Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients

Background: Current guidelines for the management of hypertension rest almo st completely on the measurement of systolic and diastolic blood pressure. However, the arterial blood pressure wave is more correctly described as co nsisting of a pulsatile (pulse pressure) and a steady (mean pressure) compo nent. Objective: To explore the independent roles of pulse pressure and mean pres sure as determinants of cardiovascular prognosis in older hypertensive pati ents. Methods: This meta-analysis, based on individual patient data, pooled the r esults 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 ra tes associated with pulse pressure and mean pressure were calculated using Cox regression analysis, with stratification for the 3 trials and with adju stments for sex, age, previous cardiovascular complications, smoking, and t reatment Results: A 10-mm Hg wider pulse pressure increased the risk of major cardio vascular complications; after controlling for mean pressure and the other c ovariates, the increase in risk ranged from approximately 13% for all coron ary end points (P = .02) to nearly 20% for cardiovascular mortality (P = .0 01). In a similar analysis, mean pressure predicted the incidence of cardio vascular complications but only after removal of pulse pressure as an expla natory variable from the model. Furthermore, the probability of a major car diovascular end point increased with higher systolic blood pressure; at any given level of systolic blood pressure, it also increased with lower diast olic blood pressure, suggesting that the wider pulse pressure was driving t he risk of major complications. Conclusions: In older hypertensive patients, pulse pressure not mean pressu re is the major determinant of cardiovascular risk. The implications of the se findings for the management of hypertensive patients should be further i nvestigated in randomized controlled outcome trials in which the pulsatile component of blood pressure is differently affected by antihypertensive dru g treatment.