Article    Table of Contents                    Full Text of this article    PDF of this article (PDFs free after 6 months)    Figures/Tables List  Services    Send comment/rapid response letter    Notify a friend about this article    Alert me when this article is cited    Add to Personal Archive    Download to Citation Manager    ACP Search                            Get Permissions  Google Scholar    Search for Related Content  PubMed Articles in PubMed by Author:    Smulyan, H.    Safar, M. E.    Related Articles in PubMed    PubMed Citation    PubMed

PERSPECTIVE

The Diastolic Blood Pressure in Systolic Hypertension

Harold Smulyan, MD, and Michel E. Safar, MD

1 February 2000 | Volume 132 Issue 3 | Pages 233-237

Because antihypertensive therapy is effective in elderly patients with isolated systolic hypertension, attention has been focused on the systolic blood pressure as a predictor of cardiovascular risk. However, it is a normal diastolic pressure that separates patients with isolated systolic hypertension from those with essential hypertension. The normal diastolic and elevated systolic pressures are largely due to age-related stiffening of the aorta. An indistensible aorta causes the pressure pulse to travel faster than normal, where it is quickly reflected off the peripheral resistance. The reflected wave then returns to the central aorta in systole rather than diastole. This augments the systolic pressure further, increasing cardiac work while reducing the diastolic pressure, on which coronary flow is dependent. The potential harm of further reducing the diastolic pressure with antihypertensive therapy, especially in patients with coronary heart disease, underlies the controversial "J curve." By decreasing the blood pressure, all antihypertensive agents improve aortic distensibility, but no agents do so directly; the nitrates come the closest. Such an agent would be useful because any therapeutic increase in aortic distensibility would decrease systolic pressure without greatly reducing diastolic pressure. The problem is complicated by the suspected inaccuracy of the cuff technique in predicting the aortic diastolic pressure. New noninvasive methods to predict the aortic diastolic pressure may help in the future. At present, the combination of a high systolic and normal diastolic pressure—a widened pulse pressure—seems to be the best predictor of cardiovascular risk in patients with hypertension or heart disease. Patients with isolated systolic hypertension should be treated, but marked diastolic hypotension should be avoided.

Author and Article Information

From State University of New York Health Science Center, Syracuse, New York; and Hôpital Broussais, Paris, France.

Requests for Single Reprints: Harold Smulyan, MD, State University of New York Health Science Center, 750 East Adams Street, Syracuse, NY 13210; e-mail, smulyanh{at}mailbox.hscsyr.edu.

Requests To Order Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.

Current Author Addresses: Dr. Smulyan: State University of New York Health Science Center, 750 East Adams Street, Syracuse, NY 13210.

Dr. Safar: Department of Internal Medicine and INSERM 337, Hôpital Broussais, 96 rue Didot, 75674 Paris Cedex 14, France.

This article has been cited by other articles:

				E. Osher and N. Stern Diastolic Pressure in Type 2 Diabetes: Can target systolic pressure be reached without "diastolic hypotension"? Diabetes Care, February 1, 2008; 31(Supplement_2): S249 - S254. [Abstract] [Full Text] [PDF]

				D. Weitzman and U. Goldbourt The Significance of Various Blood Pressure Indices for Long-Term Stroke, Coronary Heart Disease, and All-Cause Mortality in Men: The Israeli Ischemic Heart Disease Study Stroke, February 1, 2006; 37(2): 358 - 363. [Abstract] [Full Text] [PDF]

				W. M Tierney, M. Brunt, J. Kesterson, X.-H. Zhou, G. L'Italien, and P. Lapuerta Quantifying Risk of Adverse Clinical Events With One Set of Vital Signs Among Primary Care Patients with Hypertension Ann. Fam. Med, May 1, 2004; 2(3): 209 - 217. [Abstract] [Full Text] [PDF]

				A. L. Pauca, N. D. Kon, and M. F. O'Rourke The second peak of the radial artery pressure wave represents aortic systolic pressure in hypertensive and elderly patients Br. J. Anaesth., May 1, 2004; 92(5): 651 - 657. [Abstract] [Full Text] [PDF]

				S. Kony, M. Zureik, C. Neukirch, B. Leynaert, D. Vervloet, and F. Neukirch Rhinitis Is Associated with Increased Systolic Blood Pressure in Men: A Population-based Study Am. J. Respir. Crit. Care Med., February 15, 2003; 167(4): 538 - 543. [Abstract] [Full Text] [PDF]

				A. W. Haider, M. G. Larson, S. S. Franklin, and D. Levy Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Pressure as Predictors of Risk for Congestive Heart Failure in the Framingham Heart Study Ann Intern Med, January 7, 2003; 138(1): 10 - 16. [Abstract] [Full Text] [PDF]

				A.-S. Rigaud and B. Forette Hypertension in Older Adults J. Gerontol. A Biol. Sci. Med. Sci., April 1, 2001; 56(4): 217M - 225. [Abstract] [Full Text]

				Y. Jiang, K. Kohara, and K. Hiwada Association Between Risk Factors for Atherosclerosis and Mechanical Forces in Carotid Artery Stroke, October 1, 2000; 31(10): 2319 - 2324. [Abstract] [Full Text] [PDF]

				N. M. Kaplan New Issues in the Treatment of Isolated Systolic Hypertension Circulation, September 5, 2000; 102(10): 1079 - 1081. [Full Text] [PDF]