Rapid Responses to:

HEAD TO HEAD: Peter Sever Is systolic blood pressure all that matters? Yes BMJ 2009; 339: b2665 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Systolic blood pressure

Michael Blackmore   (13 July 2009)

Risk reduction strategy

J. David Leopold   (14 July 2009)

Balanced Approach to BP Measurement

Dr. Samiran Adhikari, Dr. Surendra Borgharkar, Dr. Mrunal Chokhandre   (16 July 2009)

Is systolic blood pressure all that matters?

Alex Bruce   (25 July 2009)

Pulse and mean, not systolic and diastolic

Jeffrey R. Johnstone   (10 August 2009)

Why are the determinants of blood pressure not discussed ?

Leslie O Simpson   (11 August 2009)

Systolic blood pressure 13 July 2009
Michael Blackmore, Retired NHS (UK) GP CYPRUS Send response to journal: Re: Systolic blood pressure	At last common sense prevails. The explanation of the origin of the advice to use diastolic blood pressure was interesting. I had not heard of this before. While I am sure that more use of ambulatory recording would be helpful it would be cheaper and better to use more self monitoring by patients. In my experience readings taken by patients at home correlate very well with ambulatory recordings. It would also put more emphasis on the patient's responsibility to control their blood pressure - after all its their risk factor not yours! Sadly my many attempts to interest NHS authorities in supporting the bulk purchase of suitable devices for supply to patients on prescription have consistently failed which is a pity as I suspect that the small cost would be more than offset by savings in drug costs as this has frequently been shown to result in lower pressures than "office" readings. I was first introduced to the concept of relying on systolic blood pressure only by Dr. Martin Wright (remember the peak flow meter) who first helped me with some measurements of smoke density in 1964. We co- operated again in the early 1990's when I was looking for a reliable automated device for our district nurses to use and he kindly lent me one he had developed which measured systolic blood pressure with a finger cuff remarkably constantly. It was a little fiddly to use as it was a prototype. I have relied upon systolic blood pressure to make treatment decisions ever since. I wonder how long it will take before diastolic blood pressure as a marker for disease and as a target to achieve in treatment is finally abandoned? Competing interests: None declared
Risk reduction strategy 14 July 2009
J. David Leopold, consultant physician Cwnrhydycwrw Cottage Hospital, Swansea Send response to journal: Re: Risk reduction strategy	Sir. Tellingly, the polemic does not dispute that our Gold Standard epidemiological data is dominated by Framingham's clinic based mercury column pressures. This body of knowledge has the overwhelming power of longevity. But equally important is the fact the numbers can be reliably reproduced anywhere at low cost. And there is no proprietary technology, or commercial interest to contaminate the studies. On the other hand there is no doubt we could if we wished do far better than reduce the information contained in the arterial waveform to one heritage number...using differing often covert fudge factors to allow us to map our measurements back onto the Framingham data. What we should be arguing for is the collection of a New "Framingham" database, one which uses open-source algorithms, and lowcost internationally standardised methods to acquire various derivatives of the waveform. Until this work is completed, we must encourage all to stick resolutely to the use of systolic pressures using the mercury machine, and resist commercial blandishments. Kind regards David Leopold Competing interests: None declared
Balanced Approach to BP Measurement 16 July 2009
Dr. Samiran Adhikari, Medical Advisor SUN Pharmaceutical Industries Ltd, ACME Plaza, Andheri Kurla Road, Andheri East, Mumbai 400059, Dr. Surendra Borgharkar, Dr. Mrunal Chokhandre Send response to journal: Re: Balanced Approach to BP Measurement	Earlier, we have seen significant emphasis on diastolic blood pressure. Subsequently, due recognition was given to the importance of systolic blood pressure. However, this does not mean that we need to adopt either "diastolic" or "systolic" approach. Also, hypertension appears to emerging in middle-aged people due to unhealthy lifestyle where arterial stiffening may not be the only factor contributing to hypertension. In this group, both SBP and DBP are equally important for better management of this risk factor for prevention of cardiovascular events. The majority of cardiovascular disease burden comes from developing countries whose health care delivery budgets may not be in a position to fund expensive gadgets like AMBP devices. Digital home blood pressure monitoring units are user-friendly but may yield inconsistent results, if used incorrectly. In this circumstance we need to rely on time tested in- clinic BP measurements. Moreover, this data will help us correlate with the benefit of various studies poured over the years. Competing interests: None declared
Is systolic blood pressure all that matters? 25 July 2009
Alex Bruce, Consultant Anaesthetist (Retired) Dr Gray's Hospital, Elgin, Moray, IV30 1SN Send response to journal: Re: Is systolic blood pressure all that matters?	As a retired anaesthetist I must admit that throughout my career I paid more attention to systolic than to diastolic blood pressure. It was therefore of particular interest to read Peter Sever's argument for the abandonment of diastolic measurement. His opponent, Eoin O'Brien, argues a case for ambulatory and 24 hour blood pressure measurement. However, whatever the merits of his argument, he does not address the question, which applies equally to ambulatory and twenty four hour measurements as to any other blood pressure measurement, 'Is systolic blood pressure all that matters?' As Chairman of the International Medical Advisory Board of dabl Ltd, which includes representatives from nine eminent institutions, Professor O'Brien is well placed to source evidence which might contribute meaningfully to the debate. A sample sufficiently large for statistical purposes could presumably be taken from the blood pressure data accumulated by dabl Ltd and have diastolic measurements stripped out to establish whether or not the measurement of diastolic blood pressure made any difference. Competing interests: None declared
Pulse and mean, not systolic and diastolic 10 August 2009
Jeffrey R. Johnstone, retired 7 Bruce St, Nedlands 6009, Western Australia Send response to journal: Re: Pulse and mean, not systolic and diastolic	The determinants of systolic and diastolic pressure have been understood for many years. It was early established that the related quantities pulse pressure and mean pressure were of much greater importance for the understanding of the circulation. (Wiggers, 1949; Little, 1978.) For those with an understanding of electric circuits:The circulation is analagous to a DC power supply with ripple and mean output voltage. Because of the importance of pulse and mean pressures Pickering classed hypertension as 1. "systolic hypertension", due to raised pulse pressure with raised systolic pressure only, and 2. "hypertension", with raised systolic and diastolic pressures and raised mean pressure. It would therefore seem reasonable in a screening program to check systolic pressure but I don't believe there is yet evidence to show such screening is of value for increasing life expectancy .If such evidence does exist I should like to see it. This dispute seems like an echo of the Platt/Pickering dispute of 50 years ago. Little, R.C.(1978): Physiology of the ,Heart and Circulation, Year Book Medical Publishers, Chicago. Pickering, G.(1970): Hypertension, Churchill,London Wiggers, C.J.(1949):Physiology in Health and Disease, Lea and Febiger, Philadelphia. Competing interests: None declared
Why are the determinants of blood pressure not discussed ? 11 August 2009
Leslie O Simpson, retired experimental pathologist Dunedin, New Zealand, 9077 Send response to journal: Re: Why are the determinants of blood pressure not discussed ?	It is strange that neither the original article nor the rapid responses address the question of what causes change in blood pressure. Fundamentally, the systolic blood pressure will relate to the need to overcome the resistance to flow. While vascular factors will play a role, there is much published information which shows that the physical properties of the blood and red blood cells are major factors. Hypertension is associated with increased blood viscosity and one of Dr.Leopold Dintenfass's books was titled, "Hypertension and hyperviscosity." Letcher et al also contributed significant information. Because blood viscosity is raised by smoking,and the viscosity can be increased by stressfull events or by heavy physical activity, such situations may have a fatal outcome. It will be interesting to learn whether or not Greenberg's report of "citation bias" will lead to editors requiring authors of papers on hypertension to refer to the literature which relates hypertension to hyperviscosity. But until this relationship is recognised and utilised in treatment, it is unlikely that hypertension will be managed effectively. Competing interests: None declared