MORBIDITY, MORTALITY, AND ANTIHYPERTENSIVE TREATMENT EFFECTS BY EXTENT OF ATHEROSCLEROSIS IN OLDER ADULTS WITH ISOLATED SYSTOLIC HYPERTENSION

Background and Purpose The Systolic Hypertension in the Elderly Progra m (SHEP) demonstrated a significant reduction in stroke and coronary e vent rates among participants randomly assigned to active blood pressu re treatment. Selected participants were evaluated for peripheral athe rosclerosis and followed up for cardiovascular events beyond the end o f the SHEP trial. Antihypertensive treatment effects were evaluated ba sed on the presence or absence of clinical or subclinical atherosclero sis. Methods As an ancillary study to SHEP, 190 participants at the Pi ttsburgh center were evaluated for peripheral atherosclerosis, defined as either an internal carotid stenosis (by duplex scan) or lower extr emity arterial disease (identified by ankle blood pressure). Participa nts were subsequently followed up for cardiovascular events. Results E stimates of 4-year mortality rates were 4.8% for participants with no atherosclerosis, 16.7% for those with subclinical atherosclerosis, and 23% among those with clinical evidence of atherosclerosis (P < .001). Fatal plus nonfatal cardiovascular event rates were 10.9%, 29.8%, and 58.3% for the three groups, respectively (P < .001). Differences rema ined significant after adjustment for age, sex, treatment assignment, smoking, and high-density lipoprotein cholesterol. Individuals assigne d to placebo at the beginning of SKEP had higher cardiovascular event rates than individuals assigned to active treatment (P = .011), with t he most striking difference 3 or more years after the end of the SHEP trial. When this analysis was stratified by the presence or absence of detectable atherosclerosis, the absolute treatment effect was largest among those with evidence of disease. Conclusions Individuals with sy stolic hypertension and evidence of peripheral atherosclerosis are at high risk for cardiovascular events. Targeting this group for antihype rtensive therapy would result in the prevention of a large number of c ardiovascular events.