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Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients
J Blacher1, J A Staessen, X Girerd
1Service de Médecine Interne, Hôpital Broussais, Paris, France.
Insights
In older hypertensive patients, pulse pressure, not mean pressure, significantly increases cardiovascular risk. This finding highlights the importance of the pulsatile component of blood pressure in predicting adverse outcomes.
Area of Science:
- Cardiology
- Hypertension Research
- Geriatric Medicine
Background:
- Current hypertension guidelines primarily focus on systolic and diastolic blood pressure.
- The arterial blood pressure wave comprises pulsatile (pulse pressure) and steady (mean pressure) components.
Purpose of the Study:
- To investigate the independent roles of pulse pressure and mean pressure in determining cardiovascular prognosis.
- Focus on older hypertensive patients.
Main Methods:
- Meta-analysis of individual patient data from three major trials (EWPHE, SHEP, STH).
- Cox regression analysis used to calculate relative hazard rates for pulse pressure and mean pressure.
- Adjustments made for covariates including sex, age, prior cardiovascular issues, smoking, and treatment group.
Main Results:
- A 10-mm Hg increase in pulse pressure correlated with a 13-20% rise in cardiovascular complications and mortality.
- Mean pressure predicted complications only when pulse pressure was excluded from the model.
- Higher systolic and lower diastolic pressures indicated increased risk, driven by wider pulse pressure.
Conclusions:
- Pulse pressure, rather than mean pressure, is the primary determinant of cardiovascular risk in elderly hypertensive individuals.
- Further randomized trials are needed to explore antihypertensive strategies targeting the pulsatile component of blood pressure.
Background:
Current guidelines for the management of hypertension rest almost completely on the measurement of systolic and diastolic blood pressure. However, the arterial blood pressure wave is more correctly described as consisting of a pulsatile (pulse pressure) and a steady (mean pressure) component.
Objective:
To explore the independent roles of pulse pressure and mean pressure as determinants of cardiovascular prognosis in older hypertensive patients.
Methods:
This meta-analysis, based on individual patient data, pooled the results of the European Working Party on High Blood Pressure in the Elderly trial (n = 840), the Systolic Hypertension in Europe Trial (n = 4695), and the Systolic Hypertension in China Trial (n = 2394). The relative hazard rates associated with pulse pressure and mean pressure were calculated using Cox regression analysis, with stratification for the 3 trials and with adjustments for sex, age, previous cardiovascular complications, smoking, and treatment group.
Results:
A 10-mm Hg wider pulse pressure increased the risk of major cardiovascular complications; after controlling for mean pressure and the other covariates, the increase in risk ranged from approximately 13% for all coronary end points (P = .02) to nearly 20% for cardiovascular mortality (P = .001). In a similar analysis, mean pressure predicted the incidence of cardiovascular complications but only after removal of pulse pressure as an explanatory variable from the model. Furthermore, the probability of a major cardiovascular end point increased with higher systolic blood pressure; at any given level of systolic blood pressure, it also increased with lower diastolic blood pressure, suggesting that the wider pulse pressure was driving the risk of major complications.
Conclusions:
In older hypertensive patients, pulse pressure not mean pressure is the major determinant of cardiovascular risk. The implications of these findings for the management of hypertensive patients should be further investigated in randomized controlled outcome trials in which the pulsatile component of blood pressure is differently affected by antihypertensive drug treatment.