THE BENEFITS of treating older patients with systolic hypertension have become well known since the completion of the Systolic Hypertension in the Elderly Program (SHEP),1 a placebo-controlled trial that assessed the outcome of using diuretic-based antihypertensive therapy on stroke and related cardiovascular morbidities. Cardiovascular risk is increased substantially in older patients with hypertension when concomitant comorbid illlnesses such as diabetes mellitus2 are present or if there is a history of vascular disease such as stroke or ischemic heart disease.3 Thus, much greater attention has been placed recently on the impact of blood pressure control in patients with hypertension and increased cardiovascular risk. For example, analyses of various outcomes from the diabetic subpopulation of the Systolic Hypertension in Europe (Syst-Eur) trial4 showed significant benefit for reduction of cardiovascular mortality and morbidity following treatment with the dihydropyridine calcium antagonist nitrendipine. In the Syst-Eur trial, active treatment in the patients with diabetes and systolic hypertension reduced mortality from cardiovascular disease by 76%, and stroke and cardiac events by 73% and 69%, respectively. These relative reductions in cardiovascular events were much greater in the patients with diabetes and hypertension compared with the larger, nondiabetic hypertensive population. In addition, the absolute benefit derived from the outcome model was also substantial: "following 5 years of therapy, 178 major cardiovascular events per 1000 diabetic, hypertensive patients treated would be prevented in contrast to 39 such events in the non-diabetic hypertensive patient."4
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