Hypertension in the elderly is characterized principally by increased systolic blood pressure (SBP). Consequently, isolated systolic hypertension (ISH) is the most common subtype in this population. The major haemodynamic determinant underlying ISH is increased large-artery stiffness. This is expressed as an increase in SBP and decrease in diastolic blood pressure (DBP), leading to widening pulse pressure. Epidemiological studies show that ISH and increased pulse pressure in the elderly constitute independent cardiovascular risk factors and may be more robust in predicting the adverse cardiovascular sequelae of hypertension than elevated DBP alone. Reducing high blood pressure (> 140/90 mmHg), including ISH (SBP > 140 mmHg, DBP < 90 mmHg), with conventional and newer antihypertensive agents significantly reduces the risk of major coronary events, stroke, coronary heart disease and all-cause mortality. Among the elderly population, there appears to be no age threshold beyond which treatment of hypertension, including ISH, should not be considered beneficial. Clinical management has to take into account some specific aspects related to its pathophysiology and the patient characteristics of this population. Although the therapeutic goal is < 140/90 mmHg, a decrease of 20-30 mmHg in SBP, even if the overall goal is not achieved, is associated with improved prognosis.