Recognition of systolic hypertension for hypertension.

Recently, much concern has been raised by the National High Blood Pressure Education Program (NHBPEP) about the need for a fresh focus on the recognition of hypertension and the need to revitalize hypertension control efforts. Clearly, there has been a relaxation in the intensity and vigor for the identification of new patients with hypertension, for the necessity to maintain antihypertensive therapy in those patients who have already been recognized, and, in general, for the need to revitalize a national effort directed toward the identification and maintained treatment of patients with hypertension.1,2 In response to this unacceptable situation, Dr Claude Lenfant, director of the National Heart, Lung, and Blood Institute of the National Institutes of Health, which is the sponsor of the NHBPEP, provoked intensified discussion on this subject. He advocated increased attention to this problem while not dispiriting the public. Consequently, in this issue of Hypertension, we are pleased to feature a report from the NHBPEP on a renewed need to identify patients with elevated systolic arterial pressures, to evaluate their medical circumstances, and then to bring their systolic arterial pressure under control with the use of lifestyle interventions, if possible, and/or with pharmacological interventions if not. There are several possible reasons why the problem of systolic pressure elevation has not achieved the attention that it deserves. First, it was not until recent years that systolic blood pressure was found to be of major importance.3– 6 However, treatment of patients with systolic hypertension has been advocated since publication of JNC-4.7 JNC-5 made explicit recommendations for treatment.8 Most recently, classification of the severity of hypertensive disease was made in JNC-6, taking into consideration systolic as well as diastolic pressures (.139 and .89 mm Hg, respectively).1 This report emphasized the need to identify patients with persistently elevated systolic blood pressure (ie, .139 mm Hg) and to bring their elevated arterial pressure under control. Second, in this renewed effort toward hypertension control, we should not be self-deprecating. We must realize that, over the years, the target for treating hypertension has been continuously evolving and has markedly changed: from those patients whose diastolic pressures were in excess of 104 mm Hg and then to patients whose diastolic pressures were greater than 89 mm Hg; and from not appreciating the need to control elevated systolic pressures to recognition of those patients whose systolic pressures were greater than 160 mm Hg and now 140 mm Hg– even if the diastolic pressure was less than 90 mm Hg. Thus, at present, the moving target has been directed to reduce systolic and diastolic pressures to levels below 140 and 90 mm Hg, respectively.1 And, thirdly, there is the not inconsiderable fact that, in the early days in which treatment of hypertension was advocated, an estimated 23 million Americans had hypertension. When the definition was broadened, there were about 59 million American, and now the estimate is 43 million.2 The need to focus on systolic pressure is clear. Cardiovascular risk is even greater for systolic than diastolic pressure elevation. Moreover, recent studies have demonstrated repeatedly that the higher the pulse pressure the greater the risk; and this increased pulse pressure is primarily related to the increased systolic pressure.9 We must also be aware that it is the systolic pressure which is one of the two major determinants of left ventricular wall tension and, hence, myocardial oxygen demand.10 And, all of these concerns have prompted the major multicenter cardiovascular trials that have focused on the importance of controlled systolic pressure elevation. Hence, there is an urgent need to direct broad attention to physicians and other caregivers, clinical scientists, and the general public about the importance and consequences of systolic pressure elevation, the need to recognize all patients with systolic hypertension, and, of course, the necessity for treatment and control of elevated pressure in all of these patients. The month of May has been the traditional “High Blood Pressure Education Month.” Accordingly, the journal is pleased to join with the NHBPEP, the National Institutes of Health, and the American Heart Association to refocus our attention on this important problem. As Ray W. Gifford, Jr, a former member of our editorial board and a member of the NHBPEP, has said many times, “It’s the Systolic Pressure, Stupid!” Let us correct the apparent lethargy and, in doing so, promote a national effort of major significance.