Systolic hypertension is a major health economy problem within our aging society. Increased arterial stiffness is the vascular phenotype of systolic hypertension, especially of the large arteries. Elevated systolic blood pressure is even more associated with cardiovascular morbidity and mortality than diastolic blood pressure. Treatment of systolic hypertension in the elderly should be based on nonpharmacological measures and medical therapy if the systolic hypertension cannot be controlled by conservative therapy alone. The HYVET study provided evidence-based medicine data showing that, in the very elderly, lowering blood pressure to a level of 150/80 mmHg is still very beneficial. Antihypertensive therapy needs to be tailored in the elderly because of comorbid conditions, such as ischemic heart disease, heart failure, atrial fibrillation, renal insufficiency and diabetes. Angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers should be considered in combination with diuretics or with a dihydropyridine calcium antagonist. β-blockers seem to be less effective for cardiovascular disease protection in comparison with other antihypertensive drug classes, such as diuretics, dihydropyridines, angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers. Major effort is required to reduce the therapeutic inertia and increase therapeutic adherence for better blood pressure control in the elderly with systolic hypertension.