Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Increased pulse pressure

Raymond R Townsend, MD
Section Editor
George L Bakris, MD
Deputy Editors
Daniel J Sullivan, MD, MPH
John P Forman, MD, MSc


Typical blood pressure measurements include a systolic and diastolic value, which represent the extremes of pressure fluctuation within the circulation during the cardiac cycle. There has been much debate about which increased value alone, either systolic or diastolic hypertension, is more predictive of adverse cardiovascular outcomes in various patient populations. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults".)

Mean arterial pressure measurements, which provide another indication of overall circulatory pressure load, have also been proposed as predictive for adverse cardiovascular outcomes. This is either determined directly by catheterization or can be estimated by formulas (such as diastolic blood pressure + 1/3 x [systolic pressure – diastolic pressure]). However, the mean arterial pressure provides less discriminatory power as patients age. The diastolic pressure peaks at and subsequently declines after the age of 55 years, while the systolic pressure rises relentlessly with each decade of life [1]. Thus, depending upon the respective changes in systolic and diastolic pressures with older age, the mean blood pressure may actually tend to change less as individuals age.

Since the diastolic pressure in a population rises until the sixth decade and then subsequently declines with increasing age, an elevation in the diastolic pressure alone is less useful as an outcome predictor in older patients. Increasing emphasis has therefore been placed upon systolic pressure alone as the most useful predictor of cardiovascular disease in these individuals. (See "Treatment of hypertension in older adults, particularly isolated systolic hypertension".)

Several guidelines have supported the use of systolic blood pressure (such as JNC-7) and strongly encourage the use of systolic blood pressure goals in antihypertensive treatment [2].

There is also an enhanced risk for cardiovascular events associated with increases in pulse pressure (defined below). This topic review will discuss the factors that determine pulse pressure and will present some of the evidence for and against the suggestion that there is an independent link between an increased pulse pressure and adverse cardiovascular outcomes.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jan 04, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Franklin SS, Gustin W 4th, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997; 96:308.
  2. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
  3. Pastor-Barriuso R, Banegas JR, Damián J, et al. Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality. Ann Intern Med 2003; 139:731.
  4. Nichols WW, Nicolini FA, Pepine CJ. Determinants of isolated systolic hypertension in the elderly. J Hypertens Suppl 1992; 10:S73.
  5. O'Rourke MF, Nichols WW. Aortic diameter, aortic stiffness, and wave reflection increase with age and isolated systolic hypertension. Hypertension 2005; 45:652.
  6. Messerli FH, Sundgaard-Riise K, Ventura HO, et al. Essential hypertension in the elderly: haemodynamics, intravascular volume, plasma renin activity, and circulating catecholamine levels. Lancet 1983; 2:983.
  7. Folkow B. Structure and function of the arteries in hypertension. Am Heart J 1987; 114:938.
  8. Kato N, Takeuchi F, Tabara Y, et al. Meta-analysis of genome-wide association studies identifies common variants associated with blood pressure variation in east Asians. Nat Genet 2011; 43:531.
  9. Wain LV, Verwoert GC, O'Reilly PF, et al. Genome-wide association study identifies six new loci influencing pulse pressure and mean arterial pressure. Nat Genet 2011; 43:1005.
  10. Bielinski SJ, Lynch AI, Miller MB, et al. Genome-wide linkage analysis for loci affecting pulse pressure: the Family Blood Pressure Program. Hypertension 2005; 46:1286.
  11. Hsu FC, Zaccaro DJ, Lange LA, et al. The impact of pedigree structure on heritability estimates for pulse pressure in three studies. Hum Hered 2005; 60:63.
  12. Pettersson-Fernholm K, Fröjdö S, Fagerudd J, et al. The AT2 gene may have a gender-specific effect on kidney function and pulse pressure in type I diabetic patients. Kidney Int 2006; 69:1880.
  13. Mulè G, Nardi E, Cottone S, et al. Relationship of metabolic syndrome with pulse pressure in patients with essential hypertension. Am J Hypertens 2007; 20:197.
  14. Farasat SM, Morrell CH, Scuteri A, et al. Pulse pressure is inversely related to aortic root diameter implications for the pathogenesis of systolic hypertension. Hypertension 2008; 51:196.
  15. O'Rourke M, Frohlich ED. Pulse pressure: Is this a clinically useful risk factor? Hypertension 1999; 34:372.
  16. Winston GJ, Palmas W, Lima J, et al. Pulse pressure and subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis. Am J Hypertens 2013; 26:636.
  17. Franklin SS, Khan SA, Wong ND, et al. Is pulse pressure useful in predicting risk for coronary heart Disease? The Framingham heart study. Circulation 1999; 100:354.
  18. Franklin SS, Larson MG, Khan SA, et al. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation 2001; 103:1245.
  19. Thomas F, Blacher J, Benetos A, et al. Cardiovascular risk as defined in the 2003 European blood pressure classification: the assessment of an additional predictive value of pulse pressure on mortality. J Hypertens 2008; 26:1072.
  20. Domanski M, Mitchell G, Pfeffer M, et al. Pulse pressure and cardiovascular disease-related mortality: follow-up study of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA 2002; 287:2677.
  21. Franklin SS, Lopez VA, Wong ND, et al. Single versus combined blood pressure components and risk for cardiovascular disease: the Framingham Heart Study. Circulation 2009; 119:243.
  22. Lorenzo C, Aung K, Stern MP, Haffner SM. Pulse pressure, prehypertension, and mortality: the San Antonio heart study. Am J Hypertens 2009; 22:1219.
  23. Okada K, Iso H, Cui R, et al. Pulse pressure is an independent risk factor for stroke among middle-aged Japanese with normal systolic blood pressure: the JPHC study. J Hypertens 2011; 29:319.
  24. Panagiotakos DB, Kromhout D, Menotti A, et al. The relation between pulse pressure and cardiovascular mortality in 12,763 middle-aged men from various parts of the world: a 25-year follow-up of the seven countries study. Arch Intern Med 2005; 165:2142.
  25. Assmann G, Cullen P, Evers T, et al. Importance of arterial pulse pressure as a predictor of coronary heart disease risk in PROCAM. Eur Heart J 2005; 26:2120.
  26. Sobiczewski W, Wirtwein M, Jarosz D, et al. Increased total mortality as a function of 24-h pulse pressure dipping. J Hum Hypertens 2016; 30:100.
  27. Vaccarino V, Berger AK, Abramson J, et al. Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program. Am J Cardiol 2001; 88:980.
  28. Staessen JA, Thijs L, O'Brien ET, et al. Ambulatory pulse pressure as predictor of outcome in older patients with systolic hypertension. Am J Hypertens 2002; 15:835.
  29. Yasuno S, Ueshima K, Oba K, et al. Is pulse pressure a predictor of new-onset diabetes in high-risk hypertensive patients?: a subanalysis of the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial. Diabetes Care 2010; 33:1122.
  30. Muntner P, Anderson A, Charleston J, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2010; 55:441.
  31. Arulkumaran N, Diwakar R, Tahir Z, et al. Pulse pressure and progression of chronic kidney disease. J Nephrol 2010; 23:189.
  32. Bakris GL, Weir MR, Shanifar S, et al. Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL study. Arch Intern Med 2003; 163:1555.
  33. Tanaka M, Babazono T, Takeda M, Iwamoto Y. Pulse pressure and chronic kidney disease in patients with type 2 diabetes. Hypertens Res 2006; 29:345.
  34. Weir MR, Townsend RR, Fink JC, et al. Hemodynamic correlates of proteinuria in chronic kidney disease. Clin J Am Soc Nephrol 2011; 6:2403.
  35. Kim JK, Ju YS, Moon SJ, et al. High pulse pressure and metabolic syndrome are associated with proteinuria in young adult women. BMC Nephrol 2013; 14:45.
  36. Domanski MJ, Davis BR, Pfeffer MA, et al. Isolated systolic hypertension : prognostic information provided by pulse pressure. Hypertension 1999; 34:375.
  37. Fyhrquist F, Dahlöf B, Devereux RB, et al. Pulse pressure and effects of losartan or atenolol in patients with hypertension and left ventricular hypertrophy. Hypertension 2005; 45:580.
  38. Cushman WC, Materson BJ, Williams DW, Reda DJ. Pulse pressure changes with six classes of antihypertensive agents in a randomized, controlled trial. Hypertension 2001; 38:953.
  39. Williams B, O'Rourke M, Anglo-Scandinavian Cardiac Outcomes Trial. The Conduit Artery Functional Endpoint (CAFE) study in ASCOT. J Hum Hypertens 2001; 15 Suppl 1:S69.
  40. Katakam R, Townsend RR. What's in a pulse? J Clin Hypertens (Greenwich) 2006; 8:140.
  41. Dahlöf B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005; 366:895.
  42. Williams B, Lacy PS, Thom SM, et al. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: principal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation 2006; 113:1213.
  43. Wang JG, Staessen JA, Franklin SS, et al. Systolic and diastolic blood pressure lowering as determinants of cardiovascular outcome. Hypertension 2005; 45:907.
  44. London GM, Asmar RG, O'Rourke MF, et al. Mechanism(s) of selective systolic blood pressure reduction after a low-dose combination of perindopril/indapamide in hypertensive subjects: comparison with atenolol. J Am Coll Cardiol 2004; 43:92.
  45. Safar ME. Pulse pressure: a help in medical semiology for metabolic syndrome. Am J Hypertens 2007; 20:204.
  46. Knudsen ST, Andersen NH, Poulsen SH, et al. Pulse pressure lowering effect of dual blockade with candesartan and lisinopril vs. high-dose ACE inhibition in hypertensive type 2 diabetic subjects: a CALM II study post-hoc analysis. Am J Hypertens 2008; 21:172.
  47. Izzo JL Jr, Levy D, Black HR. Clinical Advisory Statement. Importance of systolic blood pressure in older Americans. Hypertension 2000; 35:1021.
  48. Oparil S, Izzo JL Jr. Pulsology rediscovered: commentary on the Conduit Artery Function Evaluation (CAFE) study. Circulation 2006; 113:1162.
  49. Wilkinson IB, McEniery CM, Cockcroft JR. Atenolol and cardiovascular risk: an issue close to the heart. Lancet 2006; 367:627.
  50. Franklin SS. Ageing and hypertension: the assessment of blood pressure indices in predicting coronary heart disease. J Hypertens Suppl 1999; 17:S29.