Recommended Pulse Pressure (Difference Between Systolic and Diastolic Blood Pressure)
There is no single "recommended" pulse pressure target, but optimal blood pressure is defined as <120/<80 mmHg, which yields a pulse pressure of approximately 40 mmHg, and pulse pressure naturally increases with age as systolic rises and diastolic falls. 1
Understanding Pulse Pressure in Clinical Context
Pulse pressure (systolic minus diastolic) is not a treatment target itself but rather a marker of arterial stiffness and cardiovascular risk. 1 The guidelines focus on absolute systolic and diastolic values rather than the difference between them.
Normal Blood Pressure Ranges and Implied Pulse Pressures
- Optimal BP: <120/<80 mmHg (pulse pressure ~40 mmHg) 1
- Normal BP: 120-129/80-84 mmHg (pulse pressure ~40-45 mmHg) 1
- Prehypertension: 120-139/80-89 mmHg (pulse pressure ~40-50 mmHg) 1
- Hypertension: ≥140/≥90 mmHg 1
Age-Related Changes in Pulse Pressure
As adults age, systolic blood pressure tends to rise while diastolic tends to fall, resulting in progressively widening pulse pressure. 1 This widening reflects arterial stiffening and is itself a predictor of cardiovascular risk. 1
- Isolated systolic hypertension (systolic ≥140 with diastolic <90 mmHg) is common in older adults and represents increased pulse pressure that predicts cardiovascular risk. 1
- Increased pulse pressure independently predicts cardiovascular events, particularly in older populations. 2
Treatment Targets Focus on Absolute Values, Not Pulse Pressure
General Population Targets
Most patients with hypertension should be treated to <140/<90 mmHg, which would yield a pulse pressure of approximately 50 mmHg or less. 1
Optimal Diastolic Range at Controlled Systolic Pressure
When systolic blood pressure is controlled at 120-140 mmHg, the optimal diastolic blood pressure range is 70-79 mmHg, yielding pulse pressures of 40-70 mmHg depending on the systolic value. 3, 4, 5
- Diastolic BP <70 mmHg is associated with increased cardiovascular risk even when systolic is controlled, particularly for myocardial infarction and heart failure. 6, 5
- Diastolic BP ≥80 mmHg carries increased risk for stroke and heart failure. 5
Clinical Implications of Abnormal Pulse Pressure
Wide Pulse Pressure (>60-70 mmHg)
A wide pulse pressure indicates arterial stiffness and increased cardiovascular risk, particularly in older adults. 1, 2 This typically manifests as:
- Isolated systolic hypertension (e.g., 160/70 mmHg = pulse pressure 90 mmHg)
- Requires treatment focused on lowering systolic pressure while avoiding excessive diastolic reduction 1
Narrow Pulse Pressure (<30 mmHg)
Unusually narrow pulse pressure may indicate:
- Severe aortic stenosis
- Heart failure with reduced ejection fraction
- Hypovolemia
- Requires investigation of underlying cardiac pathology rather than blood pressure treatment adjustment
Critical Thresholds to Avoid
Lower Diastolic Limit
Diastolic blood pressure should generally not be reduced below 70 mmHg, as values of 60-69 mmHg are associated with increased cardiovascular events (HR 1.41), and <60 mmHg with substantially increased risk (HR 2.01). 6, 5
Upper Systolic Limit
Systolic blood pressure ≥140 mmHg requires treatment regardless of diastolic values. 1
Common Clinical Pitfalls
- Focusing only on systolic pressure while ignoring diastolic: Both components independently predict cardiovascular outcomes. 7
- Over-treating to achieve very low systolic targets in elderly patients: This can drop diastolic below 70 mmHg, increasing risk through the J-curve phenomenon. 6, 5
- Ignoring wide pulse pressure in older adults: Isolated systolic hypertension requires treatment even when diastolic is normal or low. 1
- Treating pulse pressure as a target: Guidelines specify systolic and diastolic targets; pulse pressure is a risk marker, not a treatment goal. 1