PREVENTION OF HEART-FAILURE BY ANTIHYPERTENSIVE DRUG-TREATMENT IN OLDER PERSONS WITH ISOLATED SYSTOLIC HYPERTENSION

Context.-Heart failure is often preceded by isolated systolic hyperten sion, but the effectiveness of antihypertensive treatment in preventin g heart failure is not known. Objective.-To assess the effect of diure tic-based antihypertensive stepped-care treatment on the occurrence of heart failure in older persons with isolated systolic hypertension. D esign.-Analysis of data from a multicenter, randomized, double-blind, placebo-controlled clinical trial. Participants.-A total of 4736 perso ns aged 60 years and older with systolic blood pressure between 160 an d 219 mm Hg and diastolic blood pressure below 90 mm Hg who participat ed in the Systolic Hypertension in the Elderly Program (SHEP). Interve ntion.-Stepped-care antihypertensive drug therapy, in which the step 1 drug is chlorthalidone (12.5-25 mg) or matching placebo, and the step 2 drug is atenolol (25-50 mg) or matching placebo. Main Outcome Measu res.-Fatal and nonfatal heart failure. Results.-During an average of 4 .5 years of follow-up, fatal or nonfatal heart failure occurred in 55 of 2365 patients randomized to active therapy and 105 of the 2371 pati ents randomized to placebo (relative risk [RR], 0.51; 95% confidence i nterval [CI], 0.37-0.71; P<.001; number needed to treat to prevent 1 e vent [NNT], 48). Among patients with a history of or electrocardiograp hic evidence of prior myocardial infarction (MI), the RR was 0.19 (95% CI, 0.06-0.53; P=.002; NNT, 15). Older patients, men, and those with higher systolic blood pressure or a history of or electrocardiographic evidence of MI at baseline had higher risk of developing heart failur e. Conclusion.-In older persons with isolated systolic hypertension, s tepped-care treatment based on low-dose chlorthalidone exerted a stron g protective effect in preventing heart failure. Among patients with p rior MI, an 80% risk reduction was observed.