Pulse Pressure: A Help in Medical Semiology for Metabolic Syndrome

Since the first publications on pulse pressure (PP),1,2 it is more and more accepted that this parameter is a strong independent cardiovascular (CV) risk factor, more powerful than systolic or diastolic blood pressure (BP) alone, at least in the elderly population.3 However, increased PP is much more useful to determine for medical semiology. In the present issue of the American Journal of Hypertension, a simple clinical application of PP measurement is provided by the study of Mulé et al.4 In a large population of untreated hypertensive subjects, Mulé and al4 measured BP with both clinical mercury sphygmomanometer and 24-h ambulatory measurements. The population was divided into two groups, with or without metabolic syndrome (MS). The investigators found that subjects with MS had significantly higher values of PP, independent of measurement method, presence (or not) of white coat hypertension, the level of mean arterial pressure, and other confounding variables. Mostly, PP was higher in subjects with MS than in subjects without MS at any given value of age, but only in the second and third age tertile of the total population. Due to MS, the finding suggests a particular severity of the evolution. Thus, it is evident that, using this very simple evaluation, the selection of the hypertensive population, and therefore the quality of treatment, may be consistently improved. In the recent years, a number of guidelines have been published to clarify the treatment of hypertension, but the selection of drug treatment is much more difficult to establish in subjects with severe hypertension, particularly those with MS. In such subjects, an increased arterial stiffness is present and mediated by three different factors: age, mean arterial pressure, and importance of metabolic disorders. The latter factor is quite important to consider because it is responsible for endothelium and nitric oxide (NO) dysfunction, with resulting increase in oxidative stress. From this view point, the Reason study5 had compared in hypertensive subjects the effectiveness of the β-blocking agent atenolol to the angiotensin-converting enzyme inhibitor perindopril (Per) given in association with a small dosage of the diuretic indapamide (Ind). It was shown that, after 1 year of drug treatment, for the same reduction in mean and diastolic BP, Per/Ind reduced more systolic BP and PP than atenolol. The result was observed both at the site of the brachial and the central (carotid) arteries. This characteristic BP pattern is preserved even in the presence of MS (Table 1). Moreover, under drug treatment, the reduction of central PP is not only more pronounced with Per/Ind than with atenolol, but this difference is even more accentuated in subjects with MS than in subjects without MS (Fig. 1). This finding, not observed using only carotid systolic BP, clearly shows that the medical semiology of PP may be routinely useful in the chronic treatment of subjects with hypertension. Double blind comparison for 1 year between the β-blocking agent atenolol and the combination of the angiotensin-converting enzyme perindopril (PER) associated to low doses of the diuretic indapamide (unpublished data of the reason study 5). Effects on brachial BP are studied in subjects with essential hypertension. Treated groups are divided into two groups according to the presence or absence of metabolic syndrome (MS)4 using a two-way analysis of variance. Results are adjusted to age, gender, previous antihypertensive therapy, and baseline values, if necessary. Adjusted absolute means +/− standard errors (SE) of means are presented for M0 (baseline), M12 (end of follow-up), and change from baseline (Δ). Intergroup comparisons using a general linear model procedure and two-way analysis of variance. Double blind comparison for 1 year between the β-blocking agent atenolol and the combination of the angiotensin-converting enzyme perindopril (PER) associated to low doses of the diuretic indapamide (unpublished data of the reason study 5). Effects on brachial BP are studied in subjects with essential hypertension. Treated groups are divided into two groups according to the presence or absence of metabolic syndrome (MS)4 using a two-way analysis of variance. Results are adjusted to age, gender, previous antihypertensive therapy, and baseline values, if necessary. Adjusted absolute means +/− standard errors (SE) of means are presented for M0 (baseline), M12 (end of follow-up), and change from baseline (Δ). Intergroup comparisons using a general linear model procedure and two-way analysis of variance.