Arterial Stiffness and Hypertension

Pathophysiology

• Age-related degenerative changes lead to increased arterial stiffness due to thinning, fragmentation, and fracture of elastin fibers, and increased collagen deposition in arteries, contributing to increased arterial stiffness, with endothelial dysfunction also contributing to increased arterial rigidity, particularly in elderly persons 1

Diagnosis and Risk Assessment

• Increased arterial stiffness is a better predictor of adverse cardiovascular outcomes than systolic or diastolic BP alone in some studies, identifying patients with systolic hypertension who are at high risk, with pulse pressure serving as a significant cardiovascular risk marker, calculated by subtracting diastolic blood pressure from systolic blood pressure, with normal values around 40 mmHg in adults 2, 3

Management

• The European Society of Cardiology recommends aiming for systolic BP <140 mmHg (and diastolic BP <90 mmHg) in all hypertensive patients, with the American College of Cardiology recommending a general target blood pressure of <140/90 mmHg, and <130/80 mmHg for patients with diabetes, chronic kidney disease, or established cardiovascular disease 2, 4, 5
• Medications that preferentially reduce arterial stiffness, such as calcium channel blockers, beta-blockers, thiazide diuretics, and long-acting nitrates, may be beneficial in reducing pulse pressure, with the American College of Cardiology and European Society of Cardiology recommending considering pulse pressure when identifying elderly patients with systolic hypertension who are at high risk 1, 3, 4
• Elevated pulse pressure is associated with increased all-cause mortality, cardiovascular events, and coronary disease, with a 60% mortality rate for pulse pressure ≥100 mmHg in chronic hemodialysis patients, and each 10 mmHg increase in pulse pressure associated with an 8% increase in relative risk for all-cause mortality in non-diabetic patients, according to the European Society of Cardiology and American College of Cardiology 6, 3, 7, 8
• Central pulse pressure may provide a more precise assessment than peripheral pulse pressure, with the European Society of Cardiology noting that ignoring age differences in wide pulse pressure is a potential pitfall, as it has different prognostic significance in younger versus older patients, and excessive diastolic blood pressure reduction may compromise coronary perfusion, especially in elderly patients or those with coronary artery disease 3, 9, 1, 5

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