Predominance of Isolated Systolic Hypertension Among

Middle-Aged and Elderly US Hypertensives

Analysis Based on National Health and Nutrition Examination Survey
(NHANES) III
Stanley S. Franklin, Milagros J. Jacobs, Nathan D. Wong, Gilbert J. LItalien, Pablo Lapuerta
AbstractThe purpose of the present study was to examine patterns of systolic and diastolic hypertension by age in the
nationally representative National Health and Nutrition Examination Survey (NHANES) III and to determine when
treatment and control efforts should be recommended. Percentage distribution of 3 blood pressure subtypes (isolated
systolic hypertension, combined systolic/diastolic hypertension, and isolated diastolic hypertension) was categorized for
uncontrolled hypertension (untreated and inadequately treated) in 2 age groups (ages 50 and 50 years). Overall,
isolated systolic hypertension was the most frequent subtype of uncontrolled hypertension (65%). Most subjects with
hypertension (74%) were 50 years of age, and of this untreated older group, nearly all (94%) were accurately staged
by systolic blood pressure alone, in contrast to subjects in the untreated younger group, who were best staged by diastolic
blood pressure. Furthermore, most subjects (80%) in the older untreated and the inadequately treated groups had isolated
systolic hypertension and required a greater reduction in systolic blood pressure than in the younger groups (-13.3 and
-16.5 mm Hg versus -6.8 and -6.1 mm Hg, respectively; P0.0001) to attain a systolic blood pressure treatment goal
of 140 mm Hg. Contrary to previous perceptions, isolated systolic hypertension was the majority subtype of
uncontrolled hypertension in subjects of ages 50 to 59 years, comprised 87% frequency for subjects in the sixth decade
of life, and required greater reduction in systolic blood pressure in these subjects to reach treatment goal compared with
subjects in the younger group. Better awareness of this middle-aged and older high-risk group and more aggressive
antihypertensive therapy are necessary to address this treatment gap. (Hypertension. 2001;37:869-874.)
Key Words: hypertension, essential blood pressure clinical trials hypertension, systolic, isolated

ultiple clinical and observational studies in the elderly

have demonstrated that elevated systolic blood pressure (SBP) is a more potent predictor of adverse cardiovascular outcomes than is elevated diastolic blood pressure
(DBP)15 and that treating isolated systolic hypertension
(ISH) in the elderly reduces risk of cardiovascular disease
events.6,7 Despite the strength of these observational and
intervention studies, only about one quarter of hypertensive
individuals are being treated to goal.8 Recently, the Coordinating Committee of the National High Blood Pressure
Education Program (NHBPEP), recognizing the magnitude of
this public health problem, stated that SBP in general and ISH
in particular should become the major criteria for the diagnosis, staging, and therapeutic management of hypertension
in the middle-aged and elderly.9
ISH is strongly age dependent. Both the Framingham Heart
Study and the nationally representative National Health and
Nutrition Examination Survey (NHANES) III (conducted in
1988 to 1994) showed that a similar pattern of progressively

increasing SBP occurs throughout adult life in untreated

individuals.10,11 In contrast, DBP was shown to increase in
adults until age 50 years and decline from the sixth decade
forward.10,11 This age-related pattern of increasing rates of
ISH for ages 50 years was not only observed in the
Framingham Heart Study10 and in NHANES III participants,11 but also in a meta-analysis of 10 studies that reported
the prevalence of ISH.12 In total, these studies suggest that
age 50 years is a useful cutpoint to dichotomize arbitrarily
hypertensive individuals into 2 groups for the purpose of
classifying hypertension by subtype.
The present study focused on the new NHBPEP advisory
guidelines with the expressed purpose of further characterizing subtypes of systolic and diastolic hypertension. By use of
the NHANES III national data set, specific attention was
directed toward identifying frequency of ISH and other
subtypes of hypertension by age1 and examining hypertension
awareness, staging, and treatment target goals across the
entire adult age spectrum.2 We also examined the hypothesis

Received March 5, 2000; first decision June 15, 2000; revision accepted September 5, 2000.
From the Heart Disease Prevention Program, University of California, Irvine (S.S.F., M.J.J., N.D.W.), and Bristol-Myers Squibb, Pharmaceutical
Research Institute, Princeton, NJ (G.J.L., P.L.).
Correspondence and reprint requests to Dr Stanley S. Franklin, Heart Disease Prevention Program, C240 Medical Sciences, University of California,
Irvine, CA 92697.
2001 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org

869
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March 2001

that subtypes and staging of hypertension are distinctly

different in middle-aged and older individuals versus their
younger counterparts.

Methods
Study Population
NHANES III, sponsored by the National Center for Health Statistics,
was designed to provide estimates of common chronic conditions
and associated risk factors for a representative sample of the civilian,
noninstitutionalized population of the United States.8,11 The adult BP
component of NHANES III was designed to provide estimates of the
prevalence, awareness, treatment, and control of hypertension in the
general population. A national sample of 19 661 adults 18 years of
age agreed to be interviewed in their home and have an extensive
medical examination at a mobile examination center. Methods of BP
measurement have been described previously.8,11

Definitions of Variables
Hypertension was defined as mean SBP 140 mm Hg, mean DBP
90 mm Hg, or current treatment for hypertension with prescription
medication. Awareness of hypertension was determined by interviews only with untreated hypertensive participants. Treatment of
hypertension was defined as use of a prescription medication to
manage high BP at the time of interview. Treatment success was
defined as pharmacological treatment of hypertension associated
with SBP 140 and DBP 90 mm Hg, in accordance with the Sixth
Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC-VI).13
Inadequate treatment was defined as pharmacological treatment of
hypertension with SBP 140 mm Hg and/or DBP 90 mm Hg.
Control rates for all participants being treated with antihypertensive
medications were calculated separately for SBP, DBP, and individual
hypertensive subtypes.

Study Design
NHANES III data were compared by age (50 or 50 years),
antihypertensive treatment status (uncontrolled hypertension, divided into untreated and inadequately treated groups), and hypertensive subtype (isolated diastolic hypertension [IDH], SBP 140 and
DBP 90 mm Hg; combined systolic/diastolic hypertension [SDH],
SBP 140 and DBP 90 mm Hg; and ISH, SBP 140 and DBP
90 mm Hg). Distribution of each hypertensive subtype by age was
determined and graphed separately for untreated and inadequately
treated individuals.
In addition, untreated subjects 50 and 50 years of age were
compared on the basis of BP staging by SBP and DBP. According to
JNC-VI guidelines,13,14 congruent SBP and DBP stages were defined
as follows: optimal and normal (SBP 130 mm Hg and DBP
85 mm Hg); high-normal (SBP 130 to 139 mm Hg or DBP 85 to
89 mm Hg); stage 1 hypertension (SBP 140 to 159 mm Hg or DBP
90 to 99 mm Hg); and stage 2 hypertension (SBP 160 mm Hg or
DBP 100 mm Hg). Because so few subjects had stage 3 hypertension, these subjects were collapsed into the stage 2 category. When
a disparity was seen between SBP and DBP stages, participants were
classified into the higher stage (upstaged), in accordance with the
JNC-VI guidelines. In the current analysis, participants with highnormal BP or hypertension were classified on the basis of JNC-VI
guidelines as having congruent levels of SBP and DBP, upstaged on
the basis of SBP alone, or upstaged on the basis of DBP alone.14 BP
reductions needed to reach target goals were determined for the 3
hypertensive subtypes in both the untreated and inadequately treated
groups, dichotomized at 50 years of age.

Statistical Analysis
NHANES III data were extrapolated to assess the burden of
hypertension awareness, treatment, and control among the entire
adult civilian, noninstitutionalized population of the United States.
These estimates were weighted and adjusted to reduce bias from
nonresponses during the interview. Because the design of NHANES

III was a multistage probability sample, conventional statistical

analyses with underlying distributional assumptions were inappropriate for variance estimation and statistical testing. SUDAAN
software (Research Triangle Institute) PROC DESCRIPT was used
to compute Taylor series standard errors, t test was used for
contrasted means, and 2 and the Cochran-Mantel-Haenszel test
were used for survey data.15 Statistical tests were used to compare
age grouping and treatment categories.15 All analyses were performed with SAS statistical software (SAS Corp).16

Results
Demographic Characteristics
On the basis of the extrapolated NHANES III data, 42.7
million adult Americans were identified as hypertensive,
which represented 24% of the adjusted adult US population.
A total of 23.6% of the hypertensive population was treated to
target BP goal; the remaining untreated (47.8%) and inadequately treated hypertensive individuals (28.6%) together
comprised 64.9% ISH, 21.1% SDH, and 14.0% IDH. More
than twice as many individuals (66%) had BP higher than the
SBP goal of 140 mm Hg than did higher than the DBP goal
of 90 mm Hg (27%). Participants 50 years of age comprised three fourths of all hypertensive subjects. The older
group was predominantly female (58%), whereas the younger
group was predominantly male (62.5%). The predominant
hypertensive subtype was ISH (79.8%) in the older group
(75% stage 1 and 25% stage 2 or higher) and IDH (42.8%) in
the younger group (98% stage 1 and 2% stage 2 or higher).

Awareness of Hypertension
Among untreated hypertensives in the US, 42% of individuals
with DBP 90 mm Hg were aware of their condition but only
29% with SBP 140 mm Hg knew of their hypertensive
status. Similarly, in the age 50 years group, 39% of
individuals were aware of their hypertension, whereas only
31% of those age 50 years knew of their diagnosis.
Hypertension awareness was greatest among subjects with
SDH (67.2%), intermediate among those with ISH (58.4%),
and least among those with IDH (46.8%; P0.0008), after
adjustment for age and gender. Awareness rates differed
significantly between SDH and IDH (P0.0008) and SDH
and ISH (P0.0004) but not between ISH and IDH
(P0.69), after adjustment for age and gender.

Frequency Distribution of Hypertension Subtypes

by Age
The proportion of subjects with ISH was progressively higher
and the proportion of subjects with IDH progressively lower
with increments in age in the untreated (Figure 1) and
inadequately treated groups (Figure 2). ISH was the most
common hypertension subtype in participants of age 50
years, among both untreated (79.7%) and inadequately
treated (80.1%) individuals. Conversely, for the younger
hypertensive group, IDH was most common among untreated
(46.9%) and SDH was most common among inadequately
treated individuals (45.1%). In both the untreated and inadequately treated groups, ISH became the primary hypertensive
subtype for subjects in their fifth decade (54%) of life and the
overwhelming dominant hypertensive subtype by the sixth
decade (87%) of life. Participants 50 years of age com-

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Franklin et al

Figure 1. Frequency distribution of untreated hypertensive individuals by age and hypertension subtype. Numbers at the tops
of bars represent the overall percentage distribution of all subtypes of untreated hypertension in that age group. , ISH (SBP
140 mm Hg and DBP 90 mm Hg); p, SDH (SBP
140 mm Hg and DBP 90 mm Hg); , IDH (SBP 140 mm Hg
and DBP 90 mm Hg).

prised 67% of all untreated and 86% of all inadequately

treated individuals with hypertension.

JNC-VI Staging by SBP and DBP

The magnitude of disparity between SBP and DBP in
classifying untreated individuals by JNC-VI staging criteria,
after participants with congruent normal SBP and DBP were
eliminated from study, was compared for the 2 age groups.
Figure 3 shows percentages of untreated participants with
high normal BP or hypertension who were classified into
each JNC-VI SBP and DBP category for the group of age
50 years. Among untreated participants 50 years of age
with high-normal BP or hypertension, SBP alone correctly
classified JNC-VI stage in 94% of subjects (84.8% upstaged on the basis of SBP alone and 9.0% with congruent
SBP and DBP), whereas DBP alone correctly classified only
16.3% (7.3% upstaged on the basis of DBP alone and 9.0%
with congruent SBP and DBP). In contrast to the older age
group, 45.8% of untreated younger NHANES III participants
were upstaged by DBP alone, 35.1% were upstaged on the
basis of SBP alone, and 19.1% had congruent stages of SBP
and DBP (Figure 4).

Figure 2. Frequency distribution of hypertensive individuals

classified as inadequately treated by age and hypertension
(HTN) subtype. Numbers at tops of bars represent overall percentage distribution of all subtypes of inadequately treated
hypertension in that age group. , ISH (SBP 140 mm Hg and
DBP 90 mm Hg); p;, SDH (SBP 140 mm Hg and DBP
90 mm Hg); , IDH (SBP 140 mm Hg and DBP 90 mm Hg).

Systolic and Diastolic Hypertension in the US

871

Figure 3. Percentages of NHANES III participants 50 years of

age with untreated high-normal BP and hypertension classified
into each JNC-VI SBP and DBP category after eliminating subjects with congruent normal SBP and DBP. Percentages on the
diagonal (p;) represent subjects with congruent levels of SBP
and DBP by JNC-VI classification. Percentages below and to
left of the diagonal () represent subjects upstaged on the basis
of SBP alone. Percentages above and to right of diagonal (u;)
represent subjects who were upstaged on the basis of DBP
alone.

Comparison of BP Reduction Needed to Reach

Treatment Goals

In the inadequately treated group age 50 years, 82% had

SBP in excess of the target goal versus 17% with DBP in
excess of the target goal; in contrast, 50% of the younger
group had BPs that exceeded both SBP and DBP target goals.
Comparisons of BP reductions needed to reach treatment
goals in the untreated individuals and those categorized as
inadequately treated are shown for hypertension subtypes by
age categories in the Table. A significantly greater reduction
in SBP was required to reach treatment goal in the ISH
subtype for the older versus the younger age group among
untreated people with hypertension (-13.3 versus
-6.8 mm Hg, respectively; P0.0001) and among inade-

Figure 4. Percentages of NHANES III participants 50 years of

age with untreated high-normal BP and hypertension classified
into each JNC-VI SBP and DBP category after eliminating subjects with congruent normal SBP and DBP. Percentages on the
diagonal (p;) represent subjects with congruent levels of SBP
and DBP by JNC-VI classification. Percentages below and to
left of diagonal () represent subjects upstaged on the basis of
SBP alone. Percentages above and to right of diagonal (u;) represent subjects who were upstaged on the basis of DBP alone.

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March 2001

Mean Levels of DBP and SBP With Reductions Required To Reach Targeted Goal in Untreated
and Inadequately Treated Subjects
Untreated Individuals,
t Test Category Differences by
Age (50 y vs 50 y)

Inadequate Treatment,
t Test Category Differences by
Age (50 y vs 50 y)

Age50 y

Age50 y

Age50 y

Age50 y

SBP

130.60.55*

132.80.93

130.71.06

131.41.20

DBP

93.10.26

93.00.59

93.40.47

91.80.44

4.1

4.0

4.4

2.8

SBP

148.60.77

161.91.29#

155.01.70

162.71.55

DBP

96.50.55

95.30.52

99.21.06

97.20.61

Hypertension Subtype/Blood Pressure

Component
IDH, mm Hg (meanSE)

DBP required reductions for goal

SDH, mm Hg

DBP required reductions for goal

7.5

6.3

10.2

8.2

SBP required reductions for goal

9.6

22.9

16.0

23.7

SBP

145.80.94

152.30.54#

145.10.84

155.50.59#

DBP

81.71.10

76.60.32#

83.40.80

76.20.27#

6.8

13.3

6.1

16.5

ISH, mm Hg

SBP required reductions for goal

*Standard error of the mean.

Reduction in DBP to reach JNC-VI minimum treatment goal, 90 mm Hg.
Reduction in SBP to reach JNC-VI minimum treatment goal, 140 mm Hg.
P0.05; P0.01; #P0.001.

quately treated people with hypertension (-16.5 versus

-6.1 mm Hg, respectively; P0.0001). Similarly, a significantly greater reduction in SBP was required to reach
treatment goal among older individuals in the SDH group
compared with younger individuals with SDH, both for
untreated subjects (-22.9 versus -9.6 mm Hg, respectively;
P0.0001) and those considered inadequately treated (-23.7
versus -16.0 mm Hg, respectively; P0.002). Furthermore,
52% of the older versus 11% of the younger untreated
individuals had BP 20 mm Hg higher than SBP treatment
goal and 55% of the older versus 24% of the younger
inadequately treated individuals had BP 20 mm Hg higher
than the SBP treatment goal.

Discussion
The present study demonstrated that ISH in both untreated
and inadequately treated individuals is the most frequent form
of uncontrolled hypertension in the United States (65%), that
ISH is the most common hypertension subtype (54%) for
persons between the ages of 50 and 59 years, and that ISH is
the overwhelmingly dominant hypertensive subtype (87%) by
the sixth decade of life. In contrast, the small group of
individuals with hypertension who are 50 years of age
predominantly have diastolic hypertension that consists
largely of IDH and SDH. More than 4 times as many
inadequately treated individuals of age 50 years had SBP
(82%) versus DBP (17%) that was higher than target goals,
whereas an equal number (50%) had both SBP and DBP
higher than target goals in the younger group. Furthermore,
individuals of age 50 years with ISH who were either
untreated or inadequately treated required more than a 2-fold
greater reduction in SBP to attain JNC-VI treatment goals
versus their younger counterparts.

Earlier studies in the elderly3,6,7,12,17 that defined ISH as

SBP 160 mm Hg and DBP 90 or 95 mm Hg understandably found a lower frequency of ISH of 5% to 22%.
More recently, the community-based Framingham Heart
Study, which defined ISH as SBP 140 mm Hg and DBP
90 mm Hg, reported a higher frequency of ISH in untreated
individuals of 35% to 40% in the age group of 50 to 59 years3
and values of 65% to 70% in the age group of 60 years.18
In contrast, the present NHANES III study, which examined
combined untreated and inadequately treated individuals,
observed a considerably larger ISH frequency of 54% in the
age group of 50 to 59 years and values of 87% in the age
group of age 60 years.
Frequency of ISH, also defined with a cutoff of 140/
90 mm Hg, was reported in a previous NHANES III (1988 to
1991) analysis as 64.8% in a group of age 60 years.4 These
results are consistent with those presented in the present
analysis. A key difference is that the present analysis focused
on the uncontrolled hypertensive population rather than on all
individuals with hypertension. The intent was to examine
more closely how SBP and DBP play different roles in
defining the problem of uncontrolled hypertension.
In addition to age-related differences in subtype analysis,
the 2 hypertensive age groupings were strikingly dissimilar
with respect to JNC-VI staging and eligibility for therapy in
untreated individuals. This dissimilarity was evidenced by the
pronounced difference with respect to upstaging, which was
almost entirely related to SBP in people 50 years of age,
whereas the reverse was observed in individuals 50 years of
age, among whom upstaging was mostly related to DBP. But
because most of the individuals with hypertension in the
NHANES III population were 50 years of age (74%) with
a predominance of ISH (80%), SBP was by far the most

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Systolic and Diastolic Hypertension in the US

873

important overall determinant of JNC-VI upstaging and,

hence, eligibility for therapy. These results in the NHANES
III age group of 50 years reinforce the findings of SBP
upstaging in the middle-aged and older community-based
Framingham Heart Study14 and introduce the new concept of
DBP upstaging in the younger age group.
Poor levels of awareness, treatment, and control of hypertension were a problem in all age groups. Although hypertension was less likely to be treated in younger than older
people, the absolute number of untreated individuals was
more than twice as high in older individuals. Furthermore,
awareness of ISH was significantly lower than awareness of
SDH, after correcting for the confounding effects of age and
gender.

SDH before beginning therapy but did not reach SBP goal
because of a treatment bias or because they had a more
difficult to treat form of hypertension. Exploring these trends
will be an important subject for future clinical research.
In conclusion, the present study demonstrates that ISH is
the overwhelmingly dominant subtype of hypertension in the
middle-aged and elderly population, that ISH requires a large
reduction in SBP to reach treatment goal and, that ISH is the
predominant subtype among persons with untreated and
inadequately treated hypertension. Successful treatment of
systolic hypertension in general, and ISH in particular,
represents an important public health challenge that will
require more aggressive efforts at management.

Clinical Implications

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5. ODonnell CJ, Ridker PM, Glynn RJ, Berger K, Ajani U, Manson JE,
Hennekens CH. Hypertension and borderline isolated systolic hypertension increases risk of cardiovascular disease and mortality in male
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References
Many factors may contribute to the inadequate treatment of
hypertension, as recent reviews have emphasized.19,20 Both
physician bias toward focusing primarily on a DBP treatment
goal21,22 and physician fear of excessive lowering of DBP,23
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Strengths and Limitations

The present study, which uses a national population database,
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Predominance of Isolated Systolic Hypertension Among Middle-Aged and Elderly US

Hypertensives: Analysis Based on National Health and Nutrition Examination Survey
(NHANES) III
Stanley S. Franklin, Milagros J. Jacobs, Nathan D. Wong, Gilbert J. L'Italien and Pablo
Lapuerta
Hypertension. 2001;37:869-874
doi: 10.1161/01.HYP.37.3.869
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2001 American Heart Association, Inc. All rights reserved.
Print ISSN: 0194-911X. Online ISSN: 1524-4563

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