Full text of DOI:10.1111/j.1524-6175.2001.01218.x

O r i g i n a l P a p e r s
Physician Practice Patterns in the Treatment
of Isolated Systolic Hypertension in
a Primary Care Setting
Jeff Borenstein, MD, MPH;1,2 Joanna L. Whyte, MS, RD, MSPH;3 Enkhe Badamgarav, MD;1
Delia Vogel, RN;1 Stephen Deutsch, MD;1,2 Scott Weingarten, MD, MPH;1,2 Pablo Lapuerta, MD3,4
The authors evaluated the treatment of isolated
systolic hypertension based on medical record
review of charts between 1998 and 1999 in a
multispecialty physician practice group. Two age-
stratified random samples of ambulatory medical
records were examined (393 patients aged ≥65
years and 251 patients aged 50–64 years). The
samples corresponded to the practices of 35 pri-
mary care physicians who were surveyed about
their hypertension care. Isolated systolic hyperten-
sion was defined as systolic blood pressure ≥140
mm Hg and diastolic blood pressure <90 mm Hg.
Results showed that isolated systolic hypertension
represented 76% and 45% of uncontrolled blood
pressure in the older and middle-aged samples, re-
spectively. Isolated systolic hypertension was often
undiagnosed and untreated. Physicians reported
treatment thresholds and goals that were signifi-
cantly less aggressive for their patients ≥65 years
of age. Physician awareness and treatment of iso-
lated systolic hypertension have not yet caught up
with consensus guidelines, and older patients may
be affected most by this gap. (J Clin Hypertens.
2002;4:93–100) ©2002 Le Jacq Communications, Inc.
recent study of data from the third National
Health and Nutritional Examination Survey
(NHANES III) showed that isolated systolic hy-
pertension (ISH) represented approximately 80%
of all uncontrolled hypertension in individuals
above age 50 in the United States.1
A
However, NHANES III data collection began
over a decade ago, in 1988.2 At that time, major
placebo-controlled trials in ISH had not been com-
pleted. Consensus guidelines did not recommend
treating ISH if systolic blood pressure (SBP) was
less than 160 mm Hg.3 Thus, NHANES III provid-
ed an important assessment of the epidemiology of
hypertension, but it could not serve as a specific
indicator of quality care of ISH. Expectations for
hypertension care in 1988 were significantly differ-
ent from today. Furthermore, NHANES III mea-
sured only patient attitudes and conditions. It did
not measure directly the perceptions or practices
of physicians.
The most recent US consensus guidelines regarding
ISH were issued by the sixth report of the Joint Na-
tional Committee on the Prevention, Detection, Evalu-
ation, and Treatment of High Blood Pressure (JNC
VI) in 1997. It defined ISH as SBP ≥140 mm Hg and
diastolic blood pressure (DBP) <90 mm Hg.4 Few
studies have examined the prevalence and treatment of
ISH according to this definition.
From Cedars-Sinai Health System, Los Angeles, CA;1
UCLA School of Medicine, Los Angeles, CA;2 Pharma-
ceutical Research Institute, Bristol-Myers Squibb,
Princeton, NJ;3 and Robert Wood Johnson Medical
School, New Brunswick, NJ4
We hypothesized that despite JNC VI recom-
mendations, other guidelines, major trial results,
and other studies supporting the importance of
SBP, physicians tend to overlook and undertreat
ISH. Our study was undertaken to provide more re-
cent data on ISH in a typical multispecialty physi-
cian practice group, and examine how primary care
providers diagnose and treat ISH.
Address for correspondence:
Jeff Borenstein, MD, MPH, Cedars-Sinai Health Sys-
tem, 9100 Wilshire Boulevard, East Tower, Suite 655,
Beverly Hills, CA 90212
E-mail: borensteinj@zynx.com
Manuscript received September 12, 2001;
accepted October 12, 2001
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93

PATIENTS AND METHODS
Design and Setting
the last recorded blood pressure (BP) measurement,5
and notation of a documented diagnosis of hyper-
tension were collected for the 644 patients satisfying
the above criteria. If the last recorded BP measure-
ment met criteria for ISH (SBP ≥140 mm Hg and
DBP <90 mm Hg), the following data were collected
using a standard data abstraction form:
The study was carried out in a multispecialty group
with a large primary care component located in
Southern California. A retrospective cohort study of
patients aged 50 years and older was conducted over
an 18-month period to determine the prevalence of
and treatment patterns for ISH. A survey of all pri-
mary care providers for that cohort was also per-
formed to explore physician self-reported practices
on managing systolic hypertension.
• Demographics (age, gender)
• Comorbidities (history of myocardial infarction,
diabetes, renal insufficiency, congestive heart fail-
ure, hyperlipidemia, stroke, other)
• Antihypertensive regimen as of last BP measurement
• Documented recommendations of lifestyle modifi-
cation (salt-restricted diet, stress reduction, regular
exercise, weight reduction, biofeedback, limit two
drinks of alcohol per day)
Patient Data
A list of patients 50 years of age and older who
were continuously enrolled with the provider for at
least 1 year prior to July 15, 1999 was obtained;
1009 charts meeting these criteria were available.
Patients were stratified into two age groups, mid-
dle-aged patients (50–64 years) and elderly patients
(65 years and older). To detect a significant differ-
ence between ISH treatment in elderly and middle-
aged patients, it was determined that a sample of
250 middle-aged patients and 400 elderly patients
was needed. Random numbers were assigned to pa-
tients within each age stratum and charts were re-
viewed in numeric order until the required sample
sizes were obtained. Patients were excluded from
the cohort if they had disenrolled from the provider
group after July 15, 1998 or had died, or if their
medical record was not available. A total of 393
charts of patients aged ≥65 years and 251 charts of
patients aged 50–64 years met study inclusion crite-
ria (Figure 1).
Physician Survey
A self-administered questionnaire was sent to all 35
primary care physicians in the provider group for
these patients. The questionnaire was developed
after reviewing previously published ISH question-
naires.5,6 The instrument was designed to assess
how primary care physicians treat systolic hyper-
tension and to allow a comparison of self-reported
physician practices with hypertension management
guidelines. The questionnaire was pilot-tested with
10 physicians to determine clarity. It contained two
demographic questions (medical specialty, years in
practice), seven clinical questions (including SBP
treatment thresholds and ISH treatment goals), and
a clinical scenario, which included several questions
regarding the appropriate approach to managing an
elderly female patient with uncomplicated, sus-
tained ISH (see Appendix).
Trained medical record technicians reviewed each
study subject’s medical record, retrospectively cover-
ing an 18-month period from July, 1998 to Decem-
ber, 1999. Hypertensive patients were defined as
patients with an SBP ≥140 mm Hg or a DBP ≥90
mm Hg or presence of a hypertension diagnosis (by
International Classification of Disease, Ninth Revi-
sion, [ICD-9] codes 401.1 and 409.1). Birth date,
Data Analyses
Univariate analyses were performed on patient and
physician data. Chi-square was used to test for dif-
ferences in categorical variables, and the Student t
test was used for continuous variables. Logistic re-
gression was performed to determine predictors of
treatment status. Survey data were analyzed with
the SPSS version 10.0 software package (SPSS Inc.,
Chicago, IL).
Database
review
Patients 50-64 years
n=451
Patients > 65 years
n=558
RESULTS
Patient Demographics and Prevalence of ISH
Fifty-three percent of the 251 patients in the middle-
aged group and 58% of the 393 patients in the older
group were women. Mean age was 56 ( 4.3) years
for the middle-aged group and 75 ( 7.0) years for the
older group. Elevated BP, defined as SBP ≥140 mm
Hg or DBP ≥90 mm Hg, was more prevalent in the
older group than in the middle-aged group (38% vs.
Reviewed
n=251
Excluded
n=200
Deceased: n=11
Disenrolled: n=7
No medical record: n=182
Reviewed
n=393
Excluded
n=165
Deceased: n=15
Disenrolled: n=4
No medical record: n=146
Hypertensive
n=69
Normotensive
n=182
Hypertensive
n=149
Normotensive
n=244
Figure 1. Chart review flowchart
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27%; p<0.05). The prevalence of ISH was 12.3% in
the middle-aged group and 28.7% in the older group
(Figure 2). Demographic information for patients
with ISH is presented in the Table.
Uncontrolled
ISH patients
n=144
Age groups
Middle-aged
(50-64 years)
n=31
Elderly
(>65 years)
n=113
Among those with uncontrolled BP, the mean BPs
were SBP 143.9 12.0 mm Hg and DBP 87.7 8.1 mm
Hg in the middle-aged group and SBP 148.9 11.5
mm Hg and DBP 80.6 8.9 mm Hg in the older
group. In the subgroups with ISH, mean BP was SBP
144.4 5.8 mm Hg and DBP 80.7 4.2 mm Hg for the
middle-aged and SBP 148.8 10.6 mm Hg and DBP
76.8 6.5 mm Hg for the elderly.
Diagnosis of hypertension
ICD-9 code (+)
n=13 (42%)
ICD-9 code (-)
n=18 (58%)
ICD-9 code (+)
n=71 (63%)
ICD-9 code (-)
n=42 (37%)
Treatment
Treated
n=12 (92%)
Not treated
n=1 (8%)
Treated
Not treated
n=3 (17%) n=15 (83%)
Treated
n=64 (90%)
Not treated
n=7 (10%)
Treated
n=7 (17%)
Not treated
n=35 (83%)
Figure 2. Prevalence of uncontrolled hypertension and
isolated systolic hypertension (ISH) in a multi-specialty
practice
ICD-9=International Classification of Disease, Ninth
Revision
Diagnosis and Treatment Patterns in ISH
A significant proportion (45%) of middle-aged pa-
tients with elevated BP had ISH (Figure 2). A majori-
ty (58%) of these ISH patients had no documented
diagnosis of hypertension by ICD-9 codes, and only
48% received antihypertensive therapy (Figure 2).
Treatment and diagnosis were related, as 92% of
those with a documented ICD-9 code for hyperten-
sion received antihypertensive therapy. All treated
patients with ISH in this middle-aged group received
either one or two antihypertensive medications
(60% and 40%, respectively).
and only 63% received antihypertensive therapy.
Diagnosis and treatment were related, as 90% of
those with a documented ICD-9 code for hyperten-
sion received therapy. A majority of treated pa-
tients with ISH in this older group received one or
two medications (54% and 31%, respectively).
In logistic regression models, the only statisti-
cally significant predictor of treatment status was
the presence of an ICD-9 code for hypertension
(p<0.0001 for models in both age groups). The
models adjusted for age, gender, presence or ab-
sence of comorbidities, absolute number of co-
morbidities, and hypertension stage.
In the older group, ISH was the most common
form of uncontrolled hypertension (76%) (Figure
3). Several of these ISH patients (37%) had no doc-
umented diagnosis of hypertension by ICD-9 codes,
Table. Demographics and Clinical Characteristics of Isolated Systolic Hypertension Patients Included in the
Retrospective Analysis
AGE GROUPS
DEMOGRAPHICS
50–64 YEARS(N=31)
>65 YEARS(N=113)
Mean age (years)
Women (%)
56.2+3.8
48.4
75.8+6.4
54.0
Number of comorbidities (%)
One
25.8
9.7
0
36.3
12.4
3.5
Two
Three
Four
0
1.0
Type of comorbidity (%)
Hyperlipidemia
Diabetes mellitus
Myocardial infarction
Congestive heart failure
Stroke
19.4
25.8
0
38.1
20.4
4.4
0
3.5
0
3.5
Renal insufficiency
0
2.7
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95

Only 23% of physicians reported that they initiate
antihypertensive treatment among older patients (≥65
years) with an SBP of 140 mm Hg (Figure 4). Twen-
ty-three percent indicated that they initiate treatment
at an SBP between 141 and 150 mm Hg. Forty-one
percent reported that they initiate treatment for an
SBP 151–160 mm Hg and 13% said that they initiate
treatment only for an SBP >160 mm Hg. Further-
more, only 13% of physicians reported prescribing
pharmacologic treatment for older patients with a
sustained SBP of 140 mm Hg. A majority (65%) of
physicians reported that they would aim to treat ISH
to an SBP goal of 140 mm Hg or below in older pa-
tients (≥65 years). This 65% is significantly more than
the 23% who said they would initiate treatment at an
SBP of 140 mm Hg (p<0.05).
100
90
80
70
60
50
40
30
20
10
0
50-64 years
>65 years
*
76
44
38
*
29
27
12
Uncontrolled
hypertension in
population
Uncontrolled ISH in
population
Proportion of
uncontrolled
hypertensive patients
with ISH
Figure 3. Diagnosis and treatment patterns of patients
with isolated systolic hypertension (ISH)
*p<0.005 for elderly vs. middle-aged patients
More physicians indicated that they would initiate
treatment for a sustained SBP of 140 mm Hg in mid-
dle-aged than in elderly patients (52% and 23%
respectively; p<0.005), and more would treat middle-
aged patients to the goal SBP of 140 mm Hg than
they would the elderly (90% and 65%; p=0.04).
From the remaining survey questions, no physician
offered reasons for not treating ISH (all acknowl-
edged treating it). The majority of physicians used the
fifth Korotkoff sound for measuring BP, and the
lifestyle recommendations for lowering BP were even-
ly balanced between exercise, weight loss, stress re-
duction, limiting alcohol intake, and reducing salt
(data not shown). Most physicians (55%) listed di-
uretics as their preferred choice for treating ISH.
Physician Survey
Questionnaires were sent to all 35 physicians in the
multispecialty provider group of these patients.
Thirty-one questionnaires (89%) were returned and
included in the analysis. Half of the physicians were
general practitioners (GPs) and half were general in-
ternists (GIs). The median length of time in practice
for both types of physicians (GPs and GIs) was 13
years (range, 1–44 years). Ninety-three percent of
the GPs and 75% of the GIs had been in practice for
more than 5 years. Although physician-patient data
were not explicitly linked, the 646 patients in the
chart review were all part of the practices of these
35 physicians.
Physicians were asked to rate the influence of clini-
cal experience, consensus guidelines, and other factors
on their treatment decision-making. Items were rated
on a scale of 1 to 5, with 1 indicating no influence at
all and 5 indicating a great influence. The mean rat-
ings were 4.4 0.6 for clinical experience and 4.0 0.7
for consensus guidelines. In decreasing order of im-
portance, other factors influencing physician decision-
making were continuing medical education, medical
journals, expert opinions, textbooks, and pharmaceu-
tical representatives.
Only 52% of physicians reported that they initiate
some form of antihypertensive treatment at an SBP of
140 mm Hg in their middle-aged patients (Figure 4).
Thirty-two percent reported that they initiate treat-
ment at an SBP between 141 and 150 mm Hg. Six-
teen percent reported that they initiate treatment for
an SBP >150 mm Hg. Only 35% of physicians re-
ported that they would initiate pharmacologic treat-
ment in middle-aged patients with ISH at a sustained
SBP of 140 mm Hg. In contrast, most physicians
(90%) reported that they would aim to treat middle-
aged patients with ISH to a goal of SBP 140 mm Hg
or below, once therapy was initiated.
DISCUSSION
ISH represented 76% and 45% of uncontrolled BP in
the older and middle-aged samples in this study. Al-
though the sample was relatively small, these propor-
tions are consistent with data collected from NHANES
III several years ago. In NHANES III, ISH represented
over 80% of uncontrolled hypertension in individuals
greater than 60 years of age and approximately 50%
of uncontrolled hypertension in those 50–59.
Mean BP values were somewhat lower in our
study than in NHANES III. Our older sample with
ISH had a mean SBP of 148.1 9.2 (SD) mm Hg,
whereas in NHANES III, individuals with ISH over
50 years of age had mean SBPs of 152.3 mm Hg (un-
treated) and 155.5 mm Hg (treated). Our sample size
was small, so the difference could have been due to
chance alone. Alternatively, it could reflect some
progress in treating ISH over the past decade, or it
may reflect characteristics of the site we surveyed.
Data from a 10.6-year follow-up private practice ex-
perience indicate that a higher control rate was ob-
served in patients with diastolic/systolic hypertension
than in patients with ISH; only 39% of these patients
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SBP treated to goal. 9 An international observational
study covering the period 1992–1997 indicated that
more effort was directed toward controlling DBP
than SBP, and that adequate control of SBP was sel-
dom achieved. 10
100
90
80
70
60
50
40
30
20
10
0
90
140 mm Hg
Patients aged
50-64 years
141-150 mm Hg
151-160 mm Hg
>160 mm Hg
52
Our more recent study was done after release of
the JNC VI guidelines. These guidelines have re-
ceived considerable attention and have changed ex-
pectations for managing hypertension. More than
50 MEDLINE articles between 1988 and 1999 can
be retrieved using JNC VI as a search term. The
JNC VI guidelines have also been made available by
other sources, including Web sites of the National
Heart, Lung, and Blood Institute, the American Col-
lege of Physicians, and the American Academy of
Family Practice.11–13 The JNC VI definition of ISH
is also supported by the 1999 World Health Orga-
nization Guidelines for Hypertension.14
Recent years have also seen the publication of
major trials establishing the benefits of treating ISH,
including the Systolic Hypertension in the Elderly
Program (SHEP, 1991) and the Systolic Hyperten-
sion-Europe trial (Syst-Eur, 1997).15,16. More than
200 articles in MEDLINE can be retrieved using
these study names as search terms. In addition to
documenting clinical benefits, these major trials
showed good patient tolerability, so the safety of
treating elderly patients should be of less concern
than in the past.
Given this level of activity in the middle and
late 1990s, our study was performed in a context
of different expectations for physician behavior.
Such expectations are evident in the quality of
care measure implemented by the National Com-
mittee for Quality Assurance. The percent of pa-
tients controlled to 140/90 mm Hg is used as a
measure of quality, it is applied equally to all age
groups, and there is no different BP target for ISH
than for other types of hypertension.17
Recently, a clinical advisory statement was re-
leased by the Coordinating Committee of the Na-
tional High Blood Pressure Education program, to
promote and clarify JNC VI recommendations
emphasizing the importance of SBP as the princi-
pal clinical end point for managing hypertension
in elderly patients.18 Results of our study under-
score the value of such educational programs.
There are several limitations in our study. Only
ISH patients with elevated SBP were identified. The
absence of a specific ICD-9 code for ISH and lack of
documentation of ISH in patient charts did not per-
mit us to identify individuals with successfully con-
trolled ISH. We also kept our physician questionnaire
brief and could not address in depth some of the rea-
sons for lack of adherence to guidelines.
32
16
7
3
0
0
Treatment threshold
Treatment goal
100
90
80
70
60
50
40
30
20
10
0
140 mm Hg
Patients aged 65 years and older
141-150 mm Hg
151-160 mm Hg
>160 mm Hg
64
41
23
23
23
13
13
0
Figure 4. Physician survey responses: blood pressure
treatment thresholds and treatment goals for managing
patients with isolated systolic hypertension
achieved a target BP level of less than 140 mm Hg,
whereas 69% of patients age 65 years and above with
systolic/diastolic hypertension achieved this target level.
This experience was originally reported in 1987, prior
to the availability of new agents, but was achieved in a
practice devoted to the treatment of hypertension.7
However, in our study, ISH was still often undi-
agnosed and untreated. Many physicians in this
study believed antihypertensive therapy for ISH
should not be initiated until SBP exceeds 150 mm
Hg. Their thresholds for starting therapy were more
lax than their treatment goals, indicating that they
were willing to tolerate mild to moderate elevations
in SBP. They also indicated a greater willingness to
accept elevated SBP levels in older patients.
Several studies have shown that physicians suc-
ceed more often in controlling DBP than SBP. In a
large, observational study assessing medical care de-
livered to veterans between 1990 and 1995, a DBP
of below 90 mm Hg was recorded at 67% of hyper-
tension-related visits. However, an SBP less than
140 mm Hg was recorded at only 28% of visits.
Antihypertensive therapy was increased at only
22% of visits when a DBP of less than 90 mm Hg
and an SBP of 165 mm Hg or more were recorded. 8
In a 1996 study performed in a managed care
setting, patients were more likely to have DBP than
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THE JOURNAL OF CLINICAL HYPERTENSION
97

3
4
Joint National Committee. The fifth report of the Joint Nation-
al Committee on Detection, Evaluation, and Treatment of High
Blood Pressure (JNC V). Arch Intern Med. 1993;153:154–183.
Joint National Committee. The sixth report of the Joint Na-
tional Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC VI). Arch Intern
Med. 1997;157:2413–2446.
McAlister FA, Teo KK, Laupacis A. A survey of management
practices for isolated systolic hypertension. J Am Geriatr Soc.
1997;45:1219–1222.
Ekpo EB, Shah IU, Fernando MU, et al. Isolated systolic hy-
pertension in the elderly: survey of practitioner's attitude and
management. Gerontology. 1993;39:207–214.
Moser M. Drug Treatment of Hypertension in the Elderly in Diabet-
ics. In: Van Zweiten PA, Greemlee WA, eds. Antihypertensive
Drugs. New York, NY: Harwood Academic Publishers; 1997.
Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate manage-
ment of blood pressure in a hypertensive population. N Engl J
Med. 1998;339:1957–1963.
We also do not have longitudinal data that
could assess changes in practice patterns. Mean
SBP readings for individuals with ISH in our study
are lower than in NHANES III, but without addi-
tional data one cannot conclude whether this re-
flects improvement over time, sample size issues,
or aspects of the study site. Our study serves pri-
marily to document those challenges that remain
in diagnosing and treating ISH.
We should also note that some physicians might
be waiting for additional clinical trial evidence before
they treat SBP more aggressively. However, our
physician survey showed acceptance of SBP below
140 mm Hg as an appropriate treatment target. The
difference between treatment thresholds and treat-
ment goals in our study suggests a lax attitude to-
ward mild elevations of SBP, rather than frank
disagreement over treatment benefits.
5
6
7
8
9
Alexander M, Tekawa I, Hunkeler E, et al. Evaluating hyper-
tension control in a managed care setting. Arch Intern Med.
1999;159:2673–2677.
10 Swales JD. Current clinical practice in hypertension: the EIS-
BERG (Evaluation and Interventions for Systolic Blood pres-
sure Elevation—Regional and Global) project. Am Heart J.
1999;138:S231–S237.
11 Available at: http://www.nhlbi.nih.gov/health/prof/heart/
index.htm. Accessed February 26, 2002.
12 Available at: http://www.acponline.org/journals/annals/
15jan98/currhypr.htm. Accessed February 26, 2002.
13 Available at: http://www.aafp.org/afp/980115ap/smr.html.
Accessed February 26, 2002.
In conclusion, physician awareness and treatment
of ISH have not yet caught up with consensus guide-
lines, and older patients may be affected most by this
gap. Further efforts are warranted to bridge this dif-
ference between guidelines and practice.
Acknowledgments: The authors wish to thank Dr. McAl-
ister, University of Alberta, and Dr. Ekpo, London
Greenwich District Hospital, for their contributions in
constructing the survey questionnaire. This study was
made possible by a grant from Bristol-Myers Squibb.
This article was prepared with the assistance of BioMed-
Com Consultants, Inc.
14 Guidelines Subcommittee. 1999 World Health Organiza-
tion—International Society of Hypertension Guidelines for
the Management of Hypertension. J Hypertens. 1999;17:
151–183.
15 SHEP Cooperative Research Group. Prevention of stroke by
antihypertensive drug treatment in older persons with isolated
systolic hypertension—final results of the Systolic Hyperten-
sion in the Elderly Program (SHEP). JAMA. 1991;265:
3255–3264.
16 Staessen JA, Fagard R, Thijs L, et al. Randomised double-
blind comparison of placebo and active treatment for older pa-
tients with isolated systolic hypertension. Lancet. 1997;350:
757–764.
17 Impact and risks of untreated hypertension on managed care.
Based on a presentation by Thomas H. Lee, MD. Am J Manag
Care. 2000;6(4 Suppl):S222–S230.
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Franklin SS, Jacobs MJ, Wong ND, et al. The predominance
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2
Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hyperten-
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18 Izzo JL Jr, Levy D, Black HR. Importance of systolic blood pres-
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APPENDIX: SURVEY QUESTIONNAIRE
Demographics
1. In which specialty do you practice?
(1) General/family physician
(2) General internist
(3) Internal medicine subspecialist (specifically, ___________________)
2. How long have you been practicing? __________ years
General Questions
3. When measuring a typical patient’s blood pressure, which of the following do you usually accept as the
diastolic blood pressure?
(1) Muffling of sound (fourth Korotkoff sound)
(2) Total cessation of sound (fifth Korotkoff sound)
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4. Which of the following nonpharmacologic treatments do you routinely recommend to your hypertensive
patients? (circle as many as are appropriate)
(1) Salt-restricted diet
(2) Stress reduction
(3) Regular exercise
(4) Weight reduction
(5) Biofeedback
(6) Limit alcohol to < 2 drinks/d
(7) Others
5. In your approach to the assessment and treatment of hypertension, to what extent do the influences listed
below guide your practice? (Please circle number for each influence.)
(not at all ————————— → greatly)
Clinical experience
Consensus guidelines
Continuing Medical Education
Opinion of local experts/colleagues
Pharmaceutical representatives
Medical journals*
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
5
5
5
5
5
5
5
Textbooks
Others (please specify)
______________________
______________________
1
1
2
2
3
3
4
4
5
5
6. When would you treat isolated systolic hypertension (ISH)? (Please give a specific value, not a range.)
Age:
SBP ≥
DBP <
50–64
____
____
65 +
____
____
7. Your treatment goals for ISH are: (Please give a specific value, not a range.)
Age:
SBP <
DBP <
50–64
_____
_____
65+
_____
_____
8. When do you use drug therapy for sustained systolic blood pressure above normal with diastolic pressure
of less than 90 mm Hg?
❑
SBP >
50–64 ____
65+ ____
❑
I do not use drug therapy in these patients (please check).
______________________________________________
______________________________________________
If you answered “I do not use drug therapy” to both parts of this question, please go to question 9.
9. If you do not consider drug therapy, why not? (Please check as many reasons as are applicable.)
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ISH is an inevitable consequence of aging.
ISH does not have as bad prognosis for older people as diastolic hypertension.
ISH is a compensatory mechanism to force blood through artherosclerotic arteries in older people.
Elderly patients do not comply with drug therapy.
There is no beneficial effect in treating ISH in the elderly with drugs.
Drug side effects may reduce quality of life.
Others ________________________________________________________________________
Clinical Scenario
A 73-year-old female nonsmoker presents to your clinic for evaluation of elevated blood pressure. Assume
that her blood pressure has been the same for the last three visits over the past three months. Past medical
history, family history, and physical exam are otherwise unremarkable. The patient has been compliant with
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your recommendations for nonpharmacologic measures (e.g., diet, exercise) to reduce blood pressure for the
past year.
1. Please indicate (by circling your choice) the lowest systolic blood pressure (recorded in mm Hg) at which
you would recommend pharmacologic therapy:
SBP <140 140–149
150–159
160–169
170–179
>180
2. Which medication would you advise for initial therapy? (Please specify name, dose and frequency.)
3. What would be the target systolic blood pressure you would endeavor to obtain in this patient?
< ______ mm Hg
4. If your initial therapeutic choice didn’t achieve satisfactory control despite titration to maximal dose,
what would your next choice be? (Please specify drug name, dose and frequency.)
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