Pulse pressure: Is this a clinically useful risk factor?

Again, the Framingham group has provided another surprise to the medical community with publication of its longitudinal follow-up study of persons over 50 years of age that has linked cardiovascular (and in particular coronary) mortality with pulse pressure.1 In this study, mortality was related independently with initial systolic, diastolic, and pulse pressure, but the strongest association was with pulse pressure, and when systolic pressure was initially considered, there was a negative association with diastolic pressure. In other words, for a given systolic pressure, lower diastolic pressure was associated with greater mortality. A series of questions arise from this study. What corroboration does it have from other studies on similar cohorts? How does one reconcile the findings with the wellestablished association of coronary and stroke mortality with diastolic pressure?2,3 What possible mechanism can explain a greater association between coronary mortality and greater pulse pressure (or lower diastolic pressure)? And above all, what implications does this study have to patient management?