Risk Associated with Pulse Pressure on Out-of-Office Blood Pressure Measurement

Abstract

Background: Longitudinal studies have demonstrated that the risk of cardiovascular disease increases with pulse pressure (PP). However, PP remains an elusive cardiovascular risk factor with findings being inconsistent between studies. The 2013 ESH/ESC guideline proposed that PP is useful in stratification and suggested a threshold of 60 mm Hg, which is 10 mm Hg higher compared to that in the 2007 guideline; however, no justification for this increase was provided.

Methodology: Published thresholds of PP are based on office blood pressure measurement and often on arbitrary categorical analyses. In the International Database on Ambulatory blood pressure in relation to Cardiovascular Outcomes (IDACO) and the International Database on HOme blood pressure in relation to Cardiovascular Outcome (IDHOCO), we determined outcome-driven thresholds for PP based on ambulatory or home blood pressure measurement, respectively.

Results: The main findings were that for people aged <60 years, PP did not refine risk stratification, whereas in older people the thresholds were 64 and 76 mm Hg for the ambulatory and home PP, respectively. However, PP provided little added predictive value over and beyond classical risk factors.

Keywords: Blood pressure measurement; Cardiovascular diseases; Epidemiology; Pulse pressure; Thresholds.

Fig. 1

Multivariable-adjusted HRs for outcomes in relation to 24-hour PP in the IDACO study (a) and to home PP in the IDHOCO study (b). The HRs, presented with 95% CIs, express the risk in the top decile compared with the average risk in the participants. All models were adjusted for cohort, sex, age, mean arterial pressure and pulse rate, body mass index, smoking and drinking, serum cholesterol, history of cardiovascular disease and diabetes, and antihypertensive drug treatment. The p values are for the risk in the top decile relative to the overall risk in the whole study population. E/R1-9 = Number of events and participants at risk below the 90th percentile of the PP distribution. E/R10 = Number of events and participants at risk in the top decile, respectively. Reproduced with permission from Gu et al. [19] and Aparicio et al. [22].

Fig. 2

HRs according to 24-hour PP levels ranging from the 10th to the 90th percentile in 3,910 older participants. HRs for all-cause (a) and cardiovascular (b) mortality as well as for cardiovascular (c) and cardiac (d) events express the risk at each level of PP compared with the average risk. Solid and dotted lines denote the point estimates and the 95% CIs, respectively. The HRs were adjusted as in figure 1. Reproduced with permission from Gu et al. [19].