Hypertensive heart disease in older patients: considerations for clinical practice

Appropriate management of older people with hypertension is essential to reduce the burden of hypertensive heart disease and further cardiovascular sequelae but there may be challenges given the presence of concurrent senescent changes, comorbidities and impairment in functionality. It is recommended that frailty level and functional status are assessed periodically to understand patient needs and to guide treatment decisions. Office blood pressure should be measured with an appropriate cuff as per standard guidelines. There should be a high index of suspicion for orthostatic hypotension and white coat/masked hypertension, both common in older individuals. Cardiac imaging often identifies age-related changes that may not result from hypertension alone, including smaller ventricular volumes, a sigmoid septum and non-ischaemic fibrosis. Diastolic dysfunction is common and other pathologies, including cardiac amyloidosis, may need to be considered in the presence of red flags. Screening for atrial fibrillation during blood pressure evaluation is advised. Decisions for blood pressure management should follow current recommendations and take into consideration the patient's age and tolerance. There is limited evidence regarding heart failure management in older patients, however, disease-modifying therapy as per guidelines should be pursued. Sufficient outcome data are lacking for this patient group and a multidisciplinary approach is often needed to design optimal therapy.