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Tue 12 Feb 2008 04:00 AM

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A blood pressure problem that’s isolated in name only

How to deal with isolated systolic hypertension.

How to deal with isolated systolic hypertension.

Stiff joints are an outward sign of aging. They're a pain, literally, and can slow you down or keep you from doing the things you want to do.

Stiff arteries are equally problematic. They are the main culprit behind the gradual rise in blood pressure with age.

While drug therapy targets blood pressure, the benefits of positive lifestyle changes reverberate throughout the body.

You can't feel high blood pressure, but it can stop you just as surely as stiff joints can, and sometimes more permanently.

A blood pressure reading contains two numbers. The top number is the systolic pressure. It gauges the pressure in the arteries when the heart contracts and pushes a wave of blood along the arterial tree.

The bottom number is the diastolic pressure. It reflects the pressure during the lull between waves, as the heart relaxes in between beats.

It takes a fair amount of pressure to push blood through miles of arteries. Too much pressure, though, is a bad thing.

It injures cells lining the inside of arteries. It also makes them vulnerable to the microscopic changes that lead to atherosclerosis.

In other words, high blood pressure sets the stage for cardiovascular catastrophes like heart attack and stroke.

We usually think of systolic and diastolic pressure rising in tandem, but that isn't necessarily the case. In fact, by age 60, most people with high blood pressure have what's called isolated systolic hypertension - a systolic blood pressure above 140 with a normal (under 90) diastolic pressure.

Some experts don't like the name isolated systolic hypertension. They worry that the word "isolated" sends a message that this condition isn't much of a problem. But it is.

Every 20-point increase in systolic blood pressure (and every 10-point increase in diastolic) doubles the chances of having a stroke.

This hazard is seen even among people with mildly elevated blood pressure, what is now being called prehypertension.

In fact, a study published online in the medical journal BMJ suggests that heart attacks, strokes, and deaths from cardiovascular disease are twice as common among women with what used to be called high normal blood pressure (a systolic pressure between 130 and 139 and/or a diastolic pressure between 85 and 89) as among those with normal blood pressure.

A variety of medical conditions can lead to, or contribute to, systolic hypertension.

These include anemia, an overactive thyroid or adrenal gland, a malfunctioning aortic valve, kidney disease, and even obstructive sleep apnea. Most of the time, though, it stems from the gradual stiffening of large arteries.

This occurs for many reasons. A key cause is the development of cholesterol-filled patches in artery walls, part of the artery-clogging process known as atherosclerosis.

Atherosclerosis is exacerbated by smoking, inactivity, and high blood pressure itself.

If the top number of your blood pressure reading is above 140 and the bottom number is under 90, you have isolated systolic hypertension.

Your doctor should run tests to rule out anemia and the other medical conditions that can cause isolated systolic hypertension.

He or she should also evaluate your cardiac risk factors (weight, cholesterol, etc.) and see if you are showing any signs of hypertension-related damage to the eyes and kidneys.

Then it's time to do battle with blood pressure. It isn't an entirely straightforward process.

That's reflected in the fact that only about one-third of people diagnosed with high blood pressure have it under control.

The best place to start is with the choices you make in your daily life. Smoking, carrying too many pounds, eating too much salt, drinking an excess of alcohol, not exercising - all contribute to high blood pressure.

By trading these in for their healthier alternatives, you can watch your blood pressure drift downward. Diets that emphasize fruits, vegetables, lean protein, and whole grains also help lower blood pressure.

Don't be too quick to skip the lifestyle changes and head straight for medicines that lower blood pressure. While drug therapy targets blood pressure, the benefits of positive lifestyle changes reverberate throughout the body.

They don't just improve your heart and arteries, but are also good for your lungs, muscles, bones, brain, and parts in between.

If lifestyle changes aren't enough to get your blood pressure under control, the best type of drug therapy depends on your starting systolic blood pressure.

If it is between 140 and 159 (called stage 1 hypertension), guidelines suggest starting with a thiazide diuretic (water pill) such as chlorothiazide (Aldoclor, Diupres, Diuril), chlorthalidone (Hygroton), or hydrochlorothiazide (Esidrix, HydroDiuril, Microzide).
That general advice is tempered by any other medical troubles you may be having.

If you've had a heart attack or are at high risk of having one, or you have heart failure, diabetes, or kidney disease, your doctor might start you off with an ACE inhibitor or calcium-channel blocker, with or without a diuretic.

Beta blockers have long been considered excellent drugs for fighting high blood pressure, but recent evidence suggests they shouldn't be used as first, or even second, choices.

If your systolic blood pressure is above 160 (stage 2 hypertension), your doctor won't wait for lifestyle changes to kick in, but will probably start you on medication right away.

Keep in mind that drug therapy is meant to work with lifestyle changes; it isn't a replacement for them.

Don't be surprised if you are asked to take two or even three blood pressure-lowering drugs. Attacking high blood pressure from different directions is more effective than coming at it from just one.

And taking lower doses of three drugs often causes fewer side effects than taking a higher dose of one medication.

You may not respond to a particular blood pressure medicine the same way your spouse or a friend does. It takes some trial and error to find the drug or drug combination that works best for you.

You may need to shepherd this process along. Doctors can fall victim to what's known as clinical inertia - the failure to intensify therapy when needed.

Some others don't think that isolated systolic hypertension is a big deal.

Why bother?

Treating isolated systolic hypertension - or any type of hypertension, for that matter - is good medicine. An analysis of three large trials that compared a placebo against a blood pressure-lowering medicine among nearly 12,000 men and women, most of them over age 65, showed:

• A 17% decrease in total mortality

• A 25% decrease in heart attacks and sudden cardiac deaths

• A 30% decrease in stroke.

But wait, there's more. Data from one of the largest and longest trials of treatment for isolated systolic hypertension showed that individuals in the treatment group reported fewer limitations in their daily activities.

The same study also showed that treatment reduced the chances of developing dementia (which is partly related to stiff, cholesterol-clogged arteries) and heart failure, two leading causes of disability among older people.

There are still some unanswered questions about isolated systolic hypertension. To begin with, should individuals over age 80 be treated for it? Few studies have examined this question.

The ongoing Hypertension in the Very Elderly Trial should yield some answers.

What's the benefit of drug treatment among those with systolic pressures between 140 and 159? Again, few studies have looked at this. The benefits of drug treatment in this group have been estimated from observational studies, not direct head-to-head trials.

The benefits of lifestyle changes, though, are known.

How low should you go? National guidelines set two goals for treating high blood pressure: under 130/80 for those with diabetes or kidney disease, and under 140/90 for people without these conditions.

One worry is that aggressively lowering systolic blood pressure may lower diastolic pressure too much. That's a problem because blood enters the coronary arteries when the heart relaxes between beats.

If diastolic pressure drops too low, blood flow through cholesterol-clogged coronary arteries could slow to a trickle.

These controversies aside, the evidence squarely supports keeping your blood pressure under control or working to get it there.

That's true for isolated systolic hypertension, which, once it gains a foothold, becomes entangled with many aspects of health.

Finally, it also means you should know your blood pressure, especially if you've been diagnosed with hypertension.

If you can afford one, get a $50 home blood pressure monitor and have your doctor check to make sure it is accurate; then use it at home.

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