Isolated Systolic Hypertension

The American Heart Association notes that both systolic blood pressure (SBP) and diastolic blood pressure (DBP) increase linearly up to the fifth or sixth decade of life, after which DBP gradually decreases while SBP continues to rise, leading to isolated systolic hypertension in many older adults 1, 3
By age 60, isolated systolic hypertension becomes the most common form of hypertension, affecting more than half of Americans over age 65 3
In the Framingham Heart Study, SBP alone correctly classified blood pressure stage in 94% of adults over 60 years old, while DBP alone correctly classified only 66% 4

Clinical Significance and Cardiovascular Risk

Each increase in SBP of 20 mmHg doubles the risk of fatal coronary events 3
Isolated systolic hypertension is associated with increased risk of fatal and nonfatal stroke, cardiovascular events, and death 1
The risk of cardiovascular disease increases in a log-linear fashion from SBP levels <115 mmHg to >180 mmHg 5, 6

According to current guidelines from the American Heart Association, blood pressure categories are: Normal: <120/<80 mmHg, Elevated: 120-129/<80 mmHg, Stage 1 hypertension: 130-139/80-89 mmHg, Stage 2 hypertension: ≥140/≥90 mmHg 6

The American College of Cardiology recommends a systolic blood pressure treatment goal of less than 130 mmHg for ambulatory community-dwelling adults ≥65 years with isolated systolic hypertension 1, 2
For older adults with high comorbidity burden and limited life expectancy, treatment decisions should consider risk/benefit assessment, patient preference, and a team-based approach 1, 2

Focusing solely on diastolic pressure in older adults, when systolic pressure is the more important risk factor after age 60 3, 4
Withholding treatment based on age alone - evidence shows benefit of treatment even in patients over 80 years 4
Failing to monitor for orthostatic hypotension, which is more common in older adults and can lead to falls 1, 8

Randomized controlled trials have demonstrated that improved blood pressure control does not exacerbate orthostatic hypotension and has no adverse impact on risk of injurious falls in community-dwelling older persons 1
Blood pressure-lowering therapy is one of the few interventions shown to reduce mortality risk in frail older individuals 1
For most patients with isolated systolic hypertension, combination therapy with two or more drugs is often needed to achieve optimal blood pressure control 4