HYPERTENSION IN THE ELDERLY - AGE-RELATED AND DISEASE-RELATED COMPLICATIONS AND THERAPEUTIC IMPLICATIONS

Effective treatment of hypertension in the elderly requires an underst anding of both the progressive course of the disease and the impact of aging on the cardiovascular system, including physiological, genetic, lifestyle, and environmental factors. Review of the literature that h as attempted to define the impact of an ''aging process'' on cardiovas cular structure and function reveals a diversity of findings and inter pretations. However, in general, normotensive elderly subjects exhibit the heart and vascular characteristics of ''muted'' hypertension, inc luding many features of younger hypertensive patients: cardiac hypertr ophy, diminution in resting left ventricular early diastolic filling r ate, increased arterial stiffness and aortic impedance, diminution in the baroreceptor reflex, a diminished response to catecholamines and d iminished renal blood flow, and an increase in peripheral vascular res istance (PVR). Treatment of elderly hypertensives is more challenging because of the greater likelihood of the presence of concomitant disea ses, most importantly, coronary and peripheral atherosclerosis, renal dysfunction, and diabetes mellitus. Isolated systolic hypertension (IS H), the most common form of hypertension in the elderly, has also been clearly shown to be an important predictor of cardiovascular morbidit y and mortality, including coronary artery disease, congestive heart f ailure, and stroke. Treatment of ISH has been shown to lower systolic pressure safely and effectively in the elderly. By reducing PVR, and p ossibly the arterial stiffness, and thus the early reflected pulse wav es, vasodilators, including calcium antagonists, may lower these three components of arterial impedance, and hence lower the arterial load o n the heart. The cardiac hypertrophy and reduced left ventricular fill ing rate associated with hypertension in older individuals can also be ameliorated, to some extent, by calcium channel blockers.