order article via Infotrieve]

5. Pogue VA, Ellis C, Michel J, Francis CK. New staging system of the fifth Joint National Committee report on the detection, evaluation, and treatment of high blood pressure (JNC V) alters assessment of the severity and treatment of hypertension. Hypertension. 1996;28:713–718.[Abstract/Free Full Text]

6. Kannel WB, Gordon T, Schwartz MJ. Systolic versus diastolic blood pressure and risk of coronary heart disease: Framingham Study. Am J Cardiol. 1971;27:335–345.[Medline] [Order article via Infotrieve]

7. Alli C, Avanzini F, Bettelli G, Colombo F, Torri V, Tognoni G, on behalf of doctors participating in the SPAA. The long-term prognostic significance of repeated blood pressure measurements in the elderly: different predictive value of systolic and diastolic pressure: ten year follow-up of a large prospective study in general practice, the "Studio sulla Pressione Arteriosa nell'Anziano (SPAA)." Arch Intern Med. 1999;159:1205–1212.[Abstract/Free Full Text]

8. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255–3264.[Abstract/Free Full Text]

9. Staessen JA, Fagard R, Thijs L, Celis H, Arabidzide GG, Birkenhager WH, Bulpitt CJ, de Leeuw PW, Dollery CT, Flether AE, Forette F, Leonetti F, Nachev C, O'Brien ET, Rosenfeld J, Rodicio JL, Tuomilehto J, Zanchetti A. Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension: the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757–764.[Medline] [Order article via Infotrieve]

10. Liu L, Wang JG, Gong L, Liu G, Staessen JA, for the Systolic Hypertension in China (Syst-China) Collaborative. Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. J Hypertens. 1998;16:1823–1829.[Medline] [Order article via Infotrieve]

11. Barker WH, Mullooly JP, Linton KL. Trends in hypertension prevalence, treatment, and control in a well-defined older population. Hypertension. 1998;31:552–559.[Abstract/Free Full Text]

12. Colhoun HM, Dong W, Poulter NR. Blood pressure screening, management and control in England: results from the health survey for England 1994. J Hypertens. 1998;16:747–752.[Medline] [Order article via Infotrieve]

13. Marques-Vidal P, Tuomilehto J. Hypertension awareness, treatment and control in the community: is the "rule of halves" still valid? J Hum Hypertens. 1997;11:213–220.[Medline] [Order article via Infotrieve]

14. Berlowitz DR, Ash AS, Hickey EC, Friedman RH, Glickman M, Kader B, Moskowitz MA. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339:1957–1963.[Abstract/Free Full Text]

15. Sagie A, Larson MG, Levy D. The natural history of borderline isolated systolic hypertension [see comments]. N Engl J Med. 1993;329:1912–1917.[Abstract/Free Full Text]

16. Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, Menard J, Rahn KH, Wedel H, Westerling S, on behalf on the HOT Study Group. Effects of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet. 1998;351:1755–1762.[Medline] [Order article via Infotrieve]

17. Liebson PR, Black HR. The J curve in the treatment of hypertension: new HOT information. Am J Prev Cardiol.. 1999;2:34–41.

18. Cushman WC, Black HR, Probsfield J, Holland JJ, Hamilton BP, Margolis K, Nwachuku CE, Payne GH, Ford CE, for the ALLHAT Research Group. Blood pressure control in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Am J Hypertens. 1998;11:17A. Abstract.

19. Black HR, Elliott WJ, Neaton JD, Grandits P, Grambsch P, Grimm RH, Hansson L, Lacouciere Y, Muller J, Sleight P, Weber MA, White WB, Williams G, Wittes J, Zanchetti A, Fakouhi TD. Baseline characteristics of the 16,605 patients in the CONVINCE study. J Hypertens. 1999;17:S201.

20. Fisher CM. The ascendancy of diastolic blood pressure over systolic. Lancet. 1985;2:1349–1350.[Medline] [Order article via Infotrieve]

21. Madhavan S, Ooi WL, Cohen H, Alderman MH. Relations of pulse pressure and pressure reduction to the incidence of myocardial infarction. Hypertension. 1994;23:395–401.[Abstract/Free Full Text]

22. Franklin SS, Gustin W, Wong ND, Larson MG, Weber MA, Kannel WB, Levy D. Hemodynamic patterns of age-related changes in blood pressure: the Framingham Heart Study. Circulation. 1997;96:308–315.[Abstract/Free Full Text]

23. Chae CU, Pfeffer MA, Glynn RJ, Mitchell GF, Taylor JO, Hennekens CH. Increased pulse pressure and risk of heart failure in the elderly. JAMA. 1999;281:634–639.[Abstract/Free Full Text]

24. Black HR, Yi JY. A new classification for hypertension based on relative and absolute risk with implications for treatment and reimbursement. Hypertension. 1996;28:719–724.[Abstract/Free Full Text]

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Black, H. R. Search for Related Content PubMed PubMed Citation Articles by Black, H. R. Related Collections Cardiovascular Pharmacology Other hypertension