Should I initiate antihypertensive therapy in an 82-year-old woman with a systolic blood pressure of 155 mm Hg?

Should You Treat This 82-Year-Old Woman with BP 155/68?

Yes, you should initiate antihypertensive therapy in this 82-year-old woman with a systolic blood pressure of 155 mmHg, targeting a goal of <140/90 mmHg, using either a thiazide-type diuretic (preferably chlorthalidone 12.5 mg daily) or a dihydropyridine calcium channel blocker (such as amlodipine 5 mg daily) as first-line therapy. 1, 2

Why Treatment Is Indicated

• The 2024 ESC guidelines recommend initiating blood pressure-lowering treatment in patients ≥65 years when office BP is ≥140/90 mmHg, provided treatment is well tolerated. 1
• This patient's systolic BP of 155 mmHg exceeds the treatment threshold of 140 mmHg for older adults, making her a clear candidate for pharmacologic intervention. 1
• The 2017 ACC/AHA guidelines recommend a treatment goal of <130 mmHg for noninstitutionalized ambulatory community-dwelling older adults ≥65 years, though <140/90 mmHg is the minimum acceptable target. 1

First-Line Medication Selection

Start with chlorthalidone 12.5 mg daily as the preferred first-line agent, as thiazide-type diuretics have the strongest outcome evidence for isolated systolic hypertension in elderly patients, demonstrating absolute risk reductions of 1.13% for stroke, 1.25% for cardiac events, and 1.64% for mortality. 2, 3

Alternative First-Line Option

• If thiazides are contraindicated or not tolerated, initiate amlodipine 5 mg daily (a dihydropyridine calcium channel blocker), which has equally robust trial evidence for reducing cardiovascular events in isolated systolic hypertension. 2, 3
• Calcium channel blockers are particularly effective in low-renin hypertension, which is common in elderly patients with isolated systolic hypertension. 2

Medications to Avoid as First-Line

• Do not use beta-blockers (such as atenolol or bisoprolol) as first-line therapy for isolated systolic hypertension, as they are less effective than thiazides and calcium channel blockers for stroke prevention in older adults. 2, 3
• ACE inhibitors and ARBs should be reserved for patients with compelling indications such as diabetes with proteinuria, chronic kidney disease, or left ventricular dysfunction, rather than as first-line therapy for uncomplicated isolated systolic hypertension. 2

Blood Pressure Targets and Safety Considerations

• Target a minimum systolic BP of <140 mmHg and diastolic <90 mmHg; if well tolerated, an optimal systolic target of 120-129 mmHg may be pursued. 1, 2
• Critical safety threshold: Do not allow diastolic BP to fall below 60 mmHg, as this is associated with compromised coronary perfusion and poorer outcomes, especially in patients with coronary disease. 2, 4
• Given her current diastolic of 68 mmHg, you have only an 8 mmHg safety margin, necessitating careful titration and frequent monitoring. 2

Monitoring Protocol

• Measure BP in both sitting and standing positions at every visit to detect orthostatic hypotension, which is common in elderly patients and increases fall risk. 1, 2, 3
• A standing systolic drop ≥20 mmHg or diastolic drop ≥10 mmHg should prompt dose reduction. 1
• Check serum sodium, potassium, and creatinine 2-4 weeks after initiating chlorthalidone to detect electrolyte disturbances or renal dysfunction. 2, 3
• Reassess BP within 2-4 weeks after initiating therapy, and aim to achieve target BP within 3 months. 4, 3

When to Add a Second Agent

• If BP remains ≥140/90 mmHg after titrating chlorthalidone to 25 mg daily (or amlodipine to 10 mg daily), add a second agent from a different class—either a dihydropyridine calcium channel blocker or an ARB/ACE inhibitor. 2, 4
• Approximately two-thirds of elderly patients require combination therapy to achieve target BP. 4
• The optimal triple-therapy combination for resistant hypertension is an ARB or ACE inhibitor + calcium channel blocker + thiazide-type diuretic. 2

Common Pitfalls to Avoid

• Do not overlook standing BP measurements, as failure to detect orthostatic hypotension increases fall risk in the elderly. 1, 2
• Do not discontinue effective therapy solely because the patient reaches 80 years of age; continuation is recommended when well tolerated. 1, 2
• Do not use loop diuretics (such as furosemide) in place of thiazide-type diuretics for hypertension management, as loop diuretics lack outcome evidence in isolated systolic hypertension. 2
• Do not pursue aggressive systolic targets <120 mmHg in frail elderly patients, as this raises the risk of hypotension, syncope, and falls without additional mortality benefit. 2

Special Considerations for This Patient

• The wide pulse pressure (155/68 = 87 mmHg) reflects arterial stiffness, which is typical in elderly patients with isolated systolic hypertension. 1
• Recent evidence from SPRINT and meta-analyses demonstrates that intensive BP control does not increase orthostatic hypotension or falls in older adults, and may actually reduce orthostatic hypotension by improving baroreflex function. 1
• Asymptomatic orthostatic hypotension during treatment should not trigger automatic down-titration of therapy, even with lower BP goals. 1