Management of Isolated Systolic Hypertension in the Elderly

Now that the benefits of treating diastolic hypertension in the elderly have been convincingly proved, attention is turning to the need for, and the choice of, treatment of isolated systolic hypertension in this age group. The hemodynamic mechanism differs in the elderly, whose isolated systolic hypertension is likely to be accompanied by reduced cardiac output, high peripheral resistance, and reduced plasma volume, whereas young people with similar blood pressure may have high cardiac output, normal peripheral resistance, and normal plasma volume. Increased risk of cardiovascular morbidity and mortality and the importance of reducing cardiac workload in older persons, are significant factors in the need for reduction of systolic pressure. After a good history and physical examination, and a careful check to ascertain that the elevated pressure is measured accurately, elderly patients can begin stepped-care therapy with a diuretic such as hydrochlorothiazide or chlorthalidone. The considerable dangers of a sudden drop in blood pressure can be avoided by giving small initial doses. Methyldopa or clonidine is recommended for step two; the third step can be hydralazine. Side effects, especially in the elderly, should be monitored carefully.