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April 2, 2001
Simply Systolic: New Blood Pressure Advice

or years I told my patients to pay close attention to the diastolic, or lower, blood pressure. And I asked them not to be overly concerned if their systolic, or upper, blood pressure went astray. The latter normally rises with age, I would instruct my patients -- passing on to them information instilled into me during my medical training.

Ounce of Prevention


By Elizabeth Smoots, M.D.

But times change in medicine. Today the bulk of evidence points to systolic, not diastolic, pressure as the key to high blood pressure detection and treatment success. In a dramatic reversal in policy, on May 4, 2000, an expert committee of the National Heart, Lung, and Blood Institute (NHLBI) announced that systolic pressure is the most accurate blood pressure measurement for older adults. The new guidelines hold true for all those with hypertension who are over age 40 -- a group that makes up the majority of 50 million Americans with the disease.

Shifting focus to systolic

"Don't ignore your systolic," urges Claude Lenfant, M.D., director of the NHLBI in an advisory. "If you're middle-aged or older, it's a better blood pressure indicator than diastolic of your risk of heart disease and stroke." For example, long-term findings from the Framingham Heart Study show that systolic blood pressure, which measures the force inside your arteries when your heart contracts, correctly identifies 92 percent of those at risk for cardiovascular. In contrast, diastolic pressure, which measures the force while your heart relaxes, identifies only 22 percent of those at risk.

The evidence also shines when it comes to preventing the problems that frequently accompany surging blood pressures. A study published in Archives of Internal Medicine, in which researchers followed 5,000 older Americans for five years, found those who received treatment for elevated systolic blood pressures -- which was formerly ignored -- had average rate reductions of 27 percent for heart attack, 55 percent for heart failure, and 37 percent for stroke.

Recently, several other studies have shown similar results. The findings indicate that, much like treatment of high diastolic pressure, lowering systolic pressure helps protect against heart disease and stroke -- the nation's first- and third-leading causes of death -- as well as kidney damage, dementia, and blindness.

Better pressures on my mind

Despite the new consensus, I still see far too much hypertension going unchecked. The National Institutes of Health reports that only 68 percent of people with high blood pressure are aware they have the condition, about 54 percent get treatment, and a mere 27 percent successfully lower their pressures to the desired range. Realistically, these figures are probably even worse, since they were collected before systolic pressures became recognized as the key indicator in older adults.


Now we know that a high systolic pressure is not just a part of the normal aging process. According to the current view, it's a sign of stiffening of the arteries due to widespread arteriosclerosis that may result in heart disease, stroke, and other forms of cardiovascular disease.


Many doctors have long held the belief that an acceptable systolic reading is "100 plus your age." Now we know, however, that a high systolic pressure is not just a part of the normal aging process. According to the current view, it's a sign of stiffening of the arteries due to widespread arteriosclerosis that may go on to heart disease, stroke, and other forms of cardiovascular disease.

"Systolic hypertension is a major health threat, especially for older Americans," concludes Dr. Lenfant. "While it cannot be cured, systolic hypertension can be treated and its complications [can be] prevented."

Here's where to begin: No matter what your age, work with your provider toward a blood pressure goal below 140/90 for both numbers. For those with diabetes or other chronic ailments, the NHLBI recommends aiming for an even lower target of 130/85. And start treatment early -- using diet, exercise and medication -- to maximize prevention of heart disease and stroke. For your long-term health, I cannot emphasize enough the importance of assuaging your systolic blood pressure.

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Elizabeth Smoots, M.D., F.A.A.F.P., is a board-certified family physician in Seattle, Washington. A fellow of the American Academy of Family Physicians, Dr. Smoots specializes in prevention and primary care medicine.