Response to Pseudohypertension

Abstract

1 has suggested that we have misconstrued his message with regard to pseudohypertension. Spence has long been interested in pseudohypertension in the elderly, as reflected in his list of personal publications on this topic. Indeed, he should be given credit for being the first to define this entity correctly as pseudodiastolic hypertension.2 However, as was the conventional wisdom in 1978 when he published his definitive study comparing intra-arterial with brachial cuff pressure, 2 the treatment of hypertension in patients Ն65 years of age was controversial; all but very high levels of isolated systolic hypertension (ISH) values were ignored; and treating diastolic blood pressure was generally begun when values exceeded 90 to 100 mm Hg. Spence 1 defined patients at risk for pseudohypertension as having cuff diastolic blood pressure of Ͼ100 mm Hg together with an intra-arterial diastolic blood pressure of Ͻ90 mm Hg and without evidence of retinopathy, cardiac hypertrophy, or nephropathysuggesting a "benign prognosis"; of the 24 elderly subjects who were recruited by these criteria, mean cuff pressures were 206/115 mm Hg and corresponding mean intra-arterial pressures 200/88 mm Hgclearly a high-risk ISH group by modern standards. In a publication in 1980, 3 he concluded that subjects with ISH and systolic blood pressure of Ͼ180 mm Hg might not have a benign prognosis and should receive antihypertensive therapy. Of course, current guidelines have set even lower systolic blood pressure target values for therapeutic intervention. Thus, Spence's opinion on the need for antihypertensive therapy for ISH has evolved over a period of 25 years as more randomized, controlled study data became available.To his credit, he did associate pseudodiastolic hypertension in the elderly with stiffening of arteries, but, on the other hand, he did not associate stiffened arteries with increased cardiovascular events, 4 nor did he associate stiffened arteries with wide pulse pressure and ISH as a markers of increased cardiovascular risk, 4 or low diastolic blood pressure with increased J-curve risk in patients, either in the absence 5 or presence 5 of antihypertensive therapy. In summary, Spence's writings championed the view that detecting pseudodiastolic hypertension would identify patients with less cardiovascular risk, whereas studies over the past 2 decades have come to the opposite conclusion.Moreover, today when patients report hypotensive symptoms with BP that seems high in the absence of hypertensive target organ damage, physicians should suspect either white-coat hypertension or white-coat effect, that is, overtreatment of office BP in the presence of normal or low home and/or daytime ambulatory pressures; thus, there is no need to postulate pseudohypertension. Indeed, no new cases of pseudohypertension have been reported in the past 2 decades; in fact, as we concluded in our brief review 6 : it is time to provide a proper burial for this entity! DisclosuresNone.