New concepts in the treatment of elderly hypertensive patients.

Present evidence from several secondary and primary prevention trials indicates that if antihypertensive treatment is initiated with a cardioselective beta-blocker such as metoprolol, a better preventive effect on total mortality, cardiovascular mortality, and atherosclerotic complications can be expected than if diuretics are used as initial therapy. Results from a large-scale, multicenter international study have shown that a regimen in which antihypertensive treatment is initiated with metoprolol once daily is effective, safe, and well tolerated in elderly hypertensive patients. This might be of particular importance since a steep increase in cardiovascular mortality and other atherosclerotic complications is seen with age. In many elderly hypertensive patients, symptoms of heart failure might be caused by poor filling in stiff hearts rather than ineffective systolic contractions. By reducing heart rate with use of a cardioselective beta-blocker, diastole will be prolonged; this will improve filling and hence stroke volume and will increase coronary flow. Long-term treatment with metoprolol has also been found to reduce left ventricular systolic wall stress, reverse hypertrophy, improve left ventricular compliance, decrease the stiffness of large arteries, reduce total peripheral resistance, and reduce albuminuria. The improvement in the stiffness of the large arteries might be of particular clinical importance in elderly patients who have isolated systolic hypertension.