Treatment strategies for isolated systolic hypertension in elderly patients

ABSTRACT

Introduction

Hypertension is a major and modifiable risk factor for cardiovascular disease. Its prevalence is rising as the result of population aging. Isolated systolic hypertension mostly occurs in older patients accounting for up to 80% of cases.

Areas covered

The authors systematically review published studies to appraise the scientific and clinical evidence supporting the role of blood pressure control in elderly patients with isolated systolic hypertension, and to assess the influence of different drug treatment regimens on outcomes.

Expert opinion

Antihypertensive treatment of isolated systolic hypertension significantly reduces the risk of morbidity and mortality in elderly patients. Thiazide diuretics and dihydropyridine calcium-channel blockers are the primary compounds used in randomized clinical trials. These drugs can be considered as first-line agents for the management of isolated systolic hypertension. Free or fixed combination therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and calcium-channel blockers or thiazide-like diuretics should also be considered, particularly when compelling indications such as coronary artery disease, chronic kidney disease, diabetes, and congestive heart failure coexist. There is also hot scientific debate on the optimal blood pressure target to be achieved in elderly patients with isolated systolic hypertension, but current recommendations are scarcely supported by evidence.

KEYWORDS:

• Elderly
• isolated systolic hypertension
• clinical trials
• blood pressure reduction
• therapy
• frailty
• chronic disease

Article highlights

• Among the potential targets for improving health and prevention of cardiovascular diseases in older adults, hypertension represents one of the most prevalent and potentially modifiable risk factors.

• Isolated systolic hypertension is the dominant pattern of blood pressure in elderly patients. It reflects the structural and functional deterioration of the arterial wall due to increased parietal stress and elevated pulse pressure.

• Antihypertensive treatment of isolated systolic hypertension significantly reduces the risk of morbidity and mortality in elderly patients.

• Thiazide diuretics and dihydropyridine calcium channel blockers are the primary agents tested in randomized clinical trials of elderly hypertensive patients and should be considered as first-line agents for the management of isolated systolic hypertension.

• Angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, and beta-blockers should be considered if there are compelling indications such as coronary artery disease, chronic kidney disease, diabetes, and congestive heart failure.

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Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One referee has served as a consultant for Bayer, Sanofi, Lexicon, AstraZeneca, Vifor/Relypsa, Amgen KBP Pharmaceuticals, Sarfez, scPharmaceuticals, SQinnovations, G3 pharmaceuticals and Cereno Scientific. They also have stock options in Vifor/Relypsa, KBP Pharmaceuticals, Sarfez, SQinnovations and scPharmaceuticals, G3 Pharmaceuticals and Cerono Scientific. They also declare that they have a US patent on site specific delivery of eplerenone to the myocardium. Another referee was involved in the development of the 2017 ACC/AHA hypertension guidelines, which they strongly support. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

The study was funded in part by the non-profit organization, the Fondazione Umbra Cuore e Ipertensione-ONLUS, Perugia, Italy.