Isolated systolic hypertension

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There are three main reasons why isolated systolic hypertension has become increasingly important over the past few years:

• We are seeing more and more elderly patients, and isolated systolic hypertension is the most common form of high BP in the geriatric population.

• Systolic BP has finally been recognized as the most powerful predictor of cardiovascular morbidity and mortality and, therefore, treatment of systolic BP has become more important than that of diastolic BP.

• The treatment goals of systolic BP have become increasingly lower over the past few years, thereby creating numerous hypertensive patients who, according to previous criteria, would not have fulfilled this definition.

Even in very elderly patients, a systolic BP goal of less than 140 mmHg can be a realistic goal with modern antihypertensive therapy, although sometimes there will have to be a compromise between the BP goal and the patient's well-being, health plan, and wallet.

The most common pitfall encountered in the treatment of isolated systolic hypertension is the failure to recognize that bradycardia can be its major perpetrator. Any decrease in heart rate is prone to an increase in stroke volume; a higher stroke volume ejected into a stiff aorta will elevate systolic and lower diastolic pressure. Thus, bradycardia often causes systolic hypertension, or makes it very resistant to therapy. Heart rate progressively slows throughout life and bradycardia is common in elderly patients. Bradycardia can be aggravated by underlying sick sinus syndrome and other conduction abnormalities or, more commonly, beta-blocker therapy. Beta-blockers, therefore, are not useful in the treatment of isolated systolic hypertension. Conversely, a dihydropyridine calcium antagonist, possibly in combination with an ACE inhibitor or an ARB, is prone to lower systolic pressure into, or at least close to, the target range. Of note, BP in elderly patients can be exquisitely sensitive to antihypertensive therapy; therefore, initiation of any drug should start at low doses and be uptitrated very gradually at an interval of 2-4 months. Low-dose diuretic therapy is often a helpful adjunct, although the propensity of diuretics to cause hyponatremia in the geriatric population, particularly in women, should be remembered.

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