Isolated systolic hypertension: which medication class is considered first-line therapy?

• A. Atenolol
• B. Hydrochlorothiazide
• C. Diltiazem
• D. Lisinopril

Answer: (B)

Isolated systolic hypertension is driven by decreased arterial compliance, so the goal is to reliably lower the systolic pressure and reduce cardiovascular risk in older adults. Thiazide diuretics fit this need well: they reduce intravascular volume and, over time, help decrease peripheral resistance, yielding a meaningful and durable drop in systolic blood pressure. They also have strong outcome data in hypertension, with older patients benefiting especially from these agents. Among the options, a thiazide diuretic stands out as the most appropriate first-line choice for ISH because it provides reliable systolic reduction with a favorable safety profile in this population. Other classes can be effective but don’t have the same combination of proven benefits for ISH as initial therapy, so they’re generally considered after a thiazide or in cases where a thiazide isn’t tolerated or sufficient.