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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54(20):
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297(5):
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54(8):
695 - 703.
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[Full Text]
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|
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|
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|
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54(3):
255 - 262.
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|
|
|
|
|
|
|
S. Bangalore, F. H. Messerli, S. S. Franklin, G. Mancia, A. Champion, and C. J. Pepine
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30(11):
1395 - 1401.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. L. Fontes, S. Aronson, J. P. Mathew, Y. Miao, B. Drenger, P. G. Barash, D. T. Mangano, For the Multicenter Study of Perioperative Ischemi, and the Ischemia Research and Education Foundation (IR
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107(4):
1122 - 1129.
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|
|
|
|
|
|
|
R. Dietz, R. Dechend, C.-M. Yu, M. Bheda, J. Ford, M. F. Prescott, and D. L. Keefe
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Journal of Renin-Angiotensin-Aldosterone System,
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9(3):
163 - 175.
[Abstract]
[PDF]
|
|
|
|
|
|
|
D. D. Schocken, E. J. Benjamin, G. C. Fonarow, H. M. Krumholz, D. Levy, G. A. Mensah, J. Narula, E. S. Shor, J. B. Young, and Y. Hong
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May 13, 2008;
117(19):
2544 - 2565.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. R. S. Fernandes, J. F. Polak, S. Cheng, B. D. Rosen, B. Carvalho, K. Nasir, R. McClelland, G. Hundley, G. Pearson, D. H. O'Leary, et al.
Arterial Stiffness Is Associated With Regional Ventricular Systolic and Diastolic Dysfunction: The Multi-Ethnic Study of Atherosclerosis
Arterioscler Thromb Vasc Biol,
January 1, 2008;
28(1):
194 - 201.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. S. Lee, J. M. Massaro, T. J. Wang, W. B. Kannel, E. J. Benjamin, S. Kenchaiah, D. Levy, R. B. D'Agostino Sr, and R. S. Vasan
Antecedent Blood Pressure, Body Mass Index, and the Risk of Incident Heart Failure in Later Life
Hypertension,
November 1, 2007;
50(5):
869 - 876.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. J. Roman, R. B. Devereux, J. R. Kizer, E. T. Lee, J. M. Galloway, T. Ali, J. G. Umans, and B. V. Howard
Central Pressure More Strongly Relates to Vascular Disease and Outcome Than Does Brachial Pressure: The Strong Heart Study
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July 1, 2007;
50(1):
197 - 203.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Levy, S.-J. Hwang, A. Kayalar, E. J. Benjamin, R. S. Vasan, H. Parise, M. G. Larson, T. J. Wang, J. Selhub, P. F. Jacques, et al.
Associations of Plasma Natriuretic Peptide, Adrenomedullin, and Homocysteine Levels With Alterations in Arterial Stiffness: The Framingham Heart Study
Circulation,
June 19, 2007;
115(24):
3079 - 3085.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. J. Mosley II, P. Greenland, D. B. Garside, and D. M. Lloyd-Jones
Predictive Utility of Pulse Pressure and Other Blood Pressure Measures for Cardiovascular Outcomes
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June 1, 2007;
49(6):
1256 - 1264.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Aronson, M. L. Fontes, Y. Miao, D. T. Mangano, and for the Investigators of the Multicenter Study of
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February 13, 2007;
115(6):
733 - 742.
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[Full Text]
[PDF]
|
|
|
|
|
|
|
A. A. Voors, C. J. Petrie, M. C. Petrie, A. Charlesworth, H. L. Hillege, F. Zijlstra, J. J. McMurray, and D. J. van Veldhuisen
Low pulse pressure is independently related to elevated natriuretic peptides and increased mortality in advanced chronic heart failure
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26(17):
1759 - 1764.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Bener, J. Al Suwaidi, and A. Ghaffar
Is hypertension a predictor for heart failure? A cross cultural comparison over a 10-year period
Eur J Heart Fail,
August 1, 2005;
7(5):
784 - 786.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Sutton-Tyrrell, S. S. Najjar, R. M. Boudreau, L. Venkitachalam, V. Kupelian, E. M. Simonsick, R. Havlik, E. G. Lakatta, H. Spurgeon, S. Kritchevsky, et al.
Elevated Aortic Pulse Wave Velocity, a Marker of Arterial Stiffness, Predicts Cardiovascular Events in Well-Functioning Older Adults
Circulation,
June 28, 2005;
111(25):
3384 - 3390.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. V. Nair, L. A. Chaput, E. Vittinghoff, D. M. Herrington, and for the Heart and Estrogen/Progestin Replacement S
Pulse Pressure and Cardiovascular Events in Postmenopausal Women With Coronary Heart Disease
Chest,
May 1, 2005;
127(5):
1498 - 1506.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. J. Zieman, V. Melenovsky, and D. A. Kass
Mechanisms, Pathophysiology, and Therapy of Arterial Stiffness
Arterioscler Thromb Vasc Biol,
May 1, 2005;
25(5):
932 - 943.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. de Simone, M. J. Roman, M. H. Alderman, M. Galderisi, O. de Divitiis, and R. B. Devereux
Is High Pulse Pressure a Marker of Preclinical Cardiovascular Disease?
Hypertension,
April 1, 2005;
45(4):
575 - 579.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. M. Herrington, W. V. Brown, L. Mosca, W. Davis, B. Eggleston, W. G. Hundley, and J. Raines
Relationship Between Arterial Stiffness and Subclinical Aortic Atherosclerosis
Circulation,
July 27, 2004;
110(4):
432 - 437.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. E. McVeigh
Pulse Waveform Analysis and Arterial Wall Properties
Hypertension,
May 1, 2003;
41(5):
1010 - 1011.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. W. Haider, M. G. Larson, S. S. Franklin, and D. Levy
Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Pressure as Predictors of Risk for Congestive Heart Failure in the Framingham Heart Study
Ann Intern Med,
January 7, 2003;
138(1):
10 - 16.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. H. Young, M. J. Klag, P. Muntner, J. L. Whyte, M. Pahor, and J. Coresh
Blood Pressure and Decline in Kidney Function: Findings from the Systolic Hypertension in the Elderly Program (SHEP)
J. Am. Soc. Nephrol.,
November 1, 2002;
13(11):
2776 - 2782.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Pini, M. C. Cavallini, F. Bencini, G. Silvestrini, E. Tonon, W. De Alfieri, N. Marchionni, M. Di Bari, R. B. Devereux, G. Masotti, et al.
Cardiovascular remodeling is greater in isolated systolic hypertension than in diastolic hypertension in older adults: the Insufficienza Cardiaca negli Anziani Residenti (ICARE) a Dicomano Study
J. Am. Coll. Cardiol.,
October 2, 2002;
40(7):
1283 - 1289.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Aronson, D. Boisvert, and W. Lapp
Isolated Systolic Hypertension Is Associated with Adverse Outcomes from Coronary Artery Bypass Grafting Surgery
Anesth. Analg.,
May 1, 2002;
94(5):
1079 - 1084.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. C. Deedwania
The Changing Face of Hypertension: Is Systolic Blood Pressure the Final Answer?
Arch Intern Med,
March 11, 2002;
162(5):
506 - 508.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. L. Abramson, W. S. Weintraub, and V. Vaccarino
Association Between Pulse Pressure and C-Reactive Protein Among Apparently Healthy US Adults
Hypertension,
February 1, 2002;
39(2):
197 - 202.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Pini, M. C. Cavallini, F. Bencini, L. Stagliano, E. Tonon, F. Innocenti, G. Baldereschi, N. Marchionni, M. Di Bari, R. B. Devereux, et al.
Cardiac and Vascular Remodeling in Older Adults With Borderline Isolated Systolic Hypertension: The ICARe Dicomano Study
Hypertension,
December 1, 2001;
38(6):
1372 - 1376.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Susic, J. Varagic, and E. D. Frohlich
Isolated Systolic Hypertension in Elderly WKY Is Reversed With L-Arginine and ACE Inhibition
Hypertension,
December 1, 2001;
38(6):
1422 - 1426.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Kinlay, M. A. Creager, M. Fukumoto, H. Hikita, J. C. Fang, A. P. Selwyn, and P. Ganz
Endothelium-Derived Nitric Oxide Regulates Arterial Elasticity in Human Arteries In Vivo
Hypertension,
November 1, 2001;
38(5):
1049 - 1053.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. L. Abramson, S. A. Williams, H. M. Krumholz, and V. Vaccarino
Moderate Alcohol Consumption and Risk of Heart Failure Among Older Persons
JAMA,
April 18, 2001;
285(15):
1971 - 1977.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. A. Kass, E. P. Shapiro, M. Kawaguchi, A. R. Capriotti, A. Scuteri, R. C. deGroof, and E. G. Lakatta
Improved Arterial Compliance by a Novel Advanced Glycation End-Product Crosslink Breaker
Circulation,
September 25, 2001;
104(13):
1464 - 1470.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
