0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Pulse Pressure and Mortality in Older People FREE

Robert J. Glynn, ScD; Claudia U. Chae, MD; Jack M. Guralnik, MD, PhD; James O. Taylor, MD; Charles H. Hennekens, MD, DrPH
[+] Author Affiliations

From the Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass (Drs Glynn and Chae); Department of Biostatistics, Harvard School of Public Health, Boston (Dr Glynn); Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston (Dr Chae); Epidemiology, Demography, and Biometry Program, National Institute on Aging, Bethesda, Md (Dr Guralnik); East Boston Neighborhood Health Center, East Boston, Mass (Dr Taylor); and Department of Medicine, Epidemiology, and Public Health, University of Miami School of Medicine, Miami, Fla (Dr Hennekens).


Arch Intern Med. 2000;160(18):2765-2772. doi:10.1001/archinte.160.18.2765.
Text Size: A A A
Published online

Background  In older people, observational data are unclear concerning the relationships of systolic and diastolic blood pressure with cardiovascular and total mortality. We examined which combinations of systolic, diastolic, pulse, and mean arterial pressure best predict total and cardiovascular mortality in older adults.

Methods  In 1981, the National Institute on Aging initiated its population-based Established Populations for Epidemiologic Studies of the Elderly in 3 communities. At baseline, 9431 participants, aged 65 to 102 years, had blood pressure measurements, along with measures of medical history, use of medications, disability, and physical function. During an average follow-up of 10.6 years among survivors, 4528 participants died, 2304 of cardiovascular causes.

Results  In age- and sex-adjusted survival analyses, the lowest overall death rate occurred among those with systolic pressure less than 130 mm Hg and diastolic pressure 80 to 89 mm Hg; relative to this group, the highest death rate occurred in those with systolic pressure of 160 mm Hg or more and diastolic pressure less than 70 mm Hg (relative risk, 1.90; 95% confidence interval, 1.47-2.46). Both low diastolic pressure and elevated systolic pressure independently predicted increases in cardiovascular (P<.001) and total (P<.001) mortality. Pulse pressure correlated strongly with systolic pressure (R = 0.82) but was a slightly stronger predictor of both cardiovascular and total mortality. In a model containing pulse pressure and other potentially confounding variables, diastolic pressure (P = .88) and mean arterial pressure (P = .11) had no significant association with mortality.

Conclusions  Pulse pressure appears to be the best single measure of blood pressure in predicting mortality in older people and helps explain apparently discrepant results for low diastolic blood pressure.

Figures in this Article

IN MIDDLE-AGED populations, both systolic and diastolic blood pressure have strong, linear relationships with cardiovascular and total mortality.15 Because of the high correlation between systolic and diastolic pressure, studies examining cardiovascular risk in this age group commonly find that diastolic pressure provides little additional prognostic information after consideration of systolic pressure.14 In older people, however, observational studies have been less consistent613 and have commonly found U- or J-shaped relationships of blood pressure with mortality, especially for diastolic pressure. In some studies, individuals with the lowest blood pressure had the highest mortality.14,15 Treatment implications of these relationships remain controversial.1620 With the loss of aortic compliance, systolic pressure rises with age in industrialized countries, while diastolic pressure declines after about age 60 years, leading to increased pulse pressure and a diminished association between systolic and diastolic pressure.21 This may lead to differing relationships of systolic and diastolic pressure with mortality in older people.

It is also possible that pulse pressure is the measure of blood pressure most strongly related to cardiovascular risk in older people, and that consideration of pulse pressure may explain the apparent increased risk associated with low diastolic pressure. Several prospective studies have found that elevated pulse pressure, which reflects increased arterial stiffness with age, is associated with risk of myocardial infarction, congestive heart failure, and cardiovascular and total mortality.2227 However, pulse pressure is strongly correlated with systolic pressure, and it remains unclear whether it provides independent prognostic information or is useful in clarifying J-curves.28

Using data from 3 population-based cohorts of the Established Populations for Epidemiologic Studies of the Elderly, including more than 9000 older individuals followed up for more than 10 years, we considered which measures of blood pressure, including systolic, diastolic, pulse, and mean arterial pressure, best predicted cardiovascular and total mortality. We also examined whether consideration of pairs of these measures would enhance prediction.

SUBJECTS AND MEASURES

In 1981, the National Institute on Aging initiated its Established Populations for Epidemiologic Studies of the Elderly studies of community-dwelling persons aged 65 years and older in 3 locations: East Boston, Mass; Washington and Iowa counties, Iowa; and New Haven, Conn. During 1982 and 1983, surveys were conducted in the entire populations of persons aged 65 years and older in East Boston and Iowa and in a stratified sample of residents of New Haven. To maximize participation, trained interviewers visited the homes of all eligible participants. Participation rates ranged from 80% to 85%, with 3809 participants in East Boston, 3673 participants in Iowa, and 2812 participants in New Haven, for a total population of 10,294 community-dwelling elderly subjects. Because some individuals participated through a proxy, 9431 participants had baseline blood pressure measurements, and they constitute the cohort for the current study.

In East Boston and New Haven, the trained interviewer took 3 blood pressure measurements at 30-second intervals by means of a standard mercury sphygmomanometer, after the participant had been seated for at least 5 minutes, according to the protocol used in the Hypertension Detection and Follow-up Program.29 Two measurements were taken in Iowa. For this study, systolic pressure was the average of all systolic measures; diastolic pressure was the average of all diastolic measures; pulse pressure was systolic minus diastolic pressure; and mean arterial pressure was [systolic + (2 × diastolic pressure)]/3.

The interviewer also collected information about other characteristics potentially related to both blood pressure and mortality. Participants reported their height and weight, present and past use of cigarettes and alcohol, and whether they were ever told by a physician that they had myocardial infarction, stroke, or cancer. Angina was identified by the Rose questionnaire.30 All medications used in the 2 weeks before the interview were identified by direct inspection. Disability was identified through reports of problems with activities of daily living31 and problems with physical function by a 3-item scale.32 We classified participants as low in physical activity when they reported not exercising vigorously at least once a week, rarely or never taking walks, and not working frequently around the house or garden. Further information about demographic characteristics of the population33 and quality control of blood pressure measurements34,35 has been published elsewhere.

Participants were contacted yearly during the first 6 years after baseline, with in-home interviews at the 3- and 6-year follow-up and telephone interviews in the interim years. Thereafter, mortality follow-up continued through the end of 1992 through local surveillance supplemented by linkage to the National Death Index. These sources yielded complete follow-up of the cohort for mortality up to 1992, giving an average follow-up of 10.6 years (range, 9.1-11.1 years) among survivors. Of the 9431 participants, 4528 died, and death certificates were obtained for 4494. A single trained nosologist coded the underlying cause of death according to the International Classification of Diseases, Ninth Revision.36 We used these codes to classify deaths as being caused by cardiovascular disease including stroke (codes 401-459) or other causes.

STATISTICAL ANALYSIS

We first determined correlations among the measures of blood pressure to quantify their interrelationships. To examine the joint association of systolic and diastolic pressure with mortality, we classified participants according to categories of both variables. Categories used were the same as in a previous study of blood pressure in one of these populations,12 except that a priori we grouped individuals with systolic pressure between 140 and 159 mm Hg and also formed a single group among those with diastolic pressure between 70 and 79 mm Hg. Thus, we partitioned the population into 16 groups according to category of systolic pressure (<130, 130-139, 140-159, or ≥160 mm Hg) and category of diastolic pressure (<70, 70-79, 80-89, or ≥90 mm Hg). We used proportional hazards analyses to compare age- and sex-adjusted total and cardiovascular death rates across these 16 categories.

To examine whether simpler models might summarize these relationships, we compared the ability of both single measures and pairs of measures of blood pressure to predict total and cardiovascular mortality. We categorized pulse pressure and mean arterial pressure according to approximate quartiles in the population. We compared the ability of alternative models to predict mortality by means of the R2 statistic for survival analysis and the likelihood ratio–based discrimination index D (defined as the model likelihood ratio χ2 − 1 divided by the −2 log likelihood of the null model) described by Harrell and colleagues.37 We used likelihood ratio tests to determine whether adding variables to a model significantly improved the fit. Additional models included other variables that may affect both blood pressure and risk of death, but were restricted to the 4054 deaths in 8715 participants with complete data on these potential confounding variables.

We also examined whether relationships of blood pressure with mortality differed in the following subgroups: women aged 65 to 74 years, women aged 75 years or more, men aged 65 to 74 years, men aged 75 years or more, users and nonusers of antihypertensive drugs, people with chronic disease (angina; history of myocardial infarction, stroke, or cancer; use of digoxin, loop diuretics, or hypoglycemic drugs), and those without these diseases. Because undetected diseases may affect blood pressure in those near death, we also examined deaths separately in the first 3 years and thereafter. Separate analyses in each site found comparable results.

INTERRELATIONSHIPS AMONG BLOOD PRESSURE MEASURES

Among the 9431 elderly subjects in these 3 communities, systolic blood pressure had a correlation of 0.50 with diastolic blood pressure. Although this correlation was large and highly significant (P<.001), it was substantially weaker than the correlation of nearly 0.80 between these measures found in studies of middle-aged populations.1,22

Overall, pulse pressure had a weak but slightly U-shaped relationship with diastolic pressure. On average, the lowest pulse pressures occurred among those with diastolic pressures between 70 and 89 mm Hg. Among those with diastolic pressure less than 80 mm Hg, the correlation with pulse pressure was −0.21 (P<.001), whereas above 80 mm Hg the correlation was 0.10 (P<.001). Conversely, pulse pressure and systolic pressure had a strong, almost linear association (Figure 1). The correlation of 0.82 between these measures further suggested that a straight line fits this relationship fairly well. Mean arterial pressure had strong correlations of 0.85 with systolic pressure and 0.89 with diastolic pressure but a weaker, although still highly significant (P<.001), correlation of 0.39 with pulse pressure.

Place holder to copy figure label and caption
Figure 1.

Relationship of systolic pressure with pulse pressure in 9431 elderly individuals, with associated regression line and 95% prediction interval.

Graphic Jump Location
JOINT RELATIONSHIPS WITH MORTALITY

The lowest risk of death occurred among the 321 participants with diastolic pressures between 80 and 89 mm Hg and systolic pressures less than 130 mm Hg, and we took this group as the referent (Table 1). The highest death rate occurred among the 173 participants with elevated systolic pressure (≥160 mm Hg) and low diastolic pressure (<70 mm Hg), who had a 90% higher death rate than the referent group (P<.001). The next highest death rates occurred among the individuals in the adjacent categories, with elevated systolic pressure and diastolic pressure of 70 to 79 mm Hg (relative risk [RR], 1.59; 95% confidence interval [CI], 1.28-1.99) or borderline high systolic pressure (140-159 mm Hg) and low diastolic pressure (RR, 1.56; 95% CI, 1.26-1.93). More than 100 deaths occurred in 14 of the 16 blood pressure groups, indicating the ability to estimate reliably the joint relationship of systolic and diastolic pressure with mortality in all groups except those with elevated diastolic pressure (≥90 mm Hg) and systolic pressure less than 140 mm Hg.

Table Graphic Jump LocationTable 1. Number of Participants (Number of Deaths) and Relative Risk (RR) of Death (95% CI) by Categories of Diastolic and Systolic Pressure*

The data in Table 1 strongly support the importance of pulse pressure as a determinant of the risk of death in older people. The lowest death rates occurred among normotensive subjects with low pulse pressure (ie, systolic pressure <130 mm Hg and diastolic pressure 70-89 mm Hg, or systolic pressure 130-139 mm Hg and diastolic pressure 80-89 mm Hg). The 1880 individuals in these groups all had pulse pressure less than 60 mm Hg and their mean pulse pressure was 46.7 mm Hg (interquartile range, 42-52 mm Hg). None of the groups in the lower left portion of Table 1 had significant elevations in death rates. Conversely, the highest death rates occurred among groups with the highest pulse pressures (top right of Table 1). The 1130 individuals in the 3 groups with the highest death rates all had pulse pressures greater than 70 mm Hg, and their mean pulse pressure was 92.4 mm Hg (interquartile range, 84-99 mm Hg).

We observed a similar relationship between categories of systolic and diastolic blood pressure and cardiovascular mortality (Figure 2), suggesting that pulse pressure was an important determinant of cardiovascular mortality. The same 3 groups with the highest total mortality also had the highest cardiovascular death rates, and these elevations were significant (P<.01) for each of these groups compared with the referent.

Place holder to copy figure label and caption
Figure 2.

Relative risk of cardiovascular death by categories of diastolic and systolic pressure, adjusted for age and sex and stratified by site.

Graphic Jump Location
BEST PREDICTIVE MODELS

For both total (Table 2) and cardiovascular (Table 3) mortality, an age- and sex-adjusted model including only pulse pressure had slightly better predictive ability than a model including only systolic pressure or only diastolic pressure, as indicated by higher R2 and discrimination index statistics. Those in the third quartile of pulse pressure (63-76 mm Hg) had a 19% increased risk of cardiovascular death, and those in the highest quartile (≥77 mm Hg) had a 57% increased risk of cardiovascular death, compared with those in the lowest quartile. Adding diastolic pressure to the model including pulse pressure alone left these effects of pulse pressure virtually unchanged. Within each category of diastolic pressure, persons with higher levels of pulse pressure had higher rates of cardiovascular death (Figure 3). Mean arterial pressure had a weak association with both total (Table 2) and cardiovascular (Table 3) mortality. In analyses including both pulse pressure and mean arterial pressure, pulse pressure continued to have the same strong relationship with mortality, whereas mean arterial pressure had a nonsignificant relationship with these end points (data not shown).

Table Graphic Jump LocationTable 2. Comparison of Alternative Survival Analyses Predicting Total Mortality Based on 4528 Deaths in 9431 People
Table Graphic Jump LocationTable 3. Comparison of Alternative Survival Analyses Predicting Cardiovascular Mortality Based on 2304 Cardiovascular Deaths in 9431 People
Place holder to copy figure label and caption
Figure 3.

Relative risk of cardiovascular death by categories of diastolic and pulse pressure, adjusted for age and sex and stratified by site.

Graphic Jump Location

Alternative models that included both systolic and diastolic pressure found independent and highly significant effects of both measures and were significantly better than models including only one of these measures (P<.001). After adjusting for age, sex, and diastolic pressure, higher levels of systolic pressure were associated with increased risk of cardiovascular death, with a significant 25% higher cardiovascular death rate (P<.001) among those with borderline high systolic pressure (140-159 mm Hg), relative to those with systolic pressure less than 130 mm Hg, and a 59% higher cardiovascular death rate (P<.001) among those with high systolic pressure (≥160 mm Hg). After controlling for systolic pressure, low diastolic pressure (<70 mm Hg) was independently associated with a 38% increase in risk of cardiovascular death (P<.001), relative to those with diastolic pressure 80 to 89 mm Hg, and diastolic pressure of 70 to 79 mm Hg was associated with a 17% higher cardiovascular death rate (P = .006). If diastolic pressure was not included in the model, then the effects of systolic pressure on risk were substantially reduced, and, similarly, if the model did not include systolic pressure, then the effects of diastolic pressure were also reduced. This further indicates the importance of including both systolic and diastolic pressure in predictive models in older people.

For both total mortality and cardiovascular mortality, these models including independent effects of both systolic and diastolic pressure had comparable predictive ability, compared with the models that also included interactions between these variables summarized in Table 1 and Figure 2. However, the predictive ability of the simpler model including only pulse pressure was nearly equal to that of the model including both systolic and diastolic pressure.

Further control for potential confounding variables had little effect on relationships of systolic pressure or pulse pressure with either cardiovascular mortality (Figure 4) or total mortality (data not shown). However, control for confounding variables attenuated the apparent increased risk associated with low diastolic pressure. Adjusting for systolic pressure and confounders, the risk associated with low diastolic pressure remained statistically significant (P = .02 for both total and cardiovascular death). With adjustment for pulse pressure as well as confounding variables, diastolic pressure had no significant association with mortality (P = .88 for total mortality and P = .33 for cardiovascular mortality). This suggests that pulse pressure and comorbidity explain the apparent relationships between low diastolic pressure and mortality in aging adults. With control for potential confounding variables and pulse pressure, mean arterial presure also had no association with mortality (P = .11 for total mortality and P = .21 for cardiovascular mortality).

Place holder to copy figure label and caption
Figure 4.

Joint relationships of systolic and diastolic pressure with cardiovascular mortality (A and C) and of pulse and diastolic pressure with cardiovascular mortality (B and D), based on proportional hazards models including categories of 2 blood pressure measurements and adjusting for age in years; sex; history of cancer, stroke, myocardial infarction, and angina; use of antihypertensive drugs, loop diuretics, digoxin, and hypoglycemic drugs; need for help with activities of daily living; problems with physical function; low activity level; overweight; current and past cigarette smoking; and current use of alcohol. Bars indicate 95% confidence intervals.

Graphic Jump Location
SUBGROUP ANALYSES

We found little evidence that either use of antihypertensive drugs or presence of important chronic diseases modified the relationships of pulse pressure and diastolic pressure with cardiovascular mortality, summarized for the entire population in Table 3. We did observe some apparent differences in relationships by age. In analyses of women aged 65 to 74 years and in men aged 65 to 74 years, we found somewhat stronger relationships of pulse pressure with mortality, compared with the effects in the total population: relative to women in the lowest quartile of pulse pressure, those in the highest quartile had a 2.13 higher risk of cardiovascular death (95% CI, 1.58-2.88) and men in the highest quartile had a 1.87 increased risk (95% CI, 1.43-2.44), relative to those with pulse pressure in the lowest quartile. Conversely, relationships were weaker among those aged 75 years or older at baseline. Older women in the highest quartile of pulse pressure had a 1.34 increased risk of cardiovascular death (95% CI, 1.07-1.68) relative to older women in the lowest quartile; in older men the comparable RR was 1.05 (95% CI, 0.81-1.39). It is unclear whether these results reflect the natural variability of subgroup estimates or a true modification of the impact of blood pressure in relation to age, which is supported by several previous studies.38 In none of these subgroup analyses were there any significant relationships of diastolic blood pressure with cardiovascular mortality after controlling for pulse pressure and other potential confounding variables.

We also observed some variability in results of separate analyses examining cardiovascular deaths in the first 3 years of follow-up and thereafter. Neither pulse pressure nor diastolic pressure had any significant relationship with cardiovascular deaths observed during the first 3 years after baseline. In separate analysis of deaths occurring after this time, pulse pressure had a strong graded relationship with cardiovascular mortality, with an RR of 1.61 (95% CI, 1.38-1.88) comparing those in the highest and lowest quartiles of pulse pressure.

These prospective data indicate that, in older people, both systolic and diastolic blood pressure provide important and independent prognostic information about the risk of cardiovascular and total mortality. As in middle-aged populations, higher systolic pressure predicted linear increases in cardiovascular and total mortality, with little evidence of confounding by other comorbid conditions and a clear increase in risk among those with borderline high (140-159 mm Hg) systolic pressure. Low diastolic pressure is also a marker of increased risk of death, independent of systolic pressure, although this association is largely explained by the confounding effects of frailty and comorbid conditions. Pulse pressure, although highly correlated with systolic pressure, has the advantage of incorporating the effects of both high systolic and low diastolic pressure. Prognostic models including pulse pressure are simpler and have nearly the same predictive ability as models including both systolic and diastolic pressure. Furthermore, in these data, pulse pressure appears to be the best single blood pressure measure to predict mortality risk in the elderly.

In healthy, middle-aged populations, pulse pressure is not a consistent and independent risk factor for cardiovascular disease. In the Framingham,1 Western Collaborative Group,3 and 4 Chicago, Ill–area prospective studies,28 level of systolic and/or diastolic blood pressure had stronger relationships with cardiovascular risk than pulse pressure. Results in this area are not entirely consistent, though, as some studies have found increases in cardiovascular risk associated with higher systolic pressure after controlling for level of diastolic pressure.39,40 The Multiple Risk Factor Intervention Trial found high rates of death from coronary heart disease in men with elevated systolic pressure and low diastolic pressure, but in other categories of systolic pressure, those with lower diastolic pressure had decreased death rates.41

Several studies have indicated that the prognostic significance of systolic pressure increases with increasing age, while that of diastolic pressure and mean arterial pressure decreases.1,4,42 After age 60 years, stiffening of the large arteries leads to decreased diastolic pressure and increased pulse pressure, and this changes the relationship between low diastolic pressure and cardiovascular disease. Recent data from long-term follow-up of those aged 50 years or older in the Framingham Study support an important role of pulse pressure in predicting incident coronary heart disease.27 In particular, that study found that both higher levels of systolic pressure and lower levels of diastolic pressure independently predicted risk of coronary heart disease. However, because this Framingham analysis examined a younger, health-screened population, it had limited ability to estimate precisely the joint relationship of systolic and diastolic blood pressure with cardiovascular risk. Specifically, the Framingham analysis had only 9 subjects and observed only 1 event in the group of persons with the highest pulse pressure (systolic pressure ≥160 mm Hg and diastolic pressure <70 mm Hg), compared with the 123 deaths among 173 persons in this high-risk group in our study.

Studies in high-risk and diseased populations also support an important prognostic role for pulse pressure. In patients with newly diagnosed hypertension and in patients with left ventricular dysfunction after myocardial infarction, elevated pulse pressure is a major risk factor for myocardial infarction and death.23,24 Pulse pressure appears to be the best measure of blood pressure to predict congestive heart failure in the elderly.26

Several plausible mechanisms may explain the association between elevated pulse pressure and cardiovascular disease. Arterial stiffness increases afterload43,44 and myocardial work,45 impairs ventricular relaxation,46,47 and causes ischemia.4850 It is strongly correlated with left ventricular hypertrophy,51,52 a known risk factor for cardiovascular events.53 Arterial stiffness is also correlated with the presence of atherosclerosis.54,55 The associated increase in shear stress and pulsatile strain may promote primary atheroma development56,57 and may contribute to rupture of vulnerable plaques.58

Studies in middle-aged populations have generally found higher RRs associated with elevated blood pressure, compared with the magnitude of the observed effects noted in our data.5 Factors that could explain these reduced effects include greater variability of blood pressure in older persons and greater comorbidity, which is difficult to measure precisely. Correction of risk estimates for the variability of blood pressure measures identifies a much greater impact of blood pressure on risk,5 and such corrections have a greater effect on risk estimates in older adults.12 Similarly, our predictive models for 10-year mortality in the elderly, based on baseline characteristics, have only modest performance. However, this is also the case in younger populations,59 in whom the search for additional risk factors for cardiovascular events continues. Even if RRs associated with elevated blood pressure are lower in the older population, high blood pressure remains of great public health importance because absolute risks of cardiovascular death are far greater in older adults.12

These findings have implications for treatment as well as prognosis. They provide population-based evidence for the generalizability of the efficacy of treatment for hypertension in older patients, which has been unequivocally demonstrated in randomized trials.6065 Higher levels of both systolic and pulse pressure had strong linear relationships with cardiovascular and total mortality. Borderline elevations in systolic pressure (140-159 mm Hg) were associated with significant elevations in risk, particularly among individuals who also had low diastolic pressures. Our data also shed light on the apparent J-shaped relationship between diastolic pressure and mortality. In older adults, low diastolic pressure commonly occurs in individuals with high pulse pressure and among those with substantial comorbidity.12,66,67 Control for these variables explains the apparent elevations in risk associated with low diastolic pressure. Therapies of potential value in improving arterial compliance include angiotensin-converting enzyme inhibitors,68 nitrates,69 and a low-salt diet.70 However, evidence from randomized trials with morbidity and mortality end points is needed to determine the relative value of these therapies and whether reduction of pulse pressure should be a specific treatment target. In evaluating cardiovascular risk in older persons, both systolic and diastolic blood pressure contribute independent information, but the best single measure of blood pressure to predict mortality appears to be pulse pressure.

Accepted for publication May 3, 2000.

This study was supported by contract AG02107 from the National Institute on Aging, Bethesda, Md, and a grant from Bristol-Myers Squibb, Princeton, NJ

Corresponding author: Robert J. Glynn, ScD, Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth Ave E, Boston, MA 02215 (e-mail: rglynn@rics.bwh.harvard.edu).

Kannel  WBGordon  TSchwartz  MJ Systolic versus diastolic blood pressure and risk of coronary heart disease: the Framingham Study. Am J Cardiol. 1971;27335- 346
Link to Article
Wilhelmsen  LWedel  HTiblin  G Multivariate analysis of risk factors for coronary heart disease. Circulation. 1973;48950- 958
Link to Article
Rosenman  RHSholtz  RIBrand  RJ A study of comparative blood pressure measures in predicting coronary heart disease. Circulation. 1976;5451- 58
Link to Article
Rabkin  SWMathewson  FALTate  RB Predicting risk of ischemic heart disease and cerebrovascular disease from systolic and diastolic blood pressure. Ann Intern Med. 1978;88342- 345
Link to Article
MacMahon  SPeto  RCutler  J  et al.  Blood pressure, stroke, and coronary heart disease, I: effects of prolonged differences in blood pressure. Lancet. 1990;335765- 774
Link to Article
Harris  TCook  EFKannel  WSchatzkin  AGoldman  L Blood pressure experience and risk of cardiovascular disease in the elderly. Hypertension. 1985;7118- 124
Link to Article
Lindholm  LLanke  JBengtsson  B U-shaped association between mortality and blood pressure in a thirteen year prospective study. Fam Pract. 1986;33- 8
Link to Article
Siegel  DKuller  LLazarus  NB  et al.  Predictors of cardiovascular events and mortality in the Systolic Hypertension in the Elderly Program pilot project. Am J Epidemiol. 1987;126385- 399
Coope  JWarrender  TSMcPherson  K The prognostic significance of blood pressure in the elderly. J Hum Hypertens. 1988;279- 88
Taylor  JOCornoni-Huntley  JCurb  JD  et al.  Blood pressure and mortality risk in the elderly. Am J Epidemiol. 1991;134489- 501
Benfante  RReed  DFrank  J Do coronary heart disease risk factors measured in the elderly have the same predictive roles as in the middle aged? Ann Epidemiol. 1992;2273- 282
Link to Article
Glynn  RJField  TSRosner  BHebert  PRTaylor  JOHennekens  CH Evidence for a positive linear relation between blood pressure and mortality in elderly people. Lancet. 1995;345825- 829
Link to Article
Boshuizen  HCIzaks  GJvan Buuren  SLigthart  GJ Blood pressure and mortality in elderly people aged 85 and older: community based study. BMJ. 1998;3161780- 1784
Link to Article
Mattila  KHaavisto  MRajala  SHeikinheimo  R Blood pressure and five year survival in the very old. Br Med J (Clin Res Ed). 1988;296887- 889
Link to Article
Langer  RDGaniats  TGBarrett-Connor  E Paradoxical survival of elderly men with high blood pressure. BMJ. 1989;2981356- 1358
Link to Article
Cruickshank  JMThorp  IMZacharias  FJ Benefits and potential harm of lowering high blood pressure. Lancet. 1987;1581- 584
Link to Article
Alderman  MHOoi  WLMadhavan  SCohen  H Treatment-induced blood pressure reduction and the risk of myocardial infarction. JAMA. 1989;262920- 924
Link to Article
Farnett  LMulrow  CDLinn  WDLucey  CRTuley  MR The J-curve phenomenon and the treatment of hypertension: is there a point beyond which pressure reduction is dangerous? JAMA. 1991;265489- 495
Link to Article
Hansson  LZanchetti  ACarruthers  SG  et al.  Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet. 1998;3511755- 1762
Link to Article
Kaplan  N J-curve not burned off by HOT study. Lancet. 1998;3511748- 1749
Link to Article
Franklin  SSGustin  WG  IVWong  ND  et al.  Hemodynamic patterns of age-related changes in blood pressure: the Framingham Study. Circulation. 1997;96308- 315
Link to Article
Darne  BGirerd  XSafar  MCambien  FGuize  L Pulsatile versus steady component of blood pressure: a cross-sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension. 1989;13392- 400
Link to Article
Fang  JMadhavan  SCohen  HAlderman  MH Measures of blood pressure and myocardial infarction in treated hypertensive patients. J Hypertens. 1995;13413- 419
Link to Article
Mitchell  GFMoyé  LABraunwald  E  et al.  Sphygmomanometrically determined pulse pressure is a powerful independent predictor of recurrent events after myocardial infarction in patients with impaired left ventricular function. Circulation. 1997;964254- 4260
Link to Article
Lee  MLRosner  BAWeiss  ST Relationship of blood pressure to cardiovascular death: the effects of pulse pressure in the elderly. Ann Epidemiol. 1999;9101- 107
Link to Article
Chae  CUPfeffer  MAGlynn  RJMitchell  GFTaylor  JOHennekens  CH Pulse pressure predicts congestive heart failure in the elderly. JAMA. 1999;281634- 639
Link to Article
Franklin  SSKhan  SAWong  NDLarson  MGLevy  D Is pulse pressure useful in predicting risk for coronary heart disease? the Framingham Heart Study. Circulation. 1999;100354- 360
Link to Article
Dyer  ARStamler  JShekelle  RB  et al.  Pulse pressure, III: prognostic significance in four Chicago epidemiologic studies. J Chronic Dis. 1982;35283- 294
Link to Article
Hypertension Detection and Follow-up Program Cooperative Group, Variability of blood pressure and the results of screening in the HDFP. J Chronic Dis. 1978;31651- 657
Link to Article
Rose  GABlackburn  HGillum  RFPrineas  RJ Cardiovascular Survey Methods  Geneva, Switzerland World Health Organization1982;162- 165
Branch  LGKatz  SKniepmann  K  et al.  A prospective study of functional status among community elderly. Am J Public Health. 1984;74266- 268
Link to Article
Rosow  IBreslau  N A Guttman health scale for the aged. J Gerontol. 1966;21556- 559
Link to Article
Cornoni-Huntley  JBrock  DBOstfeld  AM  et al.  Established Populations for Epidemiologic Studies of the Elderly: Resource Data Book  Bethesda, Md National Institutes of Health1986;NIH publication 86-2443
Glynn  RJField  TSSatterfield  S  et al.  Modification of increasing systolic blood pressure in the elderly during the 1980s. Am J Epidemiol. 1993;138365- 379
Glynn  RJBrock  DBHarris  T  et al.  Use of antihypertensive drugs and trends in blood pressure in the elderly. Arch Intern Med. 1995;1551855- 1860
Link to Article
World Health Organization, International Classification of Diseases, Ninth Revision (ICD-9)  Geneva, Switzerland World Health Organization1977;
Harrell  FE  JrLee  KLMark  DB Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996;15361- 387
Link to Article
Bulpitt  CJFletcher  AE Aging, blood pressure and mortality. J Hypertens Suppl. 1992;10 ((suppl 7)) S45- S49
Link to Article
Not Available, Build and Blood Pressure Study, 1959 Vol 1 Chicago, Ill Society of Actuaries1959;
Benetos  ASafar  MRudnichi  A  et al.  Pulse pressure: a predictor of long-term cardiovascular mortality in a French male population. Hypertension. 1997;301410- 1415
Link to Article
Neaton  JDWentworth  D Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;15256- 64
Link to Article
The Pooling Project Research Group, Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to incidence of major coronary events: final report of the Pooling Project. J Chronic Dis. 1978;31201- 306
Link to Article
Milnor  WR Arterial impedance as ventricular afterload. Circ Res. 1975;36565- 570
Link to Article
Urschel  CWCovel  JWSonnenblick  EHRoss  JR  JrBraunwald  E Effects of decreased aortic compliance on performance of the left ventricle. Am J Physiol. 1968;214298- 304
Kelly  RPTunin  RKass  DA Effect of reduced aortic compliance on cardiac efficiency and contractile function of in situ canine left ventricle. Circ Res. 1992;71490- 502
Link to Article
Hori  MInoue  MKitakaze  M  et al.  Loading sequence is a major determinant of afterload-dependent relaxation in intact canine heart. Am J Physiol. 1985;249H747- H754
Kohno  FKumada  TKamabayashi  MHayashida  WIshikawa  NSasayama  S Change in aortic end-systolic pressure by alterations in loading sequence and its relation to left ventricular isovolumic relaxation. Circulation. 1996;932080- 2087
Link to Article
Watanabe  HOhtsuka  SKakihana  MSugishita  Y Coronary circulation in dogs with an experimental decrease in aortic compliance. J Am Coll Cardiol. 1993;211497- 1506
Link to Article
Kass  DASaeki  ATunin  RSRecchia  FA Adverse influence of systemic vascular stiffening on cardiac dysfunction and adaptation to coronary occlusion. Circulation. 1996;931533- 1541
Link to Article
Buckberg  GDFixler  DEArchie  JPHoffman  JIE Experimental subendocardial ischemia in dogs with normal coronary arteries. Circ Res. 1972;3067- 81
Link to Article
Girerd  XLaurent  SPannier  BAsmar  RSafar  M Arterial distensibility and left ventricular hypertrophy in patients with sustained essential hypertension. Am Heart J. 1991;1221210- 1214
Link to Article
Saba  PSRoman  MJPini  RSpitzer  MGanau  ADevereux  RB Relation of arterial pressure waveform to left ventricular and carotid anatomy in normotensive subjects. J Am Coll Cardiol. 1993;221873- 1880
Link to Article
Levy  DGarrison  RJSavage  DDKannel  WBCastelli  WP Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med. 1990;3221561- 1566
Link to Article
Farrar  DJBond  MGRiley  WASawyer  JK Anatomic correlates of aortic pulse wave velocity and carotid artery elasticity during atherosclerosis progression and regression in monkeys. Circulation. 1991;831754- 1763
Link to Article
Hirai  TSasayama  SKawasaki  TYagi  S Stiffness of systemic arteries in patients with myocardial infarction: a noninvasive method to predict severity of coronary atherosclerosis. Circulation. 1989;8078- 86
Link to Article
Witteman  JCMGrobbee  DEValkenberg  HA  et al.  J-shaped relation between change in diastolic blood pressure and progression of aortic atherosclerosis. Lancet. 1994;343504- 507
Link to Article
Lyon  RTRunyon-Hass  ADavis  HRGlagov  SZarins  CK Protection from atherosclerotic lesion formation by reduction of artery wall motion. J Vasc Surg. 1987;559- 67
Link to Article
Cheng  GCLoree  HMKamm  RDFishbein  MCLee  RT Distribution of circumferential stress in ruptured and stable atherosclerotic lesions: a structural analysis with histopathological correlation. Circulation. 1993;871179- 1187
Link to Article
Wilson  PWFD'Agostino  RBLevy  DBelanger  AMSilbershatz  HKannel  WB Prediction of coronary heart disease using risk factor categories. Circulation. 1998;971837- 1847
Link to Article
Amery  ABirkenhäger  WBrixko  P  et al.  Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet. 1985;11349- 1354
Link to Article
Coope  JWarrender  TS Randomised trial of treatment of hypertension in elderly patients in primary care. Br Med J (Clin Res Ed). 1986;2931145- 1151
Link to Article
SHEP Cooperative Research Group, Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;2653255- 3264
Link to Article
Dahlöf  BLindholm  LHHannson  LScherstén  BEkbom  TWester  P-O Morbidity and mortality in the Swedish Trial in Old Patients With Hypertension (STOP-Hypertension). Lancet. 1991;3381281- 1285
Link to Article
MRC Working Party, Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ. 1992;304405- 412
Link to Article
Staessen  JAFagard  RThijs  L  et al.  Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet. 1997;350757- 764
Link to Article
Bots  MLWitteman  JCHofman  Ade Jong  PTGrobbee  DE Low diastolic blood pressure and atherosclerosis in elderly subjects: the Rotterdam Study. Arch Intern Med. 1996;156843- 848
Link to Article
D'Agostino  RBBelanger  AJKannel  WBCruickshank  JM Relation of low diastolic blood pressure to coronary heart disease death in presence of myocardial infarction: the Framingham Study. BMJ. 1991;303385- 389
Link to Article
Mitchell  GFPfeffer  MAFinn  PVPfeffer  JM Equipotent antihypertensive agents variously affect pulsatile hemodynamics and regression of cardiac hypertrophy in spontaneously hypertensive rats. Circulation. 1996;942923- 2929
Link to Article
Latson  TWHunter  WCKatoh  NSagawa  K Effect of nitroglycerin on aortic impedance, diameter and pulse-wave velocity. Circ Res. 1988;62884- 890
Link to Article
Avolio  APClyde  KMBeard  TC  et al.  Improved arterial distensibility in normotensive subjects on a low salt diet. Arteriosclerosis. 1986;6166- 169
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Relationship of systolic pressure with pulse pressure in 9431 elderly individuals, with associated regression line and 95% prediction interval.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Relative risk of cardiovascular death by categories of diastolic and systolic pressure, adjusted for age and sex and stratified by site.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Relative risk of cardiovascular death by categories of diastolic and pulse pressure, adjusted for age and sex and stratified by site.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Joint relationships of systolic and diastolic pressure with cardiovascular mortality (A and C) and of pulse and diastolic pressure with cardiovascular mortality (B and D), based on proportional hazards models including categories of 2 blood pressure measurements and adjusting for age in years; sex; history of cancer, stroke, myocardial infarction, and angina; use of antihypertensive drugs, loop diuretics, digoxin, and hypoglycemic drugs; need for help with activities of daily living; problems with physical function; low activity level; overweight; current and past cigarette smoking; and current use of alcohol. Bars indicate 95% confidence intervals.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Number of Participants (Number of Deaths) and Relative Risk (RR) of Death (95% CI) by Categories of Diastolic and Systolic Pressure*
Table Graphic Jump LocationTable 2. Comparison of Alternative Survival Analyses Predicting Total Mortality Based on 4528 Deaths in 9431 People
Table Graphic Jump LocationTable 3. Comparison of Alternative Survival Analyses Predicting Cardiovascular Mortality Based on 2304 Cardiovascular Deaths in 9431 People

References

Kannel  WBGordon  TSchwartz  MJ Systolic versus diastolic blood pressure and risk of coronary heart disease: the Framingham Study. Am J Cardiol. 1971;27335- 346
Link to Article
Wilhelmsen  LWedel  HTiblin  G Multivariate analysis of risk factors for coronary heart disease. Circulation. 1973;48950- 958
Link to Article
Rosenman  RHSholtz  RIBrand  RJ A study of comparative blood pressure measures in predicting coronary heart disease. Circulation. 1976;5451- 58
Link to Article
Rabkin  SWMathewson  FALTate  RB Predicting risk of ischemic heart disease and cerebrovascular disease from systolic and diastolic blood pressure. Ann Intern Med. 1978;88342- 345
Link to Article
MacMahon  SPeto  RCutler  J  et al.  Blood pressure, stroke, and coronary heart disease, I: effects of prolonged differences in blood pressure. Lancet. 1990;335765- 774
Link to Article
Harris  TCook  EFKannel  WSchatzkin  AGoldman  L Blood pressure experience and risk of cardiovascular disease in the elderly. Hypertension. 1985;7118- 124
Link to Article
Lindholm  LLanke  JBengtsson  B U-shaped association between mortality and blood pressure in a thirteen year prospective study. Fam Pract. 1986;33- 8
Link to Article
Siegel  DKuller  LLazarus  NB  et al.  Predictors of cardiovascular events and mortality in the Systolic Hypertension in the Elderly Program pilot project. Am J Epidemiol. 1987;126385- 399
Coope  JWarrender  TSMcPherson  K The prognostic significance of blood pressure in the elderly. J Hum Hypertens. 1988;279- 88
Taylor  JOCornoni-Huntley  JCurb  JD  et al.  Blood pressure and mortality risk in the elderly. Am J Epidemiol. 1991;134489- 501
Benfante  RReed  DFrank  J Do coronary heart disease risk factors measured in the elderly have the same predictive roles as in the middle aged? Ann Epidemiol. 1992;2273- 282
Link to Article
Glynn  RJField  TSRosner  BHebert  PRTaylor  JOHennekens  CH Evidence for a positive linear relation between blood pressure and mortality in elderly people. Lancet. 1995;345825- 829
Link to Article
Boshuizen  HCIzaks  GJvan Buuren  SLigthart  GJ Blood pressure and mortality in elderly people aged 85 and older: community based study. BMJ. 1998;3161780- 1784
Link to Article
Mattila  KHaavisto  MRajala  SHeikinheimo  R Blood pressure and five year survival in the very old. Br Med J (Clin Res Ed). 1988;296887- 889
Link to Article
Langer  RDGaniats  TGBarrett-Connor  E Paradoxical survival of elderly men with high blood pressure. BMJ. 1989;2981356- 1358
Link to Article
Cruickshank  JMThorp  IMZacharias  FJ Benefits and potential harm of lowering high blood pressure. Lancet. 1987;1581- 584
Link to Article
Alderman  MHOoi  WLMadhavan  SCohen  H Treatment-induced blood pressure reduction and the risk of myocardial infarction. JAMA. 1989;262920- 924
Link to Article
Farnett  LMulrow  CDLinn  WDLucey  CRTuley  MR The J-curve phenomenon and the treatment of hypertension: is there a point beyond which pressure reduction is dangerous? JAMA. 1991;265489- 495
Link to Article
Hansson  LZanchetti  ACarruthers  SG  et al.  Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet. 1998;3511755- 1762
Link to Article
Kaplan  N J-curve not burned off by HOT study. Lancet. 1998;3511748- 1749
Link to Article
Franklin  SSGustin  WG  IVWong  ND  et al.  Hemodynamic patterns of age-related changes in blood pressure: the Framingham Study. Circulation. 1997;96308- 315
Link to Article
Darne  BGirerd  XSafar  MCambien  FGuize  L Pulsatile versus steady component of blood pressure: a cross-sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension. 1989;13392- 400
Link to Article
Fang  JMadhavan  SCohen  HAlderman  MH Measures of blood pressure and myocardial infarction in treated hypertensive patients. J Hypertens. 1995;13413- 419
Link to Article
Mitchell  GFMoyé  LABraunwald  E  et al.  Sphygmomanometrically determined pulse pressure is a powerful independent predictor of recurrent events after myocardial infarction in patients with impaired left ventricular function. Circulation. 1997;964254- 4260
Link to Article
Lee  MLRosner  BAWeiss  ST Relationship of blood pressure to cardiovascular death: the effects of pulse pressure in the elderly. Ann Epidemiol. 1999;9101- 107
Link to Article
Chae  CUPfeffer  MAGlynn  RJMitchell  GFTaylor  JOHennekens  CH Pulse pressure predicts congestive heart failure in the elderly. JAMA. 1999;281634- 639
Link to Article
Franklin  SSKhan  SAWong  NDLarson  MGLevy  D Is pulse pressure useful in predicting risk for coronary heart disease? the Framingham Heart Study. Circulation. 1999;100354- 360
Link to Article
Dyer  ARStamler  JShekelle  RB  et al.  Pulse pressure, III: prognostic significance in four Chicago epidemiologic studies. J Chronic Dis. 1982;35283- 294
Link to Article
Hypertension Detection and Follow-up Program Cooperative Group, Variability of blood pressure and the results of screening in the HDFP. J Chronic Dis. 1978;31651- 657
Link to Article
Rose  GABlackburn  HGillum  RFPrineas  RJ Cardiovascular Survey Methods  Geneva, Switzerland World Health Organization1982;162- 165
Branch  LGKatz  SKniepmann  K  et al.  A prospective study of functional status among community elderly. Am J Public Health. 1984;74266- 268
Link to Article
Rosow  IBreslau  N A Guttman health scale for the aged. J Gerontol. 1966;21556- 559
Link to Article
Cornoni-Huntley  JBrock  DBOstfeld  AM  et al.  Established Populations for Epidemiologic Studies of the Elderly: Resource Data Book  Bethesda, Md National Institutes of Health1986;NIH publication 86-2443
Glynn  RJField  TSSatterfield  S  et al.  Modification of increasing systolic blood pressure in the elderly during the 1980s. Am J Epidemiol. 1993;138365- 379
Glynn  RJBrock  DBHarris  T  et al.  Use of antihypertensive drugs and trends in blood pressure in the elderly. Arch Intern Med. 1995;1551855- 1860
Link to Article
World Health Organization, International Classification of Diseases, Ninth Revision (ICD-9)  Geneva, Switzerland World Health Organization1977;
Harrell  FE  JrLee  KLMark  DB Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996;15361- 387
Link to Article
Bulpitt  CJFletcher  AE Aging, blood pressure and mortality. J Hypertens Suppl. 1992;10 ((suppl 7)) S45- S49
Link to Article
Not Available, Build and Blood Pressure Study, 1959 Vol 1 Chicago, Ill Society of Actuaries1959;
Benetos  ASafar  MRudnichi  A  et al.  Pulse pressure: a predictor of long-term cardiovascular mortality in a French male population. Hypertension. 1997;301410- 1415
Link to Article
Neaton  JDWentworth  D Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med. 1992;15256- 64
Link to Article
The Pooling Project Research Group, Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to incidence of major coronary events: final report of the Pooling Project. J Chronic Dis. 1978;31201- 306
Link to Article
Milnor  WR Arterial impedance as ventricular afterload. Circ Res. 1975;36565- 570
Link to Article
Urschel  CWCovel  JWSonnenblick  EHRoss  JR  JrBraunwald  E Effects of decreased aortic compliance on performance of the left ventricle. Am J Physiol. 1968;214298- 304
Kelly  RPTunin  RKass  DA Effect of reduced aortic compliance on cardiac efficiency and contractile function of in situ canine left ventricle. Circ Res. 1992;71490- 502
Link to Article
Hori  MInoue  MKitakaze  M  et al.  Loading sequence is a major determinant of afterload-dependent relaxation in intact canine heart. Am J Physiol. 1985;249H747- H754
Kohno  FKumada  TKamabayashi  MHayashida  WIshikawa  NSasayama  S Change in aortic end-systolic pressure by alterations in loading sequence and its relation to left ventricular isovolumic relaxation. Circulation. 1996;932080- 2087
Link to Article
Watanabe  HOhtsuka  SKakihana  MSugishita  Y Coronary circulation in dogs with an experimental decrease in aortic compliance. J Am Coll Cardiol. 1993;211497- 1506
Link to Article
Kass  DASaeki  ATunin  RSRecchia  FA Adverse influence of systemic vascular stiffening on cardiac dysfunction and adaptation to coronary occlusion. Circulation. 1996;931533- 1541
Link to Article
Buckberg  GDFixler  DEArchie  JPHoffman  JIE Experimental subendocardial ischemia in dogs with normal coronary arteries. Circ Res. 1972;3067- 81
Link to Article
Girerd  XLaurent  SPannier  BAsmar  RSafar  M Arterial distensibility and left ventricular hypertrophy in patients with sustained essential hypertension. Am Heart J. 1991;1221210- 1214
Link to Article
Saba  PSRoman  MJPini  RSpitzer  MGanau  ADevereux  RB Relation of arterial pressure waveform to left ventricular and carotid anatomy in normotensive subjects. J Am Coll Cardiol. 1993;221873- 1880
Link to Article
Levy  DGarrison  RJSavage  DDKannel  WBCastelli  WP Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med. 1990;3221561- 1566
Link to Article
Farrar  DJBond  MGRiley  WASawyer  JK Anatomic correlates of aortic pulse wave velocity and carotid artery elasticity during atherosclerosis progression and regression in monkeys. Circulation. 1991;831754- 1763
Link to Article
Hirai  TSasayama  SKawasaki  TYagi  S Stiffness of systemic arteries in patients with myocardial infarction: a noninvasive method to predict severity of coronary atherosclerosis. Circulation. 1989;8078- 86
Link to Article
Witteman  JCMGrobbee  DEValkenberg  HA  et al.  J-shaped relation between change in diastolic blood pressure and progression of aortic atherosclerosis. Lancet. 1994;343504- 507
Link to Article
Lyon  RTRunyon-Hass  ADavis  HRGlagov  SZarins  CK Protection from atherosclerotic lesion formation by reduction of artery wall motion. J Vasc Surg. 1987;559- 67
Link to Article
Cheng  GCLoree  HMKamm  RDFishbein  MCLee  RT Distribution of circumferential stress in ruptured and stable atherosclerotic lesions: a structural analysis with histopathological correlation. Circulation. 1993;871179- 1187
Link to Article
Wilson  PWFD'Agostino  RBLevy  DBelanger  AMSilbershatz  HKannel  WB Prediction of coronary heart disease using risk factor categories. Circulation. 1998;971837- 1847
Link to Article
Amery  ABirkenhäger  WBrixko  P  et al.  Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet. 1985;11349- 1354
Link to Article
Coope  JWarrender  TS Randomised trial of treatment of hypertension in elderly patients in primary care. Br Med J (Clin Res Ed). 1986;2931145- 1151
Link to Article
SHEP Cooperative Research Group, Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;2653255- 3264
Link to Article
Dahlöf  BLindholm  LHHannson  LScherstén  BEkbom  TWester  P-O Morbidity and mortality in the Swedish Trial in Old Patients With Hypertension (STOP-Hypertension). Lancet. 1991;3381281- 1285
Link to Article
MRC Working Party, Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ. 1992;304405- 412
Link to Article
Staessen  JAFagard  RThijs  L  et al.  Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet. 1997;350757- 764
Link to Article
Bots  MLWitteman  JCHofman  Ade Jong  PTGrobbee  DE Low diastolic blood pressure and atherosclerosis in elderly subjects: the Rotterdam Study. Arch Intern Med. 1996;156843- 848
Link to Article
D'Agostino  RBBelanger  AJKannel  WBCruickshank  JM Relation of low diastolic blood pressure to coronary heart disease death in presence of myocardial infarction: the Framingham Study. BMJ. 1991;303385- 389
Link to Article
Mitchell  GFPfeffer  MAFinn  PVPfeffer  JM Equipotent antihypertensive agents variously affect pulsatile hemodynamics and regression of cardiac hypertrophy in spontaneously hypertensive rats. Circulation. 1996;942923- 2929
Link to Article
Latson  TWHunter  WCKatoh  NSagawa  K Effect of nitroglycerin on aortic impedance, diameter and pulse-wave velocity. Circ Res. 1988;62884- 890
Link to Article
Avolio  APClyde  KMBeard  TC  et al.  Improved arterial distensibility in normotensive subjects on a low salt diet. Arteriosclerosis. 1986;6166- 169
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 116

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles