We all know that hypertension is bad. How important is it to decrease the systolic pressure below 160 mm in a patient who is over 80 years old? This is the first of two articles about blood pressure. The first article discusses the benefits of treatment. The second article discusses a challenging and common dilemma in frail elderly patients. It is important to read both posts to answer the above question.

Hypertension: Why is it important to treat?

Hypertension damages blood vessels leading to harmful buildup inside the vessels. This leads to stroke, coronary artery disease, kidney disease and other circulatory problems. It increases the risk of dementia later in life. Hypertension is diagnosed when there is a consistent elevation of blood pressure to at least 140 mm systolic or 90 mm diastolic (140/90).  Systolic blood pressure is the upper number. It measures the pressure in your arteries when your heart beats. Diastolic blood pressure is the lower number. It measures the pressure in your arteries when your heart rests between beats. Hypertension in young and middle-aged adults should be treated aggressively. Many experts recommend a blood pressure goal of 120/80 or less for these patients.

Hypertension in Older Patients: How is it different?

The patient in this case is described as having a pressure greater than 160. There is no mention of the diastolic blood pressure. This is because isolated systolic hypertension is the most common type of hypertension among seniors.  It means a systolic pressure of at least 160 mm. In contrast to “classic” hypertension (combined systolic and diastolic), the bottom/diastolic number is  normal or low.  A typical blood pressure may be 165/68.  75% of people over age 75 have isolated systolic hypertension. Isolated systolic hypertension is different. It is caused by increased stiffening of large blood vessels as people age. Classic hypertension in midlife is usually due to abnormalities of smaller blood vessels.

In the past, we did not know if treating isolated systolic hypertension was important. We now know that isolated systolic hypertension is harmful. It increases the risk of stroke and heart disease, even for people age 85 and over. When medications are used to lower the systolic blood pressure, the risk of stroke and death decreases.

But treatment of systolic hypertension is challenging. I will discuss the other side of the story in my next post. Multiple medications are frequently needed. As many as 20% of elderly patients have both hypertension and a significant drop in blood pressure when standing. This is called orthostatic hypotension. The benefit of treatment in frail patients is controversial.

Summary:

• Isolated systolic hypertension is the most common type of hypertension in older adults.
• Isolated systolic hypertension increases the risk of stroke and heart disease.
• Treatment of systolic hypertension decreases stroke death.
• Treatment of systolic hypertension with multiple medications is controversial in frail patients. This will be discussed in detail in the next post.

Addendum: An elevated systolic blood pressure also occurs with a different heart disease called aortic insufficiency/regurgitation. This disease is not the same as isolated systolic hypertension and is treated differently.

Warmest Aloha,

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PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.