High Systolic Blood Pressure in Older Adults

In older adults, elevated systolic blood pressure is significantly more concerning than elevated diastolic blood pressure and should be the primary focus of cardiovascular risk assessment and treatment, according to the American College of Cardiology 1
After age 60, systolic blood pressure continues to rise while diastolic blood pressure typically plateaus or decreases, making isolated systolic hypertension the most common form of hypertension in this population 1
By age 60, isolated systolic hypertension affects more than half of adults over 65 1
Systolic blood pressure alone correctly classified blood pressure stage in 94% of adults over 60 years old, while diastolic blood pressure alone correctly classified only 66%, as seen in the Framingham Heart Study 1
Both systolic and diastolic blood pressure increase linearly up to the fifth or sixth decade of life, after which diastolic blood pressure gradually decreases while systolic blood pressure continues to rise 1

Cardiovascular Risk Prediction

Each 20 mmHg increase in systolic blood pressure doubles the risk of fatal coronary events 1
The risk of cardiovascular disease increases in a log-linear fashion from systolic blood pressure levels <115 mmHg to >180 mmHg, as reported by the American Heart Association and supported by evidence from Circulation and Hypertension 2, 3

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

Evidence was insufficient to determine the benefit of treating diastolic hypertension in the absence of systolic hypertension, according to the Annals of Internal Medicine 4, 5
Most trials assessed treatment outcomes based on systolic blood pressure, and no trials included patients with mean diastolic blood pressure >90 mmHg and mean systolic blood pressure <140 mmHg, as reported by the Annals of Internal Medicine 4, 5

Do not focus solely on diastolic pressure in older adults when systolic pressure is the more important risk factor after age 60, as advised by the American College of Cardiology 1
Do not withhold treatment based on age alone—evidence shows benefit of treatment even in patients over 80 years, according to the American College of Cardiology 1
Do not ignore isolated systolic hypertension because diastolic blood pressure is normal; this represents significant cardiovascular risk requiring treatment, as stated by the American College of Cardiology 1
Monitor for orthostatic hypotension during treatment, which is more common in older adults, as recommended by the American College of Cardiology 1