Hypertension in the Aging Patient: New Imperatives, New Options

Over half of all people over the age of 65 in the U.S. have hypertension. In most cases this is diagnosed because of increased systolic blood pressure. It is now recognized that systolic blood pressure is more predictive of cardiovascular events than diastolic blood pressure; since these events are the major cause of death and disability in this population, current hypertension guidelines now emphasize more aggressive blood pressure criteria for both diagnosing and treating systolic hypertension. This process has been stimulated by evidence from large clinical trials that reducing systolic blood pressure improves survival and prevents strokes, heart failure, and other cardiovascular outcomes. The guidelines of both the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and the World Health Organization-International Society of Hypertension (WHO-ISH) recommend that, regardless of age, hypertension can be diagnosed when the systolic blood pressure is >140 mm Hg. The treatment target is <140 mm Hg, though in the presence of concomitant conditions like diabetes mellitus or cardiac or renal impairment, which are common findings in the elderly, even lower target levels may be justified. For patients with systolic blood pressures in the range 140 mm Hg–159 mm Hg but who are without other cardiovascular risk factors, it is not yet certain that aggressive treatment is warranted. New clinical trials are now addressing this question. So far, most experience with treating systolic hypertension in older persons has been with diuretics and calcium channel blockers. But growing evidence indicates that most antihypertensive drug classes are effective and that agents should be selected to best match the needs of individual patients.