Hypertension is a major risk factor for cardiovascular diseases and is a major public health problem worldwide, and more than half of all cardiovascular diseases in China are related to hypertension. According to the “China Cardiovascular Disease Report 2012”, there are 266 million hypertensive patients in China, with an average of at least 2 to 3 out of every 10 adults suffering from hypertension, ranking first in the prevalence of chronic diseases. 2002 China Population Nutrition and Health Survey data show that the prevalence of hypertension in people aged ≥60 years old in China is 49%, with an average of every 2 adults suffering from hypertension. The prevalence of hypertension was 49%, with an average of 1 out of 2 elderly people suffering from hypertension. With the progress of population aging, the prevalence of hypertension in China’s elderly population will increase. 1, the characteristics of hypertension in the elderly (1) systolic blood pressure increase mainly With age, the heart, vascular compliance decline, arterial wall stiffness increased, elderly patients mainly manifested as a gradual increase in systolic blood pressure level, diastolic blood pressure level decreased, the elderly simple systolic hypertension (ISH) become the most common type of hypertension in the elderly. ISH has become the most common type of hypertension in the elderly. Studies have shown that ISH accounts for more than 90% of hypertension in older adults over 80 years of age. Compared with diastolic blood pressure, systolic blood pressure levels are more closely related to target organ damage and are more important predictors of cardiovascular events. The European Systolic Hypertension Study (Syst-Eur) showed that an average decrease of 23 mmHg in systolic blood pressure reduced the incidence of stroke and cardiovascular events by 42% and 26%, respectively, in elderly hypertensive patients. The Systolic Hypertension in China Study (Syst-China) showed that a 20 mmHg reduction in systolic blood pressure was associated with a 38% and 37% reduction in stroke and cardiovascular events, respectively, and a 39%, 58%, and 39% reduction in all-cause, stroke, and cardiovascular event mortality, respectively. The results of the Hypertension in the Elderly Trial (HYVET) showed that a mean reduction in seated systolic blood pressure of 29.5 mmHg was associated with a 30% and 64% reduction in the incidence of stroke and heart failure, and a 39% and 23% reduction in mortality from stroke and cardiovascular events, respectively. (2) Increased pulse pressure Age-related atherosclerosis, decreased arterial compliance and elasticity, which reduces the storage and buffering capacity of the large arteries for blood flow, along with increased systolic pressure and decreased diastolic pressure in the elderly, increases pulse pressure; at the same time, when the degenerative changes of the aortic valve in the elderly cause moderate to severe aortic valve closure insufficiency, it can also lead to increased pulse pressure. Normal pulse pressure is 30-40 mmHg, and in elderly patients it can be 50-100 mmHg. The Framingham Heart Study showed that pulse pressure is a more important predictor of coronary heart disease than systolic and diastolic blood pressure in hypertensive patients over 60 years of age. For every 10 mmHg increase in pulse pressure, the risk of coronary heart disease increases by 1.02 times. (3) Blood pressure fluctuation Older people have reduced pressure receptor sensitivity and reduced vascular compliance, and blood pressure is more likely to fluctuate significantly with changes in mood, season and body position. The risk of adverse cardiovascular events and target organ damage increases significantly when blood pressure fluctuates sharply. (4) Postural blood pressure variability The classic diagnostic criteria for orthostatic hypotension (OH) are a decrease in systolic blood pressure of ≥20 mmHg and/or a decrease in diastolic blood pressure of ≥10 mmHg within 3 min after changing from a lying to an upright position, accompanied by symptoms of hypoperfusion. Elderly patients with hypertension are more likely to develop OH. studies have shown that the incidence of OH within 1 min was 5% in community-based elderly patients aged 70 years and older whose blood pressure was at standard (<140/90 mmHg) and 19% in patients whose blood pressure was not at standard. The risk of falls is 2.5 times higher in elderly hypertensive patients with substandard blood pressure than in those with standard blood pressure. the pathogenesis of OH is multifaceted, and the elderly are prone to upright hypotension when hypertension is accompanied by diabetes, stroke, or the application of high-dose diuretics, nitrates, α-blockers, and tricyclic antidepressants due to decreased autonomic regulation. The mechanism of OHT is still unclear. A study found that OHT is associated with overstimulation of the sympathetic nervous system, especially alpha neurons, and the incidence of asymptomatic cerebral infarction and deep brain white matter damage was significantly higher in patients with OHT and OH compared with those with non-postural blood pressure variability, and the relationship between postural blood pressure variability and the incidence of hypertensive cerebrovascular disease in the elderly showed a "U" curve. The relationship between postural blood pressure variability and the incidence of hypertensive cerebrovascular disease in the elderly showed a "U" curve, suggesting that postural blood pressure variability is a risk factor for cerebrovascular disease in the elderly. (5) Abnormal circadian rhythm of blood pressure Elderly patients with hypertension often have abnormal circadian rhythm of blood pressure, which is manifested as a decrease of blood pressure at night <10% (non arytenoid) or >20% (super arytenoid), and an increase of blood pressure at night compared with daytime (anti arytenoid), which significantly increases the risk of target organ damage such as heart, brain and kidney. Compared with younger patients, the degree of target organ damage is more closely related to the circadian rhythm of blood pressure in the elderly. (6) Many comorbidities and combined medications Hypertension in the elderly is often associated with coronary heart disease, cerebrovascular disease, peripheral vascular disease, ischemic kidney disease, obstructive lung disease, diabetes, dementia and other diseases, while taking multiple medications. If blood pressure is not well controlled for a long time, it is more likely to occur or aggravate target organ damage, significantly increasing cardiovascular disease mortality and all-cause mortality. Older patients with hypertension often have less obvious clinical symptoms, combined with multiple organ function damage or complications, which need to be considered in a comprehensive manner in the management. (7) Postprandial hypotension (PPH) is diagnosed as PPH if one of the following three criteria is met: (1) systolic blood pressure decreases >20 mmHg compared to pre-meal within 2 h after meal; (2) systolic blood pressure is not less than 100 mmHg before meal but <90 mmHg after meal; (3) postprandial blood pressure decrease does not meet the above criteria, but there are postprandial cardiac and cerebral ischemic symptoms (angina, weakness, syncope, impaired consciousness). The incidence of PPH has been increasing in recent years, and it is more likely to occur in the elderly, especially in patients with hypertension, diabetes mellitus and autonomic dysfunction caused by various reasons, sometimes accompanied by upright hypotension. The incidence of PPH is higher in elderly patients compared to young and middle-aged patients, and they are more likely to have symptoms of tissue hypoperfusion, which increases the risk of falls, fractures and target organ damage. the pathogenesis of PPH is still unclear, and it may be related to the decrease in cardiac output due to increased perfusion of visceral blood after meals, reduced sensitivity of pressure receptors and inadequate sympathetic tone after meals. the main focus of PPH is prevention, and for asymptomatic patients can For asymptomatic patients, non-pharmacological treatments such as drinking water before meals, reducing sugar intake, avoiding taking antihypertensive drugs before meals, and good blood pressure monitoring can be taken. For symptomatic people, the main focus is on drugs that reduce visceral blood flow, inhibit glucose absorption and increase peripheral vascular resistance. (8) White-coat hypertension (WCT), also known as office-based hypertension, is a special type of hypertension that manifests as elevated blood pressure only in the office and normal blood pressure outside the office. According to the 2013 European guidelines for hypertension, the incidence of WCT is 13%, accounting for 32% of hypertensive patients, and the prevalence in the elderly population is unclear. However, some studies have shown that the incidence of WCT increases with age and is more common in women and nonsmoking individuals. The European Society of Hypertension Working Group on Blood Pressure Measurement recommends that once WCT is diagnosed, it should be followed up within 3-6 months with annual 24-h ambulatory blood pressure monitoring to monitor for the development of persistent hypertension.Meta-analysis showed that after correcting for age, gender and other confounding factors, there was no statistically significant difference in the risk of cardiovascular events in patients with WCT compared with normotensive individuals. However, other studies have shown that the risk of long-term cardiovascular events in patients with WCT is intermediate between those with persistent hypertension and normotensive individuals, and that elderly ISH patients with WCT after antihypertensive treatment have a 2-fold higher risk of cardiovascular events compared with normotensive older adults. Therefore, whether WCT can be equated with normotension remains controversial. (9) Refractory hypertension Refractory hypertension is considered when blood pressure cannot be achieved after at least 1 month of treatment with a combination of 3 antihypertensive drugs with different mechanisms of action (including diuretics) based on lifestyle improvement, or when at least 4 antihypertensive drugs are required to bring blood pressure to standard. Refractory hypertension is more common in older patients, and the Framingham Heart Study showed that less than 25% of the elderly population achieved blood pressure targets. There are several possible reasons for refractory hypertension in the elderly: poorer medication compliance; other medications that interfere with the action of antihypertensive drugs; age-related vascular remodeling and sympathetic tension. In recent years, sleep apnea (OSA) has been found to be an important cause of refractory hypertension. Studies have shown that the prevalence of OSA in the elderly ranges from 37.5 to 62.0% and is an independent factor causing refractory hypertension in the elderly. The diagnosis of refractory hypertension needs to exclude pseudo-refractory hypertension caused by improper measurement methods, improper treatment regimens and white coat hypertension, and to look for causes and coexisting disease factors that affect blood pressure, such as medication compliance and drug interactions. After the above factors are excluded, screening for secondary hypertension is performed and appropriate treatment is taken. 2. Treatment of hypertension in the elderly Several studies have confirmed the importance of hypertension treatment in the elderly. The main goal of hypertension treatment in the elderly is to protect target organs and minimize the risk of cardiovascular events and death. Several large-scale clinical trials, including the Systolic Hypertension in the Elderly Study (SHEP), Syst-Eur, Syst-China and the Study of Cognitive Function and Prognosis in the Elderly (SCOPE), have confirmed that antihypertensive treatment reduces the incidence of cardiovascular and cerebrovascular events and overall mortality in elderly patients. 2010 International Verapamil SR/Qundopril Study (INVEST Study) showed that Systolic blood pressure control at 135 mmHg in 70- to 79-year-olds and 140 mmHg in ≥80-year-olds varies among guidelines for the treatment of hypertension in the elderly, but the differences are not significant. The risk of myocardial infarction, stroke, and death is lower when compared with control at <130 mmHg. Non-pharmacological treatment of hypertension in the elderly, i.e., lifestyle interventions, remains the basic measure of antihypertensive treatment and should be used throughout the course of antihypertensive treatment, including dietary modification, appropriate reduction of sodium intake, smoking cessation and alcohol restriction, and moderate exercise for weight control. The pharmacological treatment of hypertension in the elderly should follow the following points: start with small doses to lower blood pressure smoothly; combine multiple drugs to achieve the target gradually; individualize treatment according to the individual; monitor standing blood pressure to avoid hypotension; pay attention to home self-measurement of blood pressure and 24-h blood pressure measurement, and pay attention to the correct blood pressure measurement method. Currently, five types of antihypertensive drugs, namely calcium antagonists (CCB), diuretics, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARB) and β-blockers, are commonly used in the treatment of hypertension in the elderly. Although the status of β-blockers in antihypertensive therapy has been controversial in recent years, they are still recommended as the first choice for elderly patients with hypertension combined with coronary artery disease and chronic heart failure if there are no contraindications.8 JNC8 recommends that all of these drugs, except β-blockers, can be used as the starting treatment for elderly patients with hypertension (with or without diabetes). The initiation (or addition) of antihypertensive therapy in hypertensive patients with comorbid chronic kidney disease should include 1 ACEI or ARB to improve renal prognosis. The combination of drugs mainly utilizes multiple different mechanisms to lower blood pressure, synergize effects, reduce adverse effects, and protect target organs. Combination therapy with two or more drugs is usually chosen for hypertension in the elderly. To increase patient compliance, a single tablet combination can be chosen. The antihypertensive treatment of elderly patients with hypertension has its own characteristics. Since elderly hypertensive patients often have cardiac, cerebral and renal diseases, diabetes mellitus, abnormal lipid metabolism and multiple medications, treatment is more difficult and adverse drug reactions are more likely to occur. Therefore, while emphasizing the achievement of lowering blood pressure, it is necessary to pay attention to the effects of concomitant diseases and strengthen the protection of target organs to avoid excessive lowering of blood pressure. Adjust the dose or drug type according to the patient's response to antihypertensive drugs. The results of the HYVET study suggest that the elderly population over 80 years of age may benefit from antihypertensive treatment by controlling blood pressure to 150/80 mmHg or less. 2010 Meta-analysis of a randomized controlled clinical study showed that excessive blood pressure lowering did not reduce all-cause mortality. There are insufficient clinical studies to confirm the benefit of further blood pressure lowering in elderly patients, and excessive blood pressure lowering is not clinically recommended. The risk of target organ damage and death is higher in elderly patients with hypertension, and aggressive control of blood pressure in elderly patients may provide similar or even greater benefits than in young and middle-aged patients. We should combine the characteristics of hypertension in the elderly with the principle of individualized treatment to achieve smooth blood pressure lowering, reduce the incidence of cardiovascular and cerebrovascular events and mortality in elderly hypertensive patients, and improve the quality of life.