Is high pulse pressure a favourable feature in young adults with stage 1 hypertension?
High pulse pressure (PP) appears to be associated with a low risk of developing sustained hypertension or major adverse cardiovascular events (MACE) in young to middle-aged individuals, particularly males, with stage 1 hypertension, according to a study.
A total of 1,241 participants aged 18 to 45 years (mean 33.1 years) from the HARVEST* study were followed over a median follow-up of 12.1 years to evaluate the predictive value of PP and mean blood pressure (MBP) for future hypertension needing treatment and for cardiovascular events.
Compared with participants in the bottom pulse pressure tertile, those in the highest tertile had a decreased risk of incident hypertension (hazard ratio [HR], 0.75; 95 percent CI, 0.62 to 0.91; p=0.003) and MACE (HR, 0.35; 0.17 to 0.73; p=0.005). Conversely, the highest MBP tertile was associated with an increased risk of both incident hypertension (HR, 1.91; 1.57 to 2.33; p<0.001) and MACE (HR, 3.06; 1.32 to 7.09; p=0.009). [Hypertension 2017;70:537–542]
During the follow-up, more than half (65.1 percent) developed hypertension requiring pharmacological treatment, while 5.1 percent experienced a cardiovascular event. The following factors emerged as significant determinants of elevated office PP: male sex (p=0.009), younger age (p<0.001), physical activity (p=0.003), heart rate (p<0.001), systolic white-coat effect (p<0.001) and stroke volume (n=829; p<0.001).
“The present data show that in [individuals aged <45 years] screened for stage 1 hypertension, office PP is a negative predictor of future hypertension needing treatment and of MACE and that only MBP is associated with increased risk of adverse outcome,” the investigators said.
“Office PP values that would be considered ominous in the elderly have no detrimental effect in young to middle-aged [individuals] in whom they are mainly the result of a strong white-coat reaction to the medical environment,” they added.
The investigators pointed out that while the findings mainly apply to the male sex, “[it] does not necessarily mean that all young men with ISH [isolated systolic hypertension] are at low cardiovascular risk. In the present study, 11.6 percent of those with ISH had an MBP above the median of the whole group, which may imply an increase in risk.”
Based on the present data and despite the presence of several limitations, the investigators recommended that young people with elevated PP and normal MBP be followed with nonpharmacological measures and that antihypertensive drug treatment may be deferred.
In an accompanying editorial, Drs Michael O’Rourke and Audrey Adji from the St Vincent’s Clinic in Sydney, Australia, stressed that the subject of PP and MBP as predictors of hypertension and MACE in youth “bears on whether or not young persons with elevated systolic pressure and PP, but normal diastolic pressure, are at high risk and warrant the same management as in persons over age 60 years.” [Hypertension 2017;70:493-495]
In the present study, the 24-hour pressure monitoring appears to provide little additional benefit, with the exception of the ability to quantify white coat pressure and heart rate effects, O’Rourke and Adji added.
“We would not go so far as to question the value of 24-hour pressure in estimation of risk. But we would suggest that the information required to identify risk can be gained by brachial cuff blood pressure measurement, together with examination of the radial pulse waveform in the clinic, or by measurement of central aortic pressure,” they said.
*Hypertension Ambulatory Recording Venetia Study