Hypertension treatment in the elderly: doubts and certainties

Hypertension is one of the most relevant health problems in elderly patients. Several studies have shown that anti-hypertensive therapy can significantly reduce both cardiovascular mortality and morbidity. Clinical outcomes are proportionally related to blood pressure reduction rates. This is true even for old patients, including those with isolated systolic hypertension. All the most commonly used classes of drugs seem to be equivalent in terms of clinical efficacy even though with slight differences. However, the analysis of the blood pressure levels trend in treated subjects indicates that in most cases, monotherapy is not sufficient, thus it is necessary to use drug combinations, as suggested by recent data on the benefits of new preestablished associations in terms of short and long-term therapy efficacy. In Authors' opinion, due to their particular clinical features and unstable homeostasis that make old patients extremely frail, there are several unsolved problems that need to be cleared. In particular, it is difficult to establish when to start a treatment, which drug should be chosen and what pressure values must be reached, especially for diastolic pressure. Lastly, an important role must be deserved to drugs that interfere with organ damage, which is mainly due to renin-angiotensin system hyperactivation. These drugs include ACE inhibitors and ARBs, molecules with proven efficacy and tolerability, and the renin inhibitors, a class of drugs recently introduced into clinical practice.