The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure emphasizes the importance of systolic hypertension (SH), defined as systolic blood pressure (SBP) of at least 140 mm Hg and diastolic blood pressure of less than 90 mm Hg, in older persons (> or =60 years). To systematically review the literature on clinical management of SH in older persons. We performed a MEDLINE search of English-language literature from 1966-2004 to identify reports about SH in older persons, with particular emphasis on data from randomized clinical trials. We selected 1064 studies by using the search terms hypertension combined with the terms systole (or systolic) and aged. There is strong evidence from clinical trials to support the treatment of SH in older persons with SBP of at least 160 mm Hg. Large-scale trials to assess the value of antihypertensive therapy for older patients with SBP of 140 to 159 mm Hg have not been performed, and recommendations to treat these patients are based on observational studies that show a graded relationship of cardiovascular risk with increasing SBP. The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy to treat SH. Treatment of SH in older patients with SBP of at least 160 mm Hg is supported by strong evidence. The evidence available to support treatment of patients to the level of 140 mm Hg or those with baseline SBP of 140 to 159 mm Hg is less strong; thus, these treatment decisions should be more sensitive to patient preferences and tolerance of therapy.