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Systolic hypertension in the elderly—I
LETTERS
TO
THE
EDITOR
able to enter medically supervised exercise training programs. Existing programs in the United States accommodate no more than 200,000 patients with coronary disease annually. If the capacity of such programs were increased 50 percent by reducing the duration of participation, the entire capacity of these programs would be absorbed by postinfarction patients, leaving no room for patients with angina pectoris or those who have had coronary bypass operations. The problem does not stop there, because a sizable proportion of postinfarction patients reside in communities that are too small (less than approximately 100,000) to support group training programs. Further, even where programs are available, many patients cannot afford to participate for financial or logistic reasons. Thus, group programs can meet only part of the need to provide “formal rehabilitation.” Other approaches are needed to facilitate the return to normal physical activities after myocardial infarction. It is not surprising that patients become less active after infarction: They and their physicians lack information concerning their safe level of activity. Even a low level of effort, such as walking at a rate of 2 to 3 miles/h (2 to 3 METS), represents an advance over the present circumstance in which many patients are unnecessarily restricted soon after infarction. A treadmill exercise test helps to provide assurance that this level of effort is safe for a given patient. Whether the physiologic benefit of exercise training at a level more intense than walking justifies the risk and the cost of formal programs remains to be established. In summary, we believe it is too early to conclude that only formal group programs of rehabilitation can meet the needs of patients recovering from myocardial infarction. Robert F. DeBusk, MD, FACC Cardiac Rehabilitation Program Palo Alto, California References 1. Erb BD. American Heart Association Committee Report: standards for cardiovascular exercise treatment programs. Circulation 1979;59:1084A-90A. 2. American Heart Assoclatlon Committee on Exercise: Exercise Testing and Training of Awarentlv Healthv lndlvlduals (A Handbook fw Phvsicians). Dallas. Texas: American H&t Assbciation: 197224.
EFFECTS OF ANTIHYPERTENSIVE THERAPY ON CARDIOVASCULAR RESPONSE TO EXERCISE The effect of various antihypertensive
drugs on blood pressure control during exercise is an area not quite as neglected as apparent from the article by Lee et a1.l In our laboratory we have systematically studied the long-term hemodynamic effects at rest and during exercise of the following antihypertensive drugs: hydrochlorothiazide, polythiazide, chlorthalidone, alpha methyldopa, clonidine, praxosin, six different bets blocking agents and labetalol. It is true that blood pressure control during exercise often differs from that during rest, and there are large differences in the hemodynamic mechanisms behind the reduction in blood pressure. A relatively recent review (with 106 references) is found in Reference 2. Many papers on hemodynamic effects include observations during exercise. Exercise studies of more recent antihypertensive agents, such as bunitrolol and labetalol, are found in References 3 and 4. Per Lund-Johansen, MD University of Bergen School of Medicine Bergen, Norway
700
October 1980
The American Journal of CARDIOLOGY
References 1. Lea WR, For LM, Motkoff LM. Effects of antihypertensive therapy. on cardiovascular response to exercise. Am J Cardiol 1979;4433%-8. 2. Lund_ P. HaerwJdvnamic effects Of antihvDMens ive acents. than 4. In: Freis ED, ed. The Treatment of Iiypartension. Lance& MTP Press,-1978; 61: 3. Lund-Johanssn P. Longterm hemodynamlc effects of bunitrolol at rest and during exercise in essential hypertension. J Cardlovasc Pharmacol 1979;1:77-83. 4. Lund-Johansen P, B&k* OM. Haemodynamic effects and plasma concentrations of labetalol during long-term treatment of essential hypertension. Sr J Clin Fiwmacol 1979;7:169-74.
REPLY
We were aware of the works referenced by Lund-Johansen. However, only pertinent research works with a similar objective or a design comparable with ours were selected for discussion. Won Ro Lee, MD, FACC Lawrence M. Slotkoff, MD Georgetown Medical Division (Cardiology) D.C. General Hospital Washington, D.C.
SYSTOLIC HYPERTENSION
IN THE ELDERLY-l
Simon et a1.l present an interesting study on the difference in mechanisms of systolic hypertension in younger and older patients. Given the different mechanisms, the difference in response to propranolol and nitroprusside in the two groups would certainly be expected. However, I disagree with their conclusion that older patients with isolated systolic hypertension should be treated with vasodilators. It certainly has been well demonstrated that systolic hypertension, especially in the elderly, is correlated inversely with survival,2 but to my knowledge there are no studies that show that treating systolic hypertension in the absence of diastolic hypertension lessens morbidity and mortality. The major cause of systolic hypertension in older patients appears to be atherosclerotic noncompliant vessels, and treating that problem as such cannot be done. Furthermore, the therapy of systolic hypertension may decrease diastolic pressures to levels lower than desired, resulting in lower perfusion pressures than desired. This, of course, could be particularly deleterious in older patients with coronary artery disease. Older patients are also prone to the development of symptoms of orthostatic hypotension, and antihypertensive medications in older patients with isolated systolic hypertension may exacerbate these symptoms. Therefore, I believe that older patients with systolic but without diastolic hypertension should generally not be treated with antihypertensive medications. St. George T. Lee, MD Department of Cardiology Riverside Hospital Newport News, Virginia
References 1. Skin AC, Safu xj;Sysm
MA, Lwenwn JA, Khadw AM. Levy VI. Systolii hypertension: heand choice Of antihypertensive treatment. Am J Cardiol
2. K& WI. Gordon 1, Schwti coronary dfsaaw. Am J Cwdld
SYSTOUC
NJ. Systolic vs. diastolic blood pressure and risk of 1971:27:335-46.
HYPERTENSION
We are especially interested
Volume 48
IN THE ELDERLY-II
in the suggestion of Simon et al.
TO
THE
EDITOR
able to enter medically supervised exercise training programs. Existing programs in the United States accommodate no more than 200,000 patients with coronary disease annually. If the capacity of such programs were increased 50 percent by reducing the duration of participation, the entire capacity of these programs would be absorbed by postinfarction patients, leaving no room for patients with angina pectoris or those who have had coronary bypass operations. The problem does not stop there, because a sizable proportion of postinfarction patients reside in communities that are too small (less than approximately 100,000) to support group training programs. Further, even where programs are available, many patients cannot afford to participate for financial or logistic reasons. Thus, group programs can meet only part of the need to provide “formal rehabilitation.” Other approaches are needed to facilitate the return to normal physical activities after myocardial infarction. It is not surprising that patients become less active after infarction: They and their physicians lack information concerning their safe level of activity. Even a low level of effort, such as walking at a rate of 2 to 3 miles/h (2 to 3 METS), represents an advance over the present circumstance in which many patients are unnecessarily restricted soon after infarction. A treadmill exercise test helps to provide assurance that this level of effort is safe for a given patient. Whether the physiologic benefit of exercise training at a level more intense than walking justifies the risk and the cost of formal programs remains to be established. In summary, we believe it is too early to conclude that only formal group programs of rehabilitation can meet the needs of patients recovering from myocardial infarction. Robert F. DeBusk, MD, FACC Cardiac Rehabilitation Program Palo Alto, California References 1. Erb BD. American Heart Association Committee Report: standards for cardiovascular exercise treatment programs. Circulation 1979;59:1084A-90A. 2. American Heart Assoclatlon Committee on Exercise: Exercise Testing and Training of Awarentlv Healthv lndlvlduals (A Handbook fw Phvsicians). Dallas. Texas: American H&t Assbciation: 197224.
EFFECTS OF ANTIHYPERTENSIVE THERAPY ON CARDIOVASCULAR RESPONSE TO EXERCISE The effect of various antihypertensive
drugs on blood pressure control during exercise is an area not quite as neglected as apparent from the article by Lee et a1.l In our laboratory we have systematically studied the long-term hemodynamic effects at rest and during exercise of the following antihypertensive drugs: hydrochlorothiazide, polythiazide, chlorthalidone, alpha methyldopa, clonidine, praxosin, six different bets blocking agents and labetalol. It is true that blood pressure control during exercise often differs from that during rest, and there are large differences in the hemodynamic mechanisms behind the reduction in blood pressure. A relatively recent review (with 106 references) is found in Reference 2. Many papers on hemodynamic effects include observations during exercise. Exercise studies of more recent antihypertensive agents, such as bunitrolol and labetalol, are found in References 3 and 4. Per Lund-Johansen, MD University of Bergen School of Medicine Bergen, Norway
700
October 1980
The American Journal of CARDIOLOGY
References 1. Lea WR, For LM, Motkoff LM. Effects of antihypertensive therapy. on cardiovascular response to exercise. Am J Cardiol 1979;4433%-8. 2. Lund_ P. HaerwJdvnamic effects Of antihvDMens ive acents. than 4. In: Freis ED, ed. The Treatment of Iiypartension. Lance& MTP Press,-1978; 61: 3. Lund-Johanssn P. Longterm hemodynamlc effects of bunitrolol at rest and during exercise in essential hypertension. J Cardlovasc Pharmacol 1979;1:77-83. 4. Lund-Johansen P, B&k* OM. Haemodynamic effects and plasma concentrations of labetalol during long-term treatment of essential hypertension. Sr J Clin Fiwmacol 1979;7:169-74.
REPLY
We were aware of the works referenced by Lund-Johansen. However, only pertinent research works with a similar objective or a design comparable with ours were selected for discussion. Won Ro Lee, MD, FACC Lawrence M. Slotkoff, MD Georgetown Medical Division (Cardiology) D.C. General Hospital Washington, D.C.
SYSTOLIC HYPERTENSION
IN THE ELDERLY-l
Simon et a1.l present an interesting study on the difference in mechanisms of systolic hypertension in younger and older patients. Given the different mechanisms, the difference in response to propranolol and nitroprusside in the two groups would certainly be expected. However, I disagree with their conclusion that older patients with isolated systolic hypertension should be treated with vasodilators. It certainly has been well demonstrated that systolic hypertension, especially in the elderly, is correlated inversely with survival,2 but to my knowledge there are no studies that show that treating systolic hypertension in the absence of diastolic hypertension lessens morbidity and mortality. The major cause of systolic hypertension in older patients appears to be atherosclerotic noncompliant vessels, and treating that problem as such cannot be done. Furthermore, the therapy of systolic hypertension may decrease diastolic pressures to levels lower than desired, resulting in lower perfusion pressures than desired. This, of course, could be particularly deleterious in older patients with coronary artery disease. Older patients are also prone to the development of symptoms of orthostatic hypotension, and antihypertensive medications in older patients with isolated systolic hypertension may exacerbate these symptoms. Therefore, I believe that older patients with systolic but without diastolic hypertension should generally not be treated with antihypertensive medications. St. George T. Lee, MD Department of Cardiology Riverside Hospital Newport News, Virginia
References 1. Skin AC, Safu xj;Sysm
MA, Lwenwn JA, Khadw AM. Levy VI. Systolii hypertension: heand choice Of antihypertensive treatment. Am J Cardiol
2. K& WI. Gordon 1, Schwti coronary dfsaaw. Am J Cwdld
SYSTOUC
NJ. Systolic vs. diastolic blood pressure and risk of 1971:27:335-46.
HYPERTENSION
We are especially interested
Volume 48
IN THE ELDERLY-II
in the suggestion of Simon et al.