Isolated Systolic Hypertension
Basics
This occurs when the systolic blood pressure (SBP) is greater than 140mmHg and the diastolic blood pressure (DBP) is less than 90mmHg. This type of hypertension is common in the elderly population. This occurs due to a reduction of elasticity in the arterial vasculature. As people age, there is an increased deposition of calcium and collagen in the walls of the arteries. The stiffened walls result in an elevated pulse pressure and pulse wave velocity, resulting and both an increase in the SBP and a subsequent decrease in the DBP.
Management
For more comprehensive management of hypertension kindly read our article discussing the hypertension guidelines.
Non-Pharmacological
- Restrict dietary salt (<1.5g/day).
- Weight loss.
- Increase physical activity.
- Limit alcohol intake – no more than one alcoholic drink per day for women and two for men.
- Cessation of smoking.
Pharmacological
- Start with one agent. The elderly are prone to the development of orthostatic hypotension. However, if the systolic blood pressure is > 160mmHg you may use a second agent as well.
- Thiazide-like diuretics and dihydropyridine calcium channel blockers (amlodipine, nifedipine) are the preferred first-line agents.
- The ACE-Inhibitors or ARBs are used in patients that have compelling indications such as heart failure with reduced ejection fraction, post-myocardial infarction, diabetes, or chronic kidney disease. However, never use ACE inhibitors and ARBs together.
- The usage of Beta-Blockers in the management of hypertension is inferior when compared with ARB, ACE-Inhibitors or Calcium Channel Blockers for the reduction of stroke and other cardiovascular risks.
- The goal in these patients can be a systolic blood pressure < 150mmHg as studies with more strict targets do not show significant differences with certain cardiovascular outcomes. However, this is controversial. Remember that in the elderly, side effects can be more prominent. For instance, they can develop orthostatic hypotension, trauma due to falls, end-organ hypoperfusion, and polypharmacy which is also a risk. For most patients, a blood pressure < 140/90 should be a reasonable target.
J-Curve Phenomenon
The treatment of blood pressure may result in excessively low diastolic blood pressures. This results in hypoperfusion of organs during diastole. Remember that perfusion to the myocardium mainly occurs during diastole. Also, keep in mind that most of these arterial vasculatures have already been narrowed by atherosclerotic plaques.
The blood flow to an organ also depends on the organ’s autoregulation. Hence, each organ is affected differently depending on the level of hypoperfusion. The J-curve effect simply describes a phenomenon whereby there is an inverse relationship between low blood pressure and cardiovascular complications. Therefore it is important to ensure that the diastolic blood pressure remains > 70mmHg and in some cases between 80 – 85mmHg.
2. Park, C.G. and Lee, J.Y. (2011) “The significance of the J-curve in hypertension and coronary artery diseases,” Korean Circulation Journal, 41(7), p. 349. Available at: https://doi.org/10.4070/kcj.2011.41.7.349.
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