CLINICAL STUDIES: RISK FACTORS
Pulse pressure and risk for myocardial infarction and heart failure in the elderly
Viola Vaccarino, MD, PhD*,
Theodore R. Holford, PhD* and
Harlan M. Krumholz, MD, FACC* 
* Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut; USA
Department of Medicine (Cardiology), Yale University School of Medicine and Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
Manuscript received September 14, 1999;
revised manuscript received January 17, 2000,
accepted March 6, 2000.
Reprint requests and correspondence: Dr. Viola Vaccarino, Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, P.O. Box 208034, New Haven, Connecticut 06520-8034
viola.vaccarino{at}yale.edu
OBJECTIVES
We sought to determine whether pulse pressure (PP), a measure of arterial stiffness, is an independent predictor of the incidence of coronary heart disease (CHD), congestive heart failure (CHF) and overall mortality among community-dwelling elderly.
BACKGROUND
Current hypertension guidelines classify cardiovascular risk on the basis of elevated systolic blood pressure (SBP) or diastolic blood pressure (DBP) without considering their combined effects. Recent studies suggest that PP is a strong predictor of cardiovascular end points, but few data are available among community elderly.
METHODS
The study sample included 2,152 individuals age  65 years, who were participants in the Established Populations for Epidemiologic Study of the Elderly program, free of CHD and CHF at baseline and still alive at one year after enrollment. Blood pressure was measured at baseline. Incidence of CHD, incidence of CHF and total mortality were monitored in the following 10 years.
RESULTS
There were 328 incident CHD events, 224 incident CHF events and 1,046 persons who died of any cause. Pulse pressure showed a strong and linear relationship with each end point. After adjusting for demographics, comorbidity and CHD risk factors, a 10-mm Hg increment in PP was associated with a 12% increase in CHD risk (95% confidence interval [CI], 2% to 22%), a 14% increase in CHF risk (95% CI, 5% to 24%), and a 6% increase in overall mortality (95% CI, 0% to 12%). While SBP and mean arterial pressure (MAP) also showed positive associations with the end points, PP yielded the highest likelihood ratio chi-square. When PP was entered in the model in conjunction with other blood pressure parameters (SBP, DBP, MAP or hypertension stage, respectively), the association remained positive for PP but became negative for the other blood pressure variables. The effect of PP persisted after adjusting for current medication use and was present in normotensive individuals and individuals with isolated systolic hypertension but not in individuals with diastolic hypertension.
CONCLUSIONS
Elevated PP is a powerful independent predictor of cardiovascular end points in the elderly.
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Abbreviations and Acronyms
| | CHD | = coronary heart disease | | CHF | = congestive heart failure | | CI | = confidence intervals | | DBP | = diastolic blood pressure | | EPESE | = Established Populations for Epidemiologic Study of the Elderly | | ISH | = isolated systolic hypertension | | MAP | = mean arterial pressure | | MI | = myocardial infarction | | PP | = pulse pressure | | SBP | = systolic blood pressure |
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