Treatment of isolated systolic hypertension

Reinhold Kreutz, MD, PhD, is a professor of clinical pharmacology and hypertension and director of the Department of Clinical Pharmacology and Toxicology at the Charité University Medical Centre in Berlin, Germany. He has served as president of the European Society of Hypertension.

How to treat patients with isolated systolic hypertension? Which drug classes are preferred?

Reinhold Kreutz, MD, PhD: A very important question and also a question that already points to some gaps and problems we still have and where we need future research.

In the classic old trials that have been done in isolated systolic hypertension, and also from a pathophysiological point of view, we considered that calcium channel blockers (CCBs) and diuretics work very well in the older patients with isolated systolic hypertension, whereas the isolated systolic hypertension is the most prevalent form of hypertension.

Nevertheless, when we now look at the trials—even though they are not all dedicated, or most of them are not dedicated, to isolated systolic hypertension, but many of the trials included patients with isolated systolic hypertension as a proportion—all drugs work. So, a short answer to the question could be that the treatment algorithm we recommend for the general hypertensive population also applies to patients with isolated systolic hypertension.

We also mentioned in the guidelines, somewhat neglected in the past, we have focused—and if you are interested, you can read in the guidelines, which are freely available to download—on different hypertensive phenotypes, including isolated diastolic hypertension. Here, also, the same treatment algorithm applies, and we also need some more research.

But there’s also a phenotype called isolated systolic hypertension in the young. It is rarely seen there [but can be present] particularly in tall men. Sometimes you have isolated systolic hypertension in young tall men because it’s associated with the height and also with the reflection of the pulse wave. So, it’s a kind of a spurious form of hypertension. In these patients we would even recommend measuring central blood pressure. Very often it’s normal, so we don’t treat but just observe the patients with this young form of isolated systolic hypertension.