Is a high pulse pressure always pathological?

From the Guidelines

A high pulse pressure is not always pathological, as it can be elevated in normal physiological states, but persistently elevated pulse pressure at rest can indicate underlying pathological conditions. Pulse pressure, which is the difference between systolic and diastolic blood pressure, can be influenced by various factors, including age, physical activity, and medical history. According to the European guidelines on cardiovascular disease prevention in clinical practice 1, a wide pulse pressure has been shown to be a predictor of adverse cardiovascular outcomes, but its predictive value is less than that of systolic and diastolic blood pressure individually.

Some key points to consider when evaluating pulse pressure include:

• The clinical context, including the patient's age, medical history, and whether the elevation is transient or persistent
• The presence of other risk factors for cardiovascular disease, such as diabetes, insulin resistance, and dyslipidaemia
• The potential for pulse pressure to be elevated in normal physiological states, such as exercise, pregnancy, and in young, athletic individuals
• The need for regular blood pressure monitoring to distinguish between normal physiological variations and potentially concerning elevations in pulse pressure

As noted in the European guidelines 1, the predictive value of pulse pressure increases after age 55 years, and individuals with an elevated pulse pressure are at higher risk of adverse cardiovascular outcomes. However, it is essential to consider the clinical context and individual patient characteristics when evaluating the significance of a high pulse pressure, rather than relying solely on numerical values.

From the Research

Pulse Pressure and Cardiovascular Risk

• Pulse pressure is associated with cardiovascular risk factors such as diabetes, hypertension, and smoking, and predicts a higher risk of subsequent cardiovascular events, stroke, renal disease, heart failure, and mortality, particularly in the elderly 2.
• High pulse pressure is a functional marker of target organ damage, predicting cardiovascular events in hypertensive patients, even independently of well-known structural markers of target organ damage 3.
• Pulse pressure has been shown to be a significant and independent indicator of myocardial infarction and a strong indicator of cardiovascular risk even among normotensive individuals 4.

Pathophysiological Mechanisms

• Increased pulse pressure nearly always indicates reduced vascular compliance of large arteries and is always increased in patients with isolated systolic hypertension 5.
• Arterial stiffness and wave reflections in older patients are involved in the pathophysiological mechanisms of pulse pressure 6.

Therapeutic Consequences

• Targeting pulse pressure rather than systolic or diastolic blood pressure when using antihypertensive agents may be an important therapeutic consequence 6.
• Pulse pressure seems to be an appropriate tool for studies of clinical pharmacology and therapeutics in the fields of hypertension, congestive heart failure, and other cardiovascular diseases 6.

Age-Related Considerations

• The majority of individuals older than 70 years have a widened pulse pressure resulting from age-related stiffening of the central elastic arteries and systolic hypertension 2.
• Isolated systolic hypertension is a disorder typically defined when the systolic BP is greater than 140 mm Hg but with diastolic BP below 90 mm Hg, and is more common in older patients with hypertension 5.