P-49: Difficulties in diagnosis: systolic hypertension in clinical practice

• Published in: American journal of hypertension 2003-05, Vol.16 (S1), p.56A-57A
• Main Authors: Neutel, J.M., Smith, D.H.G., Weber, M.A., Nwose, D., Daley, W.
• Format: Article
• Language: English
• Subjects: Ambulatory Blood Pressure Monitoring; Isolated Systolic Hypertension; Systolic Hypertension
• ISSN: 0895-7061; 1941-7225; 1879-1905
• DOI: 10.1016/S0895-7061(03)00215-2

Systolic BP is a better predictor of cardiovascular (CV) outcomes than diastolic BP, and treatment of systolic BP results in substantial reductions in CV disease. This has resulted in an increased emphasis on the diagnosis and treatment of systolic hypertension. Despite that fact that systolic hypertension is believed to be present in 60% of patients over the age of 60 years, systolic hypertension studies performed in elderly patients, such as SHEP, SYST-EUR and OPERA have shown extremely high screen failure rates. Similar screen failures were seen in the SELECT study (Systolic Evaluation of Lotrel Efficacy and Comparative Therapies) suggesting that systolic hypertension may be less common than believed and/or difficult to diagnose in clinical practice. In the SELECT trial the screen failure rate was 54.2% (528/975 patients). Of the screen failure group, 65.1% of the patients were screen failed due to not meeting BP criteria (office systolic BP ≥160 mmHg and ≤200 mmHg, office diastolic BP ≥60 mmHg and ≤100 mmHg and a mean daytime systolic BP ≥150 mmHg and ≤200 mmHg and a mean daytime diastolic BP of ≤100 mmHg). Of this group, 37.2% of these elderly hypertensive patients had an office BP of ≤160 mmHg and did not qualify. Of particular interest were the patients who had an office BP of ≥160 mmHg but a mean daytime BP of ≤150 mmHg (systolic white coat hypertension [WCH]). This group was compared to the true systolic hypertensives. (See Table) Systolic WHC True Systolic HTN N 105 325 Age (y) 67.9 68.0 Males (%) 38 37 Race Caucasian (%) 86.0 82.2 African Am (%) 8.0 12.5 BMI (kg/m2) 29.7 28.7 Office SBP (mmHg) 165.1 169.3 Office DBP (mmHg) 86.7 87.0 Office PP (mmHg) 78.4 82.4 Daytime SBP (mmHg) 139.8 161.5** Daytime DBP (mmHg) 83.7 91.4** SBP Load 41.8 79.9** 1st hr past office BP (SBP) 148.3 166.5** 2nd hr past office BP (SBP) 140.0 160.0 SBP Variability 55.7 71.2** **P ≤ 0.0001 As is shown, a very high percentage (23%) of patients diagnosed with systolic hypertension in the office are WCH. These patients are clinically similar to true systolic hypertensives and contrary to what was previously believed, and have less systolic BP variability. The WCH patients seem to normalize within one hour of leaving the clinic and remain normotensive throughout the monitoring period. This study would suggest that ambulatory BP monitoring (even for short periods) is critical in the diagnosis of systolic hypertension.