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Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Pressure: An Evaluation of Their Joint Effect on Mortality

Roberto Pastor-Barriuso, PhD; José R. Banegas, MD, PhD; Javier Damián, MD, PhD; Lawrence J. Appel, MD, MPH; and Eliseo Guallar, MD, DrPH
[+] Article and Author Information

From National Center for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; Universidad Autónoma de Madrid, Madrid, Spain; and Johns Hopkins Medical Institutions, Baltimore, Maryland.


Grant Support: By a grant from the Instituto de Salud Carlos III (EPY 1261/02) (R. Pastor-Barriuso).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Eliseo Guallar, MD, DrPH, Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Room 2-639, Baltimore, MD 21205; e-mail, eguallar@jhsph.edu.

Current Author Addresses: Drs. Pastor-Barriuso and Damián: Epidemiology and Biostatistics Section, National Center for Epidemiology, Instituto de Salud Carlos III, Sinesio Delgado 6, 28029 Madrid, Spain.

Dr. Banegas: Department of Preventive Medicine and Public Health, Universidad Autónoma de Madrid, 28029 Madrid, Spain.

Dr. Appel: Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 East Monument Street, Room 2-630, Baltimore, MD 21205.

Dr. Guallar: Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions. 2024 East Monument Street, Room 2-639, Baltimore, MD 21205.

Author Contributions: Conception and design: R. Pastor-Barriuso, J.R. Banegas, J. Damián, E. Guallar.

Analysis and interpretation of the data: R. Pastor-Barriuso, J.R. Banegas, J. Damián, L.J. Appel, E. Guallar.

Drafting of the article: R. Pastor-Barriuso, J.R. Banegas, J. Damián, L.J. Appel, E. Guallar.

Critical revision of the article for important intellectual content: R. Pastor-Barriuso, J.R. Banegas, J. Damián, L.J. Appel, E. Guallar.

Final approval of the article: R. Pastor-Barriuso, J.R. Banegas, J. Damián, L.J. Appel, E. Guallar.

Statistical expertise: R. Pastor-Barriuso, E. Guallar.

Obtaining of funding: R. Pastor-Barriuso.

Administrative, technical, or logistic support: E. Guallar.


Ann Intern Med. 2003;139(9):731-739. doi:10.7326/0003-4819-139-9-200311040-00007
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From the initial 9250 participants in the NHANES II Mortality Follow-up Study, we excluded 1124 participants who had evidence of CVD at baseline, 146 participants with missing blood pressure values, and 150 participants who were not white or African American. Thus, the final study sample included 7830 individuals. Table 1 describes the characteristics of the study participants. Systolic blood pressure was highly correlated with diastolic blood pressure and pulse pressure in participants younger than 65 years of age and participants 65 years of age and older (Pearson correlation coefficients, 0.66 to 0.85), while diastolic blood pressure was weakly correlated with pulse pressure (Pearson correlation coefficients, 0.20 and 0.17 for participants <65 and ≥ 65 years of age, respectively). Follow-up extended from enrollment in 1976 to 1980 through 31 December 1992, with an average follow-up of 14.9 years among survivors (range, 12.8 to 16.9 years), and a total of 106 387 person-years of follow-up, 1588 all-cause deaths, and 582 CVD deaths.

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Figures

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Figure 1.
Risk surfaces for all-cause and cardiovascular mortality as a function of systolic and diastolic blood pressure by age group.

Surfaces were obtained by fitting simultaneous nonparametric terms for systolic and diastolic blood pressure in generalized additive logistic models. Breaks in gray scale are determined by the risk levels labeled in each vertical axis. Adjusted for age, sex, race or ethnicity, smoking, total cholesterol level, body mass index, education, use of antihypertensive medications, and history of diabetes. The surfaces represent the relative risk for all-cause and cardiovascular mortality for each combination of systolic and diastolic blood pressure. For a fixed diastolic blood pressure, the effect of systolic blood pressure can be evaluated by following the risk surface along lines parallel to the systolic blood pressure axis. This effect, known as the conditional effect of systolic blood pressure, can also be interpreted as the effect of increasing pulse pressure by increasing systolic blood pressure and holding diastolic blood pressure constant. Similarly, for a fixed systolic blood pressure, the conditional effect of diastolic blood pressure can be evaluated by following the risk surface along lines parallel to the diastolic blood pressure axis. This effect corresponds to the effect of decreasing pulse pressure by increasing diastolic blood pressure and holding systolic blood pressure constant.

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Figure 2.
Blood pressure and relative risk for all-cause and cardiovascular mortality among participants younger than 65 years of age.solid linesdashed lines

Risk trends were estimated from linear ( ) and nonparametric logistic models ( ) adjusted for age, sex, race or ethnicity, smoking, total cholesterol level, body mass index, education, use of antihypertensive medications, and history of diabetes. The bars represent the frequency distribution of systolic, diastolic, and pulse pressure among study participants younger than 65 years of age.

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Figure 3.
Blood pressure and relative risk for all-cause and cardiovascular mortality among participants 65 years of age or older.solid linesdashed lines

Risk trends were estimated from linear or transition logistic models ( ) and nonparametric logistic models ( ) adjusted for age, sex, race or ethnicity, smoking, total cholesterol level, body mass index, education, use of antihypertensive medications, and history of diabetes. The bars represent the frequency distribution of systolic, diastolic, and pulse pressure among study participants 65 years of age or older.

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Summary for Patients

Effects of Blood Pressure Measurements on Mortality

The summary below is from the full report titled “Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Pressure: An Evaluation of Their Joint Effect on Mortality.” It is in the 4 November 2003 issue of Annals of Internal Medicine (volume 139, pages 731-739). The authors are R. Pastor-Barriuso, J.R. Banegas, J. Damián, L.J. Appel, and E. Guallar.

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