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Prevention of Heart Failure by Antihypertensive Drug Treatment in Older Persons With Isolated Systolic Hypertension

John B. Kostis, MD; Barry R. Davis, MD, PhD; Jeffrey Cutler, MD; Richard H. Grimm Jr, MD, PhD; Kenneth G. Berge, MD; Jerome D. Cohen, MD; Clifton R. Lacy, MD; H. Mitchell Perry Jr, MD; M. Donald Blaufox, MD, PhD; Sylvia Wassertheil-Smoller, PhD; Henry R, Black, MD; Eleanor Schron, RN, MS; David M. Berkson, MD; J. David Curb, MD; W. McFate Smith, MD; Robert McDonald, MD; William B. Applegate, MD
JAMA. 1997;278(3):212-216. doi:10.1001/jama.1997.03550030052033.
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Context.  —Heart failure is often preceded by isolated systolic hypertension, but the effectiveness of antihypertensive treatment in preventing heart failure is not known.

Objective.  —To assess the effect of diuretic-based antihypertensive stepped-care treatment on the occurrence of heart failure in older persons with isolated systolic hypertension.

Design.  —Analysis of data from a multicenter, randomized, double-blind, placebo-controlled clinical trial.

Participants.  —A total of 4736 persons aged 60 years and older with systolic blood pressure between 160 and 219 mm Hg and diastolic blood pressure below 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program (SHEP).

Intervention.  —Stepped-care antihypertensive drug therapy, in which the step 1 drug is chlorthalidone (12.5-25 mg) or matching placebo, and the step 2 drug is atenolol (25-50 mg) or matching placebo.

Main Outcome Measures.  —Fatal and nonfatal heart failure.

Results.  —During an average of 4.5 years of follow-up, fatal or nonfatal heart failure occurred in 55 of 2365 patients randomized to active therapy and 105 of the 2371 patients randomized to placebo (relative risk [RR], 0.51; 95% confidence interval [CI], 0.37-0.71; P<.001; number needed to treat to prevent 1 event [NNT], 48). Among patients with a history of or electrocardiographic evidence of prior myocardial infarction (MI), the RR was 0.19 (95% CI, 0.06-0.53; P=.002; NNT, 15). Older patients, men, and those with higher systolic blood pressure or a history of or electrocardiographic evidence of MI at baseline had higher risk of developing heart failure.

Conclusion.  —In older persons with isolated systolic hypertension, stepped-care treatment based on low-dose chlorthalidone exerted a strong protective effect in preventing heart failure. Among patients with prior MI, an 80% risk reduction was observed.


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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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