Pulse pressure as a risk factor.

There is abundant evidence that the increase in pulse pressure (PP) after the sixth decade of life is a surrogate risk marker for central artery stiffness. There is also evidence that central artery stiffness is an independent risk factor for cardiovascular disease. Still unsettled, however, is whether PP, the difference between systolic (SBP) and diastolic blood pressure (DBP), is superior to SBP or mean arterial pressure (MAP) as a predictor of cardiovascular risk. This controversy has been highlighted with the recent publication of the Prospective Studies Collaboration (PSC), which concluded that MAP at any age was a far superior predictor of risk than PP. Several lines of evidence that call into question the conclusions of the PSC, including the role of pulse wave reflection, are reviewed. Pulse pressure may be useful in predicting risk in the presence of both normal and compromised cardiac function. In addition, PP may be useful in predicting benefit of antihypertensive drug therapy. Finally, the advantages and disadvantages of using PP as a predictor of cardiovascular risk are reviewed and it is concluded that public health recommendations should remain focused on SBP as the overall prime target for defining risk and goal therapy.