Hypertensive Cardiovascular Risk: Pulsatile Hemodynamics, Gender, and Therapeutic Implications

In recent years, the predictive value of 2 pulsatile parameters has been extensively studied in hypertension: aortic stiffness and pulse pressure (PP) amplification. Aortic stiffness is an index of aortic rigidity and PP-amplification is the ratio between central and brachial PP, an indirect evaluation of wave reflections. Both are safe, independent, noninvasive predictors of overall and cardiovascular risk. Our purpose is to determine the validity of these parameters in 2 different circumstances: gender and therapeutic implications.

Studies have shown that whereas steady mean arterial pressure is significantly higher in men than in women, pulsatile pressure largely predominates in women, mostly in older age and as a consequence of short stature. Gender differences require more extensive investigation due to the disparities of dose-response ranging among populations and the contribution of ethnic factors, frequently based on individual origin.

Many questions have yet to be resolved. First, the prognosis of antihypertensive therapy is largely based on blood pressure reduction but also requires evaluation of arterial rigidity and wave reflections to achieve adequate therapeutic "de-stiffening." The most effective approach appears to be the combination of angiotensin- and calcium-channel blockade, in certain cases associated with diuretic compounds. Second, antialdosterone drugs can be useful, but it is their antifibrotic more than their antihypertensive effect that appears effective. Third, prevention of comorbidities, such as those associating hypertension, diabetes, and/or kidney damage, should become primary targets for drug treatment.