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Systolic hypertension advice

Q Although I know isolated systolic hypertension has specific risk, I find it hard to manage. More antihypertensive treatment seems to result in lowering of the diastolic to a greater extent and postural hypertension. Do you have any advice on strategies?

A First, it is worth checking that the systolic BP is truly resistant. A great many such patients have a major white-coat element to their hypertension. If the ECG shows absolutely no evidence of LVH, it would be worth doing a 24-hour ABPM. Some of these patients normalise their pressures as soon as they leave the clinic.

It is also important to check that the patients are complying with their low-salt diet. It is worth emphasising that salt restriction is more effective in older patients than the young.

If the BP is truly resistant then the policy is to 'make haste slowly' sticking to the BHS guidelines, using the A(B)CD system.

The first line of attack is a thiazide diuretic in low dose. Then slowly introduce an angiotensin blocking agent, starting in low dose but building up to the full dose. This should take about three months. Then if necessary add in verapamil 120mg later increasing to 240mg daily.

There is no consensus on what to do next. I have had good results with adding spironolactone 25 to 50mg, with careful monitoring of urea and potassium. In men I add in doxazosin, but this drug is unacceptable in women due to problems with bladder control and the drug is notorious for causing postural symptoms.

I avoid ?-blockers unless there is concomitant coronary disease or clear-cut evidence of hyperanxiety. Moxonidine is sometimes helpful in resistant hypertension, although I have not been impressed.

The most important thing is to escalate doses gradually, and avoid drugs with notorious side-effects (most patients on amlodipine 10mg develop ankle swelling). Sometimes it takes up to a year to get the BP under control while avoiding side-effects.

One might argue that normalising systolic pressure over a few weeks must inevitably cause side-effects in an older patient whose pressure has been raised for years.

I explain my policy to my resistant patients, stressing that bringing the pressure down is very worthwhile in terms of stroke prevention, but is best achieved gradually.

At the end of the day there are many patients whose pressures are truly resistant, and perceived or actual drug side-effects are a problem.

Professor Gareth Beevers is professor of medicine at City Hospital, Birmingham

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