![]() Specifically, patients with HSLD demonstrated a higher incidence of myocardial infarction (5.9% vs. Although there was no difference in 30-day adverse cardiovascular outcomes between groups, there were differences in 12-month outcomes. These groups were then compared for 30-day and 12-month cardiovascular outcomes, and long-term mortality of a certain subset of patients whose records could be linked to a national death index. In contrast, patients in the LSHD grouping were younger with less comorbid diagnoses. ![]() Not surprisingly, patients in the HSLD grouping displayed characteristics that have previously been highly associated with increased pulse pressure, such as female sex, older age, and a greater prevalence of cardiovascular risk factors such as diabetes mellitus (8,9). ![]() They termed these groupings high systolic, high diastolic blood pressure (HSHD) low systolic, low diastolic blood pressure (LSLD) high systolic, low diastolic blood pressure (HSLD) (wide pulse pressure) and low systolic, high diastolic blood pressure (LSHD) (narrow pulse pressure). They chose to divide the patient population into 4 groups based on different combinations of 2 factors: a systolic blood pressure above or below 120 mm Hg, and a diastolic blood pressure above or below 70 mm Hg. The authors are to be commended for using their large dataset of >10,000 patients to study this clinically underappreciated issue. Moreover, they demonstrated that individuals with narrow pulse pressure have significantly lower long-term mortality. (7) retrospectively sought to determine if pre-procedural pulse pressure in patients undergoing percutaneous coronary intervention affected the incidence of short- and long-term adverse cardiovascular events, as well as mortality. The authors demonstrated that the presence of a wide pulse pressure should be considered an additional risk marker for subsequent cardiovascular disease in patients with existing coronary artery disease. In this issue of the Journal, using a prospectively collected registry, Warren et al. However, the incidence of coronary heart disease was not associated with pulse pressure in either the control or treatment groups in this trial. Additionally, in the SHEP (Systolic Hypertension in the Elderly Program) trial, every 10-mm Hg increase in pulse pressure in the active treatment group increased risk for heart failure by 32% and stroke risk by 24% (6). Very low diastolic pressures can limit coronary perfusion, resulting in ischemia, and widened pulse pressure is associated with worse cardiovascular outcomes as noted in the Framingham Heart Study, where every 10-mm Hg increase in pulse pressure was associated with a 23% increased risk of coronary artery disease (5). These changes in vasculature composition may contribute to changes in cardiovascular hemodynamics and are associated with increased left ventricular wall stress, myocardial oxygen consumption, and subsequent left ventricular hypertrophy (4). These processes lead to increases in large artery stiffness and are accelerated by risk factors such as impaired glucose tolerance and renal insufficiency (3). Although the precise pathophysiological mechanisms for the development of isolated systolic hypertension are not fully known, evidence suggests a combination of factors including elastin thinning, degradation, and replacement by collagen within the arterial wall, as well as medial calcification within larger arteries are contributory. These changes result in increased pulse pressure and ultimately isolated systolic hypertension. Subsequently, systolic and diastolic blood pressures diverge, with systolic continuing to rise and diastolic stabilizing and then decreasing (2). In Western population-based longitudinal studies, concomitant increases in systolic and diastolic blood pressure occur until ages 50 to 55 years. ![]() Moreover, sodium intake over time markedly affects these changes, with very low sodium intake over a lifetime preventing hypertension (1). ![]() Aging changes vascular stiffness depending on one’s genetic predisposition as well as the quality of blood pressure, cholesterol, and glucose management over the lifespan. ![]()
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