Should pulse pressure become part of the Framingham risk score?

Higher Pulse Pressure Is Associated With Increased Risk of Cardio-cerebrovascular Disease and All-Cause Mortality: A Korean National Cohort Study

BACKGROUND

This study aimed to investigate the association of pulse pressure (PP) with the cardio-cerebrovascular disease (CCVD) risk and all-cause mortality according to blood pressure level using Korean national cohort data.

METHODS

This study was retrospectively designed and based on the Korean National Health Insurance Service-National Health Screening Cohort. Participants aged 40-69 years at baseline were categorized into normal, elevated, stage 1, and stage 2 groups according to blood pressure. Each group was further classified into 5 groups separated by 10-mm Hg increments in PP. The primary composite outcome was defined as CCVDs and all-cause mortality. Cox proportional hazards regression models were adopted after stepwise adjustment for confounders to investigate the composite outcome.

RESULTS

During the follow-up period (median follow-up period, 12.0 years), the primary composite outcome occurred in 18,444 (15.0%) of 122,783 men and 10,096 (11.4%) of 88,550 women. After complete adjustment for confounders, in the stage 1 hypertensive men, the hazard ratio (95% confidence intervals [CIs]) of the 31-40, 41-50, 51-60, and >60 mm Hg PP groups was 1.112 (1.013-1.221), 1.035 (0.942-1.137), 1.009 (0.907-1.123), and 1.324 (1.130-1.551) in comparison with the ≤30 mm Hg PP group. In the stage 2 hypertensive men, the HRs (95% CIs) were 1.069 (0.949-1.204), 1.059 (0.940-1.192), 1.123 (0.999-1.263), and 1.202 (1.061-1.358) compared to the ≤30 mm Hg PP group. However, these associations were not significant in women.

CONCLUSIONS

Hypertensive men with an increased PP have an increased risk of CCVDs and all-cause mortality.

Elevated pulse pressure and its associations with demographic and clinical parameters in a clinically representative sample of outpatients with psychotic disorders

Elevated pulse pressure is associated with metabolic and neurocognitive diseases. Preliminary small-scale studies among patients with psychotic disorders have indicated that these patients had an increased pulse pressure compared with controls. However, it is unclear whether and how these associations are manifested among larger heterogenous samples of patients with psychotic disorders. We examined elevated pulse pressure and its associations with demographic and clinical characteristics in a clinically representative sample of outpatients with psychotic disorders (n = 1289). In a subsample (n = 343), we also examined associations with six domains of functioning. Controlling for age and cardiovascular disease, body mass index (BMI) and employment status independently predicted the odds ratio of having elevated pulse pressure. Elevated pulse pressure was also primarily associated with the physical domains of functioning. Outpatients with psychotic disorders that have high BMI and are unemployed thus seem to be at increased risk for elevated pulse pressure and should therefore be particularly considered for blood pressure screenings.

Upper Extremity Pulse Pressure Predicts Amputation-Free Survival after Lower Extremity Bypass

Increased pulse pressure reflects pathologic arterial stiffening and predicts cardiovascular events and mortality. The effect of pulse pressure on outcomes in lower extremity bypass patients remains unknown. We thus investigated whether preoperative pulse pressure could predict amputation-free survival in patients undergoing lower extremity bypass for atherosclerotic occlusive disease. An institutional database identified 240 included patients undergoing lower extremity bypass from 2005 to 2014. Preoperative demographics, cardiovascular risk factors, operative factors, and systolic and diastolic blood pressures were recorded, and compared between patients with pulse pressures above and below 80 mm Hg. Factors were analyzed in bi- and multivariable models to assess independent predictors of amputation-free survival. Kaplan-Meier analysis was performed to evaluate the temporal effect of pulse pressure ≥80 mm Hg on amputation-free survival. Patients with a pulse pressure ≥80 mm Hg were older, male, and had higher systolic and lower diastolic pressures. Patients with pulse pressure <80 mm Hg demonstrated a survival advantage on Kaplan-Meier analysis at six months (log-rank P = 0.003) and one year (P = 0.005) postoperatively. In multivariable analysis, independent risk factors for decreased amputation-free survival at six months included nonwhite race, tissue loss, infrapopliteal target, and preoperative pulse pressure ≥80 mm Hg (hazard ratio 2.60; P = 0.02), while only tissue loss and pulse pressure ≥80 mm Hg (hazard ratio 2.30, P = 0.02) remained predictive at one year. Increased pulse pressure is independently associated with decreased amputation-free survival in patients undergoing lower extremity bypass. Further efforts to understand the relationship between increased arterial stiffness and poor outcomes in these patients are needed.

Determinants of the components of arterial pressure among older adults--the role of anthropometric and clinical factors: a multi-continent study

OBJECTIVE

The aim of this study was to evaluate the factors associated with different components of arterial blood pressure in nine nationally-representative samples of people aged ≥50 years.

METHODS

Data were available for 53,289 people aged ≥18 years who participated in the SAGE (WHO Study on global AGEing and adult health) study conducted in China, Ghana, India, Mexico, Russia, and South Africa, and the COURAGE (Collaborative Research on Ageing in Europe) study conducted in Finland, Poland, and Spain, between 2007 and 2012. Standard procedures were used to obtain diastolic and systolic blood pressure (DBP, SBP) measurements to identify hypertensive participants, and to determine mean arterial blood pressure (MAP) and pulse pressure (PP).

RESULTS

The analytical sample consisted of 42,116 people aged 50 years or older. South Africa had the highest prevalence of hypertension (78.3%), and the highest measurements of MAP ± SD (113.6 ± 36.4 mmHg), SBP ± SD (146.4 ± 49.5 mmHg), and DBP ± SD (97.2 ± 33.9 mmHg). In the adjusted models, dose-dependent positive associations between Body Mass Index (BMI) and MAP or PP were observed in most countries (p < 0.05). Diabetes was positively associated with PP in most countries but the association between diabetes and MAP was less consistent. Stroke was associated with both higher MAP and PP in China, Ghana, and South Africa (p < 0.05).

CONCLUSIONS

Obesity and diabetes remain important modifiable risk factors for arterial peripheral resistance and stiffness as reflected by MAP and PP respectively. Controlling arterial pressure abnormalities after stroke events may be important for secondary prevention, particularly in developing countries.

Pulse pressure and stroke risk: development and validation of a new stroke risk model

OBJECTIVE

This study aims to develop and validate a stroke risk model incorporating pulse pressure (PP) as a potential risk factor. Recent evidence suggests that PP, defined as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), could be an incremental risk factor beyond SBP.

METHODS

Electronic health records (EHRs) of hypertensive patients from a US integrated health delivery system were analyzed (January 2004 to May 2012). Patients with ≥ 1 PP reading and ≥ 6 months of observation prior to the first diagnosis of hypertension were randomly split into development (two-thirds of sample) and validation (one-third of sample) datasets. Stroke events were identified using ICD-9-CM 433.xx-436.xx. Cox proportional hazards models assessed time to first stroke event within 3 years of first hypertension diagnosis based on baseline risk factors, including PP, age, gender, diabetes, and cardiac comorbidities. The optimal model was selected using the least absolute shrinkage and selection operator (LASSO); performance was evaluated by the c-statistic.

RESULTS

Among 34,797 patients selected (mean age 59.3 years, 48% male), 4272 patients (12.3%) had a stroke. PP was higher among patients who developed stroke (mean [SD] PP, stroke: 02.0 [15.3] mmHg; non-stroke: 58.1 [14.0] mmHg, p < 0.001). The best performing risk model (c-statistic, development: 0.730; validation: 0.729) included PP (hazard ratio per mmHg increase: 1.0037, p < 0.001) as a significant risk factor.

LIMITATIONS

This study was subject to limitations similar to other studies using EHRs. Only patient encounters occurring within the single healthcare network were captured in the data source. Though the model was tested internally, external validation (using a separate data source) would help assess the model's generalizability and calibration.

CONCLUSIONS

This stroke risk model shows that greater PP is a significant predictive factor for increased stroke risk, even in the presence of known risk factors. PP should be considered by practitioners along with established risk factors in stroke treatment strategies.

Factors associated with components of arterial pressure among older individuals (the multinational MEDIS study): the role of the Mediterranean diet and alcohol consumption

The aim of this work was to evaluate factors associated with arterial blood pressure in a sample of older Mediterranean people without known cardiovascular disease. During 2005 to 2011, 2813 older (aged 65-100 years) individuals from 22 Mediterranean islands and the rural Mani region (Peloponnesus) voluntarily enrolled. Standard procedures were used to determine arterial BP and pulse pressure and for the evaluation of dietary habits (including tea and alcoholic beverages consumption), lifestyle, and anthropometric and clinical characteristics of the participants. Participants who reported low alcohol consumption (ie, 0-1 glasses per day) were less likely to have hypertension (odds ratio, 0.34; 95% confidence interval, 0.14-0.84) as compared with those who reported high alcohol consumption (ie, 5+ glasses per day). Adherence to the Mediterranean diet was inversely associated with mean arterial pressure (β coefficient, -0.18; 95% confidence interval, -0.33 to -0.16). Alcohol drinking remains an important modifiable risk factor for hypertension. Adherence to the Mediterranean diet was associated with decreased arterial peripheral resistance.

Acute changes in pulse pressure in relation to constituents of particulate air pollution in elderly persons

An increased pulse pressure (difference between systolic and diastolic blood pressure) suggests aortic stiffening. The objective of this study was to examine the acute effects of both particulate matter (PM) mass and composition on blood pressure, among elderly persons. We carried out a panel study in persons living in elderly homes in Antwerp, Belgium. We recruited 88 non-smoking persons, 70% women with a mean age of 83 years (standard deviation: 5.2). Blood pressure was measured and a blood sample was collected on two time points, which were chosen so that there was an exposure contrast in ambient PM exposure. The elemental content of the collected indoor and outdoor PM(2.5) (particulate matter with an aerodynamic diameter <2.5 μm) mass concentration was measured. Oxygenated polycyclic aromatic hydrocarbons (oxy-PAHs) on outdoor PM(10) (particulate matter with an aerodynamic diameter <10 μm) were measured. Each interquartile range increase of 20.8 μg/m³ in 24-h mean outdoor PM(2.5) was associated with an increase in pulse pressure of 4.0 mm Hg (95% confidence interval: 1.8-6.2), in persons taking antihypertensive medication (n=57), but not in persons not using antihypertensive medication (n=31) (p for interaction: 0.02). Vanadium, iron and nickel contents of PM(2.5) were significantly associated with systolic blood pressure and pulse pressure, among persons on antihypertensive medication. Similar results were found for indoor concentrations. Of the oxy-PAHs, chrysene-5,6-dione and benzo[a]pyrene-3,6-dione were significantly associated with increases in systolic blood pressure and pulse pressure. In elderly, pulse pressure was positively associated with acute increases in outdoor and indoor air pollution, among persons taking antihypertensive medication. These results might form a mechanistic pathway linking air pollution as a trigger of cardiovascular events.

Arterial stiffness, central hemodynamics, and cardiovascular risk in hypertension

This review summarizes several scientific contributions at the recent Satellite Symposium of the European Society of Hypertension, held in Milan, Italy. Arterial stiffening and its hemodynamic consequences can be easily and reliably measured using a range of noninvasive techniques. However, like blood pressure (BP) measurements, arterial stiffness should be measured carefully under standardized patient conditions. Carotid-femoral pulse wave velocity has been proposed as the gold standard for arterial stiffness measurement and is a well recognized predictor of adverse cardiovascular outcome. Systolic BP and pulse pressure in the ascending aorta may be lower than pressures measured in the upper limb, especially in young individuals. A number of studies suggest closer correlation of end-organ damage with central BP than with peripheral BP, and central BP may provide additional prognostic information regarding cardiovascular risk. Moreover, BP-lowering drugs can have differential effects on central aortic pressures and hemodynamics compared with brachial BP. This may explain the greater beneficial effect provided by newer antihypertensive drugs beyond peripheral BP reduction. Although many methodological problems still hinder the wide clinical application of parameters of arterial stiffness, these will likely contribute to cardiovascular assessment and management in future clinical practice. Each of the abovementioned parameters reflects a different characteristic of the atherosclerotic process, involving functional and/or morphological changes in the vessel wall. Therefore, acquiring simultaneous measurements of different parameters of vascular function and structure could theoretically enhance the power to improve risk stratification. Continuous technological effort is necessary to refine our methods of investigation in order to detect early arterial abnormalities. Arterial stiffness and its consequences represent the great challenge of the twenty-first century for affluent countries, and "de-stiffening" will be the goal of the next decades.

Association of pulse pressure, arterial elasticity, and endothelial function with kidney function decline among adults with estimated GFR >60 mL/min/1.73 m(2): the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

The association of subclinical vascular disease and early declines in kidney function has not been well studied.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Multi-Ethnic Study of Atherosclerosis (MESA) participants with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m(2) with follow-up of 5 years.

PREDICTORS

Pulse pressure, small (SAE) and large arterial elasticity (LAE), and flow-mediated dilation.

OUTCOMES

Kidney function decline.

MEASUREMENTS

SAE and LAE were measured by pulse contour analysis of the radial artery. Kidney function was assessed by eGFR based on serum creatinine (eGFR(SCr)) and cystatin C (eGFR(SCysC)).

RESULTS

For 4,853 adults, higher pulse pressure and lower SAE and LAE had independent and linear associations with faster rates of kidney function decline. Compared with persons with pulse pressure of 40-50 mm Hg, eGFR(SCysC) declines were 0.29 (P = 0.006), 0.56 (P < 0.001), and 0.91 (P < 0.001) mL/min/1.73 m(2)/y faster in persons with pulse pressure of 50-60, 60-70, and >70 mm Hg, respectively. Compared with the highest quartile of SAE (most elastic), eGFR(SCysC) declines were 0.26 (P = 0.009), 0.35 (P = 0.001), and 0.70 (P < 0.001) mL/min/1.73 m(2)/y faster for the second, third, and fourth quartiles, respectively. For LAE, compared with the highest quartile, eGFR(SCysC) declines were 0.28 (P = 0.004), 0.58 (P < 0.001), and 0.83 (P < 0.001) mL/min/1.73 m(2)/y faster for each decreasing quartile of LAE. Findings were similar for eGFR(SCr). In contrast, for 2,997 adults with flow-mediated dilation and kidney function measures, flow-mediated dilation was not associated significantly with kidney function decline. For every 1-standard deviation greater flow-mediated dilation, eGFR(SCysC) and eGFR(SCr) changed by 0.05 (P = 0.3) and 0.06 mL/min/1.73 m(2)/y (P = 0.04), respectively.

LIMITATIONS

We had no direct measure of GFR, in common with nearly all large population-based studies.

CONCLUSIONS

Higher pulse pressure and lower arterial elasticity, but not flow-mediated dilation, were associated linearly and independently with faster kidney function decline in persons with eGFR ≥60 mL/min/1.73 m(2). Future studies should investigate whether treatments to decrease the stiffness of large and small arteries may slow the rate of kidney function loss.

Risk prediction of incident coronary heart disease in The Netherlands: re-estimation and improvement of the SCORE risk function

AIMS

To re-estimate the SCORE risk function using individual data on risk factors and coronary heart disease (CHD) incidence from the Dutch Cardiovascular Registry Maastricht (CAREMA) population-based cohort study; to evaluate changes that may improve risk prediction after re-estimation; and to compare the performance of the resulting CAREMA risk function with that of existing risk scores.

METHODS AND RESULTS

The cohort consisted of 21,148 participants, born in 1927-1977 and randomly sampled from the Maastricht region in 1987-1997. After follow-up (median 10.9 years), 783 incident CHD cases occurred. Model performance was assessed by discrimination and calibration. The additional value of including other risk factors or current risk factors in a different manner was evaluated using the net reclassification index (NRI). The c statistic of the re-estimated SCORE model was 0.799 (95% CI 0.782-0.816). Separating the total/high-density lipoprotein (HDL) cholesterol ratio into total and HDL cholesterol levels did not improve the c statistic (p = 0.22), but reclassified 6.0% of the participants into a more appropriate risk category (p < 0.001) compared with the re-estimated model. The resulting CAREMA function reclassified 28% of the participants into a more appropriate risk category than the Framingham score. Compared with the SCORE functions for high- and low-risk regions, the NRIs were 28% and 35%, respectively, which can largely be explained by the difference in outcome definition (CHD incidence vs. CHD mortality).

CONCLUSION

In this Dutch population, a re-estimated SCORE function with total and HDL cholesterol levels instead of the cholesterol ratio can be used for the risk prediction of CHD incidence.

Blood pressure variables and cardiovascular risk: new findings from ADVANCE

The relative importance of various blood pressure indices on cardiovascular risk in people with type 2 diabetes mellitus has not been established. This study compares the strengths of the associations between different baseline blood pressure variables (systolic blood pressure [SBP], diastolic blood pressure [DBP], pulse pressure [PP], and mean arterial pressure) and the 4.3-year risk of major cardiovascular events in the Action in Diabetes and Vascular Disease: Preterax and Diamicron-Modified Release Controlled Evaluation Study. Mean (SD) age for the 11 140 participants was 65.8 years (6.4 years). During follow-up, 1000 major cardiovascular events, 559 major coronary events, and 468 cardiovascular deaths were recorded. After adjustment for age, sex, and treatment allocation, the hazard ratios (95% CIs) associated with 1 increment in SD for the risk of major cardiovascular events were 1.17 (1.10 to 1.24) for SBP; 1.20 (1.13 to 1.28) for PP; 1.12 (1.05 to 1.19) for mean arterial pressure; and 1.04 (0.98 to 1.11) for DBP. The areas under the receiver operating characteristic curve were slightly higher for SBP and PP compared with mean arterial pressure and DBP for major cardiovascular and coronary events. Using achieved instead of baseline blood pressure values marginally improved the effect estimates for SBP, DBP, and mean arterial pressure, with no significant differences in the areas under the receiver operating characteristic curve between models with SBP and those with PP. In conclusion, SBP and PP are the 2 best and DBP is the least effective determinant of the risk of major cardiovascular outcomes in the relatively old patients with type 2 diabetes mellitus participating in the Action in Diabetes and Vascular Disease: Preterax and Diamicron-Modified Release Controlled Evaluation Study. However, SBP may be the simplest and most useful predictor across a wider range of age groups and populations.

Role of Pulse Pressure on Cardiovascular Risk in Chronic Kidney Disease Patients: Figure 1

Epidemiologic studies have emphasized the close relationship between high BP and cardiovascular disease (CVD). Recently published prospective studies have focus on systolic and pulse pressure (PP). Systolic BP seems to be a more important factor than diastolic BP on cardiovascular and all-cause mortality in older patients. PP reflects stiffness of the large arteries and increases with age. Increasingly, PP is recognized as an independent predictor of myocardial infarction, congestive heart failure, and cardiovascular death, even in hypertensive patients who undergo successful antihypertensive drug therapy, especially in older individuals. Chronic kidney disease (CKD) is a major public health problem. The progression of kidney disease and its associated cardiovascular complications are the major causes of morbidity and mortality. This holds true for all stages of kidney disease, including ESRD that requires renal replacement therapy. Most of the traditional CVD risk factors are highly prevalent in CKD, and several nontraditional factors also are associated with atherosclerosis in CKD. The burden of hypertension is present at all stages of CKD. Several studies have shown that PP is a reliable prognostic factor for mortality and CVD in patients who have CKD and are on hemodialysis and in renal transplant patients. The purpose of this review is to show the importance of PP on cardiovascular risk in patients with CKD, including kidney transplant recipients.

Risk scoring in the assessment of cardiovascular risk

PURPOSE OF REVIEW

Cardiovascular risk scoring is incorporated in guidelines and recommended for targeting preventive treatment. Evidence is required on the most appropriate method, its accuracy in a given population, and its effectiveness in favourably influencing clinical behaviour and health outcomes.

RECENT FINDINGS

Recent risk scores address inaccuracies that arise when methods are transferred between populations, and specific methods and recalibrations are described for use in low-risk populations. Ethnic and social differences in risk are also recognized in the context of cardiovascular risk scoring. More sensitive measures of known risk factors and numerous emerging risk factors are reported and new statistical methods and sources of data suggested. Little emphasis has been placed on evaluation of the clinical effectiveness of cardiovascular risk scores. Education in cardiovascular risk assessment may help improve uptake of methods by healthcare professionals.

SUMMARY

Numerous risk scoring methods are available to the healthcare professional but use is patchy. Accuracy varies between populations and methods have been developed to compensate for some of this variability. If risk scoring methods are to be widely used in general practice, evidence is required on both the accuracy of methods in appropriate populations and their effectiveness in improving health outcomes.

Can we improve cardiovascular risk prediction beyond risk equations in the physician's office?

BACKGROUND AND OBJECTIVES

Beyond a global estimation of the cardiovascular risk through the assessment of major risk factors and their integration in dedicated risk scales or equations, the use of specific markers provides additive prognostic information at an individual level, including predisposing factors, which are not included in the risk equations as well as the individual susceptibility to their long-term exposure. However, the majority of these markers require specific devices and skills, which are not widely available in primary care.

METHODS

Some clinical and/or "low-cost" parameters are shown to be valuable risk markers, and their use could refine the risk estimation in a physician's office. Several epidemiologic studies suggest the heart rate, the pulse pressure and the ankle-brachial index are effective cardiovascular risk markers. The arms systolic pressure asymmetry could also be a useful marker of risk.

RESULTS AND CONCLUSIONS

Through a general review, the authors evaluate the potential of these clinical markers, including their use in combination for more accurate risk determination.

Prognostic value of aortic pulse wave velocity as index of arterial stiffness in the general population

BACKGROUND

Few population studies addressed the prognostic significance of aortic pulse wave velocity (APWV) above and beyond other cardiovascular risk factors.

METHODS AND RESULTS

We studied a sex- and age-stratified random sample of 1678 Danes aged 40 to 70 years. We used Cox regression to investigate the prognostic value of APWV, office pulse pressure (PP), and 24-hour ambulatory PP while adjusting for mean arterial pressure (MAP) and other covariates. Over a median follow-up of 9.4 years, the incidence of fatal and nonfatal cardiovascular end points, cardiovascular mortality, and fatal and nonfatal coronary heart disease amounted to 154, 62, and 101 cases, respectively. We adjusted for sex, age, body mass index, MAP measured in the office (conventional PP and APWV) or by ambulatory monitoring (24-hour PP), smoking, and alcohol intake. With these adjustments, APWV maintained its prognostic significance in relation to each end point (P<0.05), whereas office and 24-hour PP lost their predictive value (P>0.19), except for office PP in relation to coronary heart disease (P=0.02). For each 1-SD increment in APWV (3.4 m/s), the risk of an event increased by 16% to 20%. In sensitivity analyses, APWV still predicted all cardiovascular events after standardization to a heart rate of 60 beats per minute, after adjustment for 24-hour MAP instead of office MAP, and/or after additional adjustment for the ratio of total to HDL serum cholesterol and diabetes mellitus at baseline.

CONCLUSIONS

In a general Danish population, APWV predicted a composite of cardiovascular outcomes above and beyond traditional cardiovascular risk factors, including 24-hour MAP.

Effect of Combination Therapy of Benidipine Hydrochloride and Candesartan Cilexetil on Serum Lipid Metabolism and Blood Pressure in Elderly Hypertensive Patients with Type 2 Diabetes Mellitus

The effects of combination therapy of angiotensin II receptor blockers (ARBs) and a calcium antagonist, benidipine hydrochloride, on glucose and lipid metabolism and pulse pressure were studied in elderly hypertensive patients with type 2 diabetes mellitus. Twenty-five hypertensive diabetic patients aged 65 years or older, who had been receiving candesartan cilexetil, were administered benidipine hydrochloride (4 mg/day) and followed for 4 months. After 4 months, systolic and diastolic blood pressure decreased significantly from 154/91 mmHg to 139/78 mmHg (p<0.01 versus before benidipine hydrochloride administration). Body mass index (BMI) and glycosylated hemoglobin (HbA1c) were apparently reduced but the changes were not statistically significant. The serum lipid profile showed no significant changes in serum total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). Serum lipoprotein lipase mass levels (preheparin LPL mass) increased significantly from 51 to 59 ng/dl (p<0.01 versus before benidipine hydrochloride administration), and the LDL/HDL motility ratio calculated from PAG disc electrophoresis decreased significantly (p<0.05 versus before benidipine hydrochloride administration). When patients were divided into a systolic hypertension group (systolic blood pressure > or =140 mmHg and diastolic blood pressure <90 mmHg) and non-systolic hypertension group (others), preheparin LPL mass was significantly lower in the systolic hypertension group, and the decrease in pulse pressure and increase in preheparin LPL mass were significantly greater in the systolic hypertension group. Stepwise regression analysis showed that low preheparin LPL mass at baseline was associated with a decrease in pulse pressure. Add-on benidipine hydrochloride therapy in elderly hypertensive patients with type 2 diabetes mellitus significantly decreases the LDL/HDL motility ratio and pulse pressure, and significantly increases preheparin LPL mass, in addition to improving blood pressure control. These findings suggest that combination therapy with benidipine hydrochloride and candesartan cilexetil may contribute to the suppression of arteriosclerosis and may be useful for elderly hypertensive patients with diabetes mellitus.

The significance of various blood pressure indices for long-term stroke, coronary heart disease, and all-cause mortality in men: the Israeli Ischemic Heart Disease study

BACKGROUND AND PURPOSE

Studies of blood pressure (BP) indices as disease predictors have offered conflicting conclusions. We compare pulse pressure (PP), systolic BP (SBP) and diastolic BP (DBP), and mean arterial pressure (MAP) as risk markers for long-term mortality with emphasis on stroke.

METHODS

Male civil servants (40 to 65 years of age; n=9611) were examined in 1963 and followed up until 1986. Multivariate analysis was used to assess the association between BP indices and subsequent mortality. Stroke mortality was analyzed separately for initially normotensive (SBP< or =140 and DBP< or =90 mm Hg), hypertensive (SBP>140 and DBP>90 mm Hg), and men with isolated systolic hypertension (ISH; SBP>140 and DBP< or =90 mm Hg).

RESULTS

During follow-up, 3167 men died, including 932 of coronary heart disease and 339 of stroke. All 4 BP indices were predictive of fatal stroke among hypertensive and normotensive men (hazard ratios [HRs] fluctuated between 1.59 and 2.51). In models with 2 BP indices among normotensive men, SBP but not DBP remained a predictor of stroke mortality. MAP and PP were independent predictors of stroke mortality. Among hypertensive men, SBP and DBP were independent predictors of stroke mortality (HRs, 1.68 and 1.51, respectively). MAP but not PP remained a predictor of stroke mortality. In men with ISH, the 4 BP indices predicted fatal stroke, with HRs fluctuating between 1.24 and 2.04.

CONCLUSIONS

All 4 BP indices were predictors of stroke mortality among hypertensive and normotensive men, with DBP possibly the weaker predictor among the latter. Models with 2 BP indices yielded complex associations.

Importance of arterial pulse pressure as a predictor of coronary heart disease risk in PROCAM

AIMS

To investigate pulse pressure (PP) as an independent predictor of coronary heart disease (CHD) risk.

METHODS AND RESULTS

On the basis of a 10-year follow-up of 5389 men aged 35-65 at recruitment into PROCAM, we used a proportional hazards model to calculate the effect of systolic blood pressure (SBP), diastolic blood pressure (DBP), and PP on CHD risk after correcting for age, high-density lipoprotein cholesterol, LDL cholesterol, triglycerides, smoking, diabetes, and family history of premature CHD. Increases of 10 mmHg in DBP, SBP, and PP were associated with an increased CHD hazard ratio (HR) of approximately 10%. When the group was divided into the age groups <50, 50-59, and >59 years, this relationship was seen in the age group 50-59 years for DBP, SBP, and PP and in men aged > or =60 for PP only (25% increase in HR). Overall, CHD risk in men with PP > or =70 mmHg was more three times that of men with PP <50 mmHg. This increased risk was not apparent at age <50 years, was greatest at age >60 years, and was also present in men who were normotensive at recruitment (SBP < or =160 mmHg, DBP < or =95 mmHg).

CONCLUSION

In older European men, increased PP is an important independent determinant of coronary risk, even among those initially considered normotensive.

Occult Vascular Lesions in Patients with Atherothrombotic Events: The AIRVAG Cohort

OBJECTIVES

To determine clinical parameters that could predict occult vascular lesions (OVL) in patients with symptomatic atherosclerosis.

PATIENTS AND METHODS

Prospective evaluation of 269 consecutive patients with symptomatic atherosclerosis (cerebral 32%, peripheral vascular 15%, and coronary 53%): complete laboratory, ultrasound exams (carotids, aorta, heart), ankle-brachial index. OVL were defined as: abdominal aortic aneurysm, carotid artery stenosis > 50%, or left ventricular segmental contraction abnormalities when affecting a different vascular bed from the symptomatic. Clinical predictors of OVL were evaluated by logistic regression analysis.

RESULTS

OVL were found in 35 patients (13%): 12 abdominal aortic aneurysms, 21 carotid artery stenosis and 15 segmental left ventricular contraction abnormalities. OVL were associated with peripheral vascular disease (intermittent claudication or reduced ankle-brachial index), cigarette smoking, increased pulse pressure, microalbuminuria and hyperhomocysteinemia. By multivariate analysis, intermittent claudication (odds ratio 5.8; 95% CI 2.6-12.8) and microalbuminuria (OR 4.2; 95% CI 1.7-10.5) were strong independent predictors of OVL. Similar results were obtained when peripheral vascular disease was defined as reduced ankle-brachial index (OR 5.3; 95% CI 2.4-11.7).

CONCLUSIONS

Clinical and subclinical peripheral vascular disease, as well as microalbuminuria are strong independent predictors of OVL in atherosclerotic patients. A screening study of OVL may be warranted in these patients.