BACKGROUND: The role of pulse pressure (PP) 'widening' at older and younger age as a cardiovascular risk factor is still controversial. Mean PP, as determined from repeated blood pressure (BP) readings, can be expressed as a sum of two components: 'elastic PP' (elPP) and 'stiffening PP' (stPP) associated, respectively, with stiffness at the diastole and its relative change during the systole. We investigated the association of 24-h ambulatory PP, elPP, and stPP ('PP variables') with mortality and composite cardiovascular events in different age classes. METHOD: Longitudinal population-based cohort study of adults with baseline observations that included 24-h ambulatory BP. Age classes were age 40 or less, 40-50, 50-60, 60-70, and over 70 years. Co-primary endpoints were total mortality and composite cardiovascular events. The relative risk expressed by hazard ratio per 1SD increase for each of the PP variables was calculated from multivariable-adjusted Cox regression models. RESULTS: The 11 848 participants from 13 cohorts (age 53 ± 16 years, 50% men) were followed for up for 13.7 ± 6.7 years. A total of 2946 participants died (18.1 per 1000 person-years) and 2093 experienced a fatal or nonfatal cardiovascular event (12.9 per 1000 person-years). Mean PP, elPP, and stPP were, respectively, 49.7, 43.5, and 6.2 mmHg, and elPP and stPP were uncorrelated ( r = -0.07). At age 50-60 years, all PP variables displayed association with risk for almost all outcomes. From age over 60 years to age over 70 years, hazard ratios of of PP and elPP were similar and decreased gradually but differently for pulse rate lower than or higher than 70 bpm, whereas stPP lacked predictive power in most cases. For age 40 years or less, elPP showed protective power for coronary events, whereas stPP and PP predicted stroke events. Adjusted and unadjusted hazard ratio variations were similar over the entire age range. CONCLUSION: This study provides a new basis for associating PP components with outcome and arterial properties in different age groups and at different pulse rates for both old and young age. The similarity between adjusted and unadjusted hazard ratios supports the clinical usefulness of PP components but further studies are needed to assess the prognostic significance of the PP components, especially at the young age.

1st Department of Cardiology Interventional Electrocardiology and Hypertension Jagiellonian University Medical College Kraków Poland

Asociación Española Primera de Socorros Mutuos Montevideo Uruguay

Biomedical Science Group University of Leuven Leuven Belgium

Centro de Nefrología and Departamento de Fisiopatología Hospital de Clínicas Universidad de la República Montevideo Uruguay

Conway Institute University College Dublin Dublin Ireland

Department of Cardiology Shanghai General Hospital Shanghai Jiao Tong University School of Medicine Shanghai China

Department of Cardiovascular Medicine Shanghai Institute of Hypertension Shanghai Key Laboratory of Hypertension China

Department of Hygiene and Public Health Teikyo University School of Medicine Tokyo

Department of Hypertension Medical University of Gdañsk Gdañsk Poland

Department of Medicine University of Padova Padova Italy

Department of Neurosciences and Department of Human Genetics University of Texas Rio Grande Valley School of Medicine Brownsville Texas USA

Faculty of Medicine Charles University Pilsen Czech Republic

Faculty of Medicine Hebrew University Jerusalem Hypertension Clinic Hadassah Medical Center Mount Scopus Jerusalem and Department of Medicine D Beilinson Hospital Petach Tikva Israel

Institute of Internal and Preventive Medicine Internal and Preventive Medicine Branch of the Institute of Cytology and Genetics Siberian Branch of the Russian Academy of Science Novosibirsk Russian Federation

Laboratory of Neurosciences Faculty of Medicine University of Zulia Maracaibo Zulia Venezuela

Research Institute Alliance for the Promotion of Preventive Medicine Mechelen

Research Unit Hypertension and Cardiovascular Epidemiology KU Leuven Department of Cardiovascular Sciences University of Leuven Leuven Belgium

Section of Geriatrics Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden

Steno Diabetes Center Copenhagen Gentofte and Research Centre for Prevention and Health Capital Region of Denmark Denmark

Stroke and Hypertension Unit Blanchardstown Dublin Ireland

Tohoku Institute for Management of Blood Pressure Sendai Japan

Yazmonit Ltd Jerusalem Israel

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