E f f e c t s o f S t r e s s a n d B e h a v i o r a l
I n t e r v e n t i o n s i n H y p e r t e n s i o n
Thomas G. Pickering, MD, DPhil, Section Editor
Isolated Diastolic Hypertension
Thomas G. Pickering, MD, DPhil
A not uncommon situation in clinical practice is a
young patient who presents with a high dias-
tolic pressure and a normal systolic reading, such as
135/95 mm Hg, or isolated diastolic hypertension.
There is a dilemma here: should the patient be treat-
ed or not? Traditionally, diastolic pressure has been
regarded as the most important of the three measures
of pressure (the others being systolic and pulse pres-
sure), but recent attention has been focused on the
other two, particularly with the recent trials showing
the benefits of treating isolated systolic hypertension,
and a flurry of papers suggesting that pulse pressure
is the most important risk factor in older patients.
The reasons for the focus on diastolic pressure
are largely historical. The first major treatment
trial, the Veterans Administration study1 conducted
by Dr. Ed Fries in the 1960s, used a high diastolic
pressure as the main entry criterion; other similar
trials have followed suit. One of the largest trials
ever conducted, the Hypertension Optimal
Treatment (HOT) study,2 attempted to resolve the
J-curve dilemma by titrating patients’ diastolic pres-
sures to three levels, 85–90 mm Hg, 80–85 mm Hg,
and <80 mm Hg. Even today, a high diastolic pres-
sure is the primary requirement for reimbursement
for antihypertensive medications in Finland.3
An analysis of 1560 participants in a worksite
hypertension control program4 categorized them as
From the Behavioral, Cardiovascular Health, and
Hypertension Program, Columbia University College of
Physicians and Surgeons, New York, NY
Address for correspondence:
Thomas G. Pickering, MD, DPhil, Columbia University
College of Physicians and Surgeons, 630 West 168th Street,
New York, NY 10032
www.lejacq.com ID: 2840
VOL. V NO. VI NOVEMBER/DECEMBER 2003
having either isolated diastolic hypertension (systolic
<160 mm Hg and diastolic >90 mm Hg) or com-
bined hypertension (systolic >160 mm Hg and dias-
tolic >90 mm Hg). Over a 4.5 year follow-up period,
there were 24 cases of myocardial infarction, giving
a rate of 3.9 per 1000 patient-years. This was higher
in the patients with combined hypertension than in
patients with isolated diastolic hypertension (5.2 vs.
2.2 per 1000 patient-years) but was zero in the sub-
group of patients with high diastolic pressures and
systolic pressures <140 mm Hg.
One of the most illuminating studies is a
prospective analysis of 3267 initially healthy
Finnish men who were originally evaluated at age
30–45 and were followed for up to 32 years.3
They were divided into four groups: normoten-
sives (systolic <160 mm Hg and diastolic <90 mm
Hg), combined hypertension (systolic >160 mm
Hg and diastolic >90 mm Hg), isolated systolic
hypertension (systolic >160 mm Hg and diastolic
<90 mm Hg), and isolated diastolic hypertension
(systolic <160 mm Hg and diastolic >90 mm Hg).
The last group was subdivided according to
whether the systolic was <140 mm Hg or between
140 and 160 mm Hg. Not surprisingly, in this rel-
atively young group there were very few with iso-
lated systolic hypertension (17 men), but there
was a substantial number (346, or more than 10%
of the total) of men with isolated diastolic hyper-
tension, where the systolic pressure was <140 mm
Hg. With the normotensives as the reference
group, the mortality was increased nearly three-
fold in the combined hypertensives (relative risk
[RR], 2.71) and in the group with diastolic hyper-
tension and systolic pressure between 140 and
160 mm Hg (RR, 1.39) but not in the group with
isolated diastolic hypertension defined by a sys-
tolic pressure <140 mm Hg.
THE JOURNAL OF CLINICAL HYPERTENSION 411

Another study5 (the Japanese Ohasama study)
has reported the same finding using home moni-
toring. This is of particular interest, since there
might be systematic errors in reporting diastolic
pressure with home monitors, all of which operate
on the oscillometric method. Home readings were
obtained in 1913 subjects aged 40 or older (aver-
age 61 years) who were followed for 8 years. The
cutoff points for the different groups (137 mm Hg
for systolic and 84 mm Hg for diastolic pressure)
were lower than used in studies based on clinic
measurements because these were the numbers
above which cardiovascular risk started to
increase, and it is well recognized that home read-
ings tend to be lower than clinic readings. The car-
diovascular event rate during the follow-up period
was the same in the normotensives (0.33 deaths
per 100 person-years) and those with isolated dias-
tolic hypertension (i.e., systolic pressure <137 mm
Hg and diastolic >84 mm Hg), where the event rate
was 0.26. Significantly higher rates were recorded
in subjects with combined hypertension (1.11) or
isolated systolic hypertension (2.04).
A study of the Honolulu Heart Program fol-
lowed 8006 men for 20 years.6 Isolated diastolic
hypertension (IDH) was defined as a systolic pres-
sure <160 mm Hg, and a diastolic pressure >90
mm Hg. For men aged 45–54 years, the relative
risks of stroke associated with IDH compared with
nonhypertensive subjects was 1.4, whereas for men
with isolated systolic hypertension or combined
hypertension the relative risks were 4.8 and 4.3.
Thus, the consensus from these four studies
that looked at the prognosis of IDH is that if the
systolic is <140 mm Hg, a high diastolic pressure
is not associated with an adverse prognosis.
In some subjects with IDH, the high diastolic
pressure may be artifactual. Some years ago we
described a method of measuring blood pressure
noninvasively using a high fidelity transducer
instead of a stethoscope (wideband external pulse
recording), which records the low frequency signals
as well as the higher frequency components that are
audible as the Korotkoff sounds.7 By visual inspec-
tion of the traces recorded during cuff deflation, a
very accurate estimation of the true systolic and
diastolic pressures can be obtained. We found that
this method gave a closer agreement with intra-arte-
rial pressure than the Korotkoff sound method.
When we looked at patients with IDH (systolic
<140 and diastolic >90), we found that the diastolic
pressure recorded by the conventional auscultatory
technique was on average 7 mm Hg higher than the
value recorded by the wideband method.8 This dif-
412 THE JOURNAL OF CLINICAL HYPERTENSION
17517176, 2003, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1524-6175.2003.02840.x, Wiley Online Library on [21/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ference was only 3 mm Hg in patients with com-
bined hypertension and zero in normotensives.
Thus, it appeared that a substantial number of
patients with IDH might be misclassified by the con-
ventional method of blood pressure measurement.
How do these findings relate to other epidemio-
logical studies, which have specifically compared the
prognostic significance of systolic and diastolic pres-
sures? A recent analysis of the Framingham Heart
Study data looked at the ability of systolic and dias-
tolic pressure to predict coronary heart disease as a
function of age.9 In subjects younger than 50 years of
age, diastolic pressure was significantly better than
systolic pressure, whereas systolic pressure was bet-
ter over the age of 50. However, when the data were
analyzed in five age groups, it was only the youngest
quintile (younger than 40) where this difference was
significant. In addition, the method of analysis may
have led to a bias favoring diastolic pressure because
the hazard ratios were calculated for a 10 mm Hg
change in each blood pressure component. A change
of diastolic pressure of 10 mm Hg would in real life
be associated with a change of systolic pressure that
would be considerably more than 10 mm Hg, so it
would be more appropriate to look at percentage
changes rather than an absolute value. A very similar
analysis was performed in the Physicians’ Health
Study,10 which found that both systolic and diastolic
pressure predicted outcomes in the two youngest age
groups (under 50 and 50–59), but it too calculated
the hazard ratios for a 10 mm Hg change of both
systolic and diastolic pressure. Interestingly, the con-
fidence intervals were much wider for diastolic than
systolic pressure, suggesting a lack of precision in the
measurement. Nevertheless, the authors concluded
that systolic pressure should be used to predict risk
even in men younger than 60. Another analysis of
the Physicians’ Health Study and the Women’s
Health Initiative developed risk equation models for
predicting clinical outcomes using both systolic and
diastolic pressures. It concluded that in men, both
systolic and diastolic pressures predicted risk, but in
women only systolic pressure was important.11
The reconciliation of these analyses with the
prospective studies of IDH is more difficult.
Unfortunately for the present discussion, none of
the studies quoted above looked at the individuals
with IDH. The only one to find any superiority for
diastolic pressure was the Framingham study,
where it applied only to subjects under the age of
40. Therefore, it would seem reasonable not to
prescribe antihypertensive treatment for patients
who present with a high diastolic pressure and a
systolic pressure <140 mm Hg at the present time.
VOL. V NO. VI NOVEMBER/DECEMBER 2003

This would be consistent with a set of simple
guidelines for primary health care published by
Sever12 in 1999, which included four rules. Rule
One was “abandon diastolic pressure measurement
and rely on systolic blood pressure values for deci-
sions on treatment thresholds and goals.” This
statement may seem like heresy, but in medicine, as
in other fields of human belief and endeavor,
today’s heresy may be tomorrow’s dogma.
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