(Hypertension. 2001;37:869.)
© 2001 American Heart Association, Inc.
Scientific Contribution |
Predominance of Isolated Systolic Hypertension Among Middle-Aged and Elderly US Hypertensives
Analysis Based on National Health and Nutrition Examination Survey (NHANES) III
From the Heart Disease Prevention Program, University of California, Irvine (S.S.F., M.J.J., N.D.W.), and Bristol-Myers Squibb, Pharmaceutical Research Institute, Princeton, NJ (G.J.L., P.L.).
Correspondence and reprint requests to Dr Stanley S. Franklin, Heart Disease Prevention Program, C240 Medical Sciences, University of California, Irvine, CA 92697.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
The purpose of the present study was to examine patterns of systolic and diastolic hypertension by age in the nationally representative National Health and Nutrition Examination Survey (NHANES) III and to determine when treatment and control efforts should be recommended. Percentage distribution of 3 blood pressure subtypes (isolated systolic hypertension, combined systolic/diastolic hypertension, and isolated diastolic hypertension) was categorized for uncontrolled hypertension (untreated and inadequately treated) in 2 age groups (ages <50 and
50 years). Overall, isolated systolic
hypertension was the most frequent subtype of uncontrolled hypertension
(65%). Most subjects with hypertension (74%) were 50 years of age,
and of this untreated older group, nearly all (94%) were accurately
staged by systolic blood pressure alone, in contrast to
subjects in the untreated younger group, who were best staged by
diastolic blood pressure. Furthermore, most subjects (80%)
in the older untreated and the inadequately treated groups had isolated
systolic hypertension and required a greater reduction in
systolic blood pressure than in the younger groups (-13.3 and
-16.5 mm Hg versus -6.8 and -6.1 mm Hg, respectively;
P=0.0001) to attain a
systolic blood pressure treatment goal of <140 mm Hg.
Contrary to previous perceptions, isolated systolic
hypertension was the majority subtype of uncontrolled hypertension in
subjects of ages 50 to 59 years, comprised 87% frequency for subjects
in the sixth decade of life, and required greater reduction in
systolic blood pressure in these subjects to reach treatment
goal compared with subjects in the younger group. Better awareness of
this middle-aged and older high-risk group and more aggressive
antihypertensive therapy are necessary to address this treatment
gap.
Key Words: hypertension, essential • blood pressure • clinical trials • hypertension, systolic, isolated
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Multiple clinical and observational studies in the elderly have demonstrated that elevated systolic blood pressure (SBP) is a more potent predictor of adverse cardiovascular outcomes than is elevated diastolic blood pressure (DBP)1 2 3 4 5 and that treating isolated systolic hypertension (ISH) in the elderly reduces risk of cardiovascular disease events.6 7 Despite the strength of these observational and intervention studies, only about one quarter of hypertensive individuals are being treated to goal.8 Recently, the Coordinating Committee of the National High Blood Pressure Education Program (NHBPEP), recognizing the magnitude of this public health problem, stated that SBP in general and ISH in particular should become the major criteria for the diagnosis, staging, and therapeutic management of hypertension in the middle-aged and elderly.9
ISH is strongly age dependent. Both the Framingham Heart
Study and the nationally representative National Health
and Nutrition Examination Survey (NHANES) III (conducted in 1988 to
1994) showed that a similar pattern of progressively increasing SBP
occurs throughout adult life in untreated
individuals.10 11
In contrast, DBP was shown to increase in adults until age 50 years and
decline from the sixth decade
forward.10 11 This
age-related pattern of increasing rates of ISH for ages 50 years was
not only observed in the Framingham Heart
Study10 and in NHANES III
participants,11 but also in a
meta-analysis of 10 studies that reported the prevalence of
ISH.12 In total, these
studies suggest that age 50 years is a useful cutpoint to dichotomize
arbitrarily hypertensive individuals into 2 groups for the purpose of
classifying hypertension by subtype.
The present study focused on the new NHBPEP advisory guidelines with the expressed purpose of further characterizing subtypes of systolic and diastolic hypertension. By use of the NHANES III national data set, specific attention was directed toward identifying frequency of ISH and other subtypes of hypertension by age1 and examining hypertension awareness, staging, and treatment target goals across the entire adult age spectrum.2 We also examined the hypothesis that subtypes and staging of hypertension are distinctly different in middle-aged and older individuals versus their younger counterparts.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Study Population
NHANES III, sponsored by the National Center for Health Statistics, was designed to provide estimates of common chronic conditions and associated risk factors for a representative sample of the civilian, noninstitutionalized population of the United States.8 11 The adult BP component of NHANES III was designed to provide estimates of the prevalence, awareness, treatment, and control of hypertension in the general population. A national sample of 19 661 adults
18 years
of age agreed to be interviewed in their home and have an extensive
medical examination at a mobile examination center. Methods of BP
measurement have been described
previously.8 11
Definitions of Variables
Hypertension was defined as mean SBP 140
mm Hg, mean DBP 90 mm Hg, or current treatment for
hypertension with prescription medication. Awareness of hypertension
was determined by interviews only with untreated hypertensive
participants. Treatment of hypertension was defined as use of a
prescription medication to manage high BP at the time of interview.
Treatment success was defined as pharmacological treatment of
hypertension associated with SBP <140 and DBP <90 mm Hg, in
accordance with the Sixth Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
(JNC-VI).13 Inadequate
treatment was defined as pharmacological treatment of hypertension with
SBP 140 mm Hg and/or DBP 90 mm Hg. Control rates for
all participants being treated with antihypertensive medications were
calculated separately for SBP, DBP, and individual hypertensive
subtypes.
Study Design
NHANES III data were compared by age (<50 or 50
years), antihypertensive treatment status (uncontrolled hypertension,
divided into untreated and inadequately treated groups), and
hypertensive subtype (isolated diastolic hypertension
[IDH], SBP <140 and DBP 90 mm Hg; combined
systolic/diastolic hypertension [SDH], SBP 140
and DBP 90 mm Hg; and ISH, SBP 140 and DBP <90 mm Hg).
Distribution of each hypertensive subtype by age was determined and
graphed separately for untreated and inadequately treated
individuals.
In addition, untreated subjects <50 and 50 years of age
were compared on the basis of BP staging by SBP and DBP. According to
JNC-VI
guidelines,13 14
congruent SBP and DBP stages were defined as follows: optimal and
normal (SBP <130 mm Hg and DBP <85 mm Hg); high-normal
(SBP 130 to 139 mm Hg or DBP 85 to 89 mm Hg); stage 1
hypertension (SBP 140 to 159 mm Hg or DBP 90 to 99 mm Hg);
and stage 2 hypertension (SBP 160 mm Hg or DBP 100
mm Hg). Because so few subjects had stage 3 hypertension, these
subjects were collapsed into the stage 2 category. When a disparity
was seen between SBP and DBP stages, participants were classified into
the higher stage (upstaged), in accordance with the JNC-VI guidelines.
In the current analysis, participants with high-normal BP or
hypertension were classified on the basis of JNC-VI guidelines as
having congruent levels of SBP and DBP, upstaged on the basis of SBP
alone, or upstaged on the basis of DBP
alone.14 BP reductions needed
to reach target goals were determined for the 3 hypertensive subtypes
in both the untreated and inadequately treated groups, dichotomized at
50 years of age.
Statistical Analysis
NHANES III data were extrapolated to assess the
burden of hypertension awareness, treatment, and control among the
entire adult civilian, noninstitutionalized population of the United
States. These estimates were weighted and adjusted to reduce bias from
nonresponses during the interview. Because the design of NHANES III was
a multistage probability sample, conventional statistical
analyses with underlying distributional assumptions were
inappropriate for variance estimation and statistical testing. SUDAAN
software (Research Triangle Institute) PROC DESCRIPT was used to
compute Taylor series standard errors,
t test was used for contrasted
means, and 
2 and the
Cochran-Mantel-Haenszel test were used for survey
data.15 Statistical tests
were used to compare age grouping and treatment
categories.15 All
analyses were performed with SAS statistical software (SAS
Corp).16
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Demographic Characteristics
On the basis of the extrapolated NHANES III data, 42.7 million adult Americans were identified as hypertensive, which represented 24% of the adjusted adult US population. A total of 23.6% of the hypertensive population was treated to target BP goal; the remaining untreated (47.8%) and inadequately treated hypertensive individuals (28.6%) together comprised 64.9% ISH, 21.1% SDH, and 14.0% IDH. More than twice as many individuals (66%) had BP higher than the SBP goal of
140 mm Hg than did higher than the
DBP goal of 90 mm Hg (27%). Participants 50 years of age
comprised three fourths of all hypertensive subjects. The older group
was predominantly female (58%), whereas the younger group was
predominantly male (62.5%). The predominant hypertensive subtype was
ISH (79.8%) in the older group (75% stage 1 and 25% stage 2 or
higher) and IDH (42.8%) in the younger group (98% stage 1 and 2%
stage 2 or higher).
Awareness of Hypertension
Among untreated hypertensives in the US, 42% of
individuals with DBP 90 mm Hg were aware of their condition but
only 29% with SBP 140 mm Hg knew of their hypertensive status.
Similarly, in the age <50 years group, 39% of individuals were aware
of their hypertension, whereas only 31% of those age 50 years knew
of their diagnosis. Hypertension awareness was greatest among subjects
with SDH (67.2%), intermediate among those with ISH (58.4%), and
least among those with IDH (46.8%;
P=0.0008), after adjustment for
age and gender. Awareness rates differed significantly between SDH and
IDH (P=0.0008) and SDH and ISH
(P=0.0004) but not between ISH
and IDH (P=0.69), after
adjustment for age and gender.
Frequency Distribution of Hypertension Subtypes
by Age
The proportion of subjects with ISH was progressively
higher and the proportion of subjects with IDH progressively lower with
increments in age in the untreated
(Figure 1) and inadequately treated groups
(Figure 2). ISH was the most common hypertension subtype in
participants of age 50 years, among both untreated (79.7%) and
inadequately treated (80.1%) individuals. Conversely, for the younger
hypertensive group, IDH was most common among untreated (46.9%) and
SDH was most common among inadequately treated individuals (45.1%). In
both the untreated and inadequately treated groups, ISH became the
primary hypertensive subtype for subjects in their fifth decade (54%)
of life and the overwhelming dominant hypertensive subtype by the sixth
decade (87%) of life. Participants 50 years of age comprised 67% of
all untreated and 86% of all inadequately treated individuals with
hypertension.
|
, ISH (SBP 
, SDH (SBP 
, IDH (SBP <140 mm Hg and DBP
|
JNC-VI Staging by SBP and DBP
The magnitude of disparity between SBP and DBP in
classifying untreated individuals by JNC-VI staging criteria, after
participants with congruent normal SBP and DBP were eliminated from
study, was compared for the 2 age groups.
Figure 3 shows percentages of untreated participants with
high normal BP or hypertension who were classified into each JNC-VI SBP
and DBP category for the group of age 50 years. Among untreated
participants 50 years of age with high-normal BP or hypertension, SBP
alone correctly classified JNC-VI stage in 
94% of subjects (84.8%
upstaged on the basis of SBP alone and 9.0% with congruent SBP and
DBP), whereas DBP alone correctly classified only 16.3% (7.3%
upstaged on the basis of DBP alone and 9.0% with congruent SBP and
DBP). In contrast to the older age group, 45.8% of untreated younger
NHANES III participants were upstaged by DBP alone, 35.1% were
upstaged on the basis of SBP alone, and 19.1% had congruent stages of
SBP and DBP
(Figure 4).
|
;) represent subjects who were upstaged on the basis of DBP alone.
|
Comparison of BP Reduction Needed to Reach
Treatment Goals
In the inadequately treated group age 50 years, 82%
had SBP in excess of the target goal versus 17% with DBP in excess of
the target goal; in contrast, 50% of the younger group had BPs that
exceeded both SBP and DBP target goals. Comparisons of BP
reductions needed to reach treatment goals in the untreated individuals
and those categorized as inadequately treated are shown for
hypertension subtypes by age categories in the
Table.
A significantly greater reduction in SBP was required to reach
treatment goal in the ISH subtype for the older versus the younger age
group among untreated people with hypertension (-13.3 versus -6.8
mm Hg, respectively; P=0.0001)
and among inadequately treated people with hypertension (-16.5 versus
-6.1 mm Hg, respectively;
P=0.0001). Similarly, a
significantly greater reduction in SBP was required to reach treatment
goal among older individuals in the SDH group compared with younger
individuals with SDH, both for untreated subjects (-22.9 versus
-9.6 mm Hg, respectively;
P=0.0001) and those considered
inadequately treated (-23.7 versus -16.0 mm Hg, respectively;
P=0.002). Furthermore, 52% of
the older versus 11% of the younger untreated individuals had BP
20 mm Hg higher than SBP treatment goal and 55% of the older
versus 24% of the younger inadequately treated individuals had BP
20 mm Hg higher than the SBP treatment
goal.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The present study demonstrated that ISH in both untreated and inadequately treated individuals is the most frequent form of uncontrolled hypertension in the United States (65%), that ISH is the most common hypertension subtype (54%) for persons between the ages of 50 and 59 years, and that ISH is the overwhelmingly dominant hypertensive subtype (87%) by the sixth decade of life. In contrast, the small group of individuals with hypertension who are <50 years of age predominantly have diastolic hypertension that consists largely of IDH and SDH. More than 4 times as many inadequately treated individuals of age
50 years had SBP (82%) versus DBP (17%) that was
higher than target goals, whereas an equal number (50%) had both SBP
and DBP higher than target goals in the younger group. Furthermore,
individuals of age 50 years with ISH who were either untreated or
inadequately treated required more than a 2-fold greater reduction in
SBP to attain JNC-VI treatment goals versus their younger
counterparts.
Earlier studies in the
elderly3 6 7 12 17
that defined ISH as SBP <160 mm Hg and DBP <90 or <95
mm Hg understandably found a lower frequency of ISH of 5% to 22%.
More recently, the community-based Framingham Heart Study, which
defined ISH as SBP <140 mm Hg and DBP <90 mm Hg, reported
a higher frequency of ISH in untreated individuals of 35% to 40% in
the age group of 50 to 59
years3 and values of 65% to
70% in the age group of 60
years.18 In contrast, the
present NHANES III study, which examined combined untreated and
inadequately treated individuals, observed a considerably larger ISH
frequency of 54% in the age group of 50 to 59 years and values of 87%
in the age group of age 60 years.
Frequency of ISH, also defined with a cutoff of
<140/90 mm Hg, was reported in a previous NHANES III (1988 to
1991) analysis as 64.8% in a group of age 60
years.4 These results are
consistent with those presented in the present
analysis. A key difference is that the present
analysis focused on the uncontrolled hypertensive population
rather than on all individuals with hypertension. The intent was to
examine more closely how SBP and DBP play different roles in defining
the problem of uncontrolled hypertension.
In addition to age-related differences in subtype
analysis, the 2 hypertensive age groupings were strikingly
dissimilar with respect to JNC-VI staging and eligibility for therapy
in untreated individuals. This dissimilarity was evidenced by the
pronounced difference with respect to upstaging, which was almost
entirely related to SBP in people 50 years of age, whereas the
reverse was observed in individuals <50 years of age, among whom
upstaging was mostly related to DBP. But because most of the
individuals with hypertension in the NHANES III population were 50
years of age (74%) with a predominance of ISH (80%), SBP was by far
the most important overall determinant of JNC-VI upstaging and, hence,
eligibility for therapy. These results in the NHANES III age group of
50 years reinforce the findings of SBP upstaging in the middle-aged
and older community-based Framingham Heart
Study14 and introduce the new
concept of DBP upstaging in the younger age group.
Poor levels of awareness, treatment, and control of hypertension were a problem in all age groups. Although hypertension was less likely to be treated in younger than older people, the absolute number of untreated individuals was more than twice as high in older individuals. Furthermore, awareness of ISH was significantly lower than awareness of SDH, after correcting for the confounding effects of age and gender.
Clinical Implications
Many factors may contribute to the inadequate treatment
of hypertension, as recent reviews have
emphasized.19 20
Both physician bias toward focusing primarily on a DBP treatment
goal21 22 and
physician fear of excessive lowering of
DBP,23 have contributed to
poor SBP control. Furthermore, as noted in the present study, among
patients with hypertension, a greater number of older persons have high
levels of SBP compared with younger patients. Most older patients with
ISH may be resistant to therapy as a result of increased left
ventricular
hypertrophy,24
vascular hypertrophy and
remodeling,25 high levels of
sympathetic tone,26 and
nonmodulation of the
renin-angiotensin-aldosterone
system27 .
Millions of people with untreated or inadequately treated hypertension would benefit from full implementation of JNC-VI guidelines, which recommend initiating lifestyle and pharmacological intervention, controlling both SBP and DBP, and simultaneously treating other major cardiovascular risk factors. The potential value of dietary management should not be underestimated, as recent investigations have demonstrated.28 However, a significant percentage of untreated and inadequately treated older individuals with high and resistant ISH or SDH require a more innovative strategy that includes a multiple drug regimen for adequate control of BP.13 29 An alternative or supplemental strategy that holds some promise is the development of more potent antihypertensive agents that have minimal side effects and are specifically targeted to reduce SBP.30
Strengths and Limitations
The present study, which uses a national population
database, reinforces and expands the conclusions of the new NHBPEP
guidelines by demonstrating that individuals with hypertension
generally fall into 1 of 2 distinct categories: (1) a smaller, younger
population presenting primarily with diastolic
hypertension and requiring a small reduction in both SBP and DBP to
reach treatment goal and (2) a much larger, middle-aged and older
population presenting primarily with ISH as the major cause of
uncontrolled hypertension and requiring a large reduction in SBP to
reach treatment goal. Because of the cross-sectional nature of NHANES
III, the effect of treatment on hypertensive subtypes and control rates
cannot be determined. However, it is probable that a significant
percentage of individuals with inadequately treated ISH may have had
SDH before beginning therapy but did not reach SBP goal because of a
treatment bias or because they had a more difficult to treat form of
hypertension. Exploring these trends will be an important subject for
future clinical research.
In conclusion, the present study demonstrates that ISH is the overwhelmingly dominant subtype of hypertension in the middle-aged and elderly population, that ISH requires a large reduction in SBP to reach treatment goal and, that ISH is the predominant subtype among persons with untreated and inadequately treated hypertension. Successful treatment of systolic hypertension in general, and ISH in particular, represents an important public health challenge that will require more aggressive efforts at management.
Received March 5, 2000; first decision June 15, 2000; accepted September 5, 2000.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Kannel WB, Gordon T, Schwartz MJ. Systolic versus diastolic blood pressure and risk of coronary heart disease. Am J Cardiol. 1971;27:335–346.[Medline] [Order article via Infotrieve]
2.
The MRFIT Research
Group. Multiple Risk Factor Intervention Trial: risk factor changes and
mortality results. JAMA. 1988;260:3451–3455.
3.
Sagie A, Larson MG,
Levy D. The natural history of borderline isolated systolic
hypertension. N Engl J
Med. 1993;329:1912–1917.
4.
ISH. ISH working
group report on hypertension in the elderly.
Hypertension. 1994;23:275–285.
5.
O’Donnell CJ,
Ridker PM, Glynn RJ, Berger K, Ajani U, Manson JE, Hennekens CH.
Hypertension and borderline isolated systolic hypertension
increases risk of cardiovascular disease and mortality
in male physicians.
Circulation. 1997;95:1132–1137.
6.
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.
7. Staesson JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhager WH. Randomized double-blind comparison of placebo and active treatment for older patients with systolic hypertension: the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350:757–764.[Medline] [Order article via Infotrieve]
8.
Burt VL, Cutler JA,
Higgins M, Horan MJ, Labarthe D, Whelton P, Brown C, Roccella EJ.
Trends in the prevalence, awareness, treatment, and control of
hypertension in the adult US population.
Hypertension. 1995;26:60–69.
9.
Izzo JL, Levy D,
Black HR. Clinical advisory statement: importance of systolic
blood pressure in older Americans.
Hypertension. 2000;35:1021–1024.
10.
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.
11.
Burt VL, Whelton
P, Roccella EJ, Brown C, Cutler JA, Higgins M, Goran MJ, Labarthe D.
Prevalence of hypertension in the US adult population: results from the
Third National Health and Nutrition Examination Survey, 1988–1991
[see comments]. Hypertension. 1995;25:305–313.
12. Staessen J, Amery A, Fagard R. Isolated systolic hypertension in the elderly. J Hypertens. 1990;9:393–405.
13.
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.
14.
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.
15. Shah BV, Barnwell BG, Bieler GS. SUDAAN Users’ Manual, release 7.5. Cary, NC: Research Triangle Institute; 1997.
16. SAS Procedures Guide, version 6.12. 3rd ed. Cary, NC: SAS Institute; 1995.
17. Wilking SVB, Belanger A, Kannel WB, D’Agostino RB, Steel K. Determinants of isolated systolic hypertension. JAMA. 1988;260:3451–3455.
18.
Kannel WB. Blood
pressure as a cardiovascular risk factor.
JAMA. 1996;275:1571–1576.
19. Swales JD. Current clinical practice in hypertension: the EISBERG (Evaluation and Intervention for Systolic Blood Pressure Elevation—Regional and Global) project. Am Heart J. 1999;138:S231–S237.
20.
Prisant LM, Moser
M. Hypertension in the elderly: can we improve results of therapy?
Arch Intern Med. 2000;160:283–289.
21.
Berlowitz DR, Ash
AS, Hickey EC, Friedman RH, Glickman MG, Kader B, Moskowitz MA.
Inadequate management of high blood pressure in a hypertensive
population. N Engl J
Med. 1998;339:1957–1963.
22. Coppola WG, Whincup PH, Walker M, Ebrahim S. Identification and management of stroke risk in older people: a national survey of current practice in primary care. J Hum Hypertens. 1997;11:185–191.[Medline] [Order article via Infotrieve]
23. Fletcher AE, Bulpitt CJ. How far should blood pressure be lowered? N Eng J Med. 1992;326:251–254.[Medline] [Order article via Infotrieve]
24.
Gardin JM,
Siscovick D, Anton-Culver H, Lynch JC, Smith VE, Klopfenstein HS,
Bommer WJ, Fried L, O’Leary D, Manolio TA. Sex, age, and disease
affect echocardiographic left ventricular
mass and systolic function in the free-living elderly: the
Cardiovascular Health Study.
Circulation. 1995;91:1739–1748.
25.
James MA,
Watt PAC, Potter JF, Thurston H, Swales JD. Pulse pressure and
resistance artery structure in the elderly.
Hypertension. 1995;26:301–306.
26. Grassi G, Dell’Oro R, Bertinieri G, Turri C, Stella ML, Mancia G. Sympathetic nerve traffic and baroreflex control of circulation in systodiastolic and isolated systolic hypertension of the elderly. J Hypertens. 1999;17(suppl 3):S45–S46.
27. Hall JE, Brands MW, Shek EW. Central role of the kidney and abnormal fluid volume control in hypertension. J Hum Hypertens. 1996;10:633–639.[Medline] [Order article via Infotrieve]
28. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. The effect of dietary patterns on blood pressure: results from the Dietary Approaches to Stop Hypertension (DASH) randomized clinical trial. N Engl J Med. 1997;1336:1117–1124.
29. Bakris GL. Maximizing cardiorenal benefit in the management of hypertension: achieving blood pressure goals. J Clin Hypertens. 1999;1:141–147.
30. Franklin SS. Is there a preferred antihypertensive therapy for isolated systolic hypertension and reduced arterial compliance? Curr Hyp Reports. 2000;2:253–259.
This article has been cited by other articles:
 |
|
 |
|
  A. P. Avolio, L. M. Van Bortel, P. Boutouyrie, J. R. Cockcroft, C. M. McEniery, A. D. Protogerou, M. J. Roman, M. E. Safar, P. Segers, and H. Smulyan Role of Pulse Pressure Amplification in Arterial Hypertension: Experts' Opinion and Review of the Data Hypertension, August 1, 2009; 54(2): 375 - 383. [Full Text] [PDF]
|
|
|
|
|
|
M. Namasivayam, B. J. McDonnell, C. M. McEniery, M. F. O'Rourke, and on behalf of the Anglo-Cardiff Collaborative Trial Does Wave Reflection Dominate Age-Related Change in Aortic Blood Pressure Across the Human Life Span? Hypertension, June 1, 2009; 53(6): 979 - 985. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. D. Solomon, D. P. Goldman, G. F. Joyce, and J. J. Escarce Cost Sharing and the Initiation of Drug Therapy for the Chronically Ill Arch Intern Med, April 27, 2009; 169(8): 740 - 748. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. A. Chirinos, S. S. Franklin, R. R. Townsend, and L. Raij Body Mass Index and Hypertension Hemodynamic Subtypes in the Adult US Population Arch Intern Med, March 23, 2009; 169(6): 580 - 586. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Kokkinos, A. Manolis, A. Pittaras, M. Doumas, A. Giannelou, D. B. Panagiotakos, C. Faselis, P. Narayan, S. Singh, and J. Myers Exercise Capacity and Mortality in Hypertensive Men With and Without Additional Risk Factors Hypertension, March 1, 2009; 53(3): 494 - 499. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. J. Ekundayo, R. M. Allman, P. W. Sanders, I. Aban, T. E. Love, D. Arnett, and A. Ahmed Isolated Systolic Hypertension and Incident Heart Failure in Older Adults: A Propensity-Matched Study Hypertension, March 1, 2009; 53(3): 458 - 465. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Schillaci, M. Pirro, and E. Mannarino Assessing Cardiovascular Risk: Should We Discard Diastolic Blood Pressure? Circulation, January 20, 2009; 119(2): 210 - 212. [Full Text] [PDF]
|
|
|
|
|
|
S. S. Franklin, V. A. Lopez, N. D. Wong, G. F. Mitchell, M. G. Larson, R. S. Vasan, and D. Levy Single Versus Combined Blood Pressure Components and Risk for Cardiovascular Disease: The Framingham Heart Study Circulation, January 20, 2009; 119(2): 243 - 250. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L.-T. Cheng, Y.-L. Gao, Y. Gu, L. Zhang, S.-H. Bi, W. Tang, and T. Wang Stepwise increase in the prevalence of isolated systolic hypertension with the stages of chronic kidney disease Nephrol. Dial. Transplant., December 1, 2008; 23(12): 3895 - 3900. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. D. Chantler, V. Melenovsky, S. P. Schulman, G. Gerstenblith, L. C. Becker, L. Ferrucci, J. L. Fleg, E. G. Lakatta, and S. S. Najjar The sex-specific impact of systolic hypertension and systolic blood pressure on arterial-ventricular coupling at rest and during exercise Am J Physiol Heart Circ Physiol, July 1, 2008; 295(1): H145 - H153. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. S. Schaeffner, T. Kurth, T. S. Bowman, R. P. Gelber, and J. M. Gaziano Blood pressure measures and risk of chronic kidney disease in men Nephrol. Dial. Transplant., April 1, 2008; 23(4): 1246 - 1251. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. M. Farasat, C. H. Morrell, A. Scuteri, C.-T. Ting, F. C.P. Yin, H. A. Spurgeon, C.-H. Chen, E. G. Lakatta, and S. S. Najjar Pulse Pressure Is Inversely Related to Aortic Root Diameter Implications for the Pathogenesis of Systolic Hypertension Hypertension, February 1, 2008; 51(2): 196 - 202. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Jami, P. Smith, S. Moningi, V. Moningi, S. A. Martin, G. Rosencrance, and B. J. Reyes Compliance With Joint National Committee 7 Guidelines in Hypertension Management in a Teaching Institution American Journal of Medical Quality, August 1, 2007; 22(4): 251 - 258. [Abstract] [PDF]
|
|
|
|
 |
|
 F. Fantin, A. Mattocks, C. J. Bulpitt, W. Banya, and C. Rajkumar Reply Age Ageing, July 1, 2007; 36(4): 476 - 476. [Full Text] [PDF]
|
|
|
|
|
|
W. Vongpatanasin, G. D. Thomas, R. Schwartz, L. A. Cassis, S. Osborne-Lawrence, L. Hahner, L. L. Gibson, S. Black, D. Samols, and P. W. Shaul C-Reactive Protein Causes Downregulation of Vascular Angiotensin Subtype 2 Receptors and Systolic Hypertension in Mice Circulation, February 27, 2007; 115(8): 1020 - 1028. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Pinto Blood pressure and ageing Postgrad. Med. J., February 1, 2007; 83(976): 109 - 114. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Weber, J. Auer, B. Eber, and M. F. O'Rourke Diastolic Blood Pressure in Coronary Artery Disease Ann Intern Med, January 16, 2007; 146(2): 149 - 149. [Full Text] [PDF]
|
|
|
|
|
|
J. Cameron Ageing and central aortic pulse wave analysis. Commentary on 'Is Augmentation Index a Good Measure of Vascular Stiffness in the Elderly?' by Fantin et al. Age Ageing, January 1, 2007; 36(1): 3 - 5. [Full Text] [PDF]
|
|
|
|
 |
|
 R. Weiss Review: {beta} blockers differ in their efficacy for preventing major cardiovascular events in younger and older patients Evid. Based Med., December 1, 2006; 11(6): 168 - 168. [Full Text] [PDF]
|
|
|
|
|
|
L. Djousse, J. S. Pankow, S. C. Hunt, G. Heiss, M. A. Province, E. K. Kabagambe, and R. C. Ellison Influence of Saturated Fat and Linolenic Acid on the Association Between Intake of Dairy Products and Blood Pressure Hypertension, August 1, 2006; 48(2): 335 - 341. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Assmann, P. Cullen, T. Evers, D. Petzinna, and H. Schulte Importance of arterial pulse pressure as a predictor of coronary heart disease risk in PROCAM Eur. Heart J., October 2, 2005; 26(20): 2120 - 2126. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Wang and R. S. Vasan Epidemiology of Uncontrolled Hypertension in the United States Circulation, September 13, 2005; 112(11): 1651 - 1662. [Full Text] [PDF]
|
|
|
|
 |
|
 J. M. Seubert, F. Xu, J. P. Graves, J. B. Collins, S. O. Sieber, R. S. Paules, D. L. Kroetz, and D. C. Zeldin Differential renal gene expression in prehypertensive and hypertensive spontaneously hypertensive rats Am J Physiol Renal Physiol, September 1, 2005; 289(3): F552 - F561. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. H. Franco, A. Peeters, L. Bonneux, and C. de Laet Blood Pressure in Adulthood and Life Expectancy With Cardiovascular Disease in Men and Women: Life Course Analysis Hypertension, August 1, 2005; 46(2): 280 - 286. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. M. Lloyd-Jones, J. C. Evans, and D. Levy Hypertension in Adults Across the Age Spectrum: Current Outcomes and Control in the Community JAMA, July 27, 2005; 294(4): 466 - 472. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. M. McEniery, Yasmin, S. Wallace, K. Maki-Petaja, B. McDonnell, J. E. Sharman, C. Retallick, S. S. Franklin, M. J. Brown, R. C. Lloyd, et al. Increased Stroke Volume and Aortic Stiffness Contribute to Isolated Systolic Hypertension in Young Adults Hypertension, July 1, 2005; 46(1): 221 - 226. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. S. Franklin, J. R. Pio, N. D. Wong, M. G. Larson, E. P. Leip, R. S. Vasan, and D. Levy Predictors of New-Onset Diastolic and Systolic Hypertension: The Framingham Heart Study Circulation, March 8, 2005; 111(9): 1121 - 1127. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. J. Elliott Management of Hypertension in the Very Elderly Patient Hypertension, December 1, 2004; 44(6): 800 - 804. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. Papademetriou, C. Farsang, D. Elmfeldt, A. Hofman, H. Lithell, B. Olofsson, I. Skoog, P. Trenkwalder, A. Zanchetti, and for the SCOPE Study Group Stroke prevention with the angiotensin II type 1-receptor blocker candesartan in elderly patients with isolated systolic hypertension: The study on cognition and prognosis in the elderly (SCOPE) J. Am. Coll. Cardiol., September 15, 2004; 44(6): 1175 - 1180. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Woo, M. Haverbusch, P. Sekar, B. Kissela, J. Khoury, A. Schneider, D. Kleindorfer, J. Szaflarski, A. Pancioli, E. Jauch, et al. Effect of Untreated Hypertension on Hemorrhagic Stroke Stroke, July 1, 2004; 35(7): 1703 - 1708. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. L. Pauca, N. D. Kon, and M. F. O'Rourke The second peak of the radial artery pressure wave represents aortic systolic pressure in hypertensive and elderly patients Br. J. Anaesth., May 1, 2004; 92(5): 651 - 657. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. J. Howell, J. W. Sear, and P. Foex Hypertension, hypertensive heart disease and perioperative cardiac risk{dagger} Br. J. Anaesth., April 1, 2004; 92(4): 570 - 583. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. J. O'Connor Overcome Clinical Inertia to Control Systolic Blood Pressure Arch Intern Med, December 8, 2003; 163(22): 2677 - 2678. [Full Text] [PDF]
|
|
|
|
|
|
K. Sutton-Tyrrell, R. Wildman, A. Newman, and L. H. Kuller Extent of Cardiovascular Risk Reduction Associated With Treatment of Isolated Systolic Hypertension Arch Intern Med, December 8, 2003; 163(22): 2728 - 2731. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. V. Chobanian, G. L. Bakris, H. R. Black, W. C. Cushman, L. A. Green, J. L. Izzo Jr, D. W. Jones, B. J. Materson, S. Oparil, J. T. Wright Jr, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Hypertension, December 1, 2003; 42(6): 1206 - 1252. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. J. Oliver and D. J. Webb Noninvasive Assessment of Arterial Stiffness and Risk of Atherosclerotic Events Arterioscler Thromb Vasc Biol, April 1, 2003; 23(4): 554 - 566. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Tamminen, J. Westerbacka, S. Vehkavaara, and H. Yki-Jarvinen Insulin-Induced Decreases in Aortic Wave Reflection and Central Systolic Pressure Are Impaired in Type 2 Diabetes Diabetes Care, December 1, 2002; 25(12): 2314 - 2319. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Lloyd-Jones, J. C. Evans, M. G. Larson, and D. Levy Treatment and Control of Hypertension in the Community: A Prospective Analysis Hypertension, November 1, 2002; 40(5): 640 - 646. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. M. Singer, M. Izhar, and H. R. Black Goal-Oriented Hypertension Management: Translating Clinical Trials to Practice Hypertension, October 1, 2002; 40(4): 464 - 469. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 I. Hajjar, K. Miller, and V. Hirth Age-Related Bias in the Management of Hypertension: A National Survey of Physicians' Opinions on Hypertension in Elderly Adults J Gerontol A Biol Sci Med Sci, August 1, 2002; 57(8): M487 - M491. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. S. Aronow Guest Editorial: What Is the Appropriate Treatment of Hypertension in Elders? J Gerontol A Biol Sci Med Sci, August 1, 2002; 57(8): M483 - M486. [Full Text] [PDF]
|
|
|
|
 |
|
 J. Blacher and M. Safar Specific aspects of high blood pressure in the elderly Journal of Renin-Angiotensin-Aldosterone System, March 1, 2002; 3(1_suppl): S10 - S15. [PDF]
|
|
|
|
|
|
P. A Meredith and P. Trenkwalder Therapy in the elderly hypertensive Journal of Renin-Angiotensin-Aldosterone System, March 1, 2002; 3(1_suppl): S49 - S56. [Abstract] [PDF]
|
|
|
|
|
|
J.-J. Mourad, J. Blacher, P. Blin, and U. Warzocha Conventional Antihypertensive Drug Therapy Does Not Prevent the Increase of Pulse Pressure With Age Hypertension, October 1, 2001; 38(4): 958 - 961. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||