Diuretic treatment of systolic hypertension in the elderly.

The publication, in 1991, of the results of the Systolic Hypertension in the Elderly Program (SHEP) constituted a major therapeutic advance for treating isolated systolic hypertension–systolic blood pressure 160 to 219 mm Hg and diastolic blood pressure ,90 mm Hg in patients .60 years of age.1 The results demonstrated not only a decrease in strokes but also coronary heart disease. In earlier studies, the ability to demonstrate a beneficial effect of treating combined systolic diastolic hypertension on the incidence of coronary heart disease was difficult to demonstrate: one possibility that was entertained to explain the difficulty was related to the dose of diuretic used. The relatively high doses of thiazide diuretics (50 to 100 mg/d) used in previous hypertension studies may have increased ventricular arrhythmias and sudden deaths and worsened glucose and lipid profiles, secondary to the occurrence of hypokalemia. These effects could have obscured any beneficial effects that lowering blood pressure has on the occurrence of coronary heart disease. In the SHEP study, a lower dose of chlorthalidone was used, generally starting with 12.5 mg/d and only increasing to a maximum of 25 mg/d. If the goal of lowering systolic blood pressure to ,160 mm Hg or by $20 mm Hg was not achieved, the b-blocker atenolol or reserpine was added.