How to treat arterial hypertension effectively in elderly subjects?

Hypertension is the most common cardiovascular risk factor in older adults, significantly contributing to morbidity and mortality. Its prevalence rises with age and is strongly associated with vascular aging, isolated systolic hypertension, and comorbidities such as cognitive impairment and chronic kidney disease. However, treatment in older adults-especially those with frailty-requires a careful balance between benefit and potential harm. This review aims to provide an updated synthesis of pathophysiological mechanisms, epidemiological trends, diagnostic considerations, and evidence-based therapeutic approaches to arterial hypertension in older adults. Emphasis is placed on tailoring treatment strategies according to frailty and functional status. We conducted a narrative review of major international guidelines (ESC, ESH), clinical trials, and real-world studies addressing hypertension in aging populations. Special focus was given to randomized controlled trials and observational studies stratified by frailty. Evidence supports blood pressure lowering in fit older adults, as demonstrated in trials such as HYVET, SPRINT-SENIOR, and STEP, which showed significant reductions in cardiovascular events and mortality. Conversely, studies like PARTAGE, OPTiMiSE, and DANTE highlight the risks of overtreatment in frail or institutionalized patients, including hypotension, falls, and increased mortality. The presence of orthostatic hypotension, impaired renal function, and polypharmacy further complicates management. In conclusion hypertension management in the elderly should follow a personalized approach based on a comprehensive geriatric assessment and frailty evaluation; patient-centered goals are essential to guide treatment intensity, aiming to protect cardiovascular health without compromising safety, cognition, or functional independence. Future studies must include frailer populations to better inform clinical decisions.