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Am Fam Physician. 2004;70(1):194

Widening of the pulse pressure (systolic minus diastolic blood pressure) is common after 60 years of age. Widening occurs because of a rise in systolic blood pressure and a drop in diastolic blood pressure in this age group. In the elderly, pulse pressure has been shown to be a predictor for adverse cardiovascular events. These events occurred even after adjustments were made for blood pressure level. Beta blockers and diuretics are the initial recommended treatment for hypertension. Several classes of antihypertensive medications are available to treat this condition. Each of these classes has been shown to reduce blood pressure and improve cardiovascular outcome, but no studies have evaluated the effect of these medications on pulse pressure. The purpose of a study undertaken by Chang and associates was to determine if differences in pulse pressure among elderly patients were associated with the use of different antihypertensive medications.

Data were collected from the Third National Health and Nutrition Examination Survey (NHANES III), which was a national assessment of health and nutritional status for the United States. The data were obtained by trained staff who administered a detailed questionnaire about the participants’ health and nutrition status in the participants’ homes. Resting pulse rate and three blood pressure measurements were recorded during the visit. The average of the three blood pressure readings was used as the recorded blood pressure, and the pulse pressure and mean arterial pressure were calculated on the basis of this average. Information was obtained about the classes of hypertensive medications the patients were currently using, and the medications were categorized as beta blockers, diuretics, calcium channel blockers, or angiotensin-converting enzyme (ACE) inhibitors. Other data included in the analysis were age, sex, lifetime history of smoking more than 100 cigarettes, race or ethnicity, total family income, and the presence of self-reported diabetes. The study analyzed cross-sectional data for participants who were 60 years and older and who were taking one or two of the antihypertensive medications.

The study included 1,429 persons who met the inclusion criteria. In the whole group, results showed no significant differences in pulse pressure measurements among the four medication classes. When assessing the impact of age on the results, the study found that patients older than 72 years who were taking diuretics alone or in combination with beta blockers had a significant reduction in pulse pressures compared with patients who used beta blockers alone. Mean pulse pressures were higher in patients taking a combination of calcium channel blockers and ACE inhibitors. In men, ACE inhibitors alone or in combination with diuretics provided lower mean pulse pressures compared with the beta blocker-only group.

The authors conclude that older hypertensive patients who take diuretics alone or in combination with beta blockers have lower mean pulse pressures compared with patients who only use beta blockers. In older men, ACE inhibitors alone or in combination with diuretics may be more effective in lowering mean pulse pressures. The authors add that this study supports the current recommendations for use of diuretics in elderly patients with hypertension.

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