Low Diastolic Ambulatory Blood Pressure Is Associated with Greater All-Cause Mortality in Older Patients with Hypertension Andrea Ungar, MD, PhD, à Giuseppe Pepe, MD, PhD, à Lorella Lambertucci, MD, à Angela Fedeli, MD, à Matteo Monami, MD, w Edoardo Mannucci, MD, w Luciano Gabbani, MD, w Giulio Masotti, MD, à Niccolo ` Marchionni, MD, w and Mauro Di Bari, MD, PhD w OBJECTIVES: To assess the relationship between office and ambulatory systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) and total mortality in elderly patients with hypertension. DESIGN: Observational prospective cohort study. SETTING: Hypertension outpatient clinic in a geriatric academic hospital. PATIENTS AND METHODS: Eight hundred five older ( 60) subjects with hypertension underwent office and ambulatory BP measurement. Mortality was assessed after a mean follow-up of 3.8 years. RESULTS: In a total of 3,090 person-years of follow-up, 107 participants died (average mortality rate 3.5% per year). With bivariate analysis, participants who died had higher SBP and PP and lower DBP, with office and ambu- latory measurements. Mortality rates were greater with higher SBP and lower with higher DBP. As a combined effect of these trends, PP was associated with the widest death rate gradients, from 12 to 66, 13 to 63, and 9 to 70 per 1,000 person-years across office, 24-hour, daytime, and nighttime PP quartiles, respectively. Multivariate Cox analysis con- firmed these trends; the adjusted hazard of death increased linearly with increasing ambulatory SBP and PP, whereas it decreased significantly with increasing ambulatory DBP. A five times greater risk of death was detected when comparing night-time PP quartile 4 (median PP value 78mmHg) with quartile 1 (median PP value 46mmHg). CONCLUSION: In older patients with hypertension, low DBP and high PP, particularly when measured using ambulatory BP monitoring, are associated with greater risk of death. The achievement of an SBP treatment goal should not be obtained at the expense of an excessive DBP reduction. J Am Geriatr Soc 57:291–296, 2009. Key words: hypertension; elderly; mortality; cardio- vascular disease; ambulatory blood pressure monitoring B ecause of its high prevalence and associated morbidity, hypertension is the most important modifiable cardio- vascular risk factor in old age. According to several obser- vational studies, more than 70% of persons aged 65 and older have high blood pressure (BP). 1 The prevalence of hypertension continues to increase in late life, to the point that more than 90% of persons aged 80 and older are hy- pertensive and, in particular, have systolic hypertension. 2 Unquestionably, as shown in several clinical trials, treat- ment for hypertension is effective in preventing cardiovas- cular events and renal function decline in older patients with hypertension, 3–5 although some controversy still per- sists as to the risk associated with hypertension in very old patients and in the presence of low diastolic BP (DBP). In a study of older subjects with hypertension from the Fra- mingham cohort, lower DBP was associated with lower incidence of cardiovascular disease when systolic BP (SBP) was normal, whereas the risk appeared to be even greater when SBP was higher than 140 mmHg, particularly in men. 6 Another observational study of more than 12,000 community-dwellers showed that, in participants aged 85 and older, higher SBP was associated with lower mortality. 7 In a meta-analysis of randomized clinical trials of treat- ments for hypertension, whereas the primary outcome of stroke was significantly prevented by active treatment at any age, total mortality was higher in participants aged 80 and older receiving drug therapy than in those randomized to placebo. Although it was overlooked in the original publication, 8 other authors subsequently emphasized this finding, 9 which generated considerable debate. 10,11 A more- recent meta-analysis of clinical trials demonstrated that, in Address correspondence to Andrea Ungar, Hypertension Centre, Geriatric Cardiology Unit, Department of Critical Care Medicine and Surgery, University of Florence, Viale Pieraccini 6, 50141, Florence, Italy. E-mail: aungar@unifi.it DOI: 10.1111/j.1532-5415.2008.02123.x From the à Hypertension Centre, Geriatric Cardiology Unit; and w Unit of Gerontology and Geriatric Medicine, Department of Critical Care Medicine and Surgery, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy. JAGS 57:291–296, 2009 r 2009, Copyright the Authors Journal compilation r 2009, The American Geriatrics Society 0002-8614/09/$15.00