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Research Article | Volume 14 Issue: 2 (March-April, 2024) | Pages 1373 - 1377
Clinical Profile of Isolated Systolic Hypertension and Its Cardiovascular and Renal Complications
 ,
 ,
 ,
 ,
1
Associate Professor, Department of General Medicine, Narayana Medical College, Nellore, Andhra Pradesh, India
2
Assistant Professor Department of General Medicine, Narayana Medical College, Nellore, Andhra Pradesh, India
3
MBBS 3rd Year, Katuri Medical College, Guntur, India
Under a Creative Commons license
Open Access
Received
March 15, 2024
Revised
March 25, 2024
Accepted
April 16, 2024
Published
April 28, 2024
Abstract

In India awareness of hypertension, its risk factors and complications are very poor. Hence, hypertension goes undiagnosed and untreated for a long time. Hence, there is a gross increase in the number of elderly populations in India. Isolated systolic hypertension is the commonest cause of raised blood pressure in the older population. Hence the present study is undertaken to study the clinical profile of isolated systolic hypertension (systolic > 140 and diastolic ≤ 90 mmHg in elderly (above the age of 60 years), to find out any other associated risk factors, any end organ complications, specially on cardia through electrocardiography and echocardiography and on kidney through creatinine clearance. Methodology: The present cross-sectional study was undertaken on patients attending the Outpatient Department as well as in-patients of Department of General Medicine, Narayana Medical college, Nellore from November 2022 to October 2023. The study group comprised of 75 elderly patients (Male=49, Female=26) of the age group of 60 to 89 years. All of these patients had isolated systolic hypertension i.e. (SBP> 140 mmHg and DBP ≤ 90 mmHg), first time detected. Detailed evaluation of these patients was done. The evaluation comprised of detailed clinical history, thorough physical examination with relevant investigations. Results: 53.33% of the patients are in the age group of 66-75 years. Females are presented more in the age group of < 70 years than males with p=0.063. Male population – 65.33%, Female population – 34.67%. As the age increases, the blood pressure also increases significantly with f=16.439, p<0.001. Patients with stage III BP are more likely to develop abnormal retinal changes with p=0.087. 36% of the patients had ECG, LVH as per Sokolow-Lyons Positive criteria. 28%of the patients had ECG, LVH as per Romhilt-Estees score criteria. As the stage of blood pressure increases the incidence of increased LVMI increases. Patients presenting with stage III blood pressure are 2.90 times more likely to develop increased LVMI with p=0.044. Conclusion: ISH is the commonest cause of high blood pressure in the elderly. The incidence increases with age advancement. It is riskier in nonwhite population. Waist/hip ratios, DM, dyslipidaemia are significant associated risk factors. ISH associated with risk factors has definite effect mainly on cardia in terms of LV hypertrophy. and on kidney in terms of reduced creatinine clearance is an even better predictor of morbidity and mortality than is diastolic blood pressure. Several large trials have documented a clear benefit to treating ISH. Even small reductions in BP have a substantial impact on patient outcome.

Keywords
INTRODUCTION

In India awareness of hypertension, its risk factors and complications are very poor. Hence, hypertension goes undiagnosed and untreated for a long time. We see many patients with hypertension diagnosed for the first time in 5th and 6th decade. [1]

 

With improvement in health facilities in India the life expectancy at birth is increased to more than 64 years for both male and female. Hence, there is a gross increase in the number of elderly population in India. [2]

 

Isolated systolic hypertension is the commonest cause of raised blood pressure in the older population. [3] As the age progresses more and more persons will be hypertensive, a disease, which is definitely the most prevalent, remediable risk factor for cardiovascular and renal diseases. [4]

 

The prevalence of isolated systolic hypertension (that is systolic blood pressure more than 140 mmHg and diastolic blood pressure less than 90 mmHg) is higher in elderly population. Many of elderly patients are asymptomatic. [5] Sometimes they may present with end organ complications, which are irreversible. [6]

 

Indeed, the JNC – 7 and JNC- 8 report recommends prompt pharmacological therapy and states that in persons older than 60 years, systolic blood pressure is a much more important cardiovascular disease risk factor than diastolic blood pressure. [7]

 

Hence the present study is undertaken to study the clinical profile of isolated systolic hypertension (systolic > 140 and diastolic ≤ 90 mmHg in elderly (above the age of 60 years), to find out any other associated risk factors, any end organ complications, especially on cardia through electrocardiography and echocardiography and on kidney through creatinine clearance. [8]

METHOD

The present cross-sectional study was undertaken on patients attending the Outpatient Department as well as in-patients of Department of General Medicine, Narayana Medical college, Nellore from November 2022 to October 2023.

 

Study group

The study group comprised of 75 elderly patients (Male=49, Female=26) of the age group of 60 to 89 years. All of these patients had isolated systolic hypertension i.e. (SBP> 140 mmHg and DBP ≤ 90 mmHg), first time detected.

 

Inclusion criteria

  • Patients above 60
  • Patients with isolated systolic hypertension (Systolic BP > 140 mmHg and DBP ≤ 90 mmHg).

 

Exclusion criteria

  • Below 60 years of
  • Patients with previous history of hypertension or hypertensives on
  • Patients having chronic kidney disease due to etiologies other than hypertension like diabetes, glomerulonephritis, sickle cell anemia, CCF.
  • Patients having secondary hypertension
  • Patients on any herbal medication, HIV.

 

METHODS:

  • Detailed evaluation of these patients was done. The evaluation comprised of detailed clinical history, thorough physical examination with relevant
  • Blood pressure recording was done as per JNC VII
  • Standard mercury sphygmomanometer properly calibrated and validated instrument is used. An appropriate sized cuff (Cuff bladder encircling atleast 80% of the arm)
  • Patients were seated quietly for atleast 5 minutes in a chair, with feet on the floor and arm supported at heart
  • Standing blood pressure was recorded.
  • Atleast two measurements on each of 2 or more visits and mean of the three readings was
  • The first appearance of the sound (phase I, Korotkoff) is the systolic BP and the disappearance of the sound (phase V) is the diastolic
  • Blood pressure recordings were documented and staging of ISH was done.
  • General physical examination and systemic examination as per proforma was
  • Height and weight measured for each patient.
  • Body surface area was calculated using the Dubios formula: BSA (m2) = 0.007184 x [weight (kgs)]425 x [Height (cm)]0.725
  • Waist and hip ratio
  • Detailed fundoscopic examination done and hypertensive retinopathy was graded to assess target organ damage. Fundoscopic findings were confirmed by an ophthalmologist, who was blinded to clinical and echocardiographic
  • Routine investigations in Hb%, TC, DC, urine – albumin, sugar, microscopy Hb less than 12 gm were excluded.
  • Blood test, FBS, PPBS, urea creatinine and lipid profile was done. Creatinine above 4 mg% were excluded.
  • Electrocardiography: ECG was recorded at 25 mm/sec speed and 10 mm/mv

 

The following were analyzed for LVH:

  1. Sokolow-Lyon criteria (SLC): SV1+RV5 or V6 (whichever is greater) ≥ 35 mm
  2. Modified Romhilt-Estees point score system:

 

These criteria were selected since they are most commonly used in the diagnosis of LVH.

 

ECHOCARDIOGRAPHY:

2-D guided M-mode echocardiography was done by an experienced echocardiographer on a Hewlett Packard Color Doppler machine using 3.5 MHz phased array sector transducer. The echocardiographer was blinded to ECG results.”

 

M-mode echocardiographic measurements were obtained using parasternal long axis view, at the mid cavity level as defined by the tip of papillary muscle. The measurements of Left Ventricular Internal Dimension (LVIDd), Inter- Ventricular Septal Thickness (IVSTd) and Posterior Wall Thickness (LVPwd) were made at the end. Diastole is defined by the peak of R-wave on a simultaneously recorded ECG.

 

Measurements were done using the ASE convention (Standard convention). In ASE convention, the thickness of the endocardial surfaces is excluded from the measurement of LVIDd and included in the measurement of interventricular septum and posterior wall thickness. The mean measurement of three consecutive beats were taken.

 

Sex specific partition values were defined based on the normal values suggested for Indian population. Echocardiographically determined LV mass was taken as the gold standard and each electrocardiographic criteria were correlated with the echo LV mass. The ejection fraction is a global index of left ventricular fibre shortening and is generally considered as one of the most meaningful measures of LV pump function. Angiographic studies have shown that the normal ejection fraction averages72% 8% and ranges from 56% to 78%.

Ejection fraction, which is the ratio of the stroke volume to the end diastolic volume noted for each patient

 

STATISTICAL METHODS:

Chi square and Fisher exact test have used to find the significance of proportions of risk factors between increased LVMI and Normal LVMI. Odds ratio has been used to find the strength of relationship of proportions of risk factors between categories of Increased LVMI and Normal LVMI and change of stage of blood pressure. The student ‘t’ test has been used to find the significance of mean values of anthropometry between male and female patients. The diagnostic statistics were used to find the diagnostic value of SLC & RES in comparison with Echo LVMI, which is the gold standard.

RESULT

Table 1: Age distribution with Sex

Age in years

Female

Male

Total

60 years

1

3.85

-

-

1

1.33

61-65

8

30.77

7

14.29

15

20.00

66-70

8

30.77

14

28.57

22

29.33

71-75

5

19.23

13

26.53

18

24.00

76-80

3

11.54

11

22.45

14

18.67

>80

1

3.85

4

8.16

5

6.67

Total

26

34.67

49

65.33

75

100.00

Mean  SD

69.656.39

72.06  6.42

71.23  6.47

 

53.33% of the patients are in the age group of 66-75 years. Females are presented more in the age group of < 70 years than males with p=0.063. Male population – 65.33%, Female population – 34.67%.

 

Table 2: Correlation of age with stage of blood pressure

Age in years

Stage 1 (140-159)

Stage II (160-179)

Stage III (>180)

≤ 60 years

1

3.70

-

-

-

-

61-65

12

44.44

1

3.70

2

9.52

66-70

11

40.74

8

29.63

3

14.29

71-75

1

3.70

13

48.15

4

19.05

76-80

1

3.70

5

18.52

8

38.10

>80

1

3.70

-

-

4

19.05

Total

27

36.00

27

36.00

21

28.0

Mean  SD

66.67  5.56

72.56  4.01

75.38  6.72

 

As the age increases, the blood pressure also increases significantly with f=16.439, p<0.001.

 

Table 3 : Relationship of stage of blood pressure with retinal changes

 

 

Fundus grade

Blood Pressure Stage

 

Stage I (n=27)

 

Stage II (n=27)

 

Stage III (n=21)

 

Total (n=75)

Normal

15 (55.6)

5 (18.5)

3 (14.3)

23 (30.7)

Grade I

2 (7.4)

4 (14.8)

4 (19.0)

10 (13.3)

Grade II

3 (11.1)

5 (18.5)

4 (19.0)

12 (16.0)

Grade III

1 (3.7)

3 (11.1)

3 (14.3)

7 (9.3)

Grade IV

-

-

1 (4.8)

1 (1.3)

Cataract

6 (22.2)

10 (37.0)

6 (28.6)

22 (29.3)

 

Patients with stage III BP are more likely to develop abnormal retinal changes with  p=0.087.

 

Table 4 Electrocardiographic changes regarding LVH

ECG (n=75)

Number

%

Sokolow-Lyons Positive (≥35 mm)

 

27

 

36.0

Romhilt-Estees scores (≥5 points)

 

21

 

28.0

 

36% of the patients had ECG, LVH as per Sokolow-Lyons Positive criteria.

28%of the patients had ECG, LVH as per Romhilt-Estees score criteria.

 

Table 5: Echocardiographic findings in ISH

 

Echo changes (n=75)

 

Number

 

%

Increased LVMI (Males >131 gm/m2,

females >100 gm/m2)

 

 

36

 

 

48.0

Increased LV Volume (>90 ml/m2)

 

12

 

16.0

 

Reduced ejection fraction (<56%)

 

20

 

26.7

 

Regional Wall Motion Abnormality

 

21

 

28.0

 

Table 6: Association of LVMI with the stage of blood pressure

Stage of Blood Pressure

Increased LVMI (n=36)

Normal

(n=39)

 

p value

Stage I

7 (19.4)

20 (51.3)

0.004**

Stage II

15 (41.7)

12 (30.8)

0.326

Stage III

14 (38.9)

7 (17.9)

0.044*

 

As the stage of blood pressure increases the incidence of increased LVMI increases. Patients presenting with stage III blood pressure are 2.90 times more likely to develop increased LVMI with p=0.044.

DISCUSSION

In the present study the mean age at stage I blood pressure was found to be 66.67±5.56 years, the mean age at stage II blood pressure was 72.56±4.01 and the mean age at stage III blood pressure was 75.38 ± 6.72 years. As the age increases the blood pressure also increases significantly, p<0.001

 

Messerli FH et al, Anery A et al found prevalence of ISH increases with age from about 5% of the persons at 60 years to 25% of those aged 80 years. [9] Rocha E et al found that there has been increase in ISH from 44-57% in the age group from 60-80 years. [10]

 

Out of 75 patients, 30 patients had developed retinal changes. 13.3% for focal arteriolar narrowing, 12% had arteriovenous nipping and about 8% for retinopathy. Patients with stage III blood pressure were found to be 3.06 times more likely to develop abnormal retinal changes.

Wong TY et al in his study found that retinal micro vascular abnormality was 8.3% for retinopathy, 9.6% for focal arteriolar narrowing and 7.7% for arteriovenous nipping. [11]

 

Out of 75 patients ,27 patients had GFR < 60ml/min/1.73m2. prevalence of CKD in present study was 36%, out of which 6.6% of patients were in stage 1,10.6% in stage 2 and 18.6% in stage 3 hypertension group. A study done by Nwachukwu et al. in southeast Nigeria found that prevalence of CKD in hypertensive group was around 29.8% but the age group included in this study was <30yrs to >70 yrs and both systolic and diastolic blood pressures are taken [12]

 

SHEP trial done by J. HUNTER YOUNG et al. shown that systolic BP is independent risk factor for a decline in kidney function among older persons with isolated systolic hypertension. The adjusted relative risk (95% confidence interval) with the highest compared with the lowest quartile of BP was 2.44 (1.67 to 3.56) for systolic. [13]

 

Anatomical and ECHO studies suggest a sensitivity of 25% for Sokolow-Lyon voltage criteria and 50% for Romhilt-Estees point score. The specificity however is approximately 95% for both criteria. [14]

 

Deveurex et al showed that ECG criteria requiring both QRS voltage and repolarization abnormalities attain sensitivities of only about 35% in this study, most sensitive means for detecting severe necropsy proven left ventricular hypertrophy were Cornell voltage criteria which showed a sensitivity >35%.[15]

 

Hypertension predisposes and at systolic pressures exceeding 180 mmHg evidence of ECG-left ventricular hypertrophy develops in 50% within 12 years according to Framingham study with more striking closer relation to systolic than to diastolic pressure. Various ECG findings found in the present study was left ventricular hypertrophy, mainly Sokolow-Lyon positive (≥35 mm) in 36% of the patients and Romhilt-Estees score (≥ 5 points) in 28% of the patients. Vrinda et al found that LVH was commonest ECG manifestations in 36.8% of the patients. [16]

Boon D. et al found, prevalence of silent myocardial ischaemia in ISH. [17]

CONCLUSION

ISH is the commonest cause of high blood pressure in the elderly. The incidence increases with age advancement. It is riskier in nonwhite population. Waist/hip ratios, DM, dyslipidaemia are significant associated risk factors. ISH associated with risk factors has definite effect mainly on cardia in terms of LV hypertrophy. and on kidney in terms of reduced creatinine clearance is an even better predictor of morbidity and mortality than is diastolic blood pressure. Several large trials have documented a clear benefit to treating ISH. Even small reductions in BP have a substantial impact on patient outcome. Hence, ISH in elderly to be detected early, treated promptly so as to prevent / reduce cardiovascular, renal morbidity and mortality in our growing elderly population.

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  1. Naomi DC, Fisher, Gordon H. Williams. Hypertensive vascular disease: 16thed, Harrison’s Principles of Internal Medicine Vol. II, 1436.
  2. Aram V. Chobanian, George L. Bakris, Henry R. Black, William C. Cushman, Lee A. Green. The VIIth report of JNC on prevention, detection, evaluation and
  3. treatment of high blood pressure. JAMA, May 2003; 289: 2560 -72
  4. Dinse G. Simons, Morton. Physical activity and blood pressure, Chapter 98,
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  6. Whelton SP, China A, Zinz, Hej. Effect of aerobic exercise on blood pressure. A meta-analysis of RCT. Ann Intern Med, 2002; 136: 493-503.
  7. Gupta R. Hypertension epidemiology in India meta-analysis of 50 yrs of prevalence rates and blood pressure trends. J Human Hypertens, 1996; 10: 465- 472.
  8. Bennet NE. Hypertension in the elderly. Lancet, 1994; 344 (8920): 447-9.
  9. Black HR. Age-related issues in the treatment of hypertension. Am J Cardiol, 1993: 72 (20): 10H-13H.
  10. Wilking SV, Belanger A, Kannel WB et al. Determinants of isolated systolic hypertension. JAMA, 1988: 260 (23): 3451-5.
  11. Sagie A. Larson MG, Levy D. The natural history of borderline isolated systolic hypertension. New Engl J Med, 1993; 329 (26): 1912-7.
  12. Messerli FH. Hypertension in special populations. Med Clin North Am, 1997: 81(6): 1335-45.
  13. Amery A., Fagard R., Guoc et al. Isolated systolic hypertension in the elderly an epidemiological review. Am J Med, 1991: 90 (3A): 645-705.
  14. Kannel WB, Gordon T, Castelli WP, Margolia et al. Role of blood pressure in the development of congestive heart failure Framingham study. NEJM, 1972; 287: 781-787.
  15. Vrinda Kulkarni, Bhagwat N, Avi Hakim, SandhyaKamat, Soneji SL Hypertension in elderly, JAPI, 49: September 2001.
  16. SHEP Cooperative Research Group: prevention of stroke by anti-hypertensive, drug treatment in older person with isolated systolic hypertension final results of ISH in elderly programme. JAMA, 1991: 265 (24): 3255-64.
  17. Gubner R. Systolic hypertension pathogenic entity, significance and therapeutic considerations. Am J Cardiol, 1962; 9, 773-777.
  18. Glagov S., Weisenberg E, Zarins CK et al. Compensatory enlargement of human atherosclerotic coronary arteries. NEJM, 1987: 316; 1371-1375.
  19. Hass GE. Elastic tissue III relationship between structure of the ageing aorta & the properties of the isolated aortic elastic tissue. Archives of Pathology, 1943; 35: 29-45.
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