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Systolic blood pressure should be considered “the major criterion for diagnosis, staging, and therapeutic management of hypertension, especially in middle-aged and older Americans”, according to a clinical advisory issued by Coordinating Committee of the National High Blood Pressure Education Program (NHBPEP).

“We’ve been focusing on diastolic through the years, but we now know that systolic blood pressure is a better predictor of future cardiovascular events such as heart attacks, strokes, and heart failure, and that treating it reduces those risks,” says Dr. Edward Roccella, NHBPEP coordinator.

“As people age, there’s a tendency for systolic blood pressure to rise, while diastolic pressure declines [after age 55]“, he explains. This is related to arteriosclerosis, a stiffening of the arteries that accompanies ageing, and may lead to increased blood pressure. “We used to think [increasing blood pressure] was a natural part of ageing. That gave rise to the erroneous belief that a systolic BP of 100 plus your age was acceptable.” Regardless of age, the Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended blood pressure (BP) goal is 140 over 90 mm Hg; achieving it may be a long-term challenge for older people.

Because diastolic BP tends to fall in older people, its predictive and diagnostic capabilities in that population are greatly reduced compared with systolic BP. For instance, the proportion of participants in the NHLBI’s Framingham Heart Study correctly identified as candidates for antihypertensive therapy was 91% using systolic BP alone, compared with 22% using only diastolic pressure. The diagnostic power was further increased in people over 60.

Isolated systolic hypertension (ISH) (systolic 140 mm Hg or above, diastolic less than 90 mm Hg) is the most common form of high blood pressure, note advisory authors. About two-thirds of hypertensive people over age 60 have isolated systolic hypertension, yet less than a quarter of hypertensive Americans over 70 years of age have managed to meet recommended BP goals. While systolic hypertension is notably more difficult to manage than diastolic pressure, it’s well worth the effort.

Dr. Roccella cites the Systolic Hypertension in the Elderly Program (SHEP) study, in which 4,736 individuals over 60 years of age with isolated systolic hypertension were randomized to receive thiazide diuretic-based treatment, with or without beta-blockers, or placebo. After five years, those receiving treatment had an overall systolic BP reduction from 171 to 142 mmHg. Heart attacks were reduced by 27%, strokes by 37%, and heart failure by 55%; as well, trends toward improvement in depression and dementia scores were noted. “Even more astounding, if you’ve had a previous heart attack, lowering your blood pressure can reduce the chance of developing heart failure by 90%,” he said.
Lifestyle changes alone may make the difference, he says. Lose some weight, walk daily, eat a high-fiber, low-salt diet, and if you drink alcohol, do so moderately. “If that fails to bring BP down to goal, stick with it, because it could improve the effectiveness of medications.”