Treatment of Isolated Systolic Hypertension in Primary Care

In This Article

Abstract and Introduction

The authors evaluated the treatment of isolated systolic hypertension based on medical record review of charts between 1998 and 1999 in a multispecialty physician practice group. Two age-stratified random samples of ambulatory medical records were examined (393 patients aged ≥65 years and 251 patients aged 50-64 years). The samples corresponded to the practices of 35 primary care physicians who were surveyed about their hypertension care. Isolated systolic hypertension was defined as systolic blood pressure ≥140 mm Hg and diastolic blood pressure <90 mm Hg. Results showed that isolated systolic hypertension represented 76% and 45% of uncontrolled blood pressure in the older and middle-aged samples, respectively. Isolated systolic hypertension was often undiagnosed and untreated. Physicians reported treatment thresholds and goals that were significantly less aggressive for their patients ≥65 years of age. Physician awareness and treatment of isolated systolic hypertension have not yet caught up with consensus guidelines, and older patients may be affected most by this gap.

A recent study of data from the third National Health and Nutritional Examination Survey (NHANES III) showed that isolated systolic hypertension (ISH) represented approximately 80% of all uncontrolled hypertension in individuals above age 50 in the United States.^[1]

However, NHANES III data collection began over a decade ago, in 1988.^[2] At that time, major placebo-controlled trials in ISH had not been completed. Consensus guidelines did not recommend treating ISH if systolic blood pressure (SBP) was less than 160 mm Hg.^[3] Thus, NHANES III provided an important assessment of the epidemiology of hypertension, but it could not serve as a specific indicator of quality care of ISH. Expectations for hypertension care in 1988 were significantly different from today. Furthermore, NHANES III measured only patient attitudes and conditions. It did not measure directly the perceptions or practices of physicians.

The most recent US consensus guidelines regarding ISH were issued by the sixth report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) in 1997. It defined ISH as SBP ≥140 mm Hg and diastolic blood pressure (DBP) <90 mm Hg.^[4] Few studies have examined the prevalence and treatment of ISH according to this definition.

We hypothesized that despite JNC VI recommendations, other guidelines, major trial results, and other studies supporting the importance of SBP, physicians tend to overlook and undertreat ISH. Our study was undertaken to provide more recent data on ISH in a typical multispecialty physician practice group, and examine how primary care providers diagnose and treat ISH.

Cite this: Physician Practice Patterns in The Treatment of Isolated Systolic Hypertension in a Primary Care Setting - Medscape - Mar 01, 2002.

Sidebar: Appendix

Demographics
In which specialty do you practice?
(1) General/family physician
(2) General internist
(3) Internal medicine subspecialist (specifically, ___________________)
How long have you been practicing?	__________ years
General Questions
When measuring a typical patient's blood pressure, which of the following do you usually accept as the diastolic blood pressure?
(1) Muffling of sound (fourth Korotkoff sound)
(2) Total cessation of sound (fifth Korotkoff sound)
Which of the following nonpharmacologic treatments do you routinely recommend to your hypertensive patients? (circle as many as are appropriate)
(1) Salt-restricted diet
(2) Stress reduction
(3) Regular exercise
(4) Weight reduction
(5) Biofeedback
(6) Limit alcohol to < 2 drinks/d
(7) Others
In your approach to the assessment and treatment of hypertension, to what extent do the influences listed below guide your practice? (Please circle number for each influence.)
	(not at all > greatly)
Clinical experience	1	2	3	4	5
Consensus guidelines	1	2	3	4	5
Continuing Medical Education	1	2	3	4	5
Opinion of local experts/colleagues	1	2	3	4	5
Pharmaceutical representatives	1	2	3	4	5
Medical journals*	1	2	3	4	5
Textbooks	1	2	3	4	5
Others (please specify)
______________________	1	2	3	4	5
______________________	1	2	3	4	5
When would you treat isolated systolic hypertension (ISH)? (Please give a specific value, not a range.)
Age:	50-64	65
SBP ≥	____	____
DBP <	____	____
Your treatment goals for ISH are: (Please give a specific value, not a range.)
Age:	50-64	65+
SBP <	_____	_____
DBP <	_____	_____
When do you use drug therapy for sustained systolic blood pressure above normal with diastolic pressure of less than 90 mm Hg?
q	SBP >	q	I do not use drug therapy in these patients (please check).
50-64	____	____
65+	____	____
If you answered "I do not use drug therapy" to both parts of this question, please go to question 9.
If you do not consider drug therapy, why not? (Please check as many reasons as are applicable.)
q	ISH is an inevitable consequence of aging.
q	ISH does not have as bad prognosis for older people as diastolic hypertension.
q	ISH is a compensatory mechanism to force blood through artherosclerotic arteries in older people.
q	Elderly patients do not comply with drug therapy.
q	There is no beneficial effect in treating ISH in the elderly with drugs.
q	Drug side effects may reduce quality of life.
q	Others ________________________________________________________________________
Clinical Scenario
A 73-year-old female nonsmoker presents to your clinic for evaluation of elevated blood pressure. Assume that her blood pressure has been the same for the last three visits over the past three months. Past medical history, family history, and physical exam are otherwise unremarkable. The patient has been compliant with your recommendations for nonpharmacologic measures (e.g., diet, exercise) to reduce blood pressure for the past year.
Please indicate (by circling your choice) the lowest systolic blood pressure (recorded in mm Hg) at which you would recommend pharmacologic therapy:
SBP <140	140-149	150-159	160-169	170-179	>180
Which medication would you advise for initial therapy? (Please specify name, dose and frequency.)
What would be the target systolic blood pressure you would endeavor to obtain in this patient? < ______ mm Hg
4. If your initial therapeutic choice didn't achieve satisfactory control despite titration to maximal dose, what would your next choice be? (Please specify drug name, dose and frequency.)