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To the Editor: In their study of cardiovascular mortality risk in chronic kidney disease,¹ Dr Shlipak and colleagues found that traditional cardiovascular risk factors, including systolic hypertension, had larger associations with cardiovascular mortality than novel risk factors in elderly persons with chronic kidney disease.

The article did not describe the risk associated with diastolic blood pressure or pulse pressure. The importance of this is controversial, with a meta-analysis² finding pulse pressure unimportant as a risk factor, but other studies^3-4 finding pulse pressure to be a more significant risk factor than diastolic or systolic pressure in older persons, especially those with renal impairment.⁵

Given this, it would be very valuable if the study by Shlipak et al included data indicating risk associated with diastolic blood pressure and pulse pressure.

Financial Disclosures: None reported.

Michael F. O’Rourke, MD, DSc
m.orourke@unsw.edu.au
St Vincent's Clinic, University of New South Wales
Sydney, Australia

Michel E. Safar, MD
Diagnosis Center
Hôtel-Dieu Hospital
Paris, France

1. Shlipak MG, Fried LF, Cushman M, et al. Cardiovascular mortality risk in chronic kidney disease. JAMA. 2005;293:1737-1745. FREE FULL TEXT 2. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality, one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913. FULL TEXT | ISI | PUBMED 3. Franklin SS, Khan SA, Wong ND, Larson MG, Levy D. Is pulse pressure useful in predicting risk for coronary heart disease? the Framingham Heart Study. Circulation. 1999;100:354-360. FREE FULL TEXT 4. Safar ME, Levy BI, Struijker-Boudier H. Current perspectives on arterial stiffness and pulse pressure in hypertension and cardiovascular disease. Circulation. 2003;107:2684-2689. FREE FULL TEXT 5. Klassen PS, Lowrie EG, Reddan DN, et al. Association between pulse pressure and mortality in patients undergoing maintenance hemodialysis. JAMA. 2002;287:1548-1555. FREE FULL TEXT

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2005;294:791.

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