Achieved Diastolic BP and Pulse Pressure at Target Systolic BP

Study Questions:

What is the association between mean attained diastolic blood pressure (DBP) and cardiovascular (CV) outcomes in patients who achieved an on-treatment systolic BP (SBP) in the range of 120 to <140 mm Hg?


The investigators analyzed the outcome data from patients ages ≥55 years with CV disease from the ONTARGET and TRANSCEND trials that randomized high-risk patients to ramipril, telmisartan, and the combination. In patients with controlled SBP (on-treatment 120 to <140 mm Hg), the composite outcome of CV death, myocardial infarction (MI), stroke, and hospital admission for heart failure (HF); the components thereof; and all-cause mortality were analyzed according to mean on-treatment DBP as categorical (<70, 70 to <80, 80 to <90, and ≥90 mm Hg) and continuous variable as well as the change of DBP according to baseline DBP. Pulse pressure (PP) was related to outcomes as a continuous variable. Yearly event rates for all outcomes were analyzed by DBP categories and tested for differences using Cox regression, adjusting for baseline patient characteristics.


In 16,099 of 31,546 patients, mean achieved SBP was 120 to <140 mm Hg. The nominally lowest risk for all outcomes was observed at an achieved DBP of 70 to <80 mm Hg. A higher achieved DBP was associated with a higher risk for the outcomes of stroke and of hospitalization for HF (≥80 mm Hg) and MI (≥90 mm Hg). A lower achieved DBP (<70 mm Hg) was associated with a higher risk for the primary outcome (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.15-1.45; p < 0.0001), MI (HR, 1.54; 95% CI, 1.26-1.88, p < 0.0001), and hospitalization for HF (HR, 1.81; 95% CI, 1.47-2.24; p < 0.0001) and all-cause death (HR, 1.19; 95% CI, 1.04-1.35; p < 0.0001), while there was no signal for stroke and CV death compared to DBP 70 to <80 mm Hg. A decrease of DBP was associated with lower risk when baseline DBP was >80 mm Hg. The associations to outcomes were similar when patients were divided to SBP 120 to <130 mm Hg or 130 to <140 mm Hg for DBP or PP.


The authors concluded that compared to a DBP of 70 to <80 mm Hg, lower and higher DBP was associated with a higher risk in patients achieving a SBP of 120 to <140 mm Hg.


This study reports that the lowest risk among patients with optimal SBP (120 to <140 mm Hg) was noted with a mean DBP 70 to <80 mm Hg, whereas risk increased for the primary outcome of MI, stroke, HF hospitalization, and total death both at lower (<70 mm Hg) and higher (≥80 mm Hg) DBP. The present findings might have important clinical implications. Since DBP follows SBP when BP-lowering therapies are initiated, it might be important for future guidelines to not only focus solely on upper boundaries, but also to define lower boundaries of SBP and DBP, below which risk is increased. Additional studies are indicated to assess whether such precise adjustments of SBP and DBP are feasible in real-world practice at all, and whether such adjustments would provide further benefit for patients with pre-existing CV disease.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Blood Pressure, Diastole, Heart Failure, Hypertension, Myocardial Infarction, Primary Prevention, Ramipril, Risk, Stroke, Systole, Treatment Outcome, Vascular Diseases

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