Isolated systolic hypertension in the elderly

Abstract

The incidence of isolated systolic hypertension starts to increase with age over 50 years. Systolic blood pressure (BP) has a higher prognostic value than diastolic BP in those aged over 50 years. Treatment of isolated systolic hypertension significantly decreases the incidence of stroke, coronary events, and total mortality. Most of the studies demonstrating the above facts were conducted in the early 1990s. In all these studies, the baseline systolic BP was ≥ 160 mmHg. This was because isolated systolic hypertension was defined at that time as a systolic BP ≥ 160 mmHg and diastolic BP < 95 mmHg. There has been no study to date showing that decreasing systolic BP in the elderly with initial BP of 140-159 mmHg has a beneficial effect on morbidity and mortality and aiming to achieve systolic BP < 140 mmHg. The recommendation of goal levels < 140 mmHg also in the elderly is based primarily on observational studies. Another problem to be still solved is the potential existence of the diastolic BP J-curve in patients with coronary heart disease. Likewise, no randomized trial comparing diastolic BP levels of < 80 mmHg, < 70 mmHg, and < 60 mmHg has been reported. The guidelines of the European Society of Hypertension and the European Society of Cardiology define goal values for isolated systolic hypertension as < 140/90 mmHg. In patients with diabetes, those with cardiovascular or renal disease (status after myocardial infarction, after stroke, and renal dysfunction), also, in metabolic syndrome patients and patients whose overall cardiovascular risk, using SCORE, is ≥ 5%, the guidelines recommend the decrease of BP to the value < 130/80 mmHg. We believe that, against the background of contradictory data regarding the J-curve of the relationship of diastolic BP and coronary events, caution is to be exercised in elderly patients with isolated systolic hypertension and coronary heart disease in cases where diastolic BP on therapy declines to < 70 mmHg. In such cases, we will not insist on achieving goal systolic BP. In our opinion, this should apply particularly to elderly patients with coronary heart disease.