Does Brachial Pulse Pressure Predict Coronary Events

Paolo Verdecchia Fabio Angelí

Unita di Ricerca Clínica, Cardiología Preventiva, Struttura Complessa di Cardiología, Ospedale R. Silvestrini, Perugia, Italy

Abstract

Brachial pulse pressure (PP) is an established risk marker for cardiovascular disease. PP is largely determined by the stroke volume in young subjects, although the progressive amplification of pulse wave from central to peripheral arteries could make brachial PP not representative of the central PP in the young. With advancing age, brachial PP better reflects the progressive stiffening of aorta and the large elastic arteries. PP correlates with vascular and cardiac hypertrophy, although the association with cardiac hypertrophy seems more closely attributable to systolic blood pressure (BP). An association has been noted in several longitudinal studies between PP and the incidence of major cardiovascular events. However, some longitudinal studies carried out in subjects with predominantly systolic and diastolic hypertension showed that PP is the dominant predictor of coronary events, while mean BP is the major predictor of cerebrovascular events. Such an assumption may not be held in subjects with isolated systolic hypertension, where a wide PP seems to predict coronary and cerebrovascular events to a similar extent. From a pathophysiological standpoint, a wide PP might reflect diffuse atherosclerotic processes potentially involving also the large coronary arteries. Some data suggest that a wide PP could also represent a direct and independent stimulus for progression of atherosclerosis.

Copyright © 2007 S. Karger AG, Basel

Introduction

Brachial pulse pressure (PP), defined as the difference between systolic and diastolic blood pressure (BP) at brachial level, is an established marker of cardiovascular risk in different clinical settings [1]. PP increases with age [1-5] and an important basic mechanism of this phenomenon is believed to be the progressive stiffening of large elastic arteries with ageing [1-5]. PP showed a direct association with vascular [4-8] and cardiac hypertrophy [9, 10] in several studies, although the association with cardiac hypertrophy appeared to be more closely determined by systolic BP than by PP [11]. Of particular note, a significant association emerged in several longitudinal studies between brachial PP and the subsequent risk of major cardiovascular events and such association was often independent of systolic and diastolic BP [12-23]. For example, in the Framingham Study, 1,924 men and women aged between 50 and 79 years, without clinical evidence of coronary artery disease and not taking antihypertensive drugs at entry, were followed for more than 20 years. Overall, these subjects contributed 433 new cases of coronary artery disease. When systolic BP and diastolic BP were jointly entered into the multivariate analysis, the association with coronary artery disease risk was positive for systolic BP (HR 1.22; 95% CI 1.15-1.30) and negative for diastolic BP (HR 0.86; 95% CI 0.750.98). Furthermore, four subgroups were defined according to systolic BP levels (<120, 120-139, 140-159, and >160 mm Hg). Within each of these subgroups, the association with coronary heart disease risk was negative for dia-stolic BP and positive for PP.

In a previous study from our group, the association between PP and cardiovascular disease risk was also independent of potent prognostic markers including left ventricular mass at echocardiography and white-coat hypertension [14].

The aim of this review is to summarize the current evidence about the prognostic impact of PP on the cardiac events with particular emphasis on the additional prognostic information provided by ambulatory monitoring of PP.

Epidemiological Aspects

Despite the established prognostic value of PP, the majority of longitudinal studies examined a composite pool of cardiovascular events, with coronary and cerebrovascular end-points rarely tested separately. However, in a study carried out by Benetos et al. [15] in the general population, PP predicted cardiac but not cerebrovascular mortality. These data have been confirmed in the setting of the Medical Research Council (MRC) Mild Hypertension Trial, where coronary events were best predicted by high levels of systolic BP associated with low values of diastolic pressure (fig. 1) [19]. In that study, PP was a stronger predictor of coronary events than systolic, diastolic or mean BP in men [19]. PP was similar to systolic pressure as a predictor of coronary events while stroke was better predicted by mean BP [19]. Also a study by Khattar et al. [24] with intra-arterial BP monitoring provided some indirect evidence of

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