What is the first-line therapy for older patients with hypertension?

First-Line Therapy for Hypertension in Older Patients

Start with a thiazide or thiazide-like diuretic, a calcium channel blocker (dihydropyridine), or an ACE inhibitor/ARB as first-line monotherapy in older patients, targeting blood pressure <140/90 mmHg with gradual titration from low initial doses. 1, 2, 3

Initial Drug Selection Algorithm

For Non-Black Elderly Patients:

• Begin with low-dose ACE inhibitor or ARB as the preferred first agent 1, 2
• Thiazide diuretics are equally appropriate and have the strongest evidence for cardiovascular mortality reduction in elderly patients 3, 4
• Calcium channel blockers (dihydropyridine) are particularly effective for isolated systolic hypertension, which is common in the elderly 3, 5

For Black Elderly Patients:

• Start with low-dose ARB plus dihydropyridine calcium channel blocker or calcium channel blocker plus thiazide-like diuretic 1
• Black patients respond less favorably to ACE inhibitors as monotherapy 1

Dosing Strategy for Elderly Patients

Always start with lower doses than standard adult dosing and titrate gradually due to age-related changes in drug metabolism and increased risk of adverse effects 2, 3, 5

• Initial doses should be approximately half the standard adult dose 3
• Titrate to full dose only after confirming tolerability 1
• Monitor for orthostatic hypotension by checking blood pressure in both sitting and standing positions at every visit 2, 3, 6

Blood Pressure Targets

Target <140/90 mmHg for patients under age 80 years 1, 2, 3, 4

For patients ≥80 years or frail elderly:

• Consider monotherapy with more conservative targets 1, 3
• A systolic blood pressure of 140-145 mmHg is acceptable if lower targets cause symptoms 3
• Individualize based on frailty status, but avoid diastolic blood pressure <70-75 mmHg in those with coronary disease 3, 6

When to Advance to Combination Therapy

Approximately two-thirds of elderly patients require combination therapy to achieve target blood pressure 3

If blood pressure remains elevated after titrating the first agent to full dose:

• Add a second agent from a different class (e.g., if started with ACE inhibitor, add calcium channel blocker or thiazide diuretic) 1, 2
• Combination therapy allows lower individual drug doses, minimizing dose-dependent side effects 3
• Achieve target blood pressure within 3 months of treatment initiation 1, 6

Critical Considerations for Elderly Patients

Avoid Common Pitfalls:

• Never use short-acting nifedipine due to dangerous rapid blood pressure drops 6
• Do not aggressively lower blood pressure in acute settings without evidence of end-organ damage, as rapid reduction increases stroke and myocardial infarction risk 6
• Monitor renal function and electrolytes when using diuretics or ACE inhibitors/ARBs 2

Special Populations:

• Patients with left ventricular hypertrophy: ARBs (particularly losartan) show superior cardiovascular outcomes compared to beta-blockers 3
• Patients with diabetes or chronic kidney disease: Always include a renin-angiotensin system blocker (ACE inhibitor or ARB) 1
• Patients with coronary disease: Avoid excessive diastolic lowering below 70-75 mmHg to prevent coronary hypoperfusion 3, 6

Monitoring Timeline

• Measure blood pressure in both arms at initial visit and use the arm with higher readings for subsequent measurements 3
• Reassess within 2-4 weeks after initiating or adjusting therapy 1
• Achieve target within 3 months of starting treatment 1, 6
• Once controlled, monitor every 3-6 months 1

Why These Agents Are Preferred

The 2020 International Society of Hypertension guidelines establish thiazide diuretics, calcium channel blockers, ACE inhibitors, and ARBs as first-line agents because they have demonstrated cardiovascular morbidity and mortality reduction in elderly patients aged ≥60 years 1, 2, 3. The proportional benefit in patients >65 years is no less than in younger patients 1. These four drug classes can all be considered equivalent in their ability to lower blood pressure and provide cardiovascular protection in the elderly, so choice should be guided by comorbidities, tolerability, and cost rather than age alone 1, 4.