Current Hypertension Reports

, Volume 2, Issue 3, pp 271–279 | Cite as

Diastolic pressure, systolic pressure, or pulse pressure?

  • Charalambos Vlachopoulos
  • Michael O’Rourke


Diastolic pressure, systolic pressure, and pulse pressure have all been assigned the role of the best predictor of cardiovascular events during the 20th century. At the dawn of the new millennium, concepts that draw attention to vascular mechanics reconcile the seemingly conflicting results of epidemiologic studies, better define the hypertensive patient, evaluate more accurately the risk and set its markers, and ultimately optimize treatment through a logical approach that aims at the mechanism and not at the manifestation. Pulse wave analysis and measurement of arterial stiffness are valuable tools in the assessment and management of the hypertensive patient.


Pulse Pressure Arterial Stiffness Pulse Wave Velocity Systolic Pressure Diastolic Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Mohomed FA: The physiology and clinical use of the sphygmograph. Medical Times and Gazette, London 1872, 1:62–65.Google Scholar
  2. 2.
    O’Rourke MF, Kelly R, Avolio A: The Arterial Pulse. Philadelphia: Lea & Febiger; 1992.Google Scholar
  3. 3.
    Mackenzie J: Principles of diagnosis and treatment in heart affections, edn 3. London: Oxford; 1926.Google Scholar
  4. 4.
    MacMahon S, Peto R, Cutler J, et al.: Blood pressure, stroke, and coronary heart disease. Lancet 1990, 335:765–774.PubMedCrossRefGoogle Scholar
  5. 5.
    Rodgers A, MacMahon S, Yee T, for the Eastern Stroke and Coronary Heart Disease Collaborative Research Group: Blood pressure, cholesterol, and stroke in eastern Asia. Lancet 1998, 352:1801–1807.CrossRefGoogle Scholar
  6. 6.
    Kannel WB, Gordon T, Schwartz MJ: Systolic versus diastolic blood pressure and risk of coronary heart disease: the Framingham study. Am J Cardiol 1971, 27:335–346.PubMedCrossRefGoogle Scholar
  7. 7.
    Kannel WB, Wolf PA, McGee DL: Systolic blood pressure, arterial rigidity and risk of stroke: the Framingham study. JAMA 1981, 245:1225–1229.PubMedCrossRefGoogle Scholar
  8. 8.
    Fisher CM: The ascendancy of diastolic blood pressure over systolic. Lancet 1985, 2:1349–1350.PubMedCrossRefGoogle Scholar
  9. 9.
    Dunstan HP: Isolated systolic hypertension: a long neglected cause of cardiovascular complications. Am J Med 1989, 86:368–368.CrossRefGoogle Scholar
  10. 10.
    Rutan GH, McDonald RH, Kuller LH: A historical perspective of elevated systolic versus diastolic blood pressure from an epidemiological and clincial viewpoint. J Clin Epidemiol 1989, 42:663–673.PubMedCrossRefGoogle Scholar
  11. 11.
    SHEP Cooperative Research Group: Prevention of stoke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991, 265:3255–3264.CrossRefGoogle Scholar
  12. 12.
    Medical Research Council Working Party: MRC trial of treatment of hypertension in older adults. Br Med J 1992, 304:405–412.CrossRefGoogle Scholar
  13. 13.
    Dahlof B, Lindholm LH, Hansson L, et al.: Morbidity and mortality in the Swedish trial in old patients with hypertension (STOP-Hypertension). Lancet 1991, 338:1281–1285.PubMedCrossRefGoogle Scholar
  14. 14.
    Staessen JA, Fagard R, Thijs L, et al.: Randomized double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial investigators. Lancet 1997, 350:757–764.PubMedCrossRefGoogle Scholar
  15. 15.
    Franklin SS, Gustin WG, Wong ND, et al.: Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997, 96:308–315. An important longitudinal study that together with the continously expanding data from the same group regarding younger ages describes elegantly the changes in blood pressure indices with age. The findings provide the explanatory basis for the varying predictive role of blood pressure indices with age and they can be attributed to the shift in underlying mechanisms from younger (increased peripheral resistance) to older (increased aortic stiffness and early wave reflection) ages.PubMedGoogle Scholar
  16. 16.
    Darne B, Girerd X, Safar M, et al.: Pulsatile versus steady component of blood pressure: a cross sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension 1989, 13:392–400.PubMedGoogle Scholar
  17. 17.
    Madhaven S, Ooi WL, Cohen H, et al.: Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infraction. Hypertension 1994, 23:395–401.Google Scholar
  18. 18.
    Fang J, Madhavan S, Cohen H, et al.: Measures of blood pressure and myocardial infraction in treated hypertensive patients. J Hypertens 1995, 13:413–419.PubMedCrossRefGoogle Scholar
  19. 19.
    Benetos A, Safar M, Rudnichi A, et al.: Pulse pressure: a predictor of long-term cardiovascular mortality in a French male population. Hypertension 1997, 30:1410–1415. In this study it was shown in a large cohort of patients with relatively low cardiovascular risk that the pulsatile component as expressed by pulse pressure is an independent and significant predictor of total and, especially cardiovascular, mortality.PubMedGoogle Scholar
  20. 20.
    Franklin SS, Sutton-Tyrell K, Belle SH: The importance of pulsatile components of hypertension in predicting carotid stenosis in older adults. J Hypertens 1997, 15:1143–1150.PubMedCrossRefGoogle Scholar
  21. 21.
    Benetos A, Rudnichi A, Safar M, Guize L: Pulse pressure and cardiovascular mortality in normotensive and hypertensive subjects. Hypertension 1998, 32:560–564.PubMedGoogle Scholar
  22. 22.
    Franklin SS, Khan SA, Wong ND, et al.: Is pulse pressure useful in predicting coronary heart disease? The Framingham study. Circulation 1999, 100:354–360. The importance of the pulsatile component in the determination of risk for coronary events in older ages was demonstrated in this study. Pulse pressure was the best predictor for coronary heart disease in middle-aged and elderly subjects, while diastolic pressure was negatively associated with events.PubMedGoogle Scholar
  23. 23.
    Chae C, Pfeffer M, Glynn RJ, et al.: Increased pulse pressure and risk of heart failure in elderly. JAMA 1999, 281:634–639.PubMedCrossRefGoogle Scholar
  24. 24.
    Domanski MJ, DAvis BR, Pfeffer MA, et al.: Isolated systolic hypertension: prognostic information provided by pulse pressure. Hypertension 1999, 34:375–380.PubMedGoogle Scholar
  25. 25.
    Millar JA, Lever AF, Burke V: Pulse pressure a risk factor for cardiovascular events in the MRC Mild Hypertension Trial. J Hypertens 1999, 17:1–8.CrossRefGoogle Scholar
  26. 26.
    O’Rourke MF, Frolich ED: Pulse pressure: is it a clinically useful risk factor? Hypertension 1999, 34:372–374.PubMedGoogle Scholar
  27. 27.
    Frolich ED: Reappearance of the J-shaped curve. Hypertension 1999, 34:1179–1180.Google Scholar
  28. 28.
    O’Rourke MF: Isolated systolic hypertension, pulse pressure, and arterial stiffness as risk factors for cardiovascular disease. Curr Hypertens Rep 1999, 3:204–211.CrossRefGoogle Scholar
  29. 29.
    MacMahon S: Blood pressure and the risk of cardiovascular disease. N Engl J Med 2000, 342:50–51.PubMedCrossRefGoogle Scholar
  30. 30.
    van den Hoogen PCW, Feskens EJM, Naglekerke NJD, et al.: The relationship between blood pressure and mortality due to coronary heart disease among men in different parts of the world. N Engl J Med 2000, 342:1–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Nichols WW, O’Rourke MF: McDonal’s Blood Flow in Arteries, edn 4. London: Edward Arnold; 1998.Google Scholar
  32. 32.
    Ledingham JM: The vascular fault in hypertension: Byrom’s work revisited. In Hypertension: Pathophysiology, Diagnosis, and Management, edn 2. Edited by Laragh JH, Brenner BM. New York: Raven Press; 1995:37–53.Google Scholar
  33. 33.
    Stefanadis C, Stratos C, Vlachopoulos C, et al.: Pressurediameter relationship of the human aorta. A new method of determination by the application of a special ultrasonic dimension catheter. Circulation 1995, 92:2210–2219.PubMedGoogle Scholar
  34. 34.
    Stefanadis C, Dernellis J, Vlachopoulos C, et al.: Aortic function in arterial hypertension determined by pressure-diameter relation: effects of diltiazem. Circulation 1997, 96:1853–1858.PubMedGoogle Scholar
  35. 35.
    O’Rourke MF: Arterial Function in Health and Disease. Edinburgh: Churchill Livingstone; 1982.Google Scholar
  36. 36.
    O’Rourke M: Mechanical principles in arterial disease. Hypertension 1995, 26:2–9.PubMedGoogle Scholar
  37. 37.
    Vlachopoulos C, O’Rourke MF: Genesis of the normal and abnormal arterial pulse. Curr Probl Cardiol, in press.Google Scholar
  38. 38.
    Pauca AL, Wallenhaupt SL, Kon ND, Tucker WY: Does radial artery pressure accurately reflect aortic pressure? Chest 1992, 102:1193–1198.PubMedGoogle Scholar
  39. 39.
    Ryan SM, Waach BJ, Weno BL, Heistad DD: Increases in pulse pressure impair acetylcholine-induced vascular relaxation. Am J Physiol 1995, 268:H359-H363.PubMedGoogle Scholar
  40. 40.
    Alexander RW: Hypertension and the pathogenesis of atherosclerosis. Oxidative stress and the mediation of arterial inflammatory response: a new perspective. Hypertension 1995, 25:155–161.PubMedGoogle Scholar
  41. 41.
    Cheng GC, Loree HM, Kamm RD, et al.: Distribution of circumferential stress in ruptured and stable atherosclerotic lesions: a structural analysis with histopathologic correlation. Circulation 1993, 87:1179–1187.PubMedGoogle Scholar
  42. 42.
    Nakayama Y, Tsumura K, Yamashita N, et al.: Pulsatility of ascending aortic pressure waveform is a powerful predictor of restenosis after percutaneous transluminal coronary angioplasty. Circulation 2000, 101:470–472.PubMedGoogle Scholar
  43. 43.
    Boutouyrie P, Bussy C, Lacolley P, et al.: Association between local pulse pressure, mean blood pressure, and large artery remodelling. Circulation 1999, 100:1387–1393.PubMedGoogle Scholar
  44. 44.
    Saba PS, Roman MJ, Pini R, et al.: Relation of arterial pressure waveforms to left ventricular and carotid anatomy in normotensive subjects. J Am Coll Cardiol 1993, 22:1873–80.PubMedCrossRefGoogle Scholar
  45. 45.
    Kohno F, Kumada T, Kambayashi M, et al.: Changes in aortic end-systolic pressure by alterations in loading sequence and its relation to left ventricular isovolumic relaxation. Circulation 1996, 93:2080–2087.PubMedGoogle Scholar
  46. 46.
    Watanabe H, Ohtsuka S, Kakihana M, Sugishita Y: Coronary circulation in dogs with an experimental decrease in aortic compliance. J Am Coll Cardiol 1993, 21:1497–1506.PubMedCrossRefGoogle Scholar
  47. 47.
    Ohtsuka S, Kakihana M, Watanabe H, Sugishita Y: Chronically decreased aortic distensibility causes deterioration of coronary perfusion during increased left ventricular contraction. J Am Coll Cardiol 1994, 24:1406–1414.PubMedCrossRefGoogle Scholar
  48. 48.
    Kass D, Sacki A, Tunin RS, Recchia FA: Adverse influence of systemic vascular stiffening on cardiac dysfunction and adaptation to acute coronary occlusion. Circulation 1996, 93:1533–1541.PubMedGoogle Scholar
  49. 49.
    Blacher J, Asmar, Djane S, et al.: Aortic pulse wave velocity as a marker of cardiovascular risk in hypertensive patients. Hypertension 1999, 33:1111–1117. Aortic pulse wave velocity, a clinically useful index of arterial distensibility, was documented as a strong predictor of cardiovascular risk in hypertensive patients, thus establishing a link between adverse events and the pathophysiologic mechanisms in which arterial stiffness is involved. Furthermore, the study emphasizes the emerging role of measuring aortic stiffness in clinical practice for risk assessment.PubMedGoogle Scholar
  50. 50.
    Staessen J, Amery A, Fagard R: Isolated systolic hypertension in the elderly. J Hypertens 1990, 8:393–405.PubMedCrossRefGoogle Scholar
  51. 51.
    Burt VL, Whelton P, Roccella EJ, et al.: Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey 1988–1991. Hypertension 1995, 25:305–313.PubMedGoogle Scholar
  52. 52.
    Uiterwaal CSPM, Anthony S, Launer LJ, et al.: Birth Weight, growth, and blood pressure: an annual follow-up of children aged 5 through 21 years. Hypertension 1997, 30:267–271.PubMedGoogle Scholar
  53. 53.
    Franklin S, Khan S, Wong N, et al.: The relation of blood pressure to coronary heart disease risk as a function of age: The Framinham Heart Study. J Am Coll Cardiol 2000, 35(suppl A):291.Google Scholar
  54. 54.
    Michell GF, Moye LA, Braunwald E, et al.: Sphygmomanometrically determined pulse pressure is a powerful independent predictor of recurrent events after myocardial infarction in patients with impaired left ventricular function. Circulation 1997, 96:4254–4250.Google Scholar
  55. 55.
    Domanski MJ, Mitchell GF, Norman J, et al.: Independent prognostic information provided by sphygomomanometrically determined pulse pressure and mean arterial pressure in patients with left ventricular dysfunction. J Am Coll Cardiol 1999, 33:951–958. This study in patients with left ventricular dysfunction demonstrated that the pulsatile component of blood pressure has a predictive value for cardiovascular events independent of the steady component. Pulse pressure and mean pressure had an opposite relationship with events: higher pulse pressure and lower mean pressure (contrary to studies in hypertensive patients) were associated with an adverse outcome.PubMedCrossRefGoogle Scholar
  56. 56.
    O’Rourke MF: Arterial stiffness, systolic blood pressure and logical treatment of arterial hypertension. Hypertension 1990, 15:339–347.PubMedGoogle Scholar
  57. 57.
    Mitchell GF, Pfeffer MA, Finn PV, et al.: Equipotent antihypertensive agents variously affect pulsatile hemodynamics and regression of cardiac hypertrophy in spontaneously hypertensive rats. Circulation 1996, 94:2923–2929.PubMedGoogle Scholar
  58. 58.
    Chen CH, Ting CT, Lin SJ, et al.: Different effects of fosinopril and atenolol on wave reflections in hypertensive patients. Hypertension 1995, 25:1034–1041.PubMedGoogle Scholar
  59. 59.
    Kelly RP, Gibbs HH, O’Rourke MF, et al.: Nitroglycerin has more favorable effect on left ventricular afterload than apparent from measurement of pressure in a peripheral artery. Eur Heart J 1990, 11:138–144.PubMedGoogle Scholar
  60. 60.
    O’Rourke MF, Kelly RP, Avolio AP, Hayward CS: Effects of dilator agents on central aortic systolic pressure and on left ventricular hydraulic load. Am J Cardiol 1989, 63:381–441.CrossRefGoogle Scholar
  61. 61.
    Simkus GJ, Fitchett DH: Radial artery pressure measurements may be a poor guide to the beneficial effects of nitroprusside on left ventricular systolic pressure in congestive heart failure. Am J Cardiol 1990, 66:323–326.PubMedCrossRefGoogle Scholar
  62. 62.
    Yaginuma T, Avolio A, O’Rourke M, et al.: Effect of glyceryl trinitrate on peripheral arteries alters left ventricular hydraulic load in man. Cardiovasc Res 1986, 20:153–160.PubMedCrossRefGoogle Scholar
  63. 63.
    The Heart Outcoms Prevention Evaluation (HOPE) Study Investigators: Effects on an angiotensin-converting-enzyme inhibitor, ramipril on cardiovascular events in high-risk patients. N Engl J Med 2000, 342:145–153.CrossRefGoogle Scholar

Copyright information

© Current Science Inc 2000

Authors and Affiliations

  • Charalambos Vlachopoulos
    • 1
  • Michael O’Rourke
    • 1
  1. 1.Medical Professorial Unit, St Vincent’s HospitalUniversity of New South WalesSydneyAustralia

Personalised recommendations