Physician Practice Patterns in The Treatment of Isolated Systolic Hypertension in a Primary Care Setting

Jeff Borenstein, MD, MPH; Joanna L. Whyte, MS, RD, MSPH; Enkhe Badamgarav, MD; Delia Vogel, RN; Stephen Deutsch, MD; Scott Weingarten, MD, MPH; , Pablo Lapuerta, MD

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.