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Excerpt
Vasan et al. [1] suggested that additional research is needed to determine whether individuals with high-normal blood pressure who are at substantial risk for cardiovascular disease, such as the elderly, might benefit from blood pressure-lowering therapy. The Framingham researchers reported that in untreated subjects aged above 65 years, the prevalence of high-normal blood pressure was 42.7% (267/626) in men and 36.6% (357/975) in women [2]. We further investigated, in two European populations [5–7], the frequencies of high–normal blood pressure and borderline isolated systolic hypertension according to age, excluding subjects on antihypertensive treatment. The prevalence of these two conditions in untreated elderly residents of the two countries is shown in Figure 2. If high-normal blood pressure as well as borderline isolated systolic hypertension required treatment, the proportion of older subjects becoming eligible for intervention would be approximately 30.5% (443/1451) in Italy and 46.8% (285/609) in Belgium.
The evidence provided by recently published secondary prevention trials including normotensive subjects, such as HOPE [8] or PROGRESS [9], cannot be extrapolated to the segment of the population described by the Framingham investigators and presented in our Figure 2. Indeed, to maximize morbid events, these studies [8,9], and other actively controlled trials in hypertension [10], limited recruitment to patients with multiple risk factors in addition to blood pressure. The benefits observed in these patient groups may not be applicable to subjects with uncomplicated high-normal blood pressure or mild isolated systolic hypertension. Moreover, in the PROGRESS trial [9], hypertension was defined irrespective of treatment status. The blood pressure cut-off points of 160 mmHg systolic and 90 mmHg diastolic were based on the lowest levels adopted in earlier trials at which antihypertensive treatment regimens had been shown to reduce the risk of stroke, but the threshold of systolic hypertension was 20 mmHg higher than the definition of normotension in recent consensus documents [3,4].
In view of the number of subjects that would become eligible for blood pressure therapy, there is a priority along the blood pressure gradient to first investigate, in a controlled clinical trial, whether older subjects with uncomplicated borderline isolated systolic hypertension might benefit from treatment to such an extent that the costs would be balanced by increases in longevity and quality of life [11].
