With the increasing aging of the population, the problem of hypertension in the elderly is of great concern. Hypertension is one of the most common diseases among the elderly, which can lead to the occurrence of stroke, congestive heart failure, coronary heart disease, kidney failure, aortic disease, and increased mortality. The prevalence of hypertension in China is 18.8%, and the prevalence of hypertension in people aged 60 and above is 49%. Many studies have demonstrated that antihypertensive treatment can benefit the elderly population. However, hypertension in the elderly has its special characteristics in terms of pathogenesis, clinical manifestations, treatment and prognosis, and the intensity and goals of antihypertensive treatment for hypertension in the elderly are still controversial. Liu Hongliang, Department of Geriatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine I. Characteristics of geriatric hypertension Geriatric hypertension is mainly due to increased arterial stiffness caused by atherosclerosis, while sympathetic activation plays a secondary role, while the central function of blood pressure regulation is diminished. The characteristics of hypertension in the elderly are as follows: increased systolic blood pressure (SBP) and increased pulse pressure; simple systolic hypertension (ISH) accounts for 60% of hypertension; large fluctuations in blood pressure, increased blood pressure “morning peak” phenomenon, hypertension combined with postural hypotension and postprandial hypotension; abnormal circadian rhythm of blood pressure is more common; white coat Hypertension and pseudohypertension are increasing; hypertension in the elderly often coexists with a variety of diseases and has many complications. Second, pay attention to the SBP and pulse pressure of elderly hypertensive patients With the increase of age, the collagen of the vascular wall increases and the degenerative changes of collagen fibers, the aortic stiffness increases progressively, and the result shows that the SBP increases with age, and the diastolic blood pressure (DBP) reaches a peak in middle age about 50 years old, and then decreases mildly after a period of plateau. Hypertension in the elderly is also mainly manifested as a more pronounced increase in SBP, or even only an increase in SBP with normal or decreasing DBP, i.e., ISH. <10% of hypertension manifested by elevated DBP in people >70 years of age, and the Framingham Heart Study demonstrated that DBP ≥90 mm Hg is as much a risk factor for cardiovascular disease (CVD) as <70 mm Hg. At arbitrary SBP levels, a decrease in DBP causes an increased risk of coronary heart disease. ISH accounts for 65% of hypertension in people >60 years of age and reaches 90% of hypertension in people >70 years of age. prior to the 1990s, it was generally accepted that elevated SBP was an age-increasing change and a normal response to maintaining organ perfusion, and DBP was widely valued and became an important basis for the diagnosis and treatment of hypertension. after the 1990s with the Framingham Heart Study and other In 2003, the seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension (JNC7) emphasized that for adults over 50 years of age, elevated SBP is a more important risk factor for CVD than elevated DBP. Pulse pressure also increases with age, and in some studies, such as the Framingham Heart Study, elevated pulse pressure in older adults is an even stronger risk factor than elevated SBP, DBP, and mean arterial pressure (MBP). The strongest risk factors predicting coronary heart disease change with increasing age. At <50 years of age, DBP is the strongest risk factor; at 50-59 years of age, SBP, DBP, and elevated pulse pressure are of equal risk; at 60-79 years of age, pulse pressure is the strongest risk factor. However, there are no clinical studies to prove that lowering pulse pressure can reduce the risk of CVD, so lowering SBP is currently the main therapeutic target for reducing cardiovascular risk in the elderly. Third, the evidence of the benefit of lowering blood pressure in elderly patients The purpose of antihypertensive treatment is to effectively prevent or delay the occurrence of complications such as stroke, myocardial infarction, heart failure, and renal insufficiency by lowering blood pressure; effectively control the disease process of hypertension and prevent the occurrence of serious conditions such as hypertensive emergencies and subacute conditions. many large-scale randomized controlled studies since the 1980s including EWPHE, STOP, and SHEP, etc. have demonstrated that elderly hypertensive patients, when blood pressure ≥ 160/90 mm Hg, receive antihypertensive treatment to reduce cardiovascular events. The risk of cardiovascular complications can be significantly reduced by antihypertensive treatment in hypertensive patients >70 years old and ISH patients, which is the most important theoretical basis for the treatment and management of hypertension. The results of clinical trials completed in China, such as Syst-China, STONE and Fever, have shown that treatment of hypertension in the elderly can significantly reduce the risk of stroke. Most previous clinical studies did not include people >80 years old. It was not until the HYVET study was published in 2008 that answered the question of whether elderly hypertensive patients >80 years of age needed antihypertensive treatment. The study enrolled 3845 patients ≥80 years of age with SBP ≥160 mm Hg. The treatment group (BP 144/78 mm Hg) had a 30% reduction in stroke, 64% reduction in heart failure, 23% reduction in cardiovascular events and death, 21% reduction in all-cause mortality, low incidence of adverse events, and good tolerability compared with the placebo group (BP 161/84 mm Hg), resulting in follow-up to 1.8 years and early termination of the study. This study provides a rationale for the cardiovascular benefit of blood pressure lowering in elderly patients >80 years of age and demonstrates that advanced age is not a reason to refuse antihypertensive therapy. IV. Clinical studies comparing the intensity of blood pressure lowering and the J-curve of hypertension treatment Clinical studies in recent years have selected hypertensive patients to find an optimal target blood pressure by comparing intensive versus non-intensive blood pressure management; or selected patients at high cardiovascular risk to explore whether a somewhat lower blood pressure would be more effective in reducing the risk of cardiovascular and cerebrovascular complications. The results of these studies were inconsistent, with a more significant reduction in the risk of some complications in the lower blood pressure group, but also a trend toward an increased risk of some complications. In the post hoc analysis of the PRoFESS and TRANCENT studies and some studies of high-risk patients receiving antihypertensive therapy (e.g., ONTARGET, TNT studies), the level of cardiovascular risk in patients with SBP close to or below 120 to 125 mm Hg and DBP below 65 to 70 mm Hg not only does not continue to decrease but gradually increases, which is known as the J-shaped curve. The ACCORD study confirmed that in high-risk cardiovascular patients with hypertension with diabetes, SBP <120 mm Hg was not superior to <140 mm Hg, with no reduction in endpoint events, high treatment costs and many adverse drug reactions. the same results were obtained in a subgroup of 1617 elderly patients ≥65 years old. the INVEST study suggested that antihypertensive treatment of elderly patients with predominantly coronary artery disease with SBP <115 to 120 mm Hg increases the risk of cardiovascular events. the study of ideal systolic blood pressure in elderly hypertension (JATOS) conducted in Japan published in 2008 [9] showed that in hypertensive patients aged 65 to 85 years with SBP >160 mm Hg, 2 years of antihypertensive treatment, the BP 135.9/74.8 mm Hg group compared to the BP 145.6/78.1 mm Hg group had major endpoint and death were not statistically different. Due to poor vascular elasticity and reduced autonomic nervous system autoregulation in the elderly, excessive lowering of blood pressure can adversely affect blood perfusion to vital organs. Lower blood pressure levels do not provide additional clinical benefit to elderly patients with hypertension. However, other studies have not demonstrated a “J-curve”, and the HOT study results suggest that a reduction in DBP to <80 mm Hg may reduce cardiovascular events. 2009, 1111 non-diabetic patients with a mean age of 67 years with a basal SBP ≥150 mm Hg in the Cardio-Sis study, compared to a target In the open study with SBP <130 mm Hg or <140 mm Hg, the incidence of left ventricular hypertrophy was reduced by 37% (P<0.013) and the cardiovascular composite endpoint was reduced by almost 50% (P<0.003) in the SBP <130 mm Hg group at 2-year follow-up. The results of the post hoc analysis showed that the mean blood pressure dropped to a minimum of 112/72 mm Hg after treatment and no "J-curve" was seen. The target BP values, patient selection, drug type, and observation time frame in the above clinical studies varied, suggesting that further BP reduction after reaching levels below 140/90 mm Hg should be individualized, taking into account the patient's disease characteristics as well as the antihypertensive treatment plan and its implementation. V. Antihypertensive targets and timing in elderly hypertension The newly published international and domestic guidelines for the prevention and treatment of hypertension have clearly described the antihypertensive targets, and the blood pressure targets for antihypertensive treatment in certain high-risk patients with hypertension are still controversial. In 2009, the ESC published a revision of the 2007 hypertension guidelines, which stated that the target values for antihypertensive therapy in general hypertensive patients are SBP <140 mm Hg and DBP <90 mm Hg, regardless of their overall cardiovascular risk level. The benefit of controlling SBP below 140 mm Hg in elderly hypertensive patients has not been confirmed in randomized controlled clinical trials and should be treated with caution. Based on the available evidence, it is reasonable to set a BP target in the range of (130-139)/(80-85) mm Hg for all hypertensive patients and to keep BP as low as possible within this range. More research evidence is needed to determine whether continued lowering of blood pressure will have a beneficial effect on patients. The 2010 Chinese hypertension guidelines state that blood pressure in elderly hypertensive patients should be lowered to less than 150/90 mm Hg, or to less than 140/90 mm Hg if tolerated. For elderly hypertensive patients over 80 years of age, blood pressure should be lowered to less than 150/90 mm Hg. For patients with ISH, it is recommended that when DBP < 60 mm Hg, such as SBP < 150 mm Hg then observe and no drugs can be used; if SBP 150-179 mm Hg, use small dose antihypertensive drugs with caution; if SBP ≥ 180 mm Hg, then use small dose antihypertensive drugs. Antihypertensive drugs can be used as low-dose diuretics, calcium channel blockers, ACEI or ARB. Close observation of changes in the condition during medication administration. In 2011, the ACCF/AHA published the 2011 Expert Consensus on Geriatric Hypertension. The consensus, the first foreign expert consensus on geriatric hypertension to date, emphasizes the damage of hypertension to target organs in elderly patients and recommends a target blood pressure value of <140/90 mm Hg for uncomplicated elderly hypertensive patients; however, this target is based on expert opinion. It is not clear whether the target SBP target for patients aged 65 to 79 years is the same as that for patients >80 years. The consensus is that previous studies still fail to give good guidance on hypertension in the elderly. the INVEST study [8] found the lowest occurrence of the endpoint event of BP <140/90 mm Hg in ≥75% of patients. the HYVET study [8] answered the benefit of treatment for SBP 140-150 mm Hg (144/78 mm Hg) in people >80 years of age. There is little basis for setting a target value of <140/90 mm Hg for hypertension in the elderly, with BP <140/90 mm Hg largely reasonable for most patients ≤79 years of age, and ≥80 years of age, if SBP 140 to 145 mm Hg is acceptable if tolerated. Due to the J-shaped curve considering antihypertensive treatment, one of the following exists to consider a target SBP ≥150 mm Hg. These are cases where blood pressure cannot be achieved despite having been treated with four appropriately selected adequate doses of antihypertensive drugs; where treatment causes unacceptable side effects, particularly postural hypotension, resulting in physical damage; and where DBP <65 mm Hg may pose a potential risk in order to achieve SBP. The 2011 British guideline on hypertension (NICE) specifies that the target value for antihypertensive treatment is <140/90 mm Hg in the office for patients aged <80 years, and <150/90 mm Hg in the office for elderly hypertensive patients aged ≥80 years. For patients who require 24-h ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to assess the effectiveness of antihypertensive treatment, the target value for antihypertensive treatment is a blood pressure <135/85 mm Hg (age <80 years) or <145/85 mm Hg (age ≥80 years) in the awake state (8:00-22:00). The 2011 ACCF/AHA Expert Consensus on the timing of treatment for geriatric hypertension cites a meta-analysis that concluded that there is limited evidence of benefit in initiating pharmacotherapy for blood pressure between 150 and 159 mm Hg. The 2010 Chinese guidelines for the prevention and treatment of hypertension [13] use the principle of stratified treatment regarding the timing of antihypertensive drug therapy. Patients with high-risk, very high-risk, or grade 3 hypertension should start antihypertensive drug therapy immediately; patients with confirmed grade 2 hypertension should be considered for initiation of drug therapy; and patients with grade 1 hypertension may start antihypertensive drug therapy when their blood pressure remains ≥140/90 mm Hg after several weeks of lifestyle intervention. Regarding the speed of blood pressure lowering most patients with hypertension should gradually lower their blood pressure to target levels over weeks to months (rather than days) depending on their condition. Younger patients with a shorter duration of hypertension may have a faster rate of blood pressure lowering; however, older patients with a longer duration of disease or those with existing target organ damage and complications should have a slower rate of blood pressure lowering. VI. Unanswered questions in the field of hypertension treatment in the elderly The significance of the HEVET study is undeniable, however, it still fails to answer the following questions: elderly patients with grade 1 hypertension were not included; the study population had relatively more low-risk cardiovascular patients and was not representative of the general elderly population; the study ended prematurely after only 1.8 years, will the benefit of blood pressure lowering last longer? Average age of the study population was 83 years; fewer people were >85 years old; does the benefit extend to an older population? Failure to improve dementia and cognitive dysfunction, and failure to study the optimal ideal blood pressure lowering target for reducing cardiovascular events and death. The 2010 Chinese guidelines for the prevention and treatment of hypertension revised the definition of geriatric hypertension to define the age of geriatric hypertension as ≥65 years, which is consistent with the international age of diagnosis of geriatric hypertension. However, the definition of geriatric hypertension in clinical practice is formulated purely in terms of physiological age has limitations. There are great differences in health and physiological functions among different older adults, and some 80-year-olds are fully able to adapt to the work environment and daily life with better health status than 70-year-olds or even some 60-year-olds. Age should not be defined mechanistically only by demographic age in treatment, but it may be more appropriate to consider the patient’s age-related disease status. The ongoing SPRINT study (Systolic Blood Pressure Intervention Trial) comparing the endpoints of high-risk adults with hypertensive SBP target values of 120 mm Hg or 140 mm Hg, in which enough elderly patients were enrolled, will further answer the question of BP lowering targets for elderly hypertensive patients. Treatment of ISH patients with high SBP but not high or even low DBP is difficult, and there is no clear evidence and uniform recommendations on how to manage them. There is not enough evidence that older patients with hypertension combined with diabetes, coronary heart disease, and chronic kidney disease at high risk should achieve lower blood pressure values. It is unclear whether there is a greater benefit to lowering blood pressure to below 140/90 mm Hg in elderly people over 80 years of age. In conclusion, the large number of elderly patients with hypertension encountered in clinical practice is very different from those enrolled in clinical trials, often with more comorbid diseases, with organ decompensation, and with more complex combined medications. Therefore, physicians should analyze the specific situation of each patient according to the recommendations of the guidelines and give individualized treatment in a tailor-made manner.