Isolated Systolic Hypertension in the Elderly.

Isolated systolic hypertension (ISH) is the predominant form of hypertension in persons older than 50 years, who represent the majority of individuals with hypertension. Systolic blood pressure (SBP) determines Joint National Committee blood pressure stage, and therefore the need for therapy, far more often than diastolic blood pressure (DBP). SBP consistently is associated with greater risk for overall mortality, coronary heart disease, stroke, congestive heart failure, renal failure, and other end points. In addition, clinicians are far less aggressive and less successful at controlling SBP compared with DBP. Thus, SBP should be acknowledged as the major criterion that determines diagnosis, staging, and therapeutic management in older individuals. Several recent large, randomized, placebo-controlled trials of drug therapy targeting ISH in the elderly have shown dramatic reductions in cardiovascular end points and mortality. The treatment of patients with ISH must occur within the framework of the larger goals associated with treatment of hypertension generally. Lifestyle modification, including salt restriction and increasing physical activity, may contribute to improvements in arterial compliance and control of ISH in particular. In clinical trials, most antihypertensive agents decrease SBP more than DBP. However, certain drug classes, such as angiotensin-converting enzyme inhibitors and nitrates, have advantageous properties that may make them particularly useful for the treatment of ISH.