Current challenges in antihypertensive treatment in the elderly

Arterial hypertension affects more than 25% of the global population, and its prevalence is increasing with age. Arterial stiffening occurs with aging and results in a pattern of increased systolic and decreased diastolic blood pressure (BP). In the elderly population, elevated BP has been related with increased cardiovascular risk. Trials on this population have shown great benefits for morbidity and mortality from reducing systolic BP (SBP) levels to less than 150 mmHg. Most guidelines for the management of elderly hypertensive patients agree on BP reduction to less than 150/90 mmHg. However, there is still uncertainty whether further BP reduction could provide beneficial results. The recently published SPRINT trial demonstrated that reducing SBP to between 120 and 125 mmHg in patients over the age of 75 years is related with increased survival and is expected to affect future recommendations. On the contrary, the limited data that are available for octogenarians and frail nursing home patients create concerns for more aggressive BP strategies in these subgroups, and thus they should be treated more conservatively. Among the various antihypertensive classes of drugs, diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers were proved beneficial in the elderly and are favored as first choices for the management of elderly hypertensive individuals. Given the common coexistence of other comorbidities and polypharmacy, physicians should be careful when initiating or uptitrating treatments to avoid potential adverse events or interaction with other drugs or diseases.