Objective:

To propose an insulin resistance–systemic vascular resistance–isolated diastolic hypertension (IR–SVR–IDH) axis as a mechanistic framework for understanding IDH and its clinical implications.

Key Findings:

• IDH is more prevalent in young and middle-aged adults and generally declines with age, indicating a need for targeted management in these populations.
• IDH is characterized by increased systemic vascular resistance with preserved large-artery compliance, which differentiates it from other hypertension types.
• Insulin resistance and compensatory hyperinsulinemia are linked to mechanisms promoting SVR elevation, suggesting potential therapeutic targets.
• Pragmatic IR surrogates like HOMA-IR and TyG index are associated with IDH risk, which could aid in risk stratification and management.

Interpretation:

Emerging data suggest metabolic status modifies IDH-associated cardiovascular risk, highlighting the need for integrated blood pressure and metabolic phenotyping in clinical practice.

Limitations:

• IDH remains underdiagnosed and undertreated in clinical practice, emphasizing the need for increased awareness among healthcare providers.
• Variability in diagnostic thresholds complicates the comparison of studies and clinical decisions, necessitating standardized definitions.

Conclusion:

The proposed IR–SVR–IDH axis supports a precision-oriented approach to understanding and managing IDH, addressing the critical issue of its underdiagnosis.