Is it acceptable to maintain an elderly patient with elevated systolic arterial pressure (hypertension) at a higher level, given adequate diastolic pressure, to avoid symptoms of hypotension?

Blood Pressure Management in Elderly Patients with Symptomatic Hypotension

Yes, it is acceptable and clinically appropriate to maintain this elderly patient at a higher systolic blood pressure (160 mmHg) given her symptomatic intolerance to lower targets and adequate diastolic pressure. 1, 2

Recommended Blood Pressure Target for This Patient

For elderly patients who develop symptomatic hypotension (dizziness, fatigue) with aggressive blood pressure lowering, a systolic blood pressure target of 140-150 mmHg is appropriate and evidence-based. 1, 3, 4

• The most recent 2024 ESC guidelines recommend systolic BP targets of 130-139 mmHg for patients aged ≥65 years, but explicitly state that personalized and more lenient systolic BP targets (e.g., <140 mmHg) should be considered for patients with pre-treatment symptomatic orthostatic hypotension. 5, 1

• Multiple international guidelines (ESH/ESC, NICE, CHEP) consistently support a target of <150/90 mmHg for patients ≥80 years based on the HYVET trial. 1, 2

• The 2013 AHA scientific statement specifically recommends that for patients ≥80 years, systolic BP of 140-145 mmHg is acceptable if tolerated, and excessive lowering of diastolic BP should be avoided in older patients to prevent deleterious reductions in coronary blood flow. 5

The Diastolic Blood Pressure Consideration

The patient's diastolic pressure of 73 mmHg is appropriate and should not be lowered further. 5

• The 2007 ESH/ESC guidelines note that in isolated systolic hypertension, an achieved diastolic pressure of less than 70 mmHg, and especially below 60 mmHg, identifies a high-risk group with poorer outcomes, possibly due to overtreatment. 5

• The 2013 AHA statement warns that some studies have found higher coronary heart disease rates when diastolic BP is reduced below 70-75 mmHg in older patients with coronary disease. 5

• The American Geriatrics Society specifically recommends maintaining diastolic blood pressure between 70-90 mmHg in very elderly patients, with caution not to reduce it below 60 mmHg. 1

Evidence Supporting Higher Targets in Symptomatic Patients

The most recent high-quality evidence supports individualized targets based on tolerability:

• A 2024 Cochrane systematic review (16,732 participants) found that while lower BP targets (<140 mmHg) reduce stroke and cardiovascular events compared to higher targets (150-160 mmHg), the lower target likely does not increase withdrawals due to adverse effects in the general elderly population. 6

• However, this same review acknowledges that additional research is warranted in those who are 80 years and older and those who are frail, in whom risks and benefits may differ. 6

• The 2003 JNC 7 guidelines state that there is no definitive evidence of increased risk with aggressive treatment (J-curve) unless diastolic BP is lowered to 55 or 60 mmHg. 5

Clinical Algorithm for This Patient

Step 1: Accept the current systolic BP of 160 mmHg as appropriate given:

• Patient has documented symptomatic hypotension with previous optimization attempts 1
• Diastolic BP is adequate at 73 mmHg 5
• Patient's baseline was 170-180 mmHg, so 160 mmHg represents improvement 5

Step 2: Monitor for:

• Orthostatic hypotension (measure BP supine and standing) 5
• Symptoms of cerebral hypoperfusion (dizziness, falls, cognitive changes) 5, 1
• Ensure diastolic BP does not fall below 70 mmHg 5, 1

Step 3: Maintain current regimen if:

• Patient remains asymptomatic at current BP 5, 1
• No evidence of target organ damage progression 5
• Quality of life is preserved 1

Important Caveats and Pitfalls

Avoid the following common errors:

• Do not pursue aggressive systolic BP lowering (<140 mmHg) in patients with symptomatic orthostatic hypotension. The 2024 ESC guidelines explicitly recommend more lenient targets for this population. 5, 1

• Do not allow diastolic BP to fall below 60-70 mmHg in pursuit of systolic targets, as this may compromise coronary perfusion and increase mortality. 5

• Do not assume "brittle hypertension" means treatment should be abandoned. The 2003 JNC 7 notes that this misperception has contributed to widespread inadequacy of BP control, but in this case, the patient has demonstrated true symptomatic intolerance. 5

• Do not stop monitoring. The 1993 British Hypertension Society guidelines note that in very old people, it may be unwise to stop treatment unless BP is normal and close monitoring determines the effects. 5

Practical Management Approach

The patient's current systolic BP of 160 mmHg with diastolic of 73 mmHg represents an acceptable compromise that:

• Avoids symptomatic hypotension that impairs quality of life 1
• Maintains adequate diastolic perfusion pressure 5
• Still provides cardiovascular protection compared to untreated hypertension (baseline 170-180 mmHg) 7
• Aligns with guideline recommendations for elderly patients with symptomatic intolerance 5, 1, 2

This approach prioritizes the patient's functional status and quality of life while still providing meaningful cardiovascular risk reduction. 1