Isolated Systolic Hypertension

Key points

• Isolated systolic hypertension (raised systolic with normal diastolic) is common in older people, affecting around half of those over 70.
• SHEP (1991) showed that treating ISH reduces stroke and ischaemic heart disease — the historical basis for treating it at all.
• Current NICE (NG136): treat ISH with exactly the SAME stepwise pathway as standard hypertension — there is no separate ISH algorithm, and the older thiazide-first advice is superseded.
• That pathway is: step 1 A or C by age/ethnicity/diabetes → step 2 A+C or A+D → step 3 A+C+D → step 4 by potassium (spironolactone if K ≤ 4.5, otherwise alpha- or beta-blocker).
• Targets in older people: clinic below 150/90 if aged 80 or over (145/85 on ABPM/HBPM); below 140/90 if under 80 (135/85 on ABPM/HBPM).