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Jacques Blacher, MD; Jan A. Staessen, MD, PhD; Xavier Girerd, MD; Jerzy Gasowski, MD; Lutgarde Thijs, BSc; Lisheng Liu, MD; Ji G. Wang, MD; Robert H. Fagard, MD; Michel E. Safar, MD

Arch Intern Med. 2000;160:1085-1089.

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.

From the Service de Médecine Interne, Hôpital Broussais, Paris, France (Drs Blacher, Girerd, and Safar); Hypertensie en Cardiovasculaire Revalidatie Eenheid, Departement Moleculair en Cardiovasculair Onderzoek, Katholieke Universiteit Leuven, Leuven, Belgium (Drs Staessen, Gasowski, and Fagard and Ms Thijs); and Hypertension Division, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China (Drs Liu and Wang).

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