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September 9, 1992, Vol 268, No. 10 >
ARTICLE | September 9, 1992

Isolated Systolic Hypertension and Subclinical Cardiovascular Disease in the Elderly: Title and subTitle BreakInitial Findings From the Cardiovascular Health Study FREE

Bruce M. Psaty, MD, PhD; Curt D. Furberg, MD, PhD; Lewis H. Kuller, MD, DrPH; Nemat O. Borhani, MD; Pentti M. Rautaharju, MD, PhD; Daniel H. O'Leary, MD; Diane E. Bild, MD, MPH; John Robbins, MD, MHS; Linda P. Fried, MD, MPH; Cheryl Reid, MD
[+] Author Affiliations

A complete list of the participants in this research study appears at the end of this article.

Reprint requests to Cardiovascular Health Study, Coordinating Center, JD-30,1107 NE 45th St, Suite 530, University of Washington, Seattle, WA 98105 (Dr Psaty).


JAMA. 1992;268(10):1287-1291. doi:10.1001/jama.1992.03490100085032
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References

Objective.  —To assess the association between isolated systolic hypertension (ISH) and subclinical disease in adults aged 65 years and above.

Design.  —Medicare eligibility lists were used to obtain a representative sample of 5201 community-dwelling elderly persons for the Cardiovascular Health Study, a National Heart, Lung, and Blood Institute—sponsored cohort study of risk factors for coronary heart disease and stroke. In this cross-sectional analysis of baseline data, we excluded 3012 participants who were receiving antihypertensive medications, had clinical cardiovascular disease, or had a diastolic blood pressure of at least 90 mm Hg.

Main Outcome Measures.  —For electrocardiogram: myocardial infarction, left ventricular hypertrophy, and left ventricular mass as measures of myocardial damage and strain; for echocardiography: left ventricular mass, fractional shortening, and Doppler flow velocities as measures of cardiac systolic and diastolic function; and for carotid sonography: carotid arterial intima-media thickness as a measure of atherosclerosis.

Results.  —Among the 2189 men and women in this analysis, 195 (9%) had ISH (systolic blood pressure, ≥160 mm Hg) and 596 (23%) had borderline ISH (systolic blood pressure, 140 to 159 mm Hg). Systolic blood pressure was associated with myocardial infarction by electrocardiogram (P=.02). Borderline and definite ISH were strongly associated with left ventricular mass (P<.001). While there was little association with cardiac systolic function, borderline and definite ISH were associated with cardiac diastolic function (P<.001). Isolated systolic hypertension was also strongly associated with increased intima-media thickness of the carotid artery (P<.001).

Conclusions.  —While cohort analyses of future repeated measures will provide a better assessment of risk, both borderline and definite ISH were strongly related to a variety of measures of subclinical disease in elderly men and women.(JAMA. 1992;268:1287-1291)

REFERENCES

1 +
Stamler J, Neaton JD, Wentworth DN.  Blood pressure (systolic and diastolic) and risk of fatal coronary heart disease. Hypertension . 1989;;13( (suppl I) ):I-2-I-12.
2 +
Veterans Administration Cooperative Study Group on Antihypertensive Agents.  Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA . 1967;;202:116-122.
3 +
Hypertension Detection and Follow-up Program Cooperative Group.  Five-year findings of the hypertension detection and follow-up program, I: reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA . 1979;; 242:2562-2571.
4 +
Medical Research Council Working Party.  MRC trial of treatment of mild hypertension: principal results. BMJ . 1985;;291:97-104.
5 +
Dustan HP.  Isolated systolic hypertension: a long-neglected cause of cardiovascular complications. Am J Med . 1989;;86:368-369.
6 +
Stokes J, Kannel WB, Wolf PA, D'Agostino RB, Cupples LA.  Blood pressure as a risk factor for cardiovascular disease: the Framingham Study-30 years of follow-up. Hypertension . 1989;;13( (suppl I) ):I-13-I-18.
7 +
Kannel WB, Dawber TR, McGee DL.  Perspectives on systolic hypertension: the Framingham Study. Circulation . 1980;;61:1179-1182.
8 +
Colandrea MA, Friedman GD, Nichaman MZ, Lynd CN.  Systolic hypertension in the elderly: an epidemiologic assessment. Circulation . 1970;;61:239-245.
9 +
Garland C, Barrett-Connor E, Suarez L, Criqui MH.  Isolated systolic hypertension and mortality after age 60. Am J Epidemiol . 1983;;118:365-376.
10 +
Rutan GH, Kuller LH, Neaton JD, Wentworth DN, McDonald RH, Smith WM.  Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial. Circulation . 1988;;77:504-514.
11 +
Staessen J, Amery A, Fagard R.  Isolated systolic hypertension in the elderly. J Hypertens . 1990;; 8:393-405.
12 +
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.
13 +
Fried LP, Borhani NO, Enright P, et al.  The Cardiovascular Health Study: design and rationale. Ann Epidemiol . 1991;;1:263-276.
14 +
Rautaharju PM, MacInnis PJ, Warren JW, Wolf HK, Rykers PM, Calhoun HP.  Methodology of ECG interpretation in the Dalhousie Program: NOVACODE ECG classification procedure for clinical trials and population health surveys. Methods Inf Med . 1990;;29:362-374.
15 +
O'Leary DH, Polak JF, Wolfson Jr SK, et al.  The use of sonography to evaluate carotid atherosclerosis in the elderly: the Cardiovascular Health Study. Stroke . 1991;;22:1155-1163.
16 +
Gardin JM, Wong ND, Bommer W, et al.  Echocardiographic design of a multi-center investigation of free-living elderly subjects: the Cardiovascular Health Study. J Am Soc Echocardiogr . 1992;;5:63-72.
17 +
Psaty BM, Lee M, Savage PJ, Rutan GH, German PS, Lyles M.  Assessing the use of medications in the elderly: method and initial results in the Cardiovascular Health Study. J Clin Epidemiol . 1992;;45:683-692.
18 +
1988 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.  The 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med . 1988;;148: 1023-1038.
19 +
Rose GA, Blackburn H, Gillum RF, Prineas RJ. Cardiovascular Survey Methods . 2nd ed. Geneva, Switzerland: World Health Organization; 1982;. World Health Organization monograph series No. 56.
20 +
Norusis MJ, for SPSS Inc. SPSS/PC+ 4.0 Base Manual for the IBM PC/XT/AT and PS/2 . Chicago, Ill: SPSS Inc; 1990;.
21 +
Snedecor GW, Cochran WG. Statistical Methods . 7th ed. Ames: Iowa State University Press; 1980;.
22 +
McCullagh P, Nelder JA. Generalized linear models . London, England: Chapman and Hall Ltd; 1983;.
23 +
Schlesselman JJ. Case-Control Studies: Design, Conduct, Analysis . New York, NY: Oxford University Press Inc; 1982;.
24 +
Kannel WB, Dannenberg AL, Abbott RD.  Unrecognized myocardial infarction and hypertension: the Framingham Study. Am Heart J . 1985;;109:581-585.
25 +
Levy D, Anderson KM, Savage DD, et al.  Echocardiographically detected left ventricular hypertrophy: prevalence and risk factors, the Framingham Heart Study. Ann Intern Med . 1988;;108:7-13.
26 +
Devereux RB.  Echocardiographic insights into the pathophysiology and prognostic significance of hypertensive cardiac hypertrophy. Am J Hypertens . 1989;;2( (suppl S) ):186S-195S.
27 +
Kitakatake A, Tanouchi J, Masuyama T, et al.  Limited atrial compensation to reduced early diastolic filling in hypertensive patients with advanced left ventricular hypertrophy: a Doppler echocardiographic study. Heart Vessels . 1989;;5:33-40.
28 +
Verdecchi P, Schillaci G, Guerrieri M, et al.  Prevalence and determinants of left-ventricular diastolic filling abnormalities in an unselected hypertensive population. Eur Heart J . 1990;;11:679-691.
29 +
O'Leary DH, Anderson KM, Kase CS, Wolf PA, Kannel WB.  Extracranial carotid atherosclerosis in a general population: the Framingham Study. Stroke . 1988;;19:143. Abstract.
30 +
Tell GS, Howard G, McKinney WM.  Risk factors for site specific extracranial carotid artery plaque distribution as measured by B-mode ultrasound. J Clin Epidemiol . 1989;;42:551-559.
31 +
Salonen R, Salonen JT.  Progression of carotid atherosclerosis and its determinants: a population-based ultrasonography study. Atherosclerosis . 1990;; 81:33-40.
32 +
Salonen R, Salonen JT.  Carotid atherosclerosis in relation to systolic and diastolic blood pressure: Kupio Ischaemic Heart Disease Risk Factor Study. Ann Med . 1991;;23:23-27.
33 +
Dahlof B, Hansson L, Lindholm L, Rastam L, Schersten B, Wester PO.  STOP-hypertension: Swedish trial in old patients with hypertension. J Hypertens . 1986;;4:511-513.

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1 +
Stamler J, Neaton JD, Wentworth DN.  Blood pressure (systolic and diastolic) and risk of fatal coronary heart disease. Hypertension . 1989;;13( (suppl I) ):I-2-I-12.
2 +
Veterans Administration Cooperative Study Group on Antihypertensive Agents.  Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA . 1967;;202:116-122.
3 +
Hypertension Detection and Follow-up Program Cooperative Group.  Five-year findings of the hypertension detection and follow-up program, I: reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA . 1979;; 242:2562-2571.
4 +
Medical Research Council Working Party.  MRC trial of treatment of mild hypertension: principal results. BMJ . 1985;;291:97-104.
5 +
Dustan HP.  Isolated systolic hypertension: a long-neglected cause of cardiovascular complications. Am J Med . 1989;;86:368-369.
6 +
Stokes J, Kannel WB, Wolf PA, D'Agostino RB, Cupples LA.  Blood pressure as a risk factor for cardiovascular disease: the Framingham Study-30 years of follow-up. Hypertension . 1989;;13( (suppl I) ):I-13-I-18.
7 +
Kannel WB, Dawber TR, McGee DL.  Perspectives on systolic hypertension: the Framingham Study. Circulation . 1980;;61:1179-1182.
8 +
Colandrea MA, Friedman GD, Nichaman MZ, Lynd CN.  Systolic hypertension in the elderly: an epidemiologic assessment. Circulation . 1970;;61:239-245.
9 +
Garland C, Barrett-Connor E, Suarez L, Criqui MH.  Isolated systolic hypertension and mortality after age 60. Am J Epidemiol . 1983;;118:365-376.
10 +
Rutan GH, Kuller LH, Neaton JD, Wentworth DN, McDonald RH, Smith WM.  Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial. Circulation . 1988;;77:504-514.
11 +
Staessen J, Amery A, Fagard R.  Isolated systolic hypertension in the elderly. J Hypertens . 1990;; 8:393-405.
12 +
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.
13 +
Fried LP, Borhani NO, Enright P, et al.  The Cardiovascular Health Study: design and rationale. Ann Epidemiol . 1991;;1:263-276.
14 +
Rautaharju PM, MacInnis PJ, Warren JW, Wolf HK, Rykers PM, Calhoun HP.  Methodology of ECG interpretation in the Dalhousie Program: NOVACODE ECG classification procedure for clinical trials and population health surveys. Methods Inf Med . 1990;;29:362-374.
15 +
O'Leary DH, Polak JF, Wolfson Jr SK, et al.  The use of sonography to evaluate carotid atherosclerosis in the elderly: the Cardiovascular Health Study. Stroke . 1991;;22:1155-1163.
16 +
Gardin JM, Wong ND, Bommer W, et al.  Echocardiographic design of a multi-center investigation of free-living elderly subjects: the Cardiovascular Health Study. J Am Soc Echocardiogr . 1992;;5:63-72.
17 +
Psaty BM, Lee M, Savage PJ, Rutan GH, German PS, Lyles M.  Assessing the use of medications in the elderly: method and initial results in the Cardiovascular Health Study. J Clin Epidemiol . 1992;;45:683-692.
18 +
1988 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.  The 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med . 1988;;148: 1023-1038.
19 +
Rose GA, Blackburn H, Gillum RF, Prineas RJ. Cardiovascular Survey Methods . 2nd ed. Geneva, Switzerland: World Health Organization; 1982;. World Health Organization monograph series No. 56.
20 +
Norusis MJ, for SPSS Inc. SPSS/PC+ 4.0 Base Manual for the IBM PC/XT/AT and PS/2 . Chicago, Ill: SPSS Inc; 1990;.
21 +
Snedecor GW, Cochran WG. Statistical Methods . 7th ed. Ames: Iowa State University Press; 1980;.
22 +
McCullagh P, Nelder JA. Generalized linear models . London, England: Chapman and Hall Ltd; 1983;.
23 +
Schlesselman JJ. Case-Control Studies: Design, Conduct, Analysis . New York, NY: Oxford University Press Inc; 1982;.
24 +
Kannel WB, Dannenberg AL, Abbott RD.  Unrecognized myocardial infarction and hypertension: the Framingham Study. Am Heart J . 1985;;109:581-585.
25 +
Levy D, Anderson KM, Savage DD, et al.  Echocardiographically detected left ventricular hypertrophy: prevalence and risk factors, the Framingham Heart Study. Ann Intern Med . 1988;;108:7-13.
26 +
Devereux RB.  Echocardiographic insights into the pathophysiology and prognostic significance of hypertensive cardiac hypertrophy. Am J Hypertens . 1989;;2( (suppl S) ):186S-195S.
27 +
Kitakatake A, Tanouchi J, Masuyama T, et al.  Limited atrial compensation to reduced early diastolic filling in hypertensive patients with advanced left ventricular hypertrophy: a Doppler echocardiographic study. Heart Vessels . 1989;;5:33-40.
28 +
Verdecchi P, Schillaci G, Guerrieri M, et al.  Prevalence and determinants of left-ventricular diastolic filling abnormalities in an unselected hypertensive population. Eur Heart J . 1990;;11:679-691.
29 +
O'Leary DH, Anderson KM, Kase CS, Wolf PA, Kannel WB.  Extracranial carotid atherosclerosis in a general population: the Framingham Study. Stroke . 1988;;19:143. Abstract.
30 +
Tell GS, Howard G, McKinney WM.  Risk factors for site specific extracranial carotid artery plaque distribution as measured by B-mode ultrasound. J Clin Epidemiol . 1989;;42:551-559.
31 +
Salonen R, Salonen JT.  Progression of carotid atherosclerosis and its determinants: a population-based ultrasonography study. Atherosclerosis . 1990;; 81:33-40.
32 +
Salonen R, Salonen JT.  Carotid atherosclerosis in relation to systolic and diastolic blood pressure: Kupio Ischaemic Heart Disease Risk Factor Study. Ann Med . 1991;;23:23-27.
33 +
Dahlof B, Hansson L, Lindholm L, Rastam L, Schersten B, Wester PO.  STOP-hypertension: Swedish trial in old patients with hypertension. J Hypertens . 1986;;4:511-513.

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