Initial assessment
Isolated systolic hypertension is defined by systolic blood pressure values equal to or above one hundred and forty millimetres of mercury, with diastolic blood pressure below eighty millimetres of mercury, occurring predominantly in older adults. The first step is to confirm the diagnosis through home blood pressure monitoring or ambulatory blood pressure monitoring, excluding white-coat hypertension or pseudo-resistance, and adjusting clinical follow-up appropriately.
Pathophysiological context and risk
This condition largely results from increased arterial stiffness and pulse pressure. In these patients, excessive reduction of diastolic blood pressure may compromise coronary and cerebral perfusion, increasing the risk of dizziness, falls, myocardial ischaemia and poorer prognosis. The approach should therefore balance cardiovascular benefit and clinical safety, avoiding overtreatment.
Assessment of diastolic blood pressure
Baseline diastolic blood pressure should be carefully analysed. Values below sixty to sixty-five millimetres of mercury are associated with coronary hypoperfusion, angina, silent ischaemia, syncope, falls and worse prognosis in older adults. This parameter is crucial for defining safe blood pressure targets, guiding drug titration and deciding when treatment should not be intensified.
Assessment of pulse pressure
Pulse pressure is an indirect marker of arterial stiffness and should be systematically assessed. High values, generally equal to or above sixty to seventy millimetres of mercury, are associated with higher cardiovascular risk and predict a greater reduction in diastolic blood pressure with treatment, justifying slow and cautious titration.
Global clinical assessment
It is essential to assess frailty, fall risk, polypharmacy, the presence of coronary artery disease and the risk of orthostatic hypotension. Older patients, those with reduced physiological reserve or low diastolic pressure, are more vulnerable to adverse effects of treatment, and therapeutic decisions should therefore be individualised.
Indication to start pharmacological treatment
Systolic blood pressure values equal to or above one hundred and sixty millimetres of mercury justify starting pharmacological treatment, regardless of cardiovascular risk, and treatment should be initiated and titrated progressively. When systolic blood pressure is between one hundred and forty and one hundred and fifty-nine millimetres of mercury, the decision should be considered in the presence of high cardiovascular risk, target-organ damage or established cardiovascular disease, while surveillance may be acceptable in frail older patients or in those with low diastolic pressure.
Choice of initial therapy
Treatment should prioritise drugs with proven efficacy and good tolerability. Thiazide-like diuretics, such as chlorthalidone or indapamide, and dihydropyridine calcium-channel blockers, such as amlodipine or nifedipine, are first-line options. Hydrochlorothiazide has lower efficacy in reducing cardiovascular events, and beta-blockers should be avoided unless there is a specific indication.
Use of ACE inhibitors or ARBs
Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are particularly indicated in the presence of heart failure with reduced ejection fraction, chronic kidney disease or stable coronary artery disease. They may be used alone in situations of moderate systolic pressure, frailty or low diastolic pressure, or in combination when systolic pressure is clearly elevated or control remains insufficient.
Blood pressure targets and safety
Systolic blood pressure targets are generally between one hundred and thirty and one hundred and thirty-nine millimetres of mercury, provided that diastolic blood pressure remains equal to or above sixty to sixty-five millimetres of mercury and no symptoms of hypotension occur, such as dizziness, falls or syncope. In this context, it is preferable to accept a systolic pressure slightly above target rather than induce excessively low diastolic pressure.
Treatment adjustment and follow-up
When systolic blood pressure remains above target with good overall tolerance, gradual treatment intensification may be considered. Conversely, the presence of low diastolic pressure or symptoms of hypotension should lead to dose reduction, treatment de-intensification or redefinition of less aggressive targets. After each adjustment, reassessment with home or ambulatory blood pressure monitoring is recommended, together with surveillance of renal function and electrolytes, particularly when diuretics or renin–angiotensin system drugs are used. In cases of difficult control or suspected secondary or iatrogenic causes, specialist referral should be considered.
