Again, the Framingham group has provided another surprise to the medical community with publication of its longitudinal follow-up study of persons over 50 years of age that has linked cardiovascular (and in particular coronary) mortality with pulse pressure.1 In this study, mortality was related independently with initial systolic, diastolic, and pulse pressure, but the strongest association was with pulse pressure, and when systolic pressure was initially considered, there was a negative association with diastolic pressure. In other words, for a given systolic pressure, lower diastolic pressure was associated with greater mortality. A series of questions arise from this study. What corroboration does it have from other studies on similar cohorts? How does one reconcile the findings with the well-established association of coronary and stroke mortality with diastolic pressure?2 3 What possible mechanism can explain a greater association between coronary mortality and greater pulse pressure (or lower diastolic pressure)? And above all, what implications does this study have to patient management? For some 30 years, the Framingham group has pointed to a more robust association between systolic, rather than diastolic, pressure and cardiovascular events4 5 and has used systolic, not diastolic, pressure in their predictive tables. Fifteen years ago, Fisher6 challenged the preoccupation with diastolic rather than systolic pressure, and soon after, Dustan7 referred to a change in hypertensive disease, with problems shifting from the young and middle-aged subjects with diastolic hypertension to older subjects with systolic hypertension. In 1989, Darne et al8 noted that pulse pressure added further risk to patients with elevated diastolic or mean pressure, at least with respect to cerebral events. A series of prospective and cross-sectional studies has followed that has associated pulse pressure with cardiovascular events.9 10 11 12 13 The most recent, the follow-up of nearly 20 …