JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 67, NO. 4, 2016

ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER

http://dx.doi.org/10.1016/j.jacc.2015.11.022

EDITORIAL COMMENT

Pulse Pressure How Valuable as a Diagnostic and Therapeutic Tool?* Stanley S. Franklin, MD, Nathan D. Wong, PHD

C

ross-sectional and longitudinal studies of

risk, (i.e., a shift from prehypertension to stage 1

age-related increases in blood pressure (BP)

and from stage 1 to stage 2 hypertension) (7). During

have shown that mean diastolic blood pres-

the past 20 years, there have been multiple observa-

sure (DBP) levels off by approximately age 50 years

tional studies and controlled trials showing the value

and begins to decrease by age 60 years, whereas sys-

of PP as an important risk factor for CVD and as a

tolic blood pressure (SBP) continues to increase; this

measure of early vascular aging. Moreover, the Euro-

results in a slow widening of pulse pressure (PP)

pean

between the ages of 50 years and 60 years and more

widened PP as a distinct risk factor that is separate

rapid widening thereafter as the decrease in DBP

from elevated SBP in older individuals (9).

accelerates with more vascular aging (1,2). Elevated mean artery pressure (MAP), as a measure of steady-

Society

of

Hypertension

has

recognized

SEE PAGE 392

state resistance, is the dominant factor in the almost

It is with this background that the authors, using

parallel increase in SBP and DBP during early adult-

data from the Reduction of Atherothrombosis for

hood; whereas widening PP as a marker of large artery

Continued Health (REACH) registry examined the

stiffness is the dominant pulsatile force that contrib-

relationship between PP and adverse CVD events (10),

utes to vascular aging from middle age onward.

published in this issue of the Journal. The novelty of

Indeed, by middle age, isolated systolic hypertension

the REACH registry is that it is the largest inter-

(ISH) becomes the dominant form of hypertension (3).

national patient population to study PP, which enabled

However, at any given SBP, the decrease in DBP adds

the authors to adjust for a significant number of

to the risk of SBP (4). The potential clinical value of

potential confounding factors, and to be able to

the widening of PP as a cardiovascular disease (CVD)

perform several key subgroup analyses with substan-

factor was first suggested in a seminal publication

tial statistical power. The study consisted of >45,000

by Darne et al. (5) in 1989. Since then, the Framing-

individuals (mean age: 68 years) from 45 countries

ham Heart Study and others (6,7), using the combina-

who had clinical atherothrombotic disease or baseline

tion of MAP and PP together, rather than any single

CVD risk factors and subsequently had a 4-year follow-

BP component separately (SBP, DBP, MAP, or PP)

up for new CVD events. Eighty-one percent were

improved the fit monotonically for predicting CVD

receiving antihypertensive therapy. Univariable and

collectively or coronary heart disease, heart failure,

multivariable regression analyses were used to deter-

and stroke separately (7,8). Using the 7th Report of

mine the association between PP and CVD outcomes as

the Joint National Committee for CVD risk classifica-

continuous and categorical variables (i.e., by quartile

tion, a DBP 60 years of

Franklin and Wong

JACC VOL. 67, NO. 4, 2016 FEBRUARY 2, 2016:404–6

Pulse Pressure

age; 3) the degree of systolic hypertension was associ-

to either a BP of 165/90 mm Hg with an elevated

ated with increased risk for nonfatal myocardial

MAP of 115 mm Hg or 140/65 mm Hg with a MAP of

infarctions and combined outcomes; and 4) antihy-

90 mm Hg. Focusing on PP alone does not clarify

pertensive treatment was associated with greater risk

which physiologic component of elevated BP is

of hospitalization, myocardial infarctions, and com-

contributing to CVD risk, and therefore what approach

bined events. In summary, the REACH registry authors

should be taken to reduce risk, (i.e., treatment may be

concluded that PP was associated with multiple CVD

directed at reducing MAP in the first person and

outcomes that provided prognostic utility beyond that

reducing arterial stiffness in the second person with

of MAP. On the other hand, this study should be

minimal further reduction in MAP). Moreover, there is

interpreted within the context of its limitations.

evidence of a DBP J-curve of increased CVD risk in individuals with ISH and DBP