The detection, treatment and control of high blood pressure in older British adults: cross-sectional findings from the British Women's Heart and Health Study and the British Regional Heart Study Results of the Ontario Survey on the Prevalence and Control of Hypertension Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View Implications of the Systolic Hypertension in the Elderly Program: The Systolic Hypertension in the Elderly Program Cooperative Research Group Detection and treatment of hypertension in older individuals. A Risk Score for Predicting Near-Term Incidence of Hypertension: The Framingham Heart Study Double-blind randomised trial of modest salt restriction in older people Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people On-treatment diastolic blood pressure and prognosis in systolic hypertension. Too Old to Benefit from Sports? The Cardiovascular Effects of Exercise Training in Elderly Subjects Treated for Isolated Systolic Hypertension Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension Effects of immediate versus delayed antihypertensive therapy on outcome in the Systolic Hypertension in Europe Trial Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. Screening for Type 2 Diabetes Mellitus: A Cost-Effectiveness Analysis Pulse pressure as a predictor of stroke Improved Hypertension Management and Control: Results From the Health Survey for England 1998 Hyperuricemia and incident atrial fibrillation in a normotensive elderly population in Taiwan. Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program. Correlates of blood pressure in an urban Zimbabwean population and comparison to other populations of African origin Subgroup and per-protocol analysis of the randomized European Trial on Isolated Systolic Hypertension in the Elderly. Systolic Blood Pressure Goals to Reduce Cardiovascular Disease Among Older Adults
Among older people , the detection and control of hypertension is particularly important to reduce cardiovascular disease risk . This cross-sectional survey aim ed to describe the detection , treatment and control of hypertension in older British adults . A total of 3059 women and 3007 men aged 60–79 years were r and omly selected from general practice age/sex registers in 24 British towns and examined from 1998 to 2001 . Of these , 52.6 % women and 47.9 % men had at least one indicator of hypertension ( high blood pressure on examination , or taking antihypertensive medication or recalled a doctor diagnosis of high blood pressure ) . Among women , 50 % of those with any indication of hypertension were on treatment and 29 % were well controlled , and among men 45 % were on treatment and 16 % were well controlled . With the exception of alcohol use in men ( adjusted odds ratio 0.67 ( 0.46 , 0.98 ) ) , socioeconomic factors , area of residence and behavioural risk factors were not associated with good control among those with hypertension in either sex . Of those on treatment , 20.7 % of women and 28 % of men were on two classes of antihypertensive medication and 3.5 and 4.9 % , respectively , were on three or more classes of antihypertensive medication . Among those with a doctor diagnosis of hypertension and taking antihypertensive medication , the proportion with well controlled blood pressure did not differ between those on more than one antihypertensive and those on just one in either sex . We conclude that targets of good control are rarely met in older individuals , who would benefit from the associated reduction in cardiovascular disease risk Background : Available information on the prevalence and management of hypertension in the Canadian population date s back to 1986–1992 and probably does not reflect the current status of this major risk factor for cardiovascular disease . We sought to evaluate the current prevalence and management of hypertension among adults in the province of Ontario . Methods : Potential respondents from r and omly selected dwellings within target neighbourhoods in 16 municipalities were contacted at their homes to request participation in the study . For potential respondents who agreed to participate ,  blood pressure  was measured with an automated device . Estimation weights were used to obtain representative estimates of population parameters . Responses were weighted to the total adult population in Ontario of 7 996 653 . Results : From 6436 eligible dwellings , contact was made with 4559 potential participants , of whom 2992 agreed to participate .  Blood pressure measurements were obtained for 2551 of these respondents ( age 20–79 years ) .  Hypertension , defined as systolic blood pressure of 140 mm Hg or more , diastolic blood pressure of 90 mm Hg or more , or treatment with an antihypertensive medication , was identified in 21.3 % of the population overall ( 23.8 % of men and 19.0 % of women ) . Prevalence increased with age , from 3.4 % among participants 20–39 years of age to 51.6 % among those 60–79 years of age . Hypertension was more common among black people and people of South Asian background than among white people ; hypertension was also associated with higher body mass index . Among participants with hypertension , 65.7 % were undergoing treatment with control of hypertension , 14.7 % were undergoing treatment but the hypertension was not controlled , and 19.5 % were not receiving any treatment ( including 13.7 % who were unaware of their hypertension ) . The extent of control of hypertension did not differ significantly by age , sex , ethnic background or comorbidities . Interpretation : In Ontario , the overall prevalence of hypertension is high in the older population but appears not to have increased in recent decades . Hypertension management has improved markedly among all age groups and for both sexes The 2014 Evidence -Based Guideline for the Management of  High Blood Pressure In Adults : Report From the Panel Members Appointed to the Eighth Joint National Committee ( JNC 8) recommends several major changes from the JNC 7 report ( 1 , 2 ) . The 2014 guideline is based on a systematic review of r and omized , controlled trials ( RCTs ) by a multidisciplinary panel using a process informed by Institute of Medicine recommendations for guideline development ( 3 ) . Although there was almost unanimous agreement on nearly all recommendations , a minority of the panel ( the authors of this commentary ) disagreed with the recommendation to increase the target systolic blood pressure ( SBP ) from 140 to 150 mm Hg in persons aged 60 years or older without diabetes mellitus ( DM ) or chronic kidney disease ( CKD ) . This target guides both the initiation of therapy and treatment goals . Although this issue has major clinical and public health implication s , the guideline only briefly summarized the concerns underlying the minority opinion to maintain the target of less than 140 mm Hg . The Institute of Medicine recommendation for guideline development encourages guidelines to provide a description and explanation of any differences of opinion regarding the recommendation ( 3 ) . This summarizes the evidence and rationale underlying the minority opinion to maintain the SBP target of 140 mm Hg or lower in persons aged 60 years or older until there is greater certainty of the risks and benefits of a higher target . First , increasing the target will probably reduce the intensity of antihypertensive treatment in a large population at high risk for cardiovascular disease ( CVD ) ( Table 1 ) . The higher SBP goal would apply to some of the groups at highest cardiovascular risk , such as African Americans , hypertensive patients with multiple CVD risk factors other than DM or CKD , and those with clinical CVD . Second , the evidence supporting increasing the SBP target from 140 to 150 mm Hg in persons aged 60 years or older was insufficient and inconsistent with the evidence supporting the panel 's recommendations for an SBP target of less than 140 mm Hg in persons younger than 60 years and those aged 60 years or older with DM or CKD . Third , the higher SBP goal in individuals aged 60 years or older may reverse the decades-long decline in CVD , especially stroke mortality ( 4 ) . In the absence of definitive evidence defining the optimum SBP target , observational studies and RCT data that the panel did not systematic ally review more strongly support the SBP goal of less than 140 mm Hg , especially in high-risk individuals . Other recent guideline groups review ing similar evidence have recommended a goal of less than 140 mm Hg , particularly in persons aged 80 years or younger ( 59 ) . Table 1 . U.S. Cardiovascular Disease Death Rates for Persons Younger and Older Than 65 y Persons Aged 60 Years or Older With Hypertension and SBP Controlled to 140 mm Hg or Lower More than half of the 72 million persons with hypertension in the United States are aged 60 years or older ( 10 , 11 ) . Among these individuals , the 2014 guideline recommends the SBP goal of 140 mm Hg or lower only for those with DM and those younger than 70 years with CKD ( 2 ) . Although the prevalence of hypertension in this age group ( 65 % to 67 % ) did not change between 1999 and 2010 , the percentage with adequate blood pressure control increased from 27.4 % ( 19992000 ) to 50.5 % ( 20112012 ) , with 82.2 % now receiving antihypertensive medications ( 10 , 12 ) . Data from NHANES ( National Health and Nutrition Examination Survey ) from 2001 to 2008 show that among treated and untreated hypertensive adults aged 60 years or older , median SBPs were 136 mm Hg and 152 mm Hg , respectively ( 13 ) , and SBPs have been decreasing in this age group over the past 5 decades ( Figure ) ( 4 ) . Thus , a target of less than 150 mm Hg would likely increase blood pressures in the treated hypertensive population and would suggest that nearly half of the untreated hypertensive patients in this age range should remain untreated . The large population at high risk for CVD , with most currently at an SBP of 140 mm Hg or lower , creates concern that a higher SBP target will adversely affect public health . Figure . Smoothed weighted frequency distribution , median , and 90th percentile of systolic blood pressure for persons aged 60 to 74 y : United States , 19592010 . Reproduced from Lackl and and colleagues ( 4 ) . NHANES = National Health and Nutrition Examination Survey ; NHES = National Health Examination Survey . High Risk in Persons With the Higher Goal Age substantially increases risk for cardiovascular events ( Table 1 ) , so differences in cardiovascular risk do not justify different targets for patients older and younger than 60 years . The risk range for white and African American men aged 60 years is 9 % to 30 % , depending on risk factor profile . For men of both ethnicities who are aged 70 years or older and have SBP controlled to 140 mm Hg , even without clinical CVD or DM , the 10-year risk exceeds 20 % ( 14 ) . Thus , on the basis of absolute risk , using an age threshold of 60 years to define eligibility for less aggressive treatment lacks consistency . Persons aged 60 to 79 years are at higher risk than those who are younger , even if the younger persons have DM . Insufficient Evidence for Differential Hypertension Treatment Benefit for Patients Older and Younger Than 60 Years The 2014 guideline panel failed to identify evidence of differential benefits or harms of treatment using an SBP goal of 140 mm Hg with an age threshold of 60 years . There is little RCT evidence of risk or benefit in treating persons younger than 60 years to this target , except in those with diastolic hypertension . The guideline indicates that no qualifying evidence was found comparing an SBP less than 140 mm Hg to any other SBP goal for persons younger than 60 years ( 2 ) . However , in persons aged 60 years or older , the SHEP ( Systolic Hypertension in the Elderly Program ) trial showed benefit of treating hypertension to an SBP goal between 140 and 145 mm Hg ( Table 2 ) ( 15 ) . HYVET ( Hypertension in the Very Elderly Trial ) found a benefit of an SBP target of less than 150 mm Hg on health outcomes , including mortality in persons aged 80 years or older ( 16 ) . Patients in the HYVET treatment group achieved an SBP of 144 mm Hg at 2 years compared with 159 mm Hg in the control group , and blood pressures continued to decrease in both groups until the end of the trial . Therefore , HYVET and the SHEP trial provide evidence that reducing SBP to around 140 mm Hg has substantial benefit without major harm in older persons . Thus , the best evidence available for an SBP target around 140 mm Hg , which meets the guideline RCT criteria , is in persons older than 60 years . The lack of benefit seen in 2 Japanese trials in older individuals ( JATOS [ Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients ] [ 17 ] and the VALISH [ Valsartan in Elderly Isolated Systolic Hypertension ] trial [ 18 ] ) was cited by some to rationalize the higher SBP target , but these trials were underpowered ( Table 2 ) . The SHEP trial and HYVET together reported 365 strokes and more than 285 coronary heart disease events , whereas JATOS and the VALISH trial only had a combined total of 125 strokes and 67 coronary heart disease events . In addition , the much larger FEVER ( Felodipine Event Reduction ) trial ( 19 ) did not meet criteria for inclusion in the panel 's deliberation ( Table 2 ) . This trial , which was conducted in a Chinese population ( age range , 50 to 79 years ; mean age , 62 years ) , reported a significant 27 % reduction in its primary outcome , as well as significant reductions in all CVD , total mortality , coronary heart disease , and heart failure in patients treated to an SBP of 137 mm Hg with a thiazide diureticcalcium-channel blocker combination versus 143 mm Hg with a thiazide diuretic plus placebo ( 19 ) . Table 2 . Trials Comparing Different Systolic Blood Pressure Thresholds In addition , generalizability of the Japanese trials to other population s of patients older than 60 years , such as African Americans , is uncertain . African Americans are at highest risk for all complications of hypertension and are historically undertreated . Thus , we believe that recommending less aggressive targets in this or other high-risk population s requires stronger justification than the guideline cites . Three recent guidelines from other countries have concluded that the appropriate cut point for an age-related differential SBP goal is 80 years or older ( 57 ) . We agree that this higher treatment target in frail hypertensive patients aged 80 years or older better reflects existing evidence . Safety and Adverse Event Risk in Hypertensive Patients Aged 60 Years or Older Despite the limited number of end points in JATOS and the VALISH trial , their size and duration provide evidence of safety of the SBP target of less than 140 mm Hg . The VALISH investigators concluded that this target was safe in relatively healthy patients aged 70 years or older with isolated systolic hypertension ( 18 ) . In JATOS , adverse events requiring treatment discontinuation were reported in only 36 patients , with no differences in discontinuation rate between groups ( 17 ) . This evidence and the favorable results at slightly higher blood pressures in the SHEP trial and HYVET provide reassurance of the safety of an SBP goal of less than 140 mm Hg in older , nonfrail persons . Other Trial Evidence of Benefit of Treatment at an SBP of 140 mm Hg or Lower Results of the SPS3 ( Secondary Prevention of Small Subcortical Strokes ) trial indicated that an SBP target of less than 130 mm Hg versus 144 mm Hg in 3020 patients ( mean age , 63 years ) reduced subsequent strokes by 19 % ( P= 0.08 ) and hemorrhagic strokes by nearly 50 % ( P < 0.01 ) ( 20 ) . Of note , the FEVER trial reported a 44 % ( P < 0.001 ) reduction in all strokes in a subgroup analysis of patients older than 65 years ( 17 ) . Finally , 2 meta-analyses & NA ; Several imperatives drive the need to establish the merit of treating isolated systolic hypertension in the elderly . These include its higher prevalence with age , the associated excess cardiovascular risks , and the rapid aging of the population . The Systolic Hypertension in the Elderly Program demonstrated a significant reduction in stroke incidence ( fatal and nonfatal ) ( 36 % , equivalent to preventing 30 strokes per 1,000 participants per 5 years ) . A 27 % reduction in coronary heart disease incidence and a 32 % reduction in all major cardiovascular events were also achieved ( equivalent to the prevention of 16 and 55 events per 1,000 participants per 5 years , respectively ) . These results were associated with a treatment regimen in which the primary agent was low‐dose chlorthalidone . The benefits accrued to all subgroups identified based on baseline age , race and sex , blood pressure , serum cholesterol levels , and electrocardiographic abnormalities . The reduction in coronary disease is consistent with predictions based on prospect i ve epidemiological studies and is concordant with other recent intervention trials . It is a reasonable inference from the Systolic Hypertension in the Elderly Program findings that middle‐aged as well as older people with isolated systolic hypertension , and people with less severe degrees of this condition , particularly when other risk factors are present , would benefit from such therapy . Another reasonable implication of the trial relates to the matter of preferred drug treatment regimens for diastolic hypertension , in middle‐aged as well as older people . A low‐dose diuretic regimen is clearly the initial treatment of choice for most hypertensive patients , based on demonstrated reduction in risk for major cardiovascular events , including coronary heart disease , and its safety , patient acceptance , and low cost . ( Hypertension 1993;21:335‐343 The Hypertension Detection and Follow-up Program screened 34,012 individuals aged 60 - 69 years old in their homes in 14 communities around the United States during 1972 and 1973 . The prevalence of hypertension , defined as diastolic blood pressure greater than or equal to 90 mmHg or on antihypertensive medication , was 42.1 % . After a second clinic screen , 2,376 hypertensives were identified and r and omized into Stepped Care , a special intensive treatment group , or Referred Care , a group referred to their usual medical care sources . These individuals were followed for five years ( until they reached the ages of 65 - 74 years ) . Over the five years , 79.4 % of older individuals remained under active care and 81.4 % of those were at their goal diastolic blood pressure . Side-effects tended to be less frequent in older individuals than in younger ones . Older Stepped Care participants with mild hypertension ( diastolic blood pressure 90 - 104 mmHg ) had a 17.2 % reduction in all-cause mortality over five years compared to Referred Care , which was primarily due to a reduction in deaths attributed to cardiovascular causes . Thus , antihypertensive treatment can be safely and beneficially administered to individuals in this age range with diastolic hypertension , including those with mild hypertension Context Identifying adults with a high probability of developing high blood pressure  could help target nonpharmacologic measures to prevent hypertension . Contribution Using data from the Framingham cohort study , the investigators devised a simple risk score with good performance characteristics that identified adults without diabetes who had low ( < 5 % ) , medium ( 5 % to 10 % ) , or high ( > 10 % ) probability of developing hypertension within 4 years . The risk score included points for age , sex , systolic and diastolic blood pressure , body mass index , parental hypertension , and cigarette smoking . Implication If this risk score is vali date d in additional patient population s , it could help clinicians identify high-risk patients with prehypertension . The Editors In 2003 , the Seventh Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure created a prehypertension category for persons with blood pressures ranging from 120 to 139 mm Hg ( systolic ) or from 80 to 89 mm Hg ( diastolic ) . The committee strongly advocated lifestyle and behavioral modification for individuals with prehypertension ( 1 ) . This new recommendation was based largely on epidemiologic evidence that individuals with nonoptimal blood pressure ( > 120/80 mm Hg ) are at increased risk for progression to overt hypertension ( 1 , 2 ) and that cardiovascular disease risk increases in a grade d fashion beginning at a blood pressure of 115/75 mm Hg , well within the normal range ( 1 , 3 ) . However , this new categorization scheme result ed in 70 million people being considered prehypertensive , a situation that poses a challenge for both physicians and patients . Recent clinical trials have focused on the treatment of persons with prehypertension to determine whether hypertension onset can be delayed . A recent clinical trial demonstrated that individuals with blood pressures of 130 to 139 mm Hg ( systolic ) and 80 to 85 mm Hg ( diastolic ) who were treated for 2 years with c and esartan , an angiotensin II receptor blocker , had a 15 % reduction in the incidence of hypertension over 4 years compared with patients r and omly assigned to placebo ( 4 ) . A clinical trial of lifestyle modification among overweight individuals without hypertension demonstrated that a low-salt diet and regular physical exercise reduced hypertension incidence in the short term and several years after the clinical trial ( 5 , 6 ) . Although these investigations have demonstrated the feasibility and efficacy of preventing hypertension , a strategy that targets all individuals with prehypertension is likely to be associated with substantial medical and economic re sources . Evidence suggests that the risk for progression to hypertension depends on clinical factors , such as baseline blood pressure , age , and body mass index ( 2 ) . An individualized approach of risk stratification and targeted treatment of the nonhypertensive persons who are at greatest risk for progression may be more desirable . We developed a simple risk score that can be used in a physician 's office to estimate the probability that an individual will develop hypertension over 1 to 4 years and to identify the persons who are at the highest risk for hypertension . Such high-risk individuals will probably derive the maximal benefit from nonpharmacologic ( lifestyle-related ) and pharmacologic interventions aim ed at preventing hypertension . Thus , we believe that knowledge of the risk for hypertension will aid patient education and counseling , and it will assist clinical decision making and design of future interventional studies . Supplement . Risk Calculator Methods Sample The Framingham Heart Study is a community-based , prospect i ve cohort study that began in 1948 with the enrollment of 5209 men and women ( whom we refer to as the original cohort ) ( 7 ) . In 1971 , 5124 men and women were enrolled into the Framingham Offspring Study cohort , which included the children of the original cohort and the spouses of the children . Participant examinations for the offspring cohort occurred approximately every 4 years . The design and methods of the Framingham Offspring Study are described elsewhere ( 8) . For our investigation , offspring cohort participants were eligible if they attended 2 consecutive examinations between the second ( 1979 to 1983 ) and seventh examinations ( 1998 to 2001 ) and if both of their parents were in the original cohort ( 8813 person-examinations ) ( Figure 1 ) . Participants were eligible for inclusion at more than 1 heart study examination cycle if they reached the next examination without meeting any exclusion criteria . We excluded participants who had prevalent hypertension ( n= 2542 ) , prevalent cardiovascular disease ( n= 233 ) , or serum creatinine values greater than 177 mol/L ( 2 mg/dL ) ( n= 4 ) ; were younger than age 20 years or older than age 69 years ( n= 77 ) ; had missing covariates ( n= 46 ) ; or had prevalent diabetes mellitus ( n= 97 ) . We excluded persons with diabetes from our analysis because lower cut-points of systolic and diastolic pressure define the target blood pressure goal in these individuals ( 1 ) . After we applied the exclusion criteria , 5814 person-examinations from 1717 unique individuals ( 54 % women ) remained eligible for analysis . All participants provided written informed consent , and the study protocol was approved by the Boston University Medical Center Institutional Review Board . Figure 1 . Number of participants available for evaluation of hypertension incidence at baseline examination and number of participants with incident hypertension at follow-up examination . Assessment of Risk Factors At each Framingham Heart Study examination , participants underwent a medical history and physical examination , anthropometric measurements , and laboratory assessment of vascular risk factors . Blood pressure  was measured on the left arm of seated participants by a physician using a mercury-column sphygmomanometer , a cuff of the appropriate size , and a st and ardized protocol . Participants had rested in a chair for 5 minutes before blood pressure was measured , and the average of 2 readings obtained by a physician was considered the examination blood pressure . Systolic blood pressure of 140 mm Hg or higher , diastolic blood pressure of 90 mm Hg or higher , or use of blood pressurelowering medications defined hypertension . Current smoking was defined as regular cigarette smoking in the year before the examination . Body mass index was calculated as body weight ( in kilograms ) divided by the square of height ( in meters ) . Consumption of more than 7 drinks per week in women and more than 14 drinks per week in men defined moderate alcohol intake ( 1 ) . A fasting blood glucose level of 7.0 mmol/L ( 126 mg/dL ) or more , use of hypoglycemic medications , or both defined diabetes mellitus . Parental hypertension was defined as documented maternal and paternal hypertension at or before the baseline examination at which offspring were eligible for our investigation . Parental hypertension status was ascertained on the basis of blood pressure readings of the original cohort participants by using serial data from examination cycle 3 ( 1952 to 1956 ) through examination 27 ( 2002 to 2004 ) . Prevalent cardiovascular disease was defined as presence of coronary heart disease , stroke , transient ischemic attack , intermittent claudication , or heart failure at any examination . The criteria for diagnosis of these cardiovascular events are described elsewhere ( 9 ) . Statistical Analysis We measured hypertension incidence during the interval between offspring cohort examinations ( median , 3.8 years ) . If a person remained without hypertension at the follow-up examination , he or she remained eligible to contribute to the next 4-year period . A Weibull regression model for interval-censored data ( 10 ) was used because only the interval during which new hypertension developed was available ; the exact date of onset of hypertension between 2 Framingham Heart Study examinations could not be determined . Significant predictors of hypertension incidence were identified by entering c and i date risk factors ( age , sex , body weight , body mass index , physical activity index , diabetes , systolic blood pressure , diastolic blood pressure , moderate alcohol intake , current smoking , and parental occurrence of hypertension [ modeled as 0 , 1 , or 2 parents with hypertension ] ) into a stepwise model . These risk factors have been associated with hypertension in other studies ( 1 ) . Because diastolic blood pressure decreases with age ( 11 ) , we evaluated an interaction term for diastolic blood pressure by age , along with the other c and i date risk factors . We also tested the following additional interaction terms in multivariable models : diastolic blood pressure by sex , systolic blood pressure by sex , body mass index by smoking , parental hypertension by age , parental hypertension by sex , and parental hypertension by body mass index . We developed a risk prediction score from -coefficients for variables associated with hypertension incidence in multivariable Weibull regression models by using methods described elsewhere ( 12 ) . Continuous variables were divided into categories to facilitate risk estimation : Age was divided into 10-year groups ; systolic blood pressure was divided into 5 mm Hg categories beginning with 110 mm Hg and ending with 139 mm Hg ; and diastolic blood pressure was divided into 5 mm Hg categories beginning with 70 mm Hg and ending with 89 mm Hg . Body mass index was classified into 3 levels : less than 25 kg/m2 ( normal ) , 25 to less than 30 kg/m2 ( overweight ) , and 30 kg/m2 or more ( obesity ) . We derived 1- , 2- and 4-year rates of hypertension incidence directly from the Weibull model ( Appendix ) . We chose to assess 4-year risk because examination cycles in the Framingham Offspring Study occurred approximately every 4 years , and we were interested in assessing a short-term risk score for hypertension . We present 1- and 2-year risks for hypertension because we believe that these short-term risk BACKGROUND Stroke is directly related to blood pressure and treatment trials in older hypertensive individuals show a reduction in strokes . However , the majority of strokes occur in normotensive individuals in whom no attempt is made to lower blood pressure . We compared the effects of modest salt restriction on blood pressure in older hypertensive and normotensive people . METHODS 47 untreated elderly people ( 24 men , age range 60 - 78 years ; blood-pressure range 123 - 205 mm Hg systolic and 64 - 112 mm Hg diastolic ) completed a 2-month double-blind r and omised placebo-controlled crossover study of modest salt restriction with slow sodium and placebo to give a salt intake of either 10 g ( equivalent to the normal amount for the UK population ) or 5 g. FINDINGS On the normal salt intake for the UK population , supine blood pressure was 163/90 ( SD 21/10 ) mm Hg with urinary sodium excretion of 177 ( 49 ) mmol/day . With modest sodium restriction , blood pressure fell to 156/87 ( 22/9 ) mm Hg ( p < 0.001/0.004 ) with a urinary sodium excretion of 94 ( 50 ) mmol/day . A reduction in sodium intake of 83 mmol/day was associated with a reduction of 7.2/3.2 mm Hg . There was no significant difference in the blood-pressure fall between 18 normotensive and 29 hypertensive participants ( 8.2/3.9 vs 6.6/2.7 mm Hg ) . INTERPRETATION A modest reduction in salt intake leads to a fall in blood pressure in both normotensive and hypertensive older people similar to that in outcome trials of thiazide-based treatment . Since the majority of strokes in older people occur below the current definition of hypertension , our results have important implication s for the prevention of stroke Summary Background The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared . In this study , we aim ed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease . Methods We used  linked electronic health records from 1997 to 2010 in the CALIBER ( CArdiovascular research using LInked Bespoke studies and Electronic health Records ) programme to assemble a cohort of 1·25 million patients , 30 years of age or older and initially free from cardiovascular disease , a fifth of whom received blood pressure-lowering treatments . We studied the heterogeneity in the age-specific associations of clinical ly measured blood pressure with 12 acute and chronic cardiovascular diseases , and estimated the lifetime risks ( up to 95 years of age ) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30 , 60 , and 80 years . This study is registered at Clinical Trials.gov , number NCT01164371 . Findings During 5·2 years median follow-up , we recorded 83 098 initial cardiovascular disease presentations . In each age group , the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90–114 mm Hg and diastolic blood pressure of 60–74 mm Hg , with no evidence of a J-shaped increased risk at lower blood pressures . The effect of high blood pressure varied by cardiovascular disease endpoint , from strongly positive to no effect . Associations with high systolic blood pressure were strongest for intracerebral haemorrhage ( hazard ratio 1·44 [ 95 % CI 1·32–1·58 ] ) , subarachnoid haemorrhage ( 1·43 [ 1·25–1·63 ] ) , and stable angina ( 1·41 [ 1·36–1·46 ] ) , and weakest for abdominal aortic aneurysm ( 1·08 [ 1·00–1·17 ] ) . Compared with diastolic blood pressure , raised systolic blood pressure had a greater effect on angina , myocardial infa rct ion , and peripheral arterial disease , whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure . Pulse pressure associations were inverse for abdominal aortic aneurysm ( HR per 10 mm Hg 0·91 [ 95 % CI 0·86–0·98 ] ) and strongest for peripheral arterial disease ( 1·23 [ 1·20–1·27 ] ) . People with  hypertension ( blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs ) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3 % ( 95 % CI 62·9–63·8 ) compared with 46·1 % ( 45·5–46·8 ) for those with normal blood pressure , and developed cardiovascular disease 5·0 years earlier ( 95 % CI 4·8–5·2 ) . Stable and unstable angina accounted for most ( 43 % ) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years , whereas heart failure and stable angina accounted for the largest proportion ( 19 % each ) of years of life lost from index age 80 years . Interpretation The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range , and that diastolic and systolic associations are concordant , are not supported by the findings of this high-resolution study . Despite modern treatments , the lifetime burden of hypertension is substantial . These findings emphasise the need for new  blood pressure-lowering strategies , and will help to inform the design of r and omised trials to assess them . Funding Medical Research Council , National Institute for Health Research , and Wellcome Trust BACKGROUND It has been suggested that low diastolic blood pressure ( BP ) while receiving antihypertensive treatment ( hereinafter called on-treatment BP ) is harmful in older patients with systolic hypertension . We examined the association between on-treatment diastolic BP , mortality , and cardiovascular events in the prospect i ve placebo-controlled Systolic Hypertension in Europe Trial . METHODS Elderly patients with systolic hypertension were r and omized into the double-blind first phase of the trial , after which all patients received active study drugs ( phase 2 ) . We assessed the relationship between outcome and on-treatment diastolic BP by use of multivariate Cox regression analysis during receipt of placebo ( phase 1 ) and during active treatment ( phases 1 and 2 ) . RESULTS Rates of noncardiovascular mortality , cardiovascular mortality , and cardiovascular events were 11.1 , 12.0 , and 29.4 , respectively , per 1000 patient-years with active treatment ( n = 2358 ) and 11.9 , 12.6 , and 39.0 , respectively , with placebo ( n = 2225 ) . Noncardiovascular mortality , but not cardiovascular mortality , increased with low diastolic BP with active treatment ( P < .005 ) and with placebo ( P < .05 ) ; for example , hazard ratios for lower diastolic BP , that is , 65 to 60 mm Hg , were , respectively , 1.15 ( 95 % confidence interval , 1.00 - 1.31 ) and 1.28 ( 95 % confidence interval , 1.03 - 1.59 ) . Low diastolic BP with active treatment was associated with increased risk of cardiovascular events , but only in patients with coronary heart disease at baseline ( P < .02 ; hazard ratio for BP 65 - 60 mm Hg , 1.17 ; 95 % confidence interval , 0.98 - 1.38 ) . CONCLUSIONS These findings support the hypothesis that antihypertensive treatment can be intensified to prevent cardiovascular events when systolic BP is not under control in older patients with systolic hypertension , at least until diastolic BP reaches 55 mm Hg . However , a prudent approach is warranted in patients with concomitant coronary heart disease , in whom diastolic BP should probably not be lowered to less than 70 mm Hg Background : Hypertension in the elderly is commonly characterized by an elevation of pulse pressure . With regard to advanced arteriosclerosis and limited physical fitness , doubt was casted whether elderly patients still achieve relevant cardiovascular benefits by physical exercise . The present work examines the impact of pulse pressure as a footprint of vascular ageing on cardiovascular benefits of endurance training in elderly hypertensives . Methods : 54 patients ≧60 years with systolic 24-hour ambulatory blood pressure ( ABP ) > 140 mm Hg and /or antihypertensive treatment and diastolic ABP ≤90 mm Hg were r and omly assigned  to sedentary activity or a 12-week treadmill exercise program ( target lactate 2.5 ± 0.5 mmol/l ) . Results : Exercise significantly decreased systolic and diastolic ABP by 8.5 ± 8.2 and 5.1 ± 3.7 mm Hg ( p < 0.001 each ) and increased physical performance . Arterial compliance remained unchanged , whereas endothelium-dependent vasodilation – measured by flow-mediated dilation – significantly increased from 5.6 ± 1.7 to 7.9 ± 3.0 % ( p < 0.007 ) . After adjustment for initial systolic ABP , pulse pressure did not affect the change of BP . Conclusion :  The exercise-induced reduction of BP , which is mediated by improved endothelial function , is independent of pulse pressure . Thus , physical exercise is a helpful adjunct to control BP even in old hypertensives with markedly increased arterial stiffness Background Isolated systolic hyprtension occurs in around 8 % of Chinese people aged 60 years or older . In 1988 , the Systolic Hypertension in China ( Syst-China ) Collaborative Group started to investigate whether active treatment could reduce the incidence of stroke and other cardiovascular complications in older patients with isolated systolic hypertension . Methods All patients were initially started on masked placebo . After stratification for centre , sex and previous cardiovascular complications , alternate patients ( n = 1253 ) were assigned nitrendipine at 10–40 mg daily , with the addition of captopril at 12.5–50.0 mg daily or hydrochlorothiazide at 12.5–50.0 mg daily , or both , if a sufficient blood pressure fall was not obtained . In the remaining 1141 control patients , matching placebos were administered similarly . Results At entry , sitting blood pressure averaged 170.5 mmHg systolic and 86.0 mmHg diastolic , age averaged 66.5 years and total serum cholesterol was 5.1 mmol/l . After 2 years of follow-up , sitting systolic and diastolic blood pressures had fallen by 10.9 mmHg and 1.9 mmHg in the placebo group and by 20.0 mmHg and 5.0 mmHg in the active treatment group . The intergroup differences were 9.1 mmHg systolic ( 95 % confidence interval 7.6–10.7 mmHg ) and 3.2 mmHg diastolic ( 95 % confidence interval 2.4–4.0 ) . Active treatment reduced total strokes by 38 % ( from 20.8 to 13.0 endpoints per 1000 patient-years , P = 0.01 ) , all-cause mortality by 39 % ( from 28.4 to 17.4 endpoints per 1000 patient-years , P = 0.003 ) , cardiovascular mortality by 39 % ( from 15.2 to 9.4 endpoints per 1000 patient-years , P = 0.03 ) , stroke mortality by 58 % ( from 6.9 to 2.9 endpoints per 1000 patient-years , P = 0.02 ) , and all fatal and nonfatal cardiovascular endpoints by 37 % ( from 33.3 to 21.4 endpoints per 1000 patient-years , P = 0.004 ) . Conclusions Antihypertensive treatment prevents stroke and other cardiovascular complications in older Chinese patients with isolated systolic hypertension . Treatment of 1000 Chinese patients for 5 years could prevent 55 deaths , 39 strokes or 59 major cardiovascular endpoints Background To assess the impact of immediate versus delayed antihypertensive treatment on the outcome of older patients with isolated systolic hypertension  , we extended the double-blind placebo-controlled Systolic Hypertension in Europe ( Syst-Eur ) trial by an open-label follow-up study lasting 4 years . Methods The Syst-Eur trial included 4695 r and omized patients with minimum age of 60 years and an untreated blood pressure of 160–219 mmHg systolic and below 95 mmHg diastolic . The double-blind trial ended after a median follow-up of 2.0 years ( range 1–97 months ) . Of 4409 patients still alive , 3517 received open-label treatment consisting of nitrendipine ( 10–40 mg daily ) with the possible addition of enalapril ( 5–20 mg daily ) , hydrochlorothiazide ( 12.5–25 mg daily ) , or both add-on drugs .  Non- participants ( n = 892 ) were also followed up . Results Median follow-up increased to 6.1 years . Systolic pressure decreased to below 150 mmHg ( target level ) in 2628 participants ( 75.0 % ) . During the 4-year open-label follow-up , stroke and cardiovascular complications occurred at similar frequencies in patients formerly r and omized to placebo and those continuing active treatment . These rates were similar to those previously observed in the active-treatment group during the double-blind trial . Considering the total follow-up of 4695 r and omized patients , immediate compared with delayed antihypertensive treatment reduced the occurrence of stroke and cardiovascular complications by 28 % ( P = 0.01 ) and 15 % ( P = 0.03 ) , respectively , with a similar tendency for total mortality ( 13 % , P = 0.09 ) . In 492 diabetic patients , the corresponding estimates of long-term benefit ( P < 0.02 ) were 60 , 51 and 38 % , respectively . Conclusions Antihypertensive treatment can achieve blood pressure control in most older patients with isolated systolic hypertension . Immediate compared with delayed treatment prevented 17 strokes or 25 major cardiovascular events per 1000 patients followed up for 6 years . These findings underscore the necessity of early treatment of isolated systolic hypertension Although the benefits of antihypertensive treatment in " young " elderly ( under 70 years ) hypertensive patients are well established , the value of treatment in older patients ( 70 - 84 years ) is less clear . The Swedish Trial in Old Patients with Hypertension ( STOP-Hypertension ) was a prospect i ve , r and omised , double-blind , intervention study set up to compare the effects of active antihypertensive therapy ( three beta-blockers and one diuretic ) and placebo on the frequency of fatal and non-fatal stroke and myocardial infa rct ion and other cardiovascular death in hypertensive Swedish men and women aged 70 - 84 years . We recruited 1627 patients at 116 health centres throughout Sweden , who were willing to participate , and who met the entry criteria of three separate recordings during a 1-month placebo run-in period of systolic blood pressure between 180 and 230 mm Hg with a diastolic pressure of at least 90 mm Hg , or a diastolic pressure between 105 and 120 mm Hg irrespective of the systolic pressure . The total duration of the study was 65 months and the average time in the study was 25 months . 812 patients were r and omly allocated active treatment and 815 placebo . The mean difference in supine blood pressure between the active treatment and placebo groups at the last follow-up before an endpoint , death , or study termination was 19.5/8.1 mm Hg . Compared with placebo , active treatment significantly reduced the number of primary endpoints ( 94 vs 58 ; p = 0.0031 ) and stroke morbidity and mortality ( 53 vs 29 ; p = 0.0081 ) . Although we did not set out to study an effect on total mortality , we also noted a significantly reduced number of deaths in the active treatment group ( 63 vs 36 ; p = 0.0079 ) . The benefits of treatment were discernible up to age 84 years . We conclude that antihypertensive treatment in hypertensive men and women aged 70 - 84 confers highly significant and clinical ly relevant reductions in cardiovascular morbidity and mortality as well as in total mortality BACKGROUND Isolated systolic hypertension occurs in about 15 % of people aged 60 years or older . In 1989 , the European Working Party on High Blood Pressure in the Elderly investigated whether active treatment could reduce cardiovascular complications of isolated systolic hypertension . Fatal and non-fatal stroke combined was the primary endpoint . METHODS All patients ( > 60 years ) were initially started on masked placebo .  At three run-in visits 1 month apart , their average sitting systolic blood pressure was 160 - 219 mm Hg with a diastolic blood pressure lower than 95 mm Hg . After stratification for centre , sex , and previous cardiovascular complications , 4695 patients were r and omly assigned to nitrendipine 10 - 40 mg daily , with the possible addition of enalapril 5 - 20 mg daily and hydrochlorothiazide 12.5 - 25.0 mg daily , or matching placebos . Patients withdrawing from double-blind treatment were still followed up . We compared occurrence of major endpoints by intention to treat . FINDINGS At a median of 2 years ' follow-up , sitting systolic and diastolic blood pressures had fallen by 13 mm Hg and 2 mm Hg in the placebo group ( n = 2297 ) and by 23 mm Hg and 7 mm Hg in the active treatment group ( n = 2398 ) . The between-group differences were systolic 10.1 mm Hg ( 95 % CI 8.8 - 11.4 ) and diastolic , 4.5 mm Hg ( 3.9 - 5.1 ) . Active treatment reduced the total rate of stroke from 13.7 to 7.9 endpoints per 1000 patient-years ( 42 % reduction ; p = 0.003 ) . Non-fatal stroke decreased by 44 % ( p = 0.007 ) . In the active treatment group , all fatal and non-fatal cardiac endpoints , including sudden death , declined by 26 % ( p = 0.03 ) . Non-fatal cardiac endpoints decreased by 33 % ( p = 0.03 ) and all fatal and non-fatal cardiovascular endpoints by 31 % ( p < 0.001 ) . Cardiovascular mortality was slightly lower on active treatment ( -27 % , p = 0.07 ) , but all-cause mortality was not influenced ( -14 % ; p = 0.22 ) . INTERPRETATION Among elderly patients with isolated systolic hypertension , antihypertensive drug treatment starting with nitrendipine reduces the rate of cardiovascular complications . Treatment of 1000 patients for 5 years with this type of regimen may prevent 29 strokes or 53 major cardiovascular endpoints BACKGROUND Recent reports suggest that calcium-channel blockers may be harmful in patients with diabetes and hypertension . We previously reported that antihypertensive treatment with the calcium-channel blocker nitrendipine reduced the risk of cardiovascular events . In this post hoc analysis , we compared the outcome of treatment with nitrendipine in diabetic and nondiabetic patients . METHODS After stratification according to center , sex , and presence or absence of previous cardiovascular complications , 4695 patients ( age , > or = 60 years ) with systolic blood pressure of 160 to 219 mm Hg and diastolic pressure below 95 mm Hg were r and omly assigned to receive active treatment or placebo . Active treatment consisted of nitrendipine ( 10 to 40 mg per day ) with the possible addition or substitution of enalapril ( 5 to 20 mg per day ) or hydrochlorothiazide ( 12.5 to 25 mg per day ) or both , titrated to reduce the systolic blood pressure by at least 20 mm Hg and to less than 150 mm Hg . In the control group , matching placebo tablets were administered similarly . RESULTS At r and omization , 492 patients ( 10.5 percent ) had diabetes . After a median follow-up of two years , the systolic and diastolic blood pressures in the placebo and active-treatment groups differed by 8.6 and 3.9 mm Hg , respectively , among the diabetic patients . Among the 4203 patients without diabetes , systolic and diastolic pressures differed by 10.3 and 4.5 mm Hg , respectively , in the two groups . After adjustment for possible confounders , active treatment was found to have reduced overall mortality by 55 percent ( from 45.1 deaths per 1000 patients to 26.4 deaths per 1000 patients ) , mortality from cardiovascular disease by 76 percent , all cardiovascular events combined by 69 percent , fatal and nonfatal strokes by 73 percent , and all cardiac events combined by 63 percent in the group of patients with diabetes . Among the nondiabetic patients , active treatment decreased all cardiovascular events combined by 26 percent and fatal and nonfatal strokes by 38 percent . In the group of patients receiving active treatment , reductions in overall mortality , mortality from cardiovascular disease , and all cardiovascular events were significantly larger among the diabetic patients than among the nondiabetic patients ( P=0.04 , P=0.02 , and P=0.01 , respectively ) . CONCLUSIONS Nitrendipine-based antihypertensive therapy is particularly beneficial in older patients with diabetes and isolated systolic hypertension . Thus , our findings do not support the hypothesis that the use of long-acting calcium-channel blockers may be harmful in diabetic patients Context In 2003 , the U.S. Preventive Services Task Force recommended screening for type 2 diabetes in adults with hypertension or hyperlipidemia . The economic implication s of this recommendation are unclear . Contribution Diabetes screening for 55-year-old hypertensive persons would cost the U.S. health care system $ 34 375 per quality -adjusted life-year gained . Exp and ing screening to all adults regardless of the presence of hypertension would cost an additional $ 360 966 per quality -adjusted life-year . Implication s The cost-effectiveness of targeting diabetes screening to hypertensive adults older than 55 years of age is similar to the cost-effectiveness of many accepted health care interventions . Universal diabetes screening is far more costly . The Editors Although many adults who meet criteria for type 2 diabetes ( hereafter , diabetes ) have not been identified ( 1 ) , screening for diabetes remains controversial ( 2 - 11 ) . Direct evidence indicates that various treatments to reduce complications are effective among people with clinical ly detected diabetes ( 12 - 14 ) , but no direct evidence tells us the magnitude of any further benefit from starting these treatments earlier , after detection by screening ( 15 ) . In the absence of direct evidence , research ers have applied mathematical models of diabetes progression to the issue of screening . One analysis found that the cost per quality -adjusted life-year ( QALY ) gained by universal diabetes screening was lower for younger than for older people : $ 13 376 at age 25 to 34 years , increasing to $ 116 908 at age 55 to 64 years ( 16 ) . This conclusion followed from the model 's focus on the provision of glycemic control after screening to prevent microvascular complications . The analysis did not consider treatments to reduce the risks for complications of cardiovascular disease ( CVD ) . More recent research suggests that the benefits of CVD risk reduction may be substantial for people with diabetes . The Hypertension Optimal Treatment ( HOT ) trial found that the optimal blood pressure target is lower for people with hypertension and diabetes than for people with hypertension without diabetes ( 14 ) . Other research supports the finding that intensive control of hypertension is beneficial among people with diabetes ( 15 , 17 - 19 ) . Because the benefit may be greater for older people ( at greater risk for CVD ) , the conclusion of the previous analysis , that diabetes screening is most cost-effective among younger people , needs to be reconsidered . We performed a new cost-effectiveness analysis to compare universal diabetes screening ( universal screening ) and diabetes screening targeted to  patients with hypertension ( targeted screening ) . When an up date d version of the model used in the previous analysis that includes benefits from intensive treatment of hypertension was applied , we estimated the incremental cost-effectiveness of these 2 strategies for people in different age groups . Our analysis considers a one-time opportunistic screening for men and women of all races and ethnicities . Methods The Model We used a Markov model of diabetes disease progression to simulate lifetime diabetes-related health care costs and QALYs for people with diabetes ( Appendix Figure 1 ) . Demographic characteristics of the simulated cohort are based on 1997 population estimates projected from the 1990 U.S. Census and data on the distribution of people with diabetes by hypertension , cholesterol level , and smoking status ( 20 ) . As people progress through the simulation model from the onset of diabetes to death , they can develop 5 types of complications : nephropathy , neuropathy , retinopathy , coronary heart disease ( CHD ) , and stroke . People can die of some of these complications or of other causes . The model includes transition probabilities between disease stages on each of the 5 complication paths . The basic model structure has been described previously ( 16 , 21 ) . Key model parameters are presented in the Appendix Tables 1 to 10 . To incorporate screening into the model , we first added a screening module in which some patients with diabetes are identified earlier than they would usually have been in the absence of screening . Second , we made assumptions about the transition probabilities between disease stages from the onset of diabetes to the time of usual clinical diagnosis of diabetes on the basis of the knowledge that progression is relatively slow during this period ( 15 ) . After clinical diagnosis , disease progression depends on the number of years after normal diagnosis . Screening allows for earlier diagnosis , which in turn allows for earlier treatment interventions , such as intensive glycemic control and intensive hypertension control . These interventions decrease the transition probabilities , thereby delaying or preventing progression to diabetes complications . Costs are incurred for screening and diagnostic testing ; st and ard glycemic control and , if the person is hypertensive , st and ard hypertension control ; interventions ( intensive glycemic control and , if the person is hypertensive , intensive hypertension control ) ; and complications over the remaining lifetime of each person with diabetes . The sum of these costs and the model 's estimate of the expected QALYs for each screening strategy are used to calculate the incremental cost-effectiveness ratio of screening relative to no screening . We discounted future costs and QALYs at a 3 % annual rate . Costs are measured in 1997 U.S. dollars . Interventions We assumed that , in the absence of screening , diabetes would be diagnosed 10 years after its onset ( 15 ) . With one-time opportunistic screening , diabetes would be diagnosed on average 5 years after onset and therefore patients would begin treatment 5 years earlier . After diabetes diagnosis , all patients are treated with intensive glycemic control and , if they have hypertension , with intensive hypertension control . With targeted screening , only people with hypertension are screened . Those who screen positive and receive a diagnosis of diabetes begin intensive glycemic control and intensive hypertensive control 5 years earlier than they would in the absence of screening . With universal screening , all people , regardless of hypertension status , are screened . Those who screen positive and receive a diagnosis of diabetes begin intensive glycemic control 5 years earlier than in the absence of screening and begin intensive hypertension control 5 years earlier if they have hypertension . We defined hypertension as a blood pressure of 140/90 mm Hg or higher . We assumed that 19 % of people age 25 to 44 years , 47 % of people age 45 to 64 years , and 60 % of people age 65 to 74 years had hypertension and therefore were included in targeted screening ( 20 ) . Treatment of hypertension is modeled as st and ard ( with a target diastolic blood pressure of 90 mm Hg ) or intensive ( with a target diastolic blood pressure of 80 mm Hg ) , as in the HOT trial ( 14 ) . All persons with hypertension receive st and ard hypertension treatment until they receive a diagnosis of diabetes , after which they receive intensive hypertension treatment . The incremental cost of intensive hypertension control relative to st and ard control is $ 149 per year . In the HOT trial , the relative risk reduction for CHD events ( fatal and nonfatal myocardial infa rct ion ) was 51 % , and the relative risk reduction for stroke was about 30 % . Although neither of these separate relative risk reductions was statistically significant , the relative risk reduction ( 51 % ) for the aggregate outcome of major CVD events was statistically significant ( P = 0.005 ) . We initially modeled the relative risk reduction for CHD events for intensive hypertension control to be 51 % , with no risk reduction for stroke . We conducted a sensitivity analysis that included a 30 % relative risk reduction for stroke on the basis of other studies showing that intensive hypertension control reduces risk among people with diabetes ( 17 , 19 ) . Model estimates of the effects of glycemic control are based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , a 10-year r and omized , controlled trial of intensive versus conventional glycemic control ( 12 ) . On the basis of the UKPDS , the reduction in hemoglobin A1c from intensive glycemic treatment is modeled as slowing the progression of microvascular complications ( 12 ) . The incremental cost of intensive glycemic control ( relative to st and ard control ) ranges from $ 900 to $ 1100 per year , depending on the number of years since diagnosis . Screening and Diagnostic Tests The Figure illustrates the screening and diagnostic testing process and shows where costs are incurred . Figure . Progression of persons screened for diabetes . Appendix Figure 1 . Markov model of diabetes disease progression . LEA CA MI Screening Tests We assume a one-time opportunistic screening during a regularly scheduled physician office visit . The model assumes screening by a fasting capillary blood glucose ( CBG ) test ( 22 ) and an extra 10 minutes over the usual 15 minutes for the physician visit , incurring a cost of $ 24.40 per person screened . Costs for the CBG test are derived from the Medicare Clinical Diagnostic Laboratory Fee Schedule ( 23 ) ; physician visit costs are derived from Relative Values for Physicians ( 24 ) . Table 1 shows prevalence ( from the National Health and Nutrition Examination Survey III data tape ) , CBG sensitivity and specificity values ( 22 ) with exact data points clarified via personal communication ( Rolka DB , 18 January 2002 ) , and the number needed to screen to detect one previously undiagnosed person with diabetes by sex , hypertension status , and age . Table 1 . Number of Screenings and Diagnostic Tests  Needed To Identify One Undiagnosed Diabetes Case Diagnostic Tests All people who screen ( true or false ) positive receive a diagnostic test , the fasting plasma glucose test , which is repeated if the result is positive . Because 2 consecutive elevated fasting plasma glucose test results define diabetes ( 11 ) , we assume The current guidelines for the detection and management of  high blood pressure  depend exclusively on the measurement of  systolic and diastolic blood pressure  , although these are only two specific points on the arterial pressure wave form [ 1,2 ] . However , it may be more appropriate to describe the cardiac cycle as consisting of a pulsatile ( pulse pressure ) and a steady ( mean pressure ) component . Pulse pressure is defined as the difference between systolic and diastolic pressures and primarily reflects the stiffness of large arteries , especially the aorta . Elevated pulse pressure increases the stretch of arteries , induces fatigue and fracture of elastic elements , and accelerates the development of aneurysms , and ultimately their rupture . Similarly , an increased pulse pressure is more likely to contribute to intimal damage , the prelude to atherosclerosis and arterial thrombotic events . Increased pulse pressure has also been associated with thickening of the carotid intima and media [ 3,4 ] . Systolic blood pressure increases across all age groups , whereas diastolic blood pressure increases until the sixth decade of life and then declines thereafter . As a result , pulse pressure increases as age rises , especially in older people as systolic and diastolic blood pressure move in opposite directions . Hence , pulse pressure may become the key blood pressure measure in older individuals and increase in importance as a risk factor for cerebrovascular diseases and death [ 5,6 ] . Several observational studies have found that pulse pressure is an independent predictor of cardiovascular risk in middle aged and older people , in subjects with high blood pressure , in survivors of myocardial infa rct ion and in patients with left ventricular dysfunction [ 7–11 ] . A meta analysis based on individual patient data from three large trials ( Syst-Eur , SystChina and EWPHE [ 12–14 ] ) showed that isolated systolic hypertension and pulse pressure were the major determinants of cardiovascular risk in elderly hypertensives [ 7 ] . A further meta- analysis of individual patient data in control groups of seven r and omized clinical trials ( SHEP , Syst-Eur , MRC 1 , HEP , MRC 2 , EWPHE and STOP ) in the INDANA project [ 8 ] also reported that pulse pressure , rather than mean pressure , was the major risk factor for adverse cardiovascular events . A 10-mmHg increase in pulse pressure at baseline was associated independently with a 6 % rise in total mortality , a 7 % rise in cardiovascular mortality and a 7 % rise in fatal coronary events . A similar rise in fatal stroke was present , although this was statistically nonsignificant due to the limited number of events . However , the relationship between pulse pressure and fatal stroke became significant ( p = 0.04 ) at higher age [ 8 ] . Importantly , pulse pressure calculated from 24 h ambulatory blood pressure recordings is a better predictor of adverse events than if derived from officemeasured blood pressure in older patients with isolated systolic hypertension [ 15 ] A survey in 1994 showed that among the 20 % of the adult English population who were identified as hypertensive , ≈30 % had their blood pressures controlled to < 160 mm Hg systolic and < 95 mm Hg diastolic . The 1998 Health Survey for Engl and data up date the 1994 findings in light of new thresholds and targets for treatment outlined in recent national and international guidelines . This cross-sectional survey is analyzed to describe the prevalence , awareness , treatment , and control of hypertension in a r and om , nationally representative sample of 11 529 English adults ( ≥16 years ) living in noninstitutional households in 1998 and to compare these rates with those from 1994 . In 1998 , 20 % and 37 % of adults were hypertensive according to the old ( systolic ≥160 mm Hg or diastolic ≥95 mm Hg ) and new ( systolic ≥140 mm Hg or diastolic ≥90 mm Hg ) definitions , respectively . Corresponding values in 1994 were 20 % and 38 % . Treatment and control rates among hypertensive adults ( new definition ) improved from 26 % to 32 % and from 6 % to 9 % , respectively , although 60 % of those on treatment received only 1 antihypertensive drug in both years . Among persons with controlled hypertension , 59 % reported having  received nonpharmacological advice  from their physicians in 1998 compared with 30 % in 1994 . Rates of hypertension treatment and control have increased significantly ( P = 0.05 and P < 0.01 , respectively ) since 1994 but remain low by international st and ards . The 1998 data suggest that improved detection , greater use of nonpharmacological measures , and increased use of > 1 antihypertensive agent per patient would produce greater success in achieving target levels . This could lead to major reductions in fatal and nonfatal cardiovascular events BACKGROUND AND AIM Atrial fibrillation ( AF ) is an important cardiovascular disease in the elderly . The association between hyperuricemia and AF is unclear . Therefore , we aim ed to investigate the prospect i ve relationship between uric acid and development of AF in a nationally representative cohort of elderly people . METHODS AND RESULTS A total of 1485 elderly people ( age ≥ 65 yrs ) from the Elderly Nutrition and Health Survey in Taiwan ( 1999 - 2000 ) were without AF on " electrocardiography " at baseline .  Incident AF events ( International Classification of Diseases , Ninth Revision , Clinical Modification , ICD-9-CM : 427.31 ) were identified using data from the National Health Insurance Data set . Hyperuricemia was defined as levels of uric acid > 7.0 mg/dL in men and 6.0 mg/dL in women . A Cox proportional hazards model was used to evaluate the association between hyperuricemia and incident AF . The follow-up period was from 1999 to 2000 to 2008 . During the follow-up period ( median : 9.16 yrs ) , 90 AF events occurred ( 44 in men and 46 in women ) . Older age , elevated systolic blood pressure , being an ex-smoker , and high uric acid were positively associated with incident AF . Hyperuricemia was positively associated with incident AF in normotensive ( age-adjusted hazard ratio ( HR ) : 2.65 and 95 % confidence intervals : 1.05 - 6.69 ) , but not in ( 1.20:0.74 - 1.94 ) hypertensive individuals ( systolic blood pressure ≥130 or diastolic blood pressure ≥85 or using hypertensive medicine ) . A significant association between hyperuricemia and AF ( 3.78 ; 1.24 - 11.59 ) remained after adjusting for other potential confounders among normotensive older persons . CONCLUSION Hyperuricemia is associated with the development of AF in elderly people with normal blood pressure Pulse pressure has been related to higher risk of cardiovascular events in older persons . Isolated systolic hypertension is common among the elderly and is accompanied by elevated pulse pressure . Treatment of isolated systolic hypertension may further increase pulse pressure if diastolic pressure is lowered to a greater extent than systolic pressure . Little is known regarding pulse pressure as a predictor of cardiovascular outcomes in elderly persons with isolated systolic hypertension , and the influence of treatment on the pulse pressure effect . We assessed the relation between pulse pressure , measured throughout the follow-up period , and the incidence of coronary heart disease ( CHD ) , heart failure ( HF ) , and stroke in 4,632 participants in the Systolic Hypertension in the Elderly Program , a 5-year r and omized , placebo-controlled clinical trial of treatment of isolated systolic hypertension in older adults . In the treatment group , a 10-mm Hg increase in pulse pressure was associated with a statistically significant 32 % increase in risk of HF and a 24 % increase in risk of stroke after controlling for systolic blood pressure and other known risk factors , as well as with a 23 % increase in risk of HF and a 19 % increase in risk of stroke after controlling for diastolic blood pressure and other risk factors . Pulse pressure was not significantly associated with HF or stroke in the placebo group , nor with incidence of CHD in either the placebo or treatment group . These results suggest that pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension We have evaluated the relationship between systolic blood pressure ( SBP ) and age , body mass index ( BMI ) , waist circumference , sodium to potassium ratio ( Na/K ) , and tobacco use in an urban African population . We conducted a r and om , population -based , cross-sectional survey of people 25 years and older in Marondera , Zimbabwe , with over-sampling in older age groups ( n = 775 ) , using a method comparable to that used in International Collaborative Study on Hypertension in Blacks ( ICSHIB ) . The age-adjusted prevalences of hypertension in Marondera ( SBP ⩾140/DBP ⩾90/antihypertensive medication ) were 30 % for women and 21 % for men . The average BMI was 26.3 kg/m2 for women and 21.4 kg/m2 for men . The prevalence of hypertension had a steep association with age and in women ranged from 15 % ( 25–34 years ) to 63 % ( 55 years and over ) and in men from 9 % to 47 % . No tobacco use in women and greater Na/K ratio in spot urines in men were significantly associated with an increased SBP . In both men and women the levels of hypertension and SBP were strongly positively associated with BMI , although the relationship appeared to plateau in women with a BMI greater than ⩾25 kg/m2 . At a given BMI , men and women had similar SBPs and prevalences of hypertension . There is a very high prevalence of hypertension among urban Zimbabweans , particularly among women . Under the assumption the studies are comparable , the prevalence of hypertension in Zimbabwean women ( 41 % ) and men ( 26 % ) after age adjustment to the ICSHIB population s , appeared higher than almost all of the ICSHIB population s , including those with higher average body mass indexes BACKGROUND In 1989 , the European Working Party on High Blood Pressure in the Elderly started the double-blind , placebo-controlled , Systolic Hypertension in Europe Trial to test the hypothesis that antihypertensive drug treatment would reduce the incidence of fatal and nonfatal stroke in older patients with isolated systolic hypertension . This report addresses whether the benefit of antihypertensive treatment varied according to sex , previous cardiovascular complications , age , initial blood pressure ( BP ) , and smoking or drinking habits in an intention-to-treat analysis and explores whether the morbidity and mortality results were consistent in a per- protocol analysis . METHODS After stratification for center , sex , and cardiovascular complications , 4695 patients 60 years of age or older with a systolic BP of 160 to 219 mm Hg and diastolic BP less than 95 mm Hg were r and omized . Active treatment consisted of nitrendipine ( 10 - 40 mg/d ) , with the possible addition of enalapril maleate ( 5 - 20 mg/d ) and /or hydrochlorothiazide ( 12.5 - 25 mg/d ) , titrated or combined to reduce the sitting systolic BP by at least 20 mm Hg , to below 150 mm Hg . In the control group , matching placebo tablets were employed similarly . RESULTS In the intention-to-treat analysis , male sex , previous cardiovascular complications , older age , higher systolic BP , and smoking at r and omization were positively and independently correlated with cardiovascular risk . Furthermore , for total ( P = .009 ) and cardiovascular ( P = .09 ) mortality , the benefit of antihypertensive drug treatment weakened with advancing age ; for total mortality ( P = .05 ) , the benefit increased with higher systolic BP at entry , while for fatal and nonfatal stroke ( P = .01 ) , it was most evident in nonsmokers ( 92.5 % of all patients ) . In the per protocol analysis , active treatment reduced total mortality by 24 % ( P = .05 ) , reduced all fatal and nonfatal cardiovascular end points by 32 % ( P<.001 ) , reduced all strokes by 44 % ( P = .004 ) , reduced nonfatal strokes by 48 % ( P = .005 ) , and reduced all cardiac end points , including sudden death , by 26 % ( P = .05 ) . CONCLUSIONS In elderly patients with isolated systolic hypertension , stepwise antihypertensive drug treatment , starting with the dihydropyridine calcium channel blocker nitrendipine , improves prognosis . The per- protocol analysis suggested that treating 1000 patients for 5 years would prevent 24 deaths , 54 major cardiovascular end points , 29 strokes , or 25 cardiac end points . The effects of antihypertensive drug treatment on total and cardiovascular mortality may be attenuated in very old patients Abstract : The 2014 Evidence -Based Guideline for the Management of  High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee ( JNC 8) was recently published . This guideline recommended that older adults ( ≥60 years ) without diabetes or chronic kidney disease with systolic blood pressure ( SBP ) ≥150 mm Hg or diastolic blood pressure ( DBP ) ≥90 mm Hg be initiated on antihypertensive medication with a treatment goal SBP/DBP < 150/90 mm Hg . In contrast , the previous 3 JNC guidelines recommended treatment for these individuals be initiated at SBP/DBP ≥140/90 mm Hg with goal SBP/DBP < 140/90 mm Hg . In this article , we review r and omized trials of antihypertensive medication and observational data on SBP and DBP with cardiovascular outcomes among older adults , possible explanations underlying the different findings from these r and omized trials and observational studies , and contemporary antihypertensive treatment patterns among older U.S. adults . In closing , we highlight future research needs related to hypertension and outcomes among older adults
The reduction in cardiovascular mortality and morbidity was primarily due to a reduction in cerebrovascular mortality and morbidity .
AUTHORS ' CONCLUSIONS Treating healthy adults 60 years or older with moderate to severe systolic and /or diastolic hypertension with antihypertensive drug therapy reduced all-cause mortality , cardiovascular mortality and morbidity , cerebrovascular mortality and morbidity , and coronary heart disease mortality and morbidity .
Most evidence of benefit pertains to a primary prevention population using a thiazide as first-line treatment
BACKGROUND This is the second substantive up date of this review .
It was originally published in 1998 and was previously up date d in 2009 .
Elevated blood pressure ( known as ' hypertension ' ) increases with age - most rapidly over age 60 .
Systolic hypertension is more strongly associated with cardiovascular disease than is diastolic hypertension , and it occurs more commonly in older people .
It is important to know the benefits and harms of antihypertensive treatment for hypertension in this age group , as well as separately for people 60 to 79 years old and people 80 years or older .