PURPOSE: Hypertension is a common chronic condition among the elderly, and the rational use of antihypertensive medications is critical for blood pressure control. This study aimed to investigate trends in the use and irrational prescription of antihypertensive medications among elderly patients with hypertension in China from 2016 to 2023. PATIENTS AND METHODS: A retrospective cross-sectional design was applied to analyze the prescription of antihypertensive drugs in hypertensive patients aged 65 years and above, utilizing outpatient electronic medical record data from 78 hospitals in nine cities in China from 2016 to 2023. Antihypertensive medications were categorized into nine classes based on hypertension treatment guidelines. Annual trends in the use of these medications were analyzed using Annual Percentage Change (APC). Irrational prescriptions were defined as contraindicated medication prescriptions and inappropriate combination medication. Poisson regression models were employed to analyze trends and influencing factors for irrational prescriptions. RESULTS: The number of patients increased from 396,408 to 542,215 during the study period. Calcium Channel Blockers had the highest usage but showed a slight decrease (APC=−3.46%, P=0.011), while β-blockers showed a slight increase (APC=1.48%, P=0.028). The overall proportion of first-line antihypertensive prescriptions was 97.47% but showed a slight declining trend (APC=−0.66%, P=0.004). The rates of inappropriate combination medication and overall irrational prescriptions decreased, while the rate of contraindicated medication prescriptions increased (P<0.001). Factors including male gender, advanced age (≥85 years), northern regions, primary healthcare settings, and geriatrics departments were associated with higher risks of contraindicated medications. CONCLUSION: This study reveals the trends and patterns in antihypertensive medication use among elderly hypertensive patients in China from 2016 to 2023. While the overall use of first-line antihypertensive drugs remained high, there were differences across subgroups. The increasing rate of contraindicated medications and the identification of high-risk groups and clinical settings provide important insights for optimizing antihypertensive treatment in elderly populations.