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In older hypertensive patients, pulse pressure not mean pressure is the major determinant of cardiovascular risk. The implications of these findings for the management of hypertensive patients should be further investigated in randomized controlled outcome trials in which the pulsatile component of blood pressure is differently affected by antihypertensive drug treatment.

The D allele is not associated with hypertension, but behaves as a marker of atherosclerotic cardiovascular complications and diabetic nephropathy. These associations do not necessarily imply a causal relationship and may have been inflated by publication bias. Nevertheless, their possible therapeutic implications may be subject to further investigation in prospective (intervention) studies.

In contrast to current recommendations, calcium channel blockers are more effective than thiazides as initial treatment in black subjects with hypertension. If treatment is started with thiazides or converting-enzyme inhibitors, combination therapy is more likely to be required to control blood pressure and reduce left ventricular mass.

In older patients with isolated systolic hypertension, antihypertensive treatment starting with the dihydropyridine calcium-channel blocker, nitrendipine, did not decrease blood pressure at the expense of renal function and prevented the development of proteinuria, especially in diabetic patients.

Isolated systolic hypertension affects 8% to 15% of all people older than 60 years of age. In the elderly, systolic hypertension is the major modifiable cardiovascular risk factor. Three placebo-controlled outcome trials on antihypertensive drug treatment of this disorder have been published. This article briefly reviews the main findings of each of these three trials and presents pooled estimates of the benefit of antihypertensive drug treatment for elderly patients with isolated systolic hypertension. A total of 11, 825 patients were enrolled in the Systolic Hypertension in the Elderly Program (SHEP, n = 4736), the Systolic Hypertension in Europe (Syst-Eur, n = 4695), and the Systolic Hypertension in China (Syst-China, n = 2394) trials. The outcome results of these trials were pooled by calculating the common odds ratio for active versus placebo treatment. The pooled results of the outcome trials in older patients with isolated systolic hypertension prove that antihypertensive drug treatment must be prescribed if, on repeated measurement, systolic blood pressure is 160 mm Hg or higher.

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