A Journal Article Based Approach to Understanding the Principles of Clinical Hypertension
Volume 1 Issue 1
January 2016  
Context and Study Objective
We assume  that "hypertension" implies elevations in both systolic and diastolic blood pressure with time. The Framingham Heart Study sought to characterize the natural history of blood pressure over time.  

Main Outcome
Change in systolic, diastolic, and pulse-pressure (difference between systolic and diastolic pressure) with aging. 

Design, Setting, and Participants
Using a population based cohort from the original Framingham Heart Study (initiated 1948), blood pressure was measured prospectively with individuals stratified as normo- or hypertensive by initial reading. Hypertensive patients who were treated prior to study enrollment were excluded.  
Results
-Top Figure: Systolic pressure rises linearly with age in both normotensive and hypertensive individuals with a greater rate of rise in those with hypertension. 
-Bottom Figure: Diastolic pressure rises in all individuals until the age of 50-60; it gradually falls thereafter in all patients, with more pronounced changes in hypertensive patients. 

Clinical Perspective 
-With aging, systolic blood pressure rises in everyone (in Western countries), even those who are initially normotensive. As such, you can educate your patients that despite everything they are doing to maintain their health, the development of hypertension is almost inevitable. 
-Hypertension in those under ages 50-60 is both a systolic and diastolic disease. However, with age, diastolic pressures fall and hypertension becomes exclusively a systolic phenomenon. As such, you shouldn't content yourself with a "controlled" diastolic pressure as low-normal pressures are the norm.
-Given that the rate of rise of systolic pressure is more rapid in hypertensives, it is expected that they will require additional agents with aging, even if their other risk factors are unchanged. 
-With falling diastolic pressures, management challenges include lowering systolic pressures while avoiding excessively low diastolic pressures (to be discussed in coming issues).
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Creator & Author: Hillel Sternlicht, M.D.