Isolated systolic hypertension is the predominant form of hypertension in the elderly population. Traditionally defined as systolic blood pressure (SBP) above 140 mm Hg with diastolic blood pressure (DBP) of less than 90 mm Hg, it is estimated that 15% of people aged 60 years and above have isolated systolic hypertension. Per the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline, however, an SBP of 130 mm Hg is now considered hypertensive at all ages. The new definition of hypertension will lead to an increased number of elderly being diagnosed with high blood pressure. Isolated systolic hypertension remains an important public health concern as chronically untreated high SBP patients carry significant mortality and morbidity.
Most patients with hypertension have primary hypertension, which is also known as essential hypertension. Rarely, isolated systolic hypertension is attributed to other causes of secondary hypertension such as hypothyroidism/hyperthyroidism, chronic kidney disease, peripheral vascular disease, diabetes mellitus, aortic insufficiency, arteriovenous fistula, anemia, Paget disease, and atherosclerotic renal artery stenosis.
Isolated systolic hypertension is common in the elderly population. Based on data from the National Health and Nutrition Examination Survey 1999-2010, approximately 30% of persons aged 60 years and above have untreated isolated systolic hypertension, as compared with 6% in adults aged 40 to 50 years and 1.8% in young adults aged 18 to 39 years. As per the Framingham Heart Study, a person aged 65 years with normal blood pressure has a 90% lifetime risk of developing hypertension. Among the elderly group, women and non-Hispanic blacks have a higher prevalence of hypertensive disorders.
Isolated systolic hypertension, in most cases, develops as a result of the reduced elasticity of the arterial system. This is commonly seen among the elderly as there is increased deposition of calcium and collagen to the arterial wall. Hence, this may result in reduced compliance of the arterial vessels, decreased lumen-to-wall ratio, and increased thickening and fibrotic remodeling of the vascular intima and media. As a result, these stiffened conduit arteries lead to the increase in pulse pressure and pulse wave velocity, causing an elevation in SBP and a further decline in DBP. Similarly, chronic diseases such as the above causes of secondary hypertension may contribute to the same pathological process by accelerating the deposition of calcium and collagen to the arterial system and the fibrotic remodeling of the vascular walls.
Isolated systolic hypertension, like any other hypertensive disorders, often results in end-organ damage when untreated. Hence, early diagnosis, addressing modifiable risk factors, and initiating appropriate treatment are prudent to decrease morbidity and mortality. The important aspects of the history in the hypertensive patient include the following:
Accurate Blood Pressure Measurement
Routine laboratory and clinical investigation These tests should be performed to evaluate cardiovascular risk and concomitant diseases.
Additional testsPerform the following tests based on the relevant history, physical examination, and routine laboratory findings.
New classifications of blood pressure according to the 2017 ACC/AHA guidelines:
Normal Blood Pressure
Elevated Blood Pressure
Hypertension Stage 1
Hypertension Stage 2
*If the blood pressure goal is not met, assess and optimize adherence to therapy or consider intensification of therapy.
*If the blood pressure goal is met, reassess in three to six months.
Several clinical trials such as HYpertension in the Very Elderly (HYVET) and Systolic Hypertension in the Elderly Program (SHEP) have shown that active treatment of isolated systolic hypertension in older adults resulted in significant reductions in the all-cause mortality (13%), cardiovascular mortality (18%), and stroke (30%) and coronary (23%) events as compared with placebo.
Blood Pressure Goals
It is important to identify white coat hypertension and masked hypertension correctly as over- or under-treatment of hypertension can have significant morbidity and mortality.
White coat Hypertension
Isolated systolic hypertension is common in patients in the elderly population. SBP has a better prediction for risk of cardiovascular disease as compared to DBP. Hence, treatment of isolated systolic hypertension is beneficial to reduce all-cause mortality and cardiovascular risk and stroke. The optimal SBP remained unclear, but an SBP goal of < 140 mmHg and keeping DBP at 70 mmHg or higher are considered appropriate in most patient populations.
Systolic hypertension is commonly encountered in clinical practice. Because it is a major risk factor for adverse cardiac events, the condition must be appropriately managed. The nurse practitioner, primary care provider, internist, cardiologist, and emergency department physician must be aware of the latest ACC guidelines on the management of hypertension. Because of the numerous drugs available to treat hypertension, a consult with a cardiologist is highly recommended if there is any doubt about the efficacy of the drug. There is ample evidence showing that when systolic hypertension is well treated, the patients have good outcomes with an interdisciplinary approach to care. (Level 1)
|||Isolated Systolic Hypertension: An Update After SPRINT., Bavishi C,Goel S,Messerli FH,, The American journal of medicine, 2016 Dec [PubMed PMID: 27639873]|
|||Whelton PK,Carey RM,Aronow WS,Casey DE Jr,Collins KJ,Dennison Himmelfarb C,DePalma SM,Gidding S,Jamerson KA,Jones DW,MacLaughlin EJ,Muntner P,Ovbiagele B,Smith SC Jr,Spencer CC,Stafford RS,Taler SJ,Thomas RJ,Williams KA Sr,Williamson JD,Wright JT Jr, 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018 Oct 23; [PubMed PMID: 30354654]|
|||Viera AJ,Neutze DM, Diagnosis of secondary hypertension: an age-based approach. American family physician. 2010 Dec 15 [PubMed PMID: 21166367]|
|||Egan BM,Li J,Hutchison FN,Ferdinand KC, Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals. Circulation. 2014 Nov 4 [PubMed PMID: 25332288]|
|||Liu X,Rodriguez CJ,Wang K, Prevalence and trends of isolated systolic hypertension among untreated adults in the United States. Journal of the American Society of Hypertension : JASH. 2015 Mar [PubMed PMID: 25795550]|
|||AlGhatrif M,Lakatta EG, The conundrum of arterial stiffness, elevated blood pressure, and aging. Current hypertension reports. 2015 Feb [PubMed PMID: 25687599]|
|||Chobanian AV, Clinical practice. Isolated systolic hypertension in the elderly. The New England journal of medicine. 2007 Aug 23 [PubMed PMID: 17715411]|
|||Mancia G,Fagard R,Narkiewicz K,Redon J,Zanchetti A,Böhm M,Christiaens T,Cifkova R,De Backer G,Dominiczak A,Galderisi M,Grobbee DE,Jaarsma T,Kirchhof P,Kjeldsen SE,Laurent S,Manolis AJ,Nilsson PM,Ruilope LM,Schmieder RE,Sirnes PA,Sleight P,Viigimaa M,Waeber B,Zannad F, 2013 ESH/ESC Practice Guidelines for the Management of Arterial Hypertension. Blood pressure. 2014 Feb [PubMed PMID: 24359485]|
|||Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA. 1991 Jun 26 [PubMed PMID: 2046107]|
|||Beckett NS,Peters R,Fletcher AE,Staessen JA,Liu L,Dumitrascu D,Stoyanovsky V,Antikainen RL,Nikitin Y,Anderson C,Belhani A,Forette F,Rajkumar C,Thijs L,Banya W,Bulpitt CJ, Treatment of hypertension in patients 80 years of age or older. The New England journal of medicine. 2008 May 1 [PubMed PMID: 18378519]|
|||Wright JT Jr,Williamson JD,Whelton PK,Snyder JK,Sink KM,Rocco MV,Reboussin DM,Rahman M,Oparil S,Lewis CE,Kimmel PL,Johnson KC,Goff DC Jr,Fine LJ,Cutler JA,Cushman WC,Cheung AK,Ambrosius WT, A Randomized Trial of Intensive versus Standard Blood-Pressure Control. The New England journal of medicine. 2015 Nov 26 [PubMed PMID: 26551272]|
|||Kimm H,Mok Y,Lee SJ,Lee S,Back JH,Jee SH, The J-curve between Diastolic Blood Pressure and Risk of All-cause and Cardiovascular Death. Korean circulation journal. 2018 Jan [PubMed PMID: 29322696]|
|||Kang YY,Wang JG, The J-Curve Phenomenon in Hypertension. Pulse (Basel, Switzerland). 2016 Jul [PubMed PMID: 27493904]|
|||Zweifler AJ,Shahab ST, Pseudohypertension: a new assessment. Journal of hypertension. 1993 Jan [PubMed PMID: 8382233]|
|||Benetos A,Petrovic M,Strandberg T, Hypertension Management in Older and Frail Older Patients. Circulation research. 2019 Mar 29; [PubMed PMID: 30920928]|
|||Ojji DB,Mayosi B,Francis V,Badri M,Cornelius V,Smythe W,Kramer N,Barasa F,Damasceno A,Dzudie A,Jones E,Mondo C,Ogah O,Ogola E,Sani MU,Shedul GL,Shedul G,Rayner B,Okpechi IG,Sliwa K,Poulter N, Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans. The New England journal of medicine. 2019 Mar 18; [PubMed PMID: 30883050]|
|||Poblete F,Barticevic N,Bastías G,Quevedo D,Vargas I, [Effectiveness of a case management intervention for high blood pressure and type II diabetes in primary health care]. Revista medica de Chile. 2018 Nov; [PubMed PMID: 30725040]|