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Published on: February 7, 2014
Diastolic blood pressure and mortality in the elderly with cardiovascular disease
Athanase D Protogerou1, Michel E Safar, Pierre Iaria
1Paris-Descartes University, Faculty of Medicine, AP-HP, Hôtel-Dieu Hospital, Diagnosis and Therapeutic Center, Paris, France.
Insights
In frail elderly patients, low diastolic blood pressure (< or =60 mm Hg) is linked to higher mortality, independent of arterial stiffness. This suggests antihypertensive therapy should consider diastolic pressure for better outcomes.
Area of Science:
- Gerontology
- Cardiovascular Medicine
- Hypertension Research
Background:
- Isolated systolic hypertension is common in the elderly due to arterial stiffness.
- Aggressive treatment can lower diastolic blood pressure (DBP) excessively, potentially leading to a J-shaped mortality curve.
- The relationship between DBP and mortality in the elderly, particularly concerning arterial stiffness, requires further investigation.
Purpose of the Study:
- To investigate the association between diastolic blood pressure and mortality in elderly hospitalized patients.
- To determine if the observed J-shaped mortality curve is an epiphenomenon of arterial stiffness and impaired cardiac function.
- To identify determinants of low diastolic blood pressure in this population.
Main Methods:
- A cohort of 331 hospitalized patients over 70 years old was studied.
- Aortic pulse wave velocity, pressure wave reflections, and cardiac function were assessed.
- A 2-year follow-up was conducted to record mortality, with 110 deaths observed.
Main Results:
- No significant association was found between systolic pressure, pulse pressure, or pulse wave velocity and prognosis.
- A J-shaped association between diastolic pressure and overall/cardiovascular mortality was observed.
- Diastolic blood pressure <= 60 mm Hg predicted mortality independently of vascular properties, risk factors, and treatment; low total peripheral resistance and advanced age determined low DBP.
Conclusions:
- In frail elderly individuals, diastolic blood pressure <= 60 mm Hg is associated with reduced survival, irrespective of arterial stiffness and left ventricular function.
- An optimal diastolic pressure of approximately 70 mm Hg was identified for isolated systolic hypertension in the elderly.
- Antihypertensive therapy in the elderly should be rationalized to consider diastolic pressure, not solely systolic levels, to improve survival.
Abstract:
Isolated systolic hypertension is predominantly observed in the elderly because of increased arterial stiffness. Aggressive treatment leads to excessive lowering of diastolic blood pressure and favors the presence of a J-shaped curve association with mortality. We investigated whether, in the elderly, this pattern of association is a simple epiphenomenon of increased arterial stiffness and impaired cardiac function. In a cohort of 331 hospitalized subjects >70 years old (mean age+/-SD: 85+/-7 years), aortic pulse wave velocity and pressure wave reflections, by pulse wave analysis, and cardiac function, by ultrasound, were assessed. During a 2-year follow-up period, 110 subjects died. No association of prognosis with systolic pressure, pulse pressure, or pulse wave velocity was observed. A J-shaped association between diastolic pressure and overall and cardiovascular mortality was observed. Unadjusted Cox regression analysis showed that patients in the first tertile of diastolic pressure (< or =60 mm Hg) had higher mortality. In Cox regression analysis, diastolic pressure < or =60 mm Hg was a predictor of mortality independently from cardiac-vascular properties, cardiovascular risk factors, and drug treatment. Multivariate regression analysis showed that increased age and low total peripheral resistance, but not left ventricular function, were the cardinal determinants of low diastolic pressure. An "optimal" diastolic pressure of 70 mm Hg in subjects with isolated systolic hypertension was found. We showed that, in the frail elderly, a value of diastolic blood pressure < or =60 mm Hg is associated with reduced survival, independent from large artery stiffness and left ventricular function, suggesting that more rational antihypertensive therapy, not only based on systolic pressure level, is needed.
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