Overcome clinical inertia to control systolic blood pressure.

But what do we do when one number is at goal and the other is not? It is clear that in individuals younger than 50 years, diastolic BP (DBP) is the better predictor of future complications of hypertension, whereas in those 50 years and older, systolic BP (SBP) is a better predictor of future complication risk. Most individuals with hypertension are 50 years or older, and for these patients, SBP control is a high priority, even in the face of a perfectly normal DBP reading. In fact, Framingham data indicate that SBP alone correctly classifies hypertensive status in approximately 98% of adult patients. To provide optimal care to our patients, it is critical that we address SBP, even when DBP is within the reference range. Primary emphasis on SBP control in patients older than 50 years will significantly improve clinical outcomes during at least a 14-year follow-up period, as Sutton-Tyrrell et al note in this issue of the ARCHIVES. These data from the Systolic Hypertension in the Elderly Program demonstrate a 21% reduction in cardiovascular end points 14 years after initiation of treatment directed at control of SBP. The data suggest that only approximately 5 patients need to have SBP controlled to prevent 1 major cardiovascular event. Owing to issues of treatment duration and crossover, this benefit estimate is likely to be conservative. Moreover, early initiation of SBP treatment, before the identification of vascular complications, further increased the likelihood of benefit.