Pulse pressure: Difference between revisions

{{short description|Difference between  systolic  and  diastolic  blood pressure}}

'''Pulse pressure''' is the difference between [[systole|systolic]] and [[diastole|diastolic]] [[blood pressure]].<ref name="Homan Cichowski 2019">{{cite book | vauthors = Homan TD, Bordes SJ, Cichowski E | chapter = Physiology, Pulse Pressure | date = 12 July 2022 | title = StatPearls [Internet]. | location = Treasure Island (FL) | publisher = StatPearls Publishing | pmid = 29494015 | chapter-url = https://www.ncbi.nlm.nih.gov/books/NBK482408/ | via = NCBI Bookshelf | access-date = 2019-07-21 }}</ref> It is measured in [[Millimeter of mercury|millimeters of mercury]] (mmHg). It represents the force that the heart generates each time it contracts. Healthy pulse pressure is around 40 &nbsp;mmHg.<ref name="Homan Cichowski 2019"/><ref name="pmid21848774">{{cite journal | vauthors = Liaw SY, Scherpbier A, Klainin-Yobas P, Rethans JJ | title = A review of educational strategies to improve nurses' roles in recognizing and responding to deteriorating patients | journal = International Nursing Review | volume = 58 | issue = 3 | pages = 296–303 | date = September 2011 | pmid = 21848774 | doi = 10.1111/j.1466-7657.2011.00915.x }}</ref> A pulse pressure that is consistently 60 &nbsp;mmHg or greater is likely to be associated with disease, and a pulse pressure of 50 &nbsp;mmHg or more increases the risk of [[cardiovascular disease]].<ref name="Homan Cichowski 2019"/><ref name="Cleveland Clinic 2021">{{cite web |url=https://my.clevelandclinic.org/health/symptoms/21629-pulse-pressure |title= Pulse pressure |author=<!--Not stated--> |date=28 July 2021 |publisher=Cleveland Clinic |access-date=10 February 2023 |quote=If you check your blood pressure regularly and notice you have an unusually wide (60 &nbsp;mmHg or more) or narrow pulse pressure (where your pulse pressure is less than one-quarter of the top blood pressure number), you should schedule an appointment with your healthcare provider to talk about it. [...] Pulse pressures of 50 &nbsp;mmHg or more can increase your risk of heart disease, heart rhythm disorders, stroke and more. Higher pulse pressures are also thought to play a role in eye and kidney damage from diseases like diabetes. }}</ref> Pulse pressure is considered low if it is less than 25% of the systolic. (For example, if the systolic pressure is 120 &nbsp;mmHg, then the pulse pressure would be considered low if it is less than 30 &nbsp;mmHg, since 30 is 25% of 120.)<ref name="pmid21848774"/> A very low pulse pressure can be a symptom of disorders such as [[congestive heart failure]].<ref name="Cleveland Clinic 2021"/>

:e.g. normal 120mmHg15mmHg - 80mmHg8mmHg = 40mmHg<ref name="Cleveland Clinic 2021"/>7mmHg

:high low: 107mmHg25mmHg - 80mmHg10mmHg = 27mmHg 15mmHg

A pulse pressure is considered abnormally low if it is less than 25% of the systolic value.<ref name="pmid21848774"/> If the pulse pressure is extremely low, i.e. 25 &nbsp;mmHg or less, it may indicate low stroke volume, as in [[congestive heart failure]].<ref name="Cleveland Clinic 2021"/>

A pulse pressures of 50 &nbsp;mmHg or more can increase the risk of heart disease, heart rhythm disorders, stroke and other cardiovascular diseases and events. Higher pulse pressures are also thought to play a role in eye and kidney damage from diseases such as diabetes.<ref name="Cleveland Clinic 2021"/> There are currently no drugs approved to lower pulse pressure, but some [[antihypertensive drugsdrug]]s have been shown to modestly lower pulse pressure, while other drugs used for [[hypertension]] can actually have the counterproductive side effect of increasing resting pulse pressure.<ref name="cushman" />

Other conditions that can lead to a high pulse pressure include [[aortic regurgitation]],<ref name=Tang2020/>, [[aortic sclerosis]], severe [[iron-deficiency anemia]] (due to decreased [[blood viscosity]]), [[arteriosclerosis]] (due to loss of arterial compliance), and [[hyperthyroidism]]<ref name=Tang2020/> (due to increased systolic pressure), or [[arteriovenous malformation]], among others.<ref name=":0" /> In aortic regurgitation, the aortic valve insufficiency results in the backward flow of blood (regurgitation) that is ejected during systole, and its return to the left ventricle of the aorta during diastole. This increases the systolic blood pressure, and decreases the diastolic blood pressure, leading to a widened pulse pressure.<ref name=":0" /><ref name="Cleveland Clinic 2021" />

* [[Atherosclerosis]]<ref name="Tang2020">{{cite journal |last1=Tang |first1=KS |last2=Medeiros |first2=ED |last3=Shah |first3=AD |title=Wide pulse pressure: A clinical review. |journal=Journal of clinicalClinical hypertensionHypertension (Greenwich, Conn.) |date=November 2020 |volume=22 |issue=11 |pages=1960-19671960–1967 |doi=10.1111/jch.14051 |pmid=32986936 |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8029839/ |access-date=29 March8029839 2024}}</ref>

* [[Pregnancy]]<ref name=Tang2020/>

Awareness of the effects of pulse pressure on morbidity and mortality is lacking relative to the awareness of the effects of elevated systolic and diastolic blood pressure. However, pulse pressure has consistently been found to be a stronger independent predictor of cardiovascular events, especially in older populations, than has systolic, diastolic, or mean arterial pressure.<ref name="Cleveland Clinic 2021"/><ref name="Mitchell Izzo Lacourcière Ouellet 2002 pp. 2955–2961"/> This increased risk existshas forbeen observed in both men and women and even when no other cardiovascular risk factors are present. The increased risk also exists even in cases in which high pulse pressure is caused by diastolic pressure decreasing over time while systolic remains steady or even slightly decreases.<ref name="Franklin Khan Wong Larson 1999 pp. 354–360">{{cite journal | last1=Franklin | first1=Stanley S. | last2=Khan | first2=Shehzad A. | last3=Wong | first3=Nathan D. | last4=Larson | first4=Martin G. | last5=Levy | first5=Daniel | title=Is Pulse Pressure Useful in Predicting Risk for Coronary Heart Disease? | journal=Circulation | publisher=Ovid Technologies (Wolters Kluwer Health) | volume=100 | issue=4 | date=27 Jul 1999 | issn=0009-7322 | doi=10.1161/01.cir.100.4.354 | pages=354–360| pmid=10421594 | doi-access=free }}</ref><ref name="Benetos Safar Rudnichi Smulyan 1997 pp. 1410–1415"/>

A [[meta-analysis]] in 2000 showed that a 10&nbsp;mmHg increase in pulse pressure was associated with a 20% increased risk of cardiovascular mortality, and a 13% increase in risk for all coronary end points. The study authors also noted that, while risks of cardiovascular end points do increase with higher systolic pressures, at any given systolic blood pressure the risk of major cardiovascular end points increases, rather than decreases, with lower diastolic levels.<ref name = "pulse pressure not mean">{{cite journal | vauthors = Blacher J, Staessen JA, Girerd X, Gasowski J, Thijs L, Liu L, Wang JG, Fagard RH, Safar ME | display-authors = 6 | title = Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients | journal = Archives of Internal Medicine | volume = 160 | issue = 8 | pages = 1085–1089 | date = April 2000 | pmid = 10789600 | doi = 10.1001/archinte.160.8.1085 | doi-access = free }}</ref> This suggests that interventions that lower diastolic pressure without also lowering systolic pressure (and thus lowering pulse pressure) could actually be counterproductive. Increased pulse pressure is also a risk factor for the development of [[atrial fibrillation]].<ref name="staerk">{{cite journal |vauthors=Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH |title=Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes |journal=Circulation Research |volume=120 |issue=9 |pages=1501–1517 |date=April 2017 |pmid=28450367 |pmc=5500874 |doi=10.1161/CIRCRESAHA.117.309732 |url=}}</ref><ref name=":0" />

There are no drugs currently approved to lower pulse pressure,. althoughAlthough some anti-hypertensive drugs currently on the market may have the effect of modestly lowering pulse pressure, while others may actually have the counterproductive effect of increasing pulse pressure. Among classes of drugs currently on the market, a 2020 review stated that [[thiazide diuretics]] and long‐acting [[Nitrate#Medicine|nitrates]] are the two most effective at lowering pulse pressure.<ref name=Tang2020/>

It has been hypothesized that vasopeptidase inhibitors and [[nitric oxide donors]] may be useful at lowering pulse pressure in patients with elevated pulse pressure by increasing the distensibility of the large arteries.<ref name = "pulse pressure not mean"/><ref name="Mitchell Izzo Lacourcière Ouellet 2002 pp. 2955–2961">{{cite journal | last1=Mitchell | first1=Gary F. | last2=Izzo | first2=Joseph L. | last3=Lacourcière | first3=Yves | last4=Ouellet | first4=Jean-Pascal | last5=Neutel | first5=Joel | last6=Qian | first6=Chunlin | last7=Kerwin | first7=Linda J. | last8=Block | first8=Alan J. | last9=Pfeffer | first9=Marc A. | title=Omapatrilat Reduces Pulse Pressure and Proximal Aortic Stiffness in Patients With Systolic Hypertension | journal=Circulation | publisher=Ovid Technologies (Wolters Kluwer Health) | volume=105 | issue=25 | date=25 Jun 2002 | issn=0009-7322 | doi=10.1161/01.cir.0000020500.77568.3c | pages=2955–2961| pmid=12081987 | s2cid=7092379 }}</ref> There is evidence that [[glyceryl trinitrate]], a nitric oxide donor, may be effective at lowering both pulse pressure and overall blood pressure in patients with acute and sub-acute stroke.<ref name="Gray Sprigg Rashid Willmot 2006 j585">{{cite journal | last1=Gray | first1=LJ | last2=Sprigg | first2=N | last3=Rashid | first3=PA | last4=Willmot | first4=MR | last5=Bath | first5=PM | title=Effect of nitric oxide donors on blood pressure and pulse pressure in acute and subacute stroke | journal=Journal of Stroke and Cerebrovascular Diseases | publisher=Centre for Reviews and Dissemination (UK) | date=2006 | volume=15 | issue=6 | pages=245–249 | doi=10.1016/j.jstrokecerebrovasdis.2006.06.002 | pmid=17904083 | url=https://www.ncbi.nlm.nih.gov/books/NBK73056/ | access-date=18 Nov 2023}}</ref>

A 2001 randomized, placebo-controlled trial of 1,292 males, compared the effects of [[hydrochlorothiazide]] (a [[thiazide diuretic]]), [[atenolol]] (a [[beta-blocker]]), [[captopril]] (an [[ACE inhibitor]]), [[clonidine]] (a central [[alpha-2 agonist|α{{sub|2}}-agonist]]), [[diltiazem]] (a [[calcium channel blocker]]), and [[prazosin]] (an [[Alpha-1 blocker|α{{sub|1}}-blocker]]) on pulse pressure and found that, after one year of treatment, hydrochlorothiazide was the most effective at lowering pulse pressure, with an average decrease of 8.6&nbsp;mm HgmmHg. Captopril and atenolol were equal as least effective, with an average decrease of 4.1&nbsp;mm HgmmHg. Clonidine (decrease of 6.3&nbsp;mm HgmmHg), diltiazem (decrease of 5.5&nbsp;mm HgmmHg), and prazosin (decrease of 5.0&nbsp;mm HgmmHg) were intermediate.<ref name="cushman">{{cite journal |last1=Cushman |first1=William C. |last2=Materson |first2=Barry J. |last3=Williams |first3=David W. |last4=Reda |first4=Domenic J. |date=1 Oct 2001 |title=Pulse Pressure Changes With Six Classes of Antihypertensive Agents in a Randomized, Controlled Trial |journal=Hypertension |volume=38 |issue=4 |pages=953–957 |doi=10.1161/hy1001.096212|pmid=11641316|s2cid=19241872 |doi-access=free }}</ref>

Diastolic blood pressure falls during the early stages of [[sepsis]], causing a widening of pulse pressure. If sepsis becomes severe and [[hemodynamic]] compromise advances, the systolic pressure also decreases, causing a narrowing of pulse pressure.<ref name=pedsepsis>{{cite journal |vauthors=Khilnani P, Singhi S, Lodha R, Santhanam I, Sachdev A, Chugh K, Jaishree M, Ranjit S, Ramachandran B, Ali U, Udani S, Uttam R, Deopujari S |date=January 2010 |title=Pediatric Sepsis Guidelines: Summary for resource-limited countries |journal=Indian J Crit Care Med |volume=14 |issue=1 |pages=41–52 |doi=10.4103/0972-5229.63029 |pmc=2888329 |pmid=20606908 |doi-access=free }}</ref> A pulse pressure of over 70 &nbsp;mmHg in patients with sepsis is correlated with an increased chance of survival. A widened pulse pressure is also correlated with an increased chance that someone with sepsis will benefit from and respond to [[Fluid replacement#Intravenous|IV fluids]].<ref name=widesepsis>{{cite journal |vauthors=Al-Khalisy H, Nikiforov I, Jhajj M, Kodali N, Cheriyath P |date=11 December 2015 |title=A widened pulse pressure: a potential valuable prognostic indicator of mortality in patients with sepsis. |journal=J Community Hosp Intern Med Perspect |volume=5 |issue=6 |page=29426 |doi=10.3402/jchimp.v5.29426 |pmc=4677588 |pmid=26653692 }}</ref>