title: Pulse pressure in acute coronary syndromes: Comparative prognostic significance with systolic blood pressure.
abstract: BACKGROUND
  Pulse pressure is a readily available vital sign that has been shown to independently predict outcomes in several cardiovascular disease states. We investigated the prognostic significance of pulse pressure (PP) and systolic blood pressure (SBP) among patients with acute coronary syndromes (ACS).
  
  
  METHODS
  A total of 14,514 patients with ACS in the prospective, multicentre Global Registry of Acute Coronary Events (GRACE), expanded GRACE (GRACE-2) and Canadian Registry of Acute Coronary Events (CANRACE) were stratified by initial PP on presentation. Patient characteristics and in-hospital outcomes were compared by PP quartiles and the independent prognostic significance of PP for in-hospital mortality was quantified. We compared the discriminative ability (c-statistic) of models incorporating either PP or SBP.
  
  
  RESULTS
  Patients with higher PPs were older, more frequently female and had higher prevalence rates of conventional cardiovascular risk factors (allp< 0.01). Lower PP was associated with ST-segment elevation myocardial infarction presentation, higher GRACE risk scores and higher rates of adverse in-hospital outcomes (p< 0.001). PP was strongly correlated with SBP (Pearson's correlation coefficient = 0.79,p< 0.001). After adjustment for other GRACE risk model predictors, lower PP was independently associated with in-hospital mortality (first vs. fourth quartile [reference]: adjusted odds ratio 2.57, 95% confidence interval 1.80-3.67). The c-statistic was slightly higher for the multivariable model incorporating SBP as compared to the model with PP (0.868 vs. 0.864, respectively,p= 0.028) for in-hospital mortality.
  
  
  CONCLUSIONS
  Higher presenting PP is associated with increased age and more prevalent cardiovascular risk factors, whereas patients with lower PP present with worse clinical characteristics and in-hospital outcomes. Lower PP is an independent adverse prognosticator in ACS. However, PP did not improve the discriminatory performance of the GRACE risk score compared with SBP.
authors.affiliation: 1 Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Nigel S
authors.initials: NS
authors.lastname: Tan
authors.affiliation: 1 Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Bradley
authors.initials: B
authors.lastname: Sarak
authors.affiliation: 2 Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK.
authors.forename: Keith Aa
authors.initials: KA
authors.lastname: Fox
authors.affiliation: 3 Concord Hospital, University of Sydney, Sydney, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Brieger
authors.affiliation: 4 FACT (French Alliance for Cardiovascular Trials), Département Hospitalo-Universitaire FIRE, Université Paris Diderot, AP-HP, Hôpital Bichat, Paris, France.|5 INSERM U-1148, Paris, France.
authors.forename: Ph Gabriel
authors.initials: PG
authors.lastname: Steg
authors.affiliation: 6 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: Chris P
authors.initials: CP
authors.lastname: Gale
authors.affiliation: 7 Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: 8 Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada.
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Spencer
authors.affiliation: 9 Hôtel-Dieu de Lévis, Lévis, QC, Canada.
authors.forename: Francois R
authors.initials: FR
authors.lastname: Grondin
authors.affiliation: 1 Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.|10 Canadian Heart Research Centre, Toronto, ON, Canada.
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
authors.affiliation: 1 Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D000368:Aged; D001794:Blood Pressure / Q000502:physiology*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D014943:Global Health; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013599:Systole; D013997:Time Factors
keywords: Acute coronary syndromes; blood pressure; mortality; prognosis; pulse pressure