How do you manage patients over 80 years old with isolated systolic hypertension and diastolic hypotension?

From the Guidelines

Managing patients over 80 with systolic hypertension but diastolic hypotension requires careful treatment to reduce cardiovascular risk while avoiding complications from excessive diastolic lowering, with a recommended approach of maintaining BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated 1.

Key Considerations

• Start with a target systolic blood pressure of 130-150 mmHg while maintaining diastolic pressure above 60-65 mmHg.
• Begin with low-dose, long-acting calcium channel blockers like amlodipine 2.5 mg daily or long-acting dihydropyridines, which effectively lower systolic pressure with minimal diastolic effects, as supported by the 2007 guidelines for the management of arterial hypertension 1.
• If needed, add low-dose thiazide-like diuretics such as indapamide 1.25 mg daily.
• Avoid beta-blockers and high-dose diuretics in this population, as they may exacerbate diastolic hypotension.
• Implement medication changes gradually with frequent monitoring (every 2-4 weeks initially), checking for orthostatic hypotension, falls, electrolyte disturbances, and renal function changes, in line with the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Non-Pharmacological Approaches

• Encourage moderate sodium restriction, regular light physical activity, weight management if appropriate, and alcohol moderation.
• Pursue non-pharmacological approaches as the first-line treatment of orthostatic hypotension among persons with supine hypertension, and consider switching BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy 1.

Monitoring and Follow-Up

• Test for orthostatic hypotension by measuring BP 1 and/or 3 min after standing, as recommended in the 2024 ESC guidelines 1.
• Regularly monitor patients for signs of excessive diastolic lowering, such as dizziness, lightheadedness, or falls.
• Adjust treatment as needed to balance the benefits of systolic pressure reduction against the risks of excessive diastolic lowering.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Managing Systolic Hypertension with Diastolic Hypotension in Over 80's

• The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend reducing systolic blood pressure to 140-145 mmHg if tolerated in adults aged 80 years and older 2.
• A goal systolic blood pressure level lower than 150 mmHg is reasonable for nearly all adults 60 years and older, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 2, 3.
• In patients with isolated systolic hypertension, the degree to which systolic blood pressure lowering can be tolerated may be limited if the diastolic blood pressure decreases below 60 to 65 mmHg 3.
• Orthostatic hypotension is common among older hypertensive patients, and symptoms of light-headedness should prompt an evaluation for orthostatic hypotension and a possible decrease in drug treatment 3, 4.
• For relatively healthy older adults at increased cardiovascular risk, a systolic blood pressure level goal lower than 140 mmHg may be pursued, but more aggressive blood pressure lowering is associated with a higher number of adverse events 3.
• The 2017 ACC/AHA hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with an average systolic blood pressure of 130 mmHg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mmHg 5, 6.
• Clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of systolic blood pressure lowering and the choice of antihypertensive drugs to use for treatment in elderly adults with hypertension and a high burden of comorbidities and limited life expectancy 5, 6.