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TreatmentofIsolatedSystolicHypertensioninthe
Elderly
DanielDuprez
ExpertRevCardiovascTher.201210(11):13671373.

Abstract
Systolichypertensionisamajorhealtheconomyproblemwithinouragingsociety.Increasedarterialstiffnessisthe
vascularphenotypeofsystolichypertension,especiallyofthelargearteries.Elevatedsystolicbloodpressureisevenmore
associatedwithcardiovascularmorbidityandmortalitythandiastolicbloodpressure.Treatmentofsystolichypertensionin
theelderlyshouldbebasedonnonpharmacologicalmeasuresandmedicaltherapyifthesystolichypertensioncannotbe
controlledbyconservativetherapyalone.TheHYVETstudyprovidedevidencebasedmedicinedatashowingthat,inthe
veryelderly,loweringbloodpressuretoalevelof150/80mmHgisstillverybeneficial.Antihypertensivetherapyneedsto
betailoredintheelderlybecauseofcomorbidconditions,suchasischemicheartdisease,heartfailure,atrialfibrillation,
renalinsufficiencyanddiabetes.AngiotensinconvertingenzymeinhibitorsorangiotensinIIreceptorblockersshouldbe
consideredincombinationwithdiureticsorwithadihydropyridinecalciumantagonist.blockersseemtobelesseffective
forcardiovasculardiseaseprotectionincomparisonwithotherantihypertensivedrugclasses,suchasdiuretics,
dihydropyridines,angiotensinconvertingenzymeinhibitorsorangiotensinIIreceptorblockers.Majoreffortisrequiredto
reducethetherapeuticinertiaandincreasetherapeuticadherenceforbetterbloodpressurecontrolintheelderlywith
systolichypertension.

FacingtheProblem
Withthegrowingnumberofelderlyindividuals,oneofthemajorhealthburdensisthedevelopmentofisolated
hypertension.Arterialhypertensionisoneofthemostimportantriskfactorsthatleadstoleftventricularhypertrophy,
heartfailure,coronaryheartdiseaseandstroke. [1]Agingisassociatedwithadeclineinrenalfunction,whichwill
acceleratetheprocessofrisingbloodpressure(BP)beyondtheprogressionofarterialstiffness.Thisphenomenonwill
leadtoanabnormalventricularvascularcouplingleadingtoventricularremodeling,fibrosisandimpaireddiastolic
relaxation.Diastolicheartfailureisamajorchallengeintheelderlywithisolatedsystolichypertension.Treatmentof
systolichypertensionintheelderlyshouldbeoneoftheprioritiesinhealthcareowingtothegrowingnumberofelderlyin
society.TheProspectiveStudiesCollaborationisthelargestmetaanalysisofsubjectswithanagerangebetween40and
80years,whichshowedtheassociationofsystolicanddiastolicBPandcardiovascularmorbidityandmortality. [2]An
increaseofsystolicBPby20mmHgwasrelatedwithadoublingintheriskofdeathduetostrokeandischemicheart
disease.Thereisnearlynoinformationabouttheriskofhypertensionintheveryelderly.

PathophysiologyofSystolicHypertensionintheElderly
SeveralfunctionalandstructuralabnormalitiesareinvolvedintheriseofsystolicBPwithagingandconsequentlythe
developmentofisolatedsystolichypertensionintheelderly.Endothelialdysfunctiontogetherwithvascularremodeling
andfibrosiswilldecreasearterialelasticityorincreasearterialstiffness.Consequentlytherewillbeanincreaseofthe
arterialwavereflectionsleadingtoanincreasedsecondsystolicpeakandenhanceddevelopmentofsystolichypertension.
[3]Thereninangiotensinaldosteronesystemplaysakeyroleinsodiumhandling,vascularremodelingandinflammation.
[4]Figure1illustratesthepathogenesisofsystolichypertensionintheelderlyandtheclinicalconsequences.Agingis
associatedwithincreasedarterialstiffnessduetoendothelialdysfunction,vascularremodelingandachangeinthe
extracellularmatrix.Thereisadecreaseinelastinfibersandanincreaseincollagenfibersinthearterialwall.Increased
arterialstiffnessandarterialwavereflectionswillleadtoariseinsystolicBPand,consequently,tothedevelopmentof
isolatedsystolichypertension.TheincreasedarterialloadduetoincreasedsystolicBPandarterialwavereflectionswill
promoteleftventricularhypertrophyandconsequentlyheartfailure,atheroscleroticdiseaseresultingincoronaryheart
disease,cerebrovasculardiseaseandaorticaneurysms.

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Figure1.

Pathogenesisofsystolichypertensionintheelderlyandclinicalconsequences.CKD:ChronickidneydiseaseLV:Left
ventricularLVH:Leftventricularhypertrophy.
TheelderlymeritspecialconsiderationforBPmeasurement.Thesehypertensivepatientsarepronetohaveautonomic
failurewithposturalhypotensionand,therefore,BPshouldbemeasuredinsupine,sittingandstandingpositionsbefore
startingantihypertensivetherapy.
Elderlyhypertensivepatientsareathigherriskforarrhythmias(e.g.,atrialfibrillation).InsuchpatientsBPmeasurement
maybedifficultandthemeanofanumberofmeasurementsmayhavetobeestimated.Bilateralmeasurementsshould
bemadeonfirstconsultationand,ifpersistentdifferencesgreaterthan20mmHgforsystolicor10mmHgfordiastolic
BParepresentonconsecutivereadings,arterialdiseaseoftheupperextremitiesshouldberuledout.Measurementof
BPathomecanbeuseful.Thiscanbedoneeitherbythepatientorwiththehelpofahomehealthnurse.Incaseofa
difficulttotreatarterialhypertension,a24hambulatoryBPmonitoringcanhelpustoestimatetheBPvariability(more
pronouncedintheelderly)andalsoobtainthenocturnalpatternoftheBP(dippingvsnondipping).Severalstudieshave
demonstratedthatambulatoryBPisabetterpredictorofcardiovascular,cerebralandrenaldiseaseinolderhypertensive
patients,forexample,Whiteetal.showedthat24hsystolicBPisassociatedwithprogressionofmicrovasculardisease
ofthebrainandwithafunctionaldeclineinmobilityandcognitioninolderpeople. [5]

TreatmentGoals
Theprimarygoalofantihypertensivetreatmentintheelderlywithsystolichypertensionistoreducecardiovascular
morbidityandmortality.ThegoalistolowersystolicBPbelow140mmHganddiastolicBPbelow90mmHg.Incaseof
hypertensioninpresenceofdiabetesorkidneydisease,theBPtargetis130/80mmHg.In2011theAmericanHeart
AssociationandAmericanCollegeofcardiologypublishedspecifictherapeuticconsiderationsforthetreatmentof
hypertensionintheelderly. [6]JNC8guidelinesareexpectedtoreplacetheJNC7, [7]whichwerewrittennearlyadecade
ago,andthemostrecentESH/ISHguidelines,whichwerepublishedin2007. [8]Thecornerstoneofallthese
recommendationsistostartwithlifestylechanges.

NonpharmacologicalTreatment
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Thefollowingpreventivemeasuresneedtobediscussedwiththeelderlywithhypertension:stopsmoking,weight
reduction,reductionofsaltintakeandalcoholandmoderateexercise. [6]ThesepreventivemeasuresareeffectiveatBP
loweringandcanavoidtheneedtostartwithpharmacologicaltherapy,especiallyinborderlinetomildhypertension.

PharmacologicalTreatment
Medicaltreatmentforelderlyhypertensivepatientshasbeengenerallyrecommended.Oneneedstobecautiousinthe
elderlybecausethemajorityofolderhypertensivepatientshaveothermedicalconditions,whichneedtobetreated
medicallyareathigherriskfororthostatichypotensionandareatriskfordruginteractionanddecreaseddrug
metabolism.
Thetargetforhypertensiveelderlypatientsisbasedonexpertopinionratherthanondatafromrandomizedcontrolled
trials.ItisunclearwhethertargetSBPshouldbethesameinelderlypatientsoverawideagerangestartingat65years.
Multipledrugclasses,withdifferentmechanismsofactionanddifferentsideeffects,areavailableforthetreatmentof
hypertension. [7,8]Severalclassesofantihypertensivedrugs,includingdiuretics,calciumchannelblockers,angiotensin
convertingenzymeinhibitors(ACEIs),andangiotensinIIreceptorblockers(ARBs),aresuitablefortheinitiationand
maintenanceofantihypertensivetherapy.aandblockersarelessfavoredbymanycliniciansandguidelinesasfirstline
therapy.

WhichAntihypertensiveDrugRegimensAreSuitableforTreatingElderlyPatients?
Diuretics

DiureticshavebeenusedforseveraldecadesandhavebeeneffectiveinloweringBPintheelderlypopulation.However,
onehastobecautiousinusingdiureticsintheelderlybecausetheseelderlyhypertensivesoftendonottakeenoughfluid
duringthedayandgeteasilydehydratedanddevelopprerenalinsufficiency.Becauseofapotentialhypovolemicstatus,
theyaremorepronefororthostatichypotension.Itiswellknownthatthiazidediureticsincreaseuricacidand,thus,older
hypertensivescanbecomeatrisktodevelopgout.ElderlyhypertensivesareoftenprediabeticorTypeIIdiabeticandthe
intakeofthiazidediureticscanmakethesepatientsmoreinsulinresistant.Aldosteroneantagonistsareusedinresistant
hypertension.Potassiumandrenalfunctionneedtobemonitoredcarefullybecauseelderlyhypertensivepatientshave
oftenrenalinsufficiencyandtheuseofdiureticdrugscancausehyperkalemia.
Itiscommonthattheelderlytakeantiinflammatoryagentsforosteoarthritis.Itiswidelyknownthatthesenonsteroidal
antiinflammatorydrugswillreducethepotencyofthesethiazidediureticsleadingtouncontrolledhypertension.
Thereisanevidencethatinpatientsolderthan60yearswithisolatedsystolichypertensionchlorthalidoneisassociated
withareductionincardiovascularmorbidityandmortality,butalsowithincreasedlifeexpectancy.TheSystolic
HypertensionintheElderlyProgram(SHEP)trialwasadoubleblindstudywherechlorthalidonebasedsteppedcare
therapywascomparedwithplaceboinpatientswithisolatedsystolichypertensionolderthan60years.After4.5yearsthe
resultsshowedthattherewasasignificantlylowerrateofcardiovasculareventsinthechlorthalidonebasedgroupthan
placebo,buteffectsonmortalitywerenotsignificant.Thestudypatientswerethanrandomizedtoactivechlorthalidone
therapyandthefollowupwas22years.IntheSHEPtrial,treatmentofisolatedsystolichypertensionwithchlorthalidone
steppedcaretherapyfor4.5yearswasassociatedwithalongerlifeexpectancyat22yearsoffollowup. [9]
blockers

Despiteblockersbeingusedforthetreatmentofhypertensionintheelderlyfordecades,thebenefitshavebeenless
convincingthandiuretics.Ametaanalysisoftenstudiescomparingblockerswithdiureticsinhypertensivepatientswho
were60yearsoroldershowedthatdiureticsweresuperiortoblockerswithregardtoallclinicaloutcomes,andwere
moreeffectiveinpreventingCVevents. [10]Therefore,blockersdonotseemtobethefirstchoicetostartinelderly
hypertensivepatients. [11]However,therearestillcomorbidconditionsinwhichblockersneedtobeconsideredfor
antihypertensivetherapyintheelderly,suchascoronaryarterydisease,postmyocardialinfarction,heartfailure,senile
tremor,andsupraandventriculararrhythmias.Palatinietal.demonstratedthataclinicalheartrateof79beats/minor
higherisasignificantpredictorforanincreaseinallcause,CVandnonCVmortality. [12]
TheinternationalverapamilSR/trandolaprilstudy(INVEST)studiedmorethan11,000hypertensivepatientswithcoronary
arterydiseaseolderthan66years. [13]Theywererandomizedeithertoablocker(atenolol)ortoacalciumantagonist
(verapamil).Thepatientsrandomizedtoablockerstrategyhadlowerontreatmentheartrates,buttherewasno
differenceindeath,myocardialinfarctionorstrokecomparedwithaverapamilstrategy.
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adrenergicBlockingAgents

Theusefulnessoftheadrenergicblockingagentsislimited.TheAntihypertensiveandLipidLoweringTreatmentto
PreventHeartAttackTrial(ALLHAT)demonstratedthatdoxazosin28mgdailyintheALLHATshowed25%excess
cardiovasculareventscomparedwithchlorthalidone,largelydrivenbyahigherincidenceofheartfailureandtoalesser
extentbyanincreaseinstroke. [14]Therefore,basedonthisstudy,adrenergicblockersshouldnotbeconsideredasa
firstlinetherapyforhypertensioninolderhypertensivepatients.adrenergicblockingagentsareoftenusedforurinary
symptomsrelatedtoprostatehypertrophy.Oneneedstobeverycautiouswiththismedicationbecauseoftheriskfor
orthostatichypotensioninapopulationalreadypronetothisproblem.
CalciumAntagonists

Calciumantagonistshavebeenextensivelystudiedintheelderlyhypertensivepopulationandtheresultsshoweda
significantreductioninCVevents. [1416]Calciumantagonistsarewelltoleratedandveryeffectiveinsystolic
hypertension.Mostadverseeffectsofthedihydropyridinesrelatetovasodilation(e.g.,ankleedema,headacheand
posturalhypotension).Therearemultipleindicationstochoosecalciumantagonistsincasesofhypertensionin
associationwiththeclinicalcomorbiditiescoronaryarterydiseaseorangina.Verapamilanddiltiazemareusedtoalesser
extentasantihypertensiveagents,butmainlyincasesofsupraventriculararrhythmiashowever,theycanalsocause
conductionabnormalities.Thefirstgenerationdihydropyridinesverapamilandnifedipineshouldbeavoidedinpatients
withleftventriculardysfunction.
ACEIs

ACEIsblocktheconversionofangiotensinItoangiotensinIIbothsystemicallyandlocally.Angiotensinlevelsarelower
withagingintheabsenceofheartfailureand,theoretically,ACEIshouldnotbeaseffectiveasothertherapies,but
multiplestudieshaveshownotherwise.ThereareextensiveevidencebasedmedicaldatafromlargetrialsthatACEIare
beneficialinhypertensionandheartfailure,postmyocardialinfarction,diabeticnephropathyandatheroscleroticdisease
ingeneral. [1720]ThereareadditionalcardiovascularprotectiveeffectsbyACEIbeyondtheBPloweringeffectofthe
ACEI. [21,22]ACEIshouldbeconsideredastheantihypertensivetherapyofchoiceinelderlypatientswithhypertension
andheartfailure,and/ordiabetesmellitusorchronickidneydisease.ThemainadverseeffectsofACEIincludedry
cough,hypotensionand,rarely,angioedemaorrash.Renalfailureandhyperkalemiacandevelop,andthereforeregular
monitoringofrenalfunctionandelectrolytesismandatory.
ARBs

ARBsselectivelyblocktheangiotensinIreceptorsubtype.ARBsaresimilartootheragentsinreducingBPandarewell
tolerated.ARBsreducemorbidityandmortalityinheartfailureandarerenoprotectiveinTypeIIdiabetesmellitus. [23,24]
Inhypertensiveelderlywithdiabetesmellitus,ARBsareconsideredthefirstlinetreatmentandanalternativetoACEIsin
patientswithhypertensionandheartfailure,whocannottolerateACEIs. [25,26]InthestudyonCognitionandPrognosisin
theElderly(SCOPE),candesartanreducednonfatalstrokeby28%andshowedatrendforreductionoffatalstroke
amongpatients7089yearsofage. [27]Recently,theauthorsdemonstratedthatbaselineplasmareninactivityisnota
usefulguidetotheBPresponsesofARBcombinationinelderlyindividualswithsystolichypertension. [28]
DirectReninInhibitors

Aliskirenisanorallyactivedirectrenininhibitorapprovedforhypertension150300mgq.d.appearsaseffectiveas
ARBsandACEIsforBPmanagement. [29]Theauthorsdemonstratedthatinelderlypatientswithsystolichypertension,
aliskiren,withoptionaladdonhydrochlorothiazideandamlodipine,appearedmoreeffectiveandbettertoleratedoverall
versusramipril. [30]InDecember2011,thelongterm,randomized,placebocontrolled,morbidity/mortalitytrial,Aliskiren
TrialinTypeIIDiabetesUsingCardioRenalEndpoints(ALTITUDE),whichincluded8600patientswithTypeIIdiabetes,
proteinuriaandahighcardiovascularriskalreadytreatedwithACEIsorARBswasterminatedbecauseofanincreased
incidenceofseriousadverseevents,includingnonfatalstroke,renalcomplications,hyperkalemiaandhypotensioninthe
aliskirenarm. [31]Specialprecautionsaretakenforotherlargeclinicaltrialsstudyingtheeffectofaliskirenon
cardiovascularmorbidityandmoraltityinheartfailureandinindividualsabove65yearsofagewithincreased
cardiovascularrisk.
NonspecificVasodilators

Hydralazineandminoxidilareusedasfourthlineantihypertensivedrugsinseverehypertension.Theyarecombinedwith
diureticsandblockersbecauseofthefluidretentiontheycauseandalsothereflextachycardia.Minoxidilwillbeadded
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inthesecaseswhenotherantihypertensivecombinationsfailedtocontroltheBP.
CentrallyActingAgents

Centrallyactingagents(e.g.,clonidine)arenotfirstlinetreatmentsintheelderlybecausemanypatientsexperience
troublesomesedationorbradycardia,andabruptdiscontinuationleadstoareboundphenomenoncharacterizedby
increasedBPandheartrate.
CombinationTherapy

Thelargestnumberofelderlypatientswithsystolichypertensionrequiredualantihypertensivetherapyoreventriple
antihypertensivetherapytocontrolsystolicBP.Thepreferentialcombinationsare:ACEIanddiureticARBanddiuretic
orACEIanddihydropyridinecalciumantagonist.Thelastcombinationseemsmorefavorablethanthecombinationofan
ACEIandadiuretic.ThisfindingwasderivedfromtheAvoidingCardiovascularEventsthroughCombinationTherapyin
PatientsLivingwithSystolicHypertension(ACCOMPLISH)trial,whichcomparedtreatmentwithanACEI,benazepril,
combinedwithamlodipineversusthesameACEIcombinedwithathiazidediureticinreducingtheriskofcardiovascular
eventsandofdeathamonghighriskpatientswithhypertension. [32]Themeanageofthestudypatientsinthistrialwas
68.4years66%ofthestudypatientswere65yearsorolderand41%were75yearsorolderand39.5%ofthepatients
werewomen.Thistrialshowedthatcombinationtreatmentwithbenazeprilplusamlodipinewassuperiortotreatment
withbenazeprilplushydrochlorothiazideinreducingthecardiovasculareventsanddeath.Fortheprimaryoutcome,
definedasthecompositeofdeathfromcardiovascularcauses,nonfatalmyocardialinfarction,nonfatalstroke,
hospitalizationforangina,resuscitationaftersuddencardiacarrestandcoronaryrevascularization,therewasanabsolute
riskreductionof2.2percentagepointsandarelativeriskreductionof19.6%(hazardratio:0.80p<0.001).Forthe
secondaryendpointofdeathfromcardiovascularcausesplusnonfatalmyocardialinfarctionandnonfatalstroke,there
wasanabsoluteriskreductionof1.3percentagepointsandarelativeriskreductionof21.2%(hazardratio:0.79p=
0.002).Forthesecondaryendpointofcardiovascularevents,anabsoluteriskreductionof1.7percentagepointsanda
relativeriskreductionof17.4%(hazardratio:0.83p=0.002).

ToWhatAgeShouldWeTreatHypertension?
Arterialhypertensionaffectsmostelderlypeople(65yearsofageorolder).Thereisnodoubtthattheantihypertensive
therapyneedstobecontinued.Afrequentquestionthatisoftendebatedisifthereisanagelimittostart
antihypertensivedrugsandarethebeneficialeffectsofantihypertensivetherapysimilarintheveryelderly(definedas80
yearsandolder)asinyoungerelderly?Inmostclinicalantihypertensivetrials,thereisanagelimitforinclusion.Other
studiesdidnotoftendiscusstheagespecificeffectsoftheantihypertensivetherapy.
TheHypertensionintheVeryElderlyTrial(HYVET)isconsideredasthelandmarktrialoftreatmentofsystolic
hypertensionduringthelastdecade. [33]TheHYVETwasadoubleblind,randomizedtrialthatenrolled3845hypertensive
patientswhoseagewas80yearsorolderandtheyhadasustainedsystolicBPof160mmHgorhigher.Theywere
randomizedtoeitheradiuretic(indapamide2mg)orplacebo.ThetargetBPwas150/80mmHg.Iftheystillexceeded
thisBPeitheranACEI(perindopril2or4mg)wasaddedorplacebo.At2yearsfollowuptheBPintheactivetreatment
groupwas15.0/6.1mmHglowerthanintheplacebogroup.Inanintentiontotreatanalysis,activetreatmentwas
associatedwitha30%reductionintherateoffatalornonfatalstroke(95%CI:1to51p=0.06),a39%reductioninthe
rateofdeathfromstroke(95%CI:162p=0.05),a21%reductionintherateofdeathfromanycause(95%CI:435p
=0.02),a23%reductionintherateofdeathfromcardiovascularcauses(95%CI:1to40p=0.06),anda64%
reductionintherateofheartfailure(95%CI:4278p<0.001).Fewerseriousadverseeventswerereportedinthe
activetreatmentgroup(358vs448intheplacebogroupp=0.001).
ThereweresomelimitationsoftheHYVETstudy.PatientswithstageIhypertensionwerenotincludedinthisstudy.One
ofthemajorcriticismsabouttheHYVETstudywasthatthestudysubjectrecruitmentwasfocusedonpatientsin
relativelygoodphysicalandmentalconditionandwithalowrateofpreviouscardiovasculardisease.Becausethemedian
followupwas1.8years,itisstillanunansweredquestionifthebeneficialantihypertensiveeffectpersistsafterseveral
yearsintheseveryelderly.Anotherunansweredquestionwastheagelimitofthisbenefitbecausethemeanageofthe
studypopulationwas83yearsandtherewasonlyaminorgroup85yearsandolder.Animportantfindingwasalsothat
thiscombinationtherapyofadiureticandACEIdidnotreducetheriskofdementiaandcognitivefunction. [34]

PersonalizedTreatmentStrategies
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PhysicianshavebeenreluctanttochangeortoaddmedicationsinelderlyhypertensivepatientswhoseBPisnotat
recommendedgoals.Thisphenomenon,whichiscommonlyseeninthemanagementofhypertension,isnowreferredto
astherapeuticinertia.Thereisstillalotofhesitationtostartwithacombinationtherapy.Theadvantageisthatonecan
reducethenumberofpillsandcangoforalowerdoseofthedifferentcomponents.Thiswillleadtofewersideeffects,
bettertherapeuticadherence,greaterpatientsatisfactionandlast,butnotleast,betterBPcontrol. [34]
Theselectionofaspecificmedicationforinitialtreatmentofhypertensionintheelderlyiscomplexandmaydependona
varietyoffactorssuchasgender,race,comorbidcardiovasculardiseaseandnoncardiovasculardiseaseandtargetorgan
damage. [35]Elderlypatientshavedifferentmedicaltherapiesforothermedicalissuesand,therefore,potentialdrugdrug
interactionswithapatient'sexistingmedicalregimenmayfurtherlimittherapeuticoptions.Inthediscussionaboutthe
differenttherapeuticantihypertensiveclasses,tailoringwithdifferentcomorbiditieshasalreadymentioned.Withaging,
hypertensivepatientsareathigherriskforperipheralarterialdisease,aorticaneurysmsandaorticdissection. [36,37]
blockersshouldbeusedincasesofaorticaneurysmsandaorticdissection.Themedicalcommunityisanxiouslywaiting
forthenewJNC8guidelines,especiallyfortheBPgoalincaseofdiabetesmellitus.TheACCORDstudyshowedusthat
therewasnodifferenceincardiovascularoutcomeinTypeIIdiabeticpatientsiftheBPwastreatedforatargetof140or
120mmHg. [38]

TherapeuticAdherence
Adherenceisamajorissueinantihypertensivetherapy.Alargeproportionofelderlypatientswilldiscontinueortake
drugsinappropriately.NonadherenceoftenresultsinfailingtoreachBPtargetsandimpactsoutcomes.Toimprove
antihypertensiveefficacyoneshouldconsiderinthetherapeuticchoicetheadditiveandsynergisticeffectsofadual
therapy.Anotherimportantaspectistoreduceadverseeventsbylowdosestrategyanddrugswithoffsettingactions.
Thiswillenhanceconvenienceandtherapeuticcomplianceforthepatientandthecaretakeroftheelderlyhypertensive
patient.Theselectionofantihypertensivetherapyshouldhaveapotentialforadditivetargetorganprotection.

ExpertCommentary&FiveyearView
Agingisassociatedwithincreasedarterialstiffness,andconsequentlywithariseinsystolicBPleadingtoisolated
systolichypertension.Itisimportanttodetectearlychangesinarterialstiffnessbecausetheyarenotonlypredictivefor
cardiovascularevents[39]anddeclineinrenalfunction, [40]butalsoforthedevelopmentofarterialhypertension. [41]There
isaneedtobetterunderstandtheventricularvascularcouplingwithagingandthedevelopmentofdiastolicdysfunction
beyondtheprocessofleftventricularhypertrophyduetothesystolicloadandthearterialwavereflections.Weneedto
exploretheinteractiontherolebetweenthereninangiotensinaldosteronesystem,inflammationandfibrosis,because
withagingtheendprocessofinflammationisfibrosis.Thiswillhelpustodevelopnewtherapiestonotonlydelaythe
progressionofvascularagingandthedevelopmentofsystolichypertension,butalsotoprotectagainsttargetorgan
damage.Thiswillreducetheproblemofresistanthypertensionbecausetherapywillbestartedearlierandwithatailored
approachfocusedonthereverseofpathologicalmechanismsinvolvedinsystolichypertensionanddeclineinrenal
function,whichcanpotentiatethesecondarycauseofhypertension.Oneofthemajorchallengeswillbetorevealthe
interactionofsystolichypertension,agingandtheimpactofdementia.Thisrequiresaholisticapproachtosystolic
hypertensiontogetherwiththedifferentcomorbiditiesintheelderly,andthedevelopmentofplansnotonlytoassure
therapeuticadherence,butalsotoreducetherapeuticinertiaamongelderlycaregivers.Alltheseeffortsneedtobe
evaluatedtoimprovethecostbenefitofthelargestpatientpopulationsinthecomingdecades.

Sidebar
KeyIssues

Arterialhypertensionintheelderlyisamajorhealtheconomyburden.
Systolichypertensionisanexpressionofincreasedarterialstiffness,especiallyofthelargearteries.
Adequateantihypertensivetherapyintheelderlywillsignificantlyreducecardiovascularmorbidityandmortality.
Thebloodpressuregoalintheveryelderlyis150/80mmHg.
Moreeffortisnecessarytoreducetherapeuticinertiainolderhypertensivepatients.

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Itisbettertotailortheantihypertensivetherapyinconsiderationwiththeothercomorbidities.
Startingdualtherapycancontrolbloodpressurebetterthaninitiatingsingletherapyuntilmaximumdosageis
reached.
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Papersofspecialnotehavebeenhighlightedas:
*ofinterest
**ofconsiderableinterest

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