From the Guidelines
Managing patients with systolic hypertension but diastolic hypotension requires careful consideration of both cardiovascular risk and potential adverse effects of treatment, with the primary goal of lowering systolic blood pressure while avoiding further reduction in diastolic pressure. The condition often occurs in elderly patients with arterial stiffness, where the loss of arterial elasticity causes elevated systolic pressure while diastolic pressure remains low. According to the 2020 European Heart Journal guidelines 1, the target systolic blood pressure should be individualized, generally aiming for <130 mmHg in patients with diabetes and <130 mmHg if tolerated, but not <120 mmHg, while maintaining diastolic pressure above 70 mmHg.
When pharmacotherapy is necessary, begin with low doses of long-acting calcium channel blockers (such as amlodipine 2.5 mg daily) or angiotensin receptor blockers (such as losartan 25 mg daily) as recommended by the 2020 guidelines 1. Avoid high-dose diuretics and beta-blockers as they may exacerbate diastolic hypotension. Some key points to consider in treatment include:
- Lifestyle modifications including sodium restriction, weight management, regular physical activity, and limiting alcohol consumption
- Monitoring patients closely for symptoms of hypoperfusion such as dizziness, fatigue, or syncope
- Balancing the benefits of systolic blood pressure reduction against the risks of compromising organ perfusion from further lowering diastolic pressure
- Considering the use of a renin-angiotensin system blocker, such as an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB), as part of the treatment regimen, as recommended by the 2007 European Society of Hypertension guidelines 1.
It is essential to weigh the benefits of treatment against the potential risks, particularly in elderly patients, and to individualize treatment goals based on the patient's specific needs and health status. The 2007 guidelines 1 also suggest that a blocker of the renin-angiotensin system should be a regular component of combination treatment and the one preferred when monotherapy is sufficient.
From the Research
Management of Patients with Systolic Hypertension but Diastolic Hypotension
- The management of patients with systolic hypertension but diastolic hypotension is complex and requires careful consideration of the potential risks and benefits of treatment 2.
- Antihypertensive therapy can be effective in reducing systolic blood pressure, but it can also lead to further reductions in diastolic blood pressure, which can be harmful, particularly in patients with coronary heart disease 2.
- The use of certain antihypertensive agents, such as nitrates, may be beneficial in improving aortic distensibility and reducing systolic blood pressure without greatly reducing diastolic pressure 2.
- Combination therapy with an angiotensin-receptor blocker (ARB) and either a calcium-channel blocker (CCB) or a diuretic may be effective in improving left ventricular relaxation and reducing systolic blood pressure 3, 4.
- However, the risk of diastolic hypotension should be carefully considered, particularly in older patients, patients with diabetes, and patients with isolated systolic hypertension 5.
- The choice of antihypertensive agent should be individualized based on the patient's specific characteristics and medical history, and the potential benefits and risks of treatment should be carefully weighed 6.
Treatment Options
- Calcium-channel blockers and diuretics may be more effective than other antihypertensive agents in lowering systolic blood pressure in elderly patients with systolic hypertension 6.
- Angiotensin-converting enzyme inhibitors (ACEIs) and ARBs may also be effective in reducing systolic blood pressure and improving cardiovascular outcomes 4.
- Beta-blockers may be less effective in lowering systolic blood pressure and may have more side effects than other antihypertensive agents 6.