Hi Vijay, nice paper. But the researchers at KPW are missing a fundamental fact that the brachial systolic BP is not the pressure that is exerted on the brain or other critical organs like the heart and kidneys, it is just the BP in the arm at any particular time and therefore is not the best measurement.  The researchers should be measuring Central Aortic Blood Pressure (cBP). We already know from BP GUIDE study (J. Sharman et al.) that guidance of hypertension management with Central Blood Pressure (measured by an arm cuff such as the Uscom BP+ device https://uscom.com.au/products/bp/overview/) results in a significantly different therapeutic pathway than conventional cuff BP, with less use of medication to achieve BP control and no adverse effects on left ventricular mass, aortic stiffness, or quality of life. The study found that 16% of people don’t need medication if guided by central BP and this can easily explain why simplistic BP thresholds are not that helpful.

Carmel McEniery in 2008 showed in a study of 10000 patients, 70% of individuals with high-normal brachial pressure had similar central aortic pressures to those with stage 1 hypertension, who should have been treated but were not.

The conclusion of this latest publication www.thelancet.com/.../fulltext is that for a wide range of blood pressures, the rate of cardiovascular disease and effectiveness of blood pressure drug treatment was mainly determined by predicted risk, with blood pressure thresholds 140/90 mm Hg or 160/100 mm Hg—ubiquitous in most countries—adding little useful information. When medium-term predicted risk is low, there is no urgency to initiate drug treatment, allowing time to attempt non-pharmacological blood pressure reduction.

Additional work has also shown that there is a very good association between central blood pressure and subclinical cerebrovascular disease in older adults. The study by Matsumoto et al, supports central blood pressure as a more accurate marker of risk for cerebral microvascular disease among the elderly compared with traditional brachial blood pressure assessments. Cerebral microvascular disease correlates with cognitive decline and vascular dementia in patients with high central blood pressures.

Today you just can't practice good clinical medicine if you're not measuring central blood pressure and pulse wave analysis.