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Arterial Stiffness and Central Blood Pressure: Ready for Prime Time ? Arterial stiffness and central blood pressure: ready for prime time ? Phil Chowienczyk King’s College London British Heart Foundation Centre Arterial stiffness and central blood pressure: ready for prime time ? “It’s the blood pressure stupid” Why bother/complicate by measuring arterial stiffness and central blood pressure ? Arterial stiffness • What is it ? • Why does it matter ? • How should we use it ? Stiffness and elasticity Stress Strain Young’s elastic modulus E = “Pulling force”/ “Stretch” E = Stress/strain Elastic modulus Elastic Strain Stiffness of an artery Pressure P Pressure P + DP wall thickness h Diameter D Diameter D + DD Distensibility = DD/(DP D) (mmHg-1) DP D E = DD h Elastic modulus and distending pressure Berry & Greenwald 1976 Pulse wave velocity: PWV L PWV= L /DT E.h PWV= ρ.D h, wall thickness DT ρ, density D, diameter Arterial stiffness • What is it ? • Why does it matter ? • How should we use it ? Ventricular-vascular coupling Ventricular contraction PPPP P Aortic stiffness MAPP Peripheral resistance MAP = Cardiac output x Peripheral resistance Ventricular-vascular coupling Ventricular contraction PPPP P Aortic stiffness MAPP Peripheral resistance MAP = Cardiac output x Peripheral resistance PP ≈ PWV x Flow Ventricular-vascular coupling Ventricular contraction PPPP P Aortic stiffness MAPP Peripheral resistance MAP = Cardiac output x Peripheral resistance PP ≈ PWV x Flow PP ≈ PWV x Ventricular contraction (rate of) Pulse pressure ≈ PWV x Flow n = 18 Mean±SD Parameter (mmHg) RMSE 3.4±1.3 P1 1.9±5.3 SBP 1.4±2.0 P2 0.9±3.4 Vennin et al. Non-invasive calculation of the aortic blood pressure waveform from the flow velocity waveform: a proof of concept. Am J Physiol - Heart Circ Physiol, 2015, 309(5), H969-H976 Arterial pressure components by age Stanley S. Franklin et al. Circulation. 1997;96:308-315 Copyright © American Heart Association, Inc. All rights reserved. Arterial pressure components by age Stanley S. Franklin et al. Circulation. 1997;96:308-315 Copyright © American Heart Association, Inc. All rights reserved. Frequency of systolic and diastolic hypertension ISH (SBP ³140 mm Hg and DBP <90 mm Hg) SDH (SBP ³140 mm Hg and DBP ³90 mm Hg) IDH (SBP <140 mm Hg and DBP ³90 mm Hg) 17% 16% 16% 20% 20% 11% 100 80 60 40 20 0 <40 40-49 50-59 60-69 70-79 80+ Age Franklin et al. Hypertension 2001;37: 869-874. Association of PWV with risk factors: a systematic review 29,970 Subjects Cecelja et al Hypertension 2009 Association of PWV with risk factors: a systematic review 29,970 Subjects Cecelja et al Hypertension 2009 Mechanical stress, inflammation and calcification Marina Cecelja, and Philip Chowienczyk Hypertension. 2010;56:29-30 Copyright © American Heart Association, Inc. All rights reserved. Hypertension and arterial stiffening MAP (acute) PP (chronic) BP PWV PP Marina Cecelja, and Philip Chowienczyk Hypertension. 2010;56:29-30 Copyright © American Heart Association, Inc. All rights reserved. Aortic PWV and outcome Blacher et al. Circulation 1999 Vlachopoulos et al. JACC 2010 Arterial stiffness • What is it ? • Why does is it matter ? Determinant of pulse pressure Integrative measure of impact of BP on the arterial wall Predictive of outcome • How should we use it ? Arterial stiffness • What is it ? • Why does it matter ? Determinant of pulse pressure Integrative measure of impact of BP on the atrial wall Predictive of outcome • How should we use it ? The role of vascular biomarkers for primary and secondary prevention. A position paper from the European Society of Cardiology Working Group on peripheral circulation Table 1Criteria for vascular biomarkers to qualify as clinical surrogate endpoints. 1 Proof of concept Do novel biomarker levels differ between subjects with and without outcome? Does the novel biomarker predict development of future outcomes in a 2 Prospective prospective cohort or nested case-cohort study? validation Does it add predictive information over and above established, standard risk 3 Incremental value markers? 4 Clinical utility Does it change predicted risk sufficiently to change recommended therapy? Does the use of the novel biomarker improve clinical outcomes, especially 5 Clinical outcomes when tested in a randomized clinical trial? Does the use of the biomarker improve clinical outcomes sufficiently to 6 Cost-effectiveness justify the additional costs? 7 Ease of use Is it easy to use, allowing widespread application? Is the biomarker measured uniformly in different laboratories? Are study 8 Methodological results directly comparable? consensus 9 Reference values Are there published reference values, or, at least, cut-off values? (or cut-off values) Vlachopoulos et al. Modified from: Hlatky et al. Circulation 2009. Criteria 7–9 constitute additional essential criteria to the original criteria 1–6 proposed by Hlatky and coworkers [7]. Atherosclerosis 2015 The role of vascular biomarkers for primary and secondary prevention. A position paper from the European Society of Cardiology Working Group on peripheral circulation Recommendation Level of evidence Comments Carotid IIa A Moderate usefulness for risk stratification. ultrasonography Concomitant identification of plaque presence. Ankle-brachial index IIa A Useful for risk stratification, especially women. Arterial stiffness Carotid-femoral pulse IIa A Useful for risk stratification. wave velocity Brachial-ankle pulse IIb B wave velocity Central IIb B haemodynamics/Wave reflections Endothelial function Flow mediated dilatation III B Requires skilled, trained operator. Reactive hyperaemia is stressful. Methodological problems are not resolved. Added value is not proven. Endothelial peripheral III C Reactive hyperaemia is stressful. arterial tonometry Added value is not proven. Circulating biomarkers related to vascular wall biology High sensitivity C- IIb B reactive protein Vlachopoulos et al. Atherosclerosis 2015 Arterial stiffness: clinical application • Gold standard method time consuming/expensive • Bewildering array of “simplified” methods • Limited reclassification (10% at best) • ? Better methods of reclassification • No real agreement between experts Can we change PWV ? 3 R>0.99, P<0.0001 = LNMMA = DOB 2.5 2 = DOB 5 = DOB 10 PWV(m/s) D 1 = NA 0 0 5 10 15 20 25 D MAP (mmHg) ARB vs. control antihypertensives on PWV Chen et al. 2015 ARB vs. control antihypertensives on PWV Chen et al. 2015 Hypertension and arterial stiffening MAP (acute) PP (chronic) BP PWV PP Marina Cecelja, and Philip Chowienczyk Hypertension. 2010;56:29-30 Copyright © American Heart Association, Inc. All rights reserved. Arterial stiffness • What is it? PWV the most pragmatic definition/means of measurement • Why does it matter ? Determinant of pulse pressure Integrative measure of impact of BP on the arterial wall Predictive of outcome • How should we use it ? Risk stratification (but beware “simplified” techniques) Indication for BP treatment (research) Target for treatment (research) Central vs. peripheral BP ΔSBP MBP DBP Peripheral pulse Central pulse Central blood pressure: methods Carotid ≈ Central BP FFT IFFT GENERAL T.F. Relative risk (RR) and 95% confidence interval (CI) of clinical events for a 1 standard deviation increase in pulse pressure (A) and systolic pressure (B), according to the site of measurement (central vs. brachial). Vlachopoulos C et al. Eur Heart J 2010;31:1865-1871 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: [email protected] Brachial (solid symbols) and derived central aortic (open symbols) pulse pressure with time (mean, 95% CI) for patients randomized to receive atenolol±thiazide- or amlodipine±perindopril-based therapy. The CAFE Investigators et al. Circulation 2006;113:1213- 1225 Copyright © American Heart Association Systolic amplification in children 25 SphygmoCor 20 ArtLab 15 cSBP (mmHg) cSBP - Adult values 10 5 Mean pSBP pSBP Mean 0 <10 10-14.9 >15 Age (years) Milne et al. 2015 Systolic amplification in children/young adults Peripheral BP Central BP 18 years 150/80 130/80 50 years 140/80 130/80 From: Isolated Systolic Hypertension in Young and Middle-Aged Adults and 31-Year Risk for Cardiovascular Mortality: The Chicago Heart Association Detection Project in Industry Study J Am Coll Cardiol. 2015;65(4):327-335. doi:10.1016/j.jacc.2014.10.060 Date of download: Copyright © The American College of Cardiology. 5/25/2015 All rights reserved. Central blood pressure • What is central blood pressure ? SBP in the arm is amplified above that at the aortic root • Why does it matter ? May be more closely linked to target organ damage May predict beneficial effects of treatments with differential effects on cSBP and pSBP More important (greater amplification) in children • How should we use it ? Evaluating new treatments (research) ? Evaluating need for treatment in children/young adults with ISH Arterial stiffness and central blood pressure: ready for prime time ? “It’s the blood pressure stupid” Why bother/complicate by measuring arterial stiffness and central blood pressure ? Arterial stiffness and central blood pressure: ready for prime time ? “It’s the blood pressure stupid” Why bother/complicate by measuring arterial stiffness and central blood pressure ? Arterial stiffness the major determinant of systolic hypertension Future: Measure PWV, start (PWV lowering) treatment .
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