Treating Isolated Systolic Hypertension in the Elderly

Abstract

OBJECTIVE: To review the prevalence, pathophysiology, vascular risk, and treatment of isolated systolic hypertension (ISH) in the elderly. DATA SOURCE: A MEDLINE search of the English language literature was performed to identify pertinent literature. Key search terms were hypertension, systolic, and elderly. STUDY SELECTION: All studies available evaluating drug therapy for ISH or hypertension in the elderly as well as review articles discussing the prevalence, pathophysiology, and treatment of ISH were selected. SYNTHESIS: ISH occurs commonly in the elderly and is associated with increased risk for cardiovascular and cerebrovascular disease. Although the mechanism for ISH in the elderly is not completely understood, the primary factor is believed to be a reduction in arterial compliance. Results of the Systolic Hypertension in the Elderly Program demonstrated that control of ISH using a diuretic alone or in combination with a beta-blocker significantly reduced the incidence of strokes and cardiovascular events. In this trial, drug therapy was found to be safe and generally well tolerated by the elderly. Newer antihypertensive agents such as the calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors have also been shown to effectively lower SBP in the elderly, but the effects on long-term morbidity and mortality are not yet known. CONCLUSIONS: ISH is an important risk factor for vascular disease in the elderly. Accurate diagnosis and effective drug treatment can result in significant reductions in the risk of cardiovascular and cerebrovascular events. Based on the available trial data, diuretics appear to be the drugs of first choice unless there are contraindications. If combination drug therapy is required, beta-blockers should be considered although their contribution to vascular risk reduction remains less clear. Additional studies are needed to determine the long-term benefits and risks of alternative antihypertensive agents such as calcium-channel blockers and ACE inhibitors.