CLINICAL STUDIES
Independent prognostic information provided by sphygmomanometrically determined pulse pressure and mean arterial pressure in patients with left ventricular dysfunction
Michael J. Domanski, MD, FACC*,
Gary F. Mitchell, MD ,
James E. Norman, PhD ,
Derek V. Exner, MD*,
Bertram Pitt, MD, FACC and
Marc A. Pfeffer, MD, PhD, FACC
* Clinical Trials Group, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
Division of Cardiology, Brigham and Women’s Hospital and the Harvard Medical School, Boston, Massachusetts, USA
Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
Division of Cardiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
Manuscript received June 16, 1998;
revised manuscript received October 20, 1998,
accepted December 11, 1998.
Reprint requests and correspondence: Dr. Michael J. Domanski, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, RM 8146, Bethesda, Maryland 20892-7936
domanskm{at}gwgate.nhlbi.nih.gov
OBJECTIVES
The purpose of this study was to evaluate the relationship of baseline pulse pressure and mean arterial pressure to mortality in patients with left ventricular dysfunction.
BACKGROUND
Increased conduit vessel stiffness increases pulse pressure and pulsatile load, potentially contributing to adverse outcomes in patients with left ventricular dysfunction.
METHODS
Pulse and mean arterial pressure were analyzed for their effect on mortality, adjusting for other modifiers of risk, using Cox proportional hazards regression analysis of data collected from 6,781 patients randomized into the Studies of Left Ventricular Dysfunction trials.
RESULTS
Pulse and mean arterial pressure were related positively to each other, age, ejection fraction and prevalence of diabetes and hypertension and inversely to prior myocardial infarction and beta-adrenergic blocking agent use. Higher pulse pressure was associated with increased prevalence of female gender, greater calcium channel blocking agent, digoxin and diuretic use, lower heart rate and a higher rate of reported smoking history. Higher mean arterial pressure was associated with higher heart rate, lower calcium channel blocker and digoxin use and lower New York Heart Association functional class. Over a 61-month follow-up 1,582 deaths (1,397 cardiovascular) occurred. In a multivariate analysis adjusting for the above covariates and treatment assignment, higher pulse pressure remained an independent predictor of total and cardiovascular mortality (total mortality relative risk, 1.05 per 10 mm Hg increment; 95% confidence interval, 1.01 to 1.10; p = 0.02). Mean arterial pressure was inversely related to total and cardiovascular mortality (total mortality relative risk, 0.89; 95% confidence interval, 0.85 to 0.94; p <0.0001).
CONCLUSIONS
One noninvasive blood pressure measurement provides two independent prognostic factors for survival. Increased conduit vessel stiffness, as assessed by pulse pressure, may contribute to increased mortality in patients with left ventricular dysfunction, independent of mean arterial pressure.
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Abbreviations and Acronyms
| | ACE | = angiotensin-converting enzyme | | CI | = confidence interval | | NYHA | = New York Heart Association | | SAVE | = Survival and Ventricular Enlargement | | SOLVD | = Studies of Left Ventricular Dysfunction |
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