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March 11, 2002

The Changing Face of Hypertension: Is Systolic Blood Pressure the Final Answer?

Arch Intern Med. 2002;162(5):506-508. doi:10.1001/archinte.162.5.506

ALTHOUGH HYPERTENSION has been recognized as a risk factor for cardiovascular disease (CVD) for more than a century, there has been an ongoing debate regarding the relative importance of various components of blood pressure (BP) in predicting the future risk of CVD. Ever since its inception, there has been changing opinion regarding the importance of diastolic blood pressure (DBP) vs systolic blood pressure (SBP). With the development of the sphygmomanometer, it became fanciful for experts to measure DBP. In the early 1900s, it was thought that higher SBP represented cardiac strength whereas elevated DBP reflected increased peripheral resistance, the load to which heart and vasculature were exposed in a constant manner and hence increase in DBP was considered deleterious to the heart. Furthermore, because DBP measurement was more reproducible, it was chosen as the primary parameter for diagnosing and staging of hypertension as well as the main target for therapy in most clinical trials. However, beginning with the report of the Framingham Study more than 30 years ago, a number of additional studies during the past 2 decades have challenged the traditional focus on DBP for predicting the risk of CVD.1-25 The results of these studies had demonstrated that both SBP and pulse pressure (PP) are better predictors of CVD than DBP.1-26 Although for a long time these data were ignored in favor of maintaining the preeminence of DBP, based on the strength of available evidence, the recent clinical advisory statement from the National High Blood Pressure Education Program has recommended that SBP become the major criterion for diagnosis, staging, and therapeutic management of hypertension, particularly in middle-aged and elderly Americans.27

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