Systolic hypertension

# Overview
Systolic hypertension is defined as an elevated systolic blood pressure with a normal diastolic blood pressure. Systolic hypertension may be due to reduced compliance of the aorta with increasing age.

# Treatment
Several randomized controlled trials have established the value of treating systolic hypertension.

## SHEP study
This randomized controlled trial showed a reduction of three strokes per 100 patients treated for five years
- Patients: inclusion criteria were SBP greater than 160 to 219 mm Hg and DBP less than 90 mm Hg. Exclusion criteria included "history of stroke with  residual  paresisor  other  neurological  disability." Mean initial BP was 170/77.
- Treatment goal: 20 mmHg reduction in systolic pressure or a systolic pressure of less than 160 mmHg, whichever was lower
- Mean final blood pressure in the treatment group: 143/68

## Syst-Eur Trial
This randomized controlled trial showed a reduction of 0.3 strokes per 100 patients treated for a median follow-up of two years.
- Patients: inclusion criteria were systolic of 160-219 mm Hg and diastolic blood pressure lower than 95 mm Hg. Average was 174/86 mm HG.
- Treatment goal: "We aimed to reduce the sitting systolic blood pressure by at least 20 mm Hg to less than 150 mm Hg"
- Mean final blood pressure in the treatment group: 151/79. 44% of patients reached the target blood pressure goals.

## HYVET Trial
Although not labeled a trial of systolic hypertension, the separate report of the subgroup of patients were 80 years old or older, on average had systolic hypertension with baseline mean blood pressure values of 173/91
- Patients: inclusion criteria were systolic of over 160 mm Hg. Average was 173/91 mm Hg.
- Treatment goal: 150/80
- Mean final blood pressure in the treatment group: not repeated. Only the differences between groups were reported.

## SPRINT
Although not labeled a trial of systolic hypertension, the separate report of the subgroup of patients 75 years old or older, on average had systolic hypertension with baseline mean blood pressure values of 142/71.
- Patients: inclusion criteria were 75 years or older with hypertension but without diabetes, SPRINT exclusion criteria included: history of stroke, "an SBP of less than 110 mm Hg following 1 minute of standing."
- Treatment goal: "systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment)"
- Mean final blood pressure in the treatment group: 123/63. Mean final blood pressure in the control group: 135/67.

## The treatment goal
Based on these studies, treating to a systolic blood pressure of 140, as long as the diastolic blood pressure is 68 or more seems safe. Corroborating this, a re-analysis of the SHEP data suggest that allowing the diastolic to go below 70 may increase adverse effects..
A meta-analysis of  individual-patient data from randomized controlled trials found that the nadir diastolic blood pressure below which cardiovascular outcomes increase is 85 mm Hg for untreated hypertensives and 85 mm Hg for treated hypertensives. The authors concluded "poor health conditions leading to low blood pressure and an increased risk for death probably explain the J-shaped curve". Interpreting the meta-analysis is difficult, but avoiding a diastolic blood pressure below 68-70 mm Hg seems reasonable because:
- The nadir value of 85 mm Hg for treated hypertensives in the meta-analysis is higher than the value of 68-70 mm Hg that is the nadir suggested by the two major randomized controlled trials of isolated systolic hypertension
- The two largest trials in the meta-analysis, Hypertension Detection and Follow-up Program (HDFP) and Medical Research Council trial in mild hypertension (MRC1) were predominantly middle aged subjects, all of whom had diastolic hypertension before treatment.
- The independent contributions of incidental comorbid diseases versus effects of treatment are not clear in the meta-analysis
More recent analyses that include the SPRINT trial, find conflicting results:
- No relation to blood pressure treatment
- Avoid treating  below 70
- No relationship unless in the setting of tight diabetic control

### Practice guidelines =
The 2018 ESC/ESH Guidelines include the statements:
- Among patients with coronary artery disease, treat to a DBP target of < 80, but not less than 70 mmHg
- The 2017 ACC/AHA guidelines to not discuss low DBP