Isolated systolic hypertension: a radical rethink
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7251.1685 (Published 24 June 2000) Cite this as: BMJ 2000;320:1685All rapid responses
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Is it time for me to retire from medicine?
I quit English when I found that all theses and the very few
monographs or surveys on the topic failed to define their terms. In that case it was love poetry. They plunged into
their topic without the faintest idea of what they were
writing about, or if they did they didn't let on.
Here I have a strange sense of déjà vue, how is it
possible to write an article about and get it published in the BMJ no less without letting on what it is they are talking about.
What is systolic hypertension? Over 125 or 134
or 143 or 150 or 160? This remains a mystery. So any
discussion or communication is mute, as we do not have
a mutually agreed upon definition of terms.
The termini technici systolic, diastolic,
mean arterial pressure, etc are clear enough but curiously
what should be most objective, numeration, is least so.
Even if you mention a number the problems of
definition are only beginning. One reading, two, ten,
the mean or the highest or perhaps to be scientific or
at least rigorous + - 1 or 2 SD.
We still haven't touched upon interobserver
variability, instrumental e.g aneroid or mercury
sphygmomanometer variation, and temporal and indeed
locational differences. Medical office, hospital ER
pharmacy, MD RN, female vs male, all these give
sometimes significantly distinct readings, so much so
that a hypertensive becomes normotensive or vice versa.
Finally the only reliable method which of course is
prohibitive the 24 h BP monitoring itself is either
highly suspect or not yet normative.
So pray tell what do you mean when you
utter the word systolic hypertension?
Actually I have a definition of love poetry
but not of the topic at issue.
Alexander Jablanczy B.A., M.D.
Competing interests: No competing interests
Ascendency of systolic hypertension over the conventional diastolic
has been a foregone conclusion right from the time of the MRFIT screenees
study years ago. The correct diagnosis, however, is another matter
altogether. In practice it is not as simple as it is made out in paper.
No two readings of systolic pressures ever be the same, while in theory we
talk about 4-5 mm. pressure differences. Two readings taken at a given
time, after empathetically listening to the patient's woes, would
sometimes be markedly different.
Diagnosis of systolic hypertension is too serious a matter to be left to
box pressures alone, as war is too serious a matter to be left to the
Generals alone!
The usual problem is in effectively lowering the elevated isolated
systolic pressures in the elderly.
The guidelines do not hold good for the majority of those falling into
this category.
My personal empirical experience is that it is very difficult to
adequately control isolated systolic pressures without very high doses of
the drugs.(that many times interfere with elderly people's lives)
Would the authors care to give their experience in this field?
After nearly four decades in this business I am really frustrated that
results of clinical trials do not seem to replicate in real life
situations!
Even if one were to compute all the six guidelines available still a large
chunk of patients (may be in the range of 60%) do not seem to fit into
them.
Competing interests: No competing interests
isolated systolic hypertension
Editor - I have to take issue with the clarions of Wilkinson, Webb
and Cockcroft (1).
Their final paragraph implores us to take up arms against the enemy,
"..... no longer arterial pressure taken in isolation, but a collection of
factors, of which age and doctors' conservatism are amongst the most
important".
Those of us in clinical practice are familiar with the difficulties of
controlling blood pressure. It is rarely straightforward and involves a
range of factors, not
least of which is the informed co-operation of the patient. This is an
area fraught with difficulty and whilst I am prepared to believe that the
elderly people selected by Mulrow et al tolerated their antihypertensive
drugs with few side effects (2), I would seriously doubt the
reproducibility of these findings in ethnically diverse and impoverished
areas where we struggle to implement other
health promotion strategies with limited resources.
If they really mean what they say, I challenge them to do substantially
more than compose sermons on their laptop computers. They need to get
amongst those of us who will be doing the work (if we use their figures
perhaps an extra
50-100 patients per GP principle) and help us fight for resources.
Jim Hardy, GP trainer.
1. Wilkinson IB, Webb Christian DJ, Cockcroft JR. Isolated systolic
hypertension: a radical rethink. BMJ 2000:320;1685. (24th June).
2. Mulrow C, Lau J, Cornell J, Brand M, Pharmacotherapy for
hypertension in the elderly. The Cochrane Library, Issue 1. Oxford: Update
Software. 2000.
Competing interests: No competing interests