Int J Angiol 2022; 31(04): 222-228
DOI: 10.1055/s-0042-1759486
Invited Article

Pathophysiology, Diagnosis, and Management of Hypertension in the Elderly

1   Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan
2   Department of Cardiology, Oakland University William Beaumont School of Medicine, Rochester, Michigan
› Author Affiliations


There is a high prevalence of systemic arterial hypertension in the elderly; 70% of adults >65 years have this disease. A key mechanism in the development of hypertension in the elderly is increased arterial stiffness. This accounts for the increase in systolic blood pressure and pulse pressure and fall in diastolic blood pressure (isolated systolic hypertension) that are commonly seen in the elderly, compared with younger persons. The diagnosis of hypertension is made on the basis of in-office blood pressure measurements together with ambulatory and home blood pressure recordings. Lifestyle changes are the cornerstone of management of hypertension.

Comprehensive guidelines regarding blood pressure threshold at which to start pharmacotherapy as well as target blood pressure levels have been issued by both European and American professional bodies. In recent years, there has been considerable interest in intensive lowering of blood pressure in older patients with hypertension. Several large, randomized controlled trials have suggested that a strategy of aiming for a target systolic blood pressure of <120 mm Hg (intensive treatment) rather than a target of <140 mm Hg (standard treatment) results in significant reduction in the incidence of adverse cardiovascular events and total mortality. A systolic blood pressure treatment of <130 mm Hg should be considered favorably in non-institutionalized, ambulatory, free living older patients. In contrast, in the older patient with a high burden of comorbidities and limited life expectancy, an individualized team-based approach, based on clinical judgment and patient preference should be adopted. An increasing body of evidence for older adults with hypertension suggests that intensive blood pressure lowering may prevent or at least partially prevent cognitive decline.

Publication History

Article published online:
29 November 2022

© 2022. International College of Angiology. This article is published by Thieme.

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  • References

  • 1 Kulkarni A, Mehta A, Yang E, Parapid B. “Older Adults and Hypertension: Beyond the 2017 Guideline for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.” American College of Cardiology 2020. Accessed August 28, 2022, at:
  • 2 Mozaffarian D, Benjamin EJ, Go AS. et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2015 update: a report from the American Heart Association. Circulation 2015; 131 (04) e29-e322
  • 3 Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population (2014 to 2060). (US Census Bureau website) 2015. Accessed August 22, 2022, at:
  • 4 Olsen MH, Angell SY, Asma S. et al. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. Lancet 2016; 388 (10060): 2665-2712
  • 5 MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ 1992; 304 (6824): 405-412
  • 6 Franklin SS, Larson MG, Khan SA. et al. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation 2001; 103 (09) 1245-1249
  • 7 Benetos A. Hypertension in Older People. In: Bakris GL, Sorrentino M, eds. Hypertension: A Companion to Braunwald's Heart Disease. Philadelphia, PA: Elsevier; 2018: 374-382
  • 8 Pimenta E, Oparil S. Management of hypertension in the elderly. Nat Rev Cardiol 2012; 9 (05) 286-296
  • 9 Dao HH, Essalihi R, Bouvet C, Moreau P. Evolution and modulation of age-related medial elastocalcinosis: impact on large artery stiffness and isolated systolic hypertension. Cardiovasc Res 2005; 66 (02) 307-317
  • 10 Alecu C, Labat C, Kearney-Schwartz A. et al. Reference values of aortic pulse wave velocity in the elderly. J Hypertens 2008; 26 (11) 2207-2212
  • 11 Wallace SM, Yasmin, McEniery CM. et al. Isolated systolic hypertension is characterized by increased aortic stiffness and endothelial dysfunction. Hypertension 2007; 50 (01) 228-233
  • 12 Abhayaratna WP, Barnes ME, O'Rourke MF. et al. Relation of arterial stiffness to left ventricular diastolic function and cardiovascular risk prediction in patients > or =65 years of age. Am J Cardiol 2006; 98 (10) 1387-1392
  • 13 Nadruz W, Shah AM, Solomon SD. Diastolic dysfunction and hypertension. Med Clin North Am 2017; 101 (01) 7-17
  • 14 Williams B, Mancia G, Spiering W. et al; Authors/Task Force Members. 2018 ESC/ESH Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: the Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36 (10) 1953-2041
  • 15 Whelton PK, Carey RM, Aronow WS. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71 (19) e127-e248
  • 16 Berg S. “4 Big Ways BP Measurement Goes Wrong, and How to Tackle Them.” American Medical Association, 13 June 2019. Accessed August 25, 2022, at:
  • 17 Padwal R, Campbell NRC, Schutte AE. et al. Optimizing observer performance of clinic blood pressure measurement: a position statement from the Lancet Commission on Hypertension Group. J Hypertens 2019; 37 (09) 1737-1745
  • 18 O'Brien E. First Thomas Pickering memorial lecture*: ambulatory blood pressure measurement is essential for the management of hypertension. J Clin Hypertens (Greenwich) 2012; 14 (12) 836-847
  • 19 Lionakis N, Mendrinos D, Sanidas E, Favatas G, Georgopoulou M. Hypertension in the elderly. World J Cardiol 2012; 4 (05) 135-147
  • 20 Messerli FH, Ventura HO, Amodeo C. Osler's maneuver and pseudohypertension. N Engl J Med 1985; 312 (24) 1548-1551
  • 21 Spence JD, Sibbald WJ, Cape RD. Pseudohypertension in the elderly. Clin Sci Mol Med Suppl 1978; 4: 399s-402s
  • 22 Oliveros E, Patel H, Kyung S. et al. Hypertension in older adults: assessment, management, and challenges. Clin Cardiol 2020; 43 (02) 99-107
  • 23 Appel LJ, Moore TJ, Obarzanek E. et al; DASH Collaborative Research Group. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997; 336 (16) 1117-1124
  • 24 Whelton PK, Appel LJ, Espeland MA. et al; TONE Collaborative Research Group. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). JAMA 1998; 279 (11) 839-846
  • 25 Sardeli AV, Griffth GJ, Dos Santos MVMA, Ito MSR, Chacon-Mikahil MPT. The effects of exercise training on hypertensive older adults: an umbrella meta-analysis. Hypertens Res 2021; 44 (11) 1434-1443
  • 26 Qaseem A, Wilt TJ, Rich R. et al; Clinical Guidelines Committee of the American College of Physicians and the Commission on Health of the Public and Science of the American Academy of Family Physicians. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017; 166 (06) 430-437
  • 27 Beckett NS, Peters R, Fletcher AE. et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358 (18) 1887-1898
  • 28 Wright Jr JT, Williamson JD, Whelton PK. et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373 (22) 2103-2116
  • 29 Williamson JD, Supiano MA, Applegate WB. et al; SPRINT Research Group. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA 2016; 315 (24) 2673-2682
  • 30 Zhang W, Zhang S, Deng Y. et al; STEP Study Group. Trial of intensive blood-pressure control in older patients with hypertension. N Engl J Med 2021; 385 (14) 1268-1279
  • 31 Benetos A, Petrovic M, Strandberg T. Hypertension management in older and frail older patients. Circ Res 2019; 124 (07) 1045-1060
  • 32 Carey RM, Wright Jr JT, Taler SJ, Whelton PK. Guideline-driven management of hypertension: an evidence-based update. Circ Res 2021; 128 (07) 827-846
  • 33 Carey RM, Whelton PK. New findings bearing on the prevention, detection and management of high blood pressure. Curr Opin Cardiol 2021; 36 (04) 429-435
  • 34 Williamson JD, Pajewski NM, Auchus AP. et al; SPRINT MIND Investigators for the SPRINT Research Group. Effect of intensive vs standard blood pressure control on probable dementia: a randomized clinical trial. JAMA 2019; 321 (06) 553-561
  • 35 Nasrallah IM, Pajewski NM, Auchus AP. et al; SPRINT MIND Investigators for the SPRINT Research Group. Association of intensive vs standard blood pressure control with cerebral white matter lesions. JAMA 2019; 322 (06) 524-534