Sara L. Pressel

Long-Term Fatal Outcomes in Subjects With Stroke or Transient Ischemic Attack Fourteen-Year Follow-Up of the Systolic Hypertension in the Elderly Program

Background and Purpose— Epidemiologic studies have demonstrated that hypertension increases the risk of stroke, and clinical trials have shown that antihypertensive therapy reduces this risk. Incident stroke was significantly decreased by treatment in the Systolic Hypertension in Elderly Program (SHEP) Trial, but the reduction in fatal events was not statistically significant. Methods— Vital status was determined for 4736 SHEP participants by matching to the National Death Index. We assessed the impact of antihypertensive treatment, stroke, and transient ischemic attacks (TIAs) during SHEP on long-term (mean, 14.3 years) mortality. Results— Treatment with a chlorthalidone-based antihypertensive regimen significantly reduced the risk of cardiovascular death (adjusted relative risk [RR]=0.86; 95% CI, 0.76 to 0.98, P=0.026) in the SHEP cohort without a significant (P=0.39) interaction with stroke status. Patients who sustained a stroke during SHEP had significantly higher all-cause mortality at the 14.3-year mean follow-up: 65.6% compared with 40.6% among those free of stroke or TIA (adjusted RR=1.97; 95% CI, 1.67 to 2.33). They also were at higher risk for cardiovascular death (RR=2.00; 95% CI, 1.58 to 2.53) and stroke death (RR=2.94; 95% CI, 1.87 to 4.64). TIA was not significantly associated with increased total mortality (RR=1.13; 95% CI, 0.88 to 1.44), cardiovascular death (RR=1.30; 95% CI, 0.94 to 1.81), or stroke death (RR=1.76; 95% CI, 0.95 to 3.26). Conclusions— In SHEP, chlorthalidone-based treatment reduced the risk of cardiovascular death after 14 years of extended follow-up. Nearly two thirds of elderly persons with isolated systolic hypertension who experienced stroke died within 14 years.

Management of High Blood Pressure in Clinical Practice: Perceptible Qualitative Differences in Approaches Utilized by Clinicians

The authors recruited a group of physicians from among the investigators participating in the Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) with a greater (more successful) or lesser (less successful) proportion of trial patients meeting blood pressure (BP) control goals. The authors utilized qualitative focus group methods to identify similarities and differences in practice behaviors. Successful and less successful physicians had similarities in knowledge and practice behaviors regarding awareness of treatment guidelines, approaches to diagnosis, use of pharmacologic management, and the opinion that systolic BP guidelines should consider a patient’s age. However, there were discernible differences between the two physician groups in their views on doctor‐patient relationships: physicians from the less successful group were more paternalistic with their patients, while physicians from the more successful group were more likely to use a patient‐centered clinical approach to BP awareness and management.

THE U-SHAPED RELATIONSHIP OF BODY MASS INDEX WITH ALL-CAUSE MORTALITY AT EIGHT YEARS IN THE ALLHAT

Background: Two types of relationships between risk factors and cardiovascular outcomes have been described: linear, as is the case with smoking where even one cigarette is worse than total abstinence, and U- or J-shaped as is the case for body mass index (BMI). Using data from the Antihypertensive

ASSOCIATION OF ORTHOSTATIC HYPERTENSION WITH MORTALITY IN THE SYSTOLIC HYPERTENSION IN THE ELDERLY PROGRAM

History and physical, target organ damage, and biomarkers are used to estimate risk in patients with hypertension. Orthostatic hypertension is a marker of elevated risk that can be identified during physical examination but is not usually appreciated by clinicians. Vital status and cause of death

VISIT-TO-VISIT VARIABILITY OF SYSTOLIC BLOOD PRESSURE PREDICTS OUTCOMES MAINLY IN THE ACTIVE TREATMENT GROUP RATHER THAN THE PLACEBO GROUP IN THE SYSTOLIC HYPERTENSION IN THE ELDERLY PROGRAM: PATHOPHYSIOLOGIC IMPLICATIONS

Previous studies of blood pressure visit-to-visit variability (VVV) were of rather short duration and rarely included placebo. We investigated VVV of systolic blood pressure (SBP) in the active and placebo groups of Systolic Hypertension in the Elderly Program (SHEP). SHEP was a placebo-controlled

Response to Letter by Bath et al

Response: We read with interest the comments of Dr Bath and his associates related to our article. The focus of our report was the persistence of the effect of chlorthalidone-based therapy in significantly decreasing cardiovascular mortality up to 14.3 years after randomization in spite of the advice to all SHEP participants to receive …