Central blood pressure: current evidence and clinical importance (original) (raw)
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Indian Heart Journal, 2018
Background: High brachial blood pressure (BP) is an important cardiovascular risk factor. However major differences in central systolic BP can occur among people with similar brachial systolic BP. It is known that central aortic pressure responses to antihypertensive therapy can differ substantially from brachial BP responses, such that true treatment effects cannot be gauged from conventional brachial BP. Objective: The purpose of this study was to examine if adequate control of brachial BP was concordant with central BP control in treated hypertensive subjects. Methods: Non-invasive acquisition of brachial and central pressures and wave forms was obtained from 100 subjects with systemic arterial hypertension on drug therapy and 50 healthy individuals. After all necessary precautions according to the guidelines, brachial and central pressures and wave forms were measured 3 times at 5 min intervals using an upper arm cuff (AGEDIO K900 HDP Stolberg, Germany). The mean of the last two measurements of each was recorded as representative of brachial and central aortic pressures and wave forms. Results: In 45 of 50 healthy subjects with normotension (41 male, 9 female, mean age 38 years), central systolic BP was <120 mmHg. Five healthy subjects (10%) had falsely normal brachial systolic BP, but raised central systolic BP. Out of 100 patients with known hypertension and on various anti-hypertensive drug combinations, 9 had uncontrolled hypertension (defined as brachial BP of >140/90 mmHg and central systolic BP > 120 mmHg). Ninety-one patients had controlled hypertension as estimated by brachial BP of whom, 37 patients had uncontrolled central BP (systolic BP > 120 mmHg). Thus, brachial BP estimation overestimated control of hypertension in 41% patients (p < 0.01). Central systolic BP control was inadequate in 9 out of 41 patients (22%) on angiotensin receptor blocking therapy versus 27 out of 31 (87%) patients on beta-blocking therapy (p < 0.05). Thus, there was a marked mismatch with regard to control of hypertension between central and peripheral measurements. Conclusion: Central BP measurement provides important information on true prevalence of uncontrolled hypertension in the outpatient setting which is higher than current estimates from brachial BP measurement. Optimal BP control by central BP is far less than observed from peripheral pressure measurement. Residual cardiovascular risk despite adequate control of brachial BP can also be explained by the substantial frequency of uncontrolled hypertension as determined by the central BP in patients with apparently controlled hypertension. Both these conclusions have significant impact on prevalence of uncontrolled hypertension and its proper management. Further studies are required to confirm the current data and to provide evidence that treatment decisions based on measurements of central BP result in better outcomes.
Central hypertension is a non‐negligible cardiovascular risk factor
Journal of Clinical Hypertension, 2022
High blood pressure (BP) confers cardiovascular risk. However, the clinical value of central BP remains debatable. In this article, we aim to briefly review the prognosis, diagnosis, and treatment of central hypertension. Central and brachial BPs are closely correlated. In most prospective investigations, elevated central and peripheral BPs were similarly associated with adverse outcomes. Outcome‐driven thresholds of the central systolic BP estimated by the type I device were on average 10 mmHg lower than their brachial counterparts. Cross‐classification based on the central and brachial BPs identified that nearly 10% of patients had discrepancy in their status of central and brachial hypertension. Irrespective of the brachial BP status, central hypertension was associated with increased cardiovascular risk, highlighting the importance of central BP assessment in the management of hypertensive patients. Newer antihypertensive agents, such as renin–angiotensin–aldosterone system inhibitors and calcium channel blockers, were more efficacious than older agents in central BP reduction. Clinical trials are warranted to demonstrate whether controlling central hypertension with an optimized antihypertensive drug treatment will be beneficial beyond the control of brachial hypertension.
Artery Research, 2011
Pulse wave velocity (PWV) is a valid and well-documented predictor of cardiovascular risk in hypertensive patients. It is essential to adjust for potential confounders, and especially age and blood pressure (BP) modulate the level of PWV. Both systolic BP and mean arterial pressure (MAP) have been used when adjusting in statistical models. However, in recent years MAP has been favoured for BP adjustment. The aim was to investigate if MAP was superiorly correlated to PWV compared to systolic BP in newly diagnosed untreated hypertension. We included 126 newly diagnosed untreated hypertensive patients. Twentyfour hour ambulatory BP measurement was performed and PWV was measured using the SphygmoCor device. The cohort consisted of 61 men and 73 women with an average age of 50 AE 12 years. The mean systolic BP was 146 AE 12 mmHg and the mean MAP was 108 AE 9 mmHg with no significant difference between genders. The median PWV was 8.4 m/s (range 5.3 to 16.8) with no gender difference. In a linear regression model age was highly positively correlated with PWV (ß Z.004, p<.001). In an age-adjusted model, MAP was positively correlated with PWV (ßZ.004, pZ.02) but systolic BP showed a higher positive correlation with PWV (ßZ.003, pZ.008). PWV measurements must be corrected for BP levels as well as age. Adjusting for systolic BP may be superior to adjusting for MAP in newly diagnosed untreated hypertensive patients.
The Journal of Clinical Hypertension
Since noninvasive central blood pressure (BP) measuring devices are readily available, central BP has gained growing attention regarding its clinical application in the management of hypertension. The disagreement between central and peripheral BP has long been recognized. Some previous studies showed that noninvasive central BP may be better than the conventional brachial BP in association with target organ damages and long-term cardiovascular outcomes. Recent studies further suggest that the central BP strategy for confirming a diagnosis of hypertension may be more cost-effective than the conventional strategy, and guidance of hypertension management with central BP may result in less use of medications to achieve BP control. Despite the use of central BP being promising, more randomized controlled studies comparing central BP-guided therapeutic strategies with conventional care for cardiovascular events reduction are required because noninvasive central and brachial BP measures are conveniently available. In this brief review, the rationale supporting the utility of central BP in clinical practice and relating challenges are summarized.
Central Aortic Blood Pressure and Management of Hypertension: Confirmation of a Paradigm Shift?
Hypertension, 2013
H ypertension, a condition of elevated arterial blood pressure (BP) conventionally diagnosed by brachial cuff sphygmomanometry, is associated with increased risk of cardiovascular mortality and morbidity and end-organ damage. However, the marked differences in pulse pressure between the central aorta and peripheral limbs 1 suggest that effects of peak values of arterial BP (eg, systolic BP) on centrally located organs (heart, brain, kidney) may not be accurately assessed using peripheral measurements. Our early studies 2 showed substantial difference in the effects of sublingual nitroglycerin on peripheral and central (carotid) pulse pressures: in some cases, central systolic BP decreasing ≤20 mm Hg with little or no effect on brachial or radial systolic BP. There were, however, marked changes in the pulse wave form. The relationship between central aortic and radial pressure waves, quantified in terms of a mathematical transfer function, has been validated to be applicable across a large range of physiological pressures. 3 The use of this noninvasive technique (and other variations, including other forms of analysis of the radial pulse or direct registration of the carotid pulse) has facilitated a large number of studies highlighting the differential effects of antihypertensive therapy on central aortic systolic BP for similar values of brachial cuff systolic BP. 4 A seminal study by McEniery et al 5 in >10 000 subjects demonstrated a substantial overlap of central and brachial BP between categories of hypertension. Approximately 32% of men and 10% of women who would be considered to have normal brachial systolic BP (and therefore, not treated) would be classified as having stage 1 hypertension based on equivalent central aortic systolic BP. Indeed, the implications of these findings suggested a possible sign of a paradigm shift in the management and treatment of hypertension as a significant cardiovascular risk. 6 Subsequent studies produced additional evidence of the possibility of added value of central aortic BP. In the assessment of modern combination therapies, the amlodipine-valsartan combination was shown to decrease central aortic systolic BP to a greater extent than the amlodipineatenolol combination for a similar effect on brachial systolic BP. 7 Central pulse pressure has also been shown to be superior to ambulatory BP in the prediction of all-cause and cardiovascular mortality. 8 However, notwithstanding these and other studies, there is still insufficient evidence for central aortic BP to be integrated in guidelines for treatment and management of hypertension. The study by Sharman et al 10 in this issue of Hypertension addresses the use of central aortic BP as an additional measure in the management of hypertension. However, in contrast to other studies that perform a comparison of effects of treatments 2,4,7 or risk categories, 5,8 this study uses central aortic BP as a guide for treatment. Although conducted in a relatively small population (286 hypertensive patients), the study is particular in both the design and the relevance of the demonstration of the added value of central aortic BP. It is a prospective, randomized, open-label, blinded end point (PROBE) study in which patients were randomized to treatment decisions that were guided by best-practice usual care for BP (n=142; using office BP, home BP, and 24-hour ambulatory BP) or the addition of a central aortic BP intervention (n=144) where central aortic BP was measured using radial applanation tonometry (SphygmoCor). The study duration was 12 months, and therapy was reviewed at intervals of 3 months.
Bratislava Medical Journal, 2021
OBJECTIVES: Higher CSBP than brachial SBP in individual patient increases cardiovascular (CV) risk. For follow-up it is important to assess the reproducibility of such measurements. The aim of this study was to assess the reproducibility of these differences, expressed as a CSBP/BrachSBP ratios. SUBJECTS AND METHODS: Eighty-three patients on antihypertensive therapy were analysed for the reproducibility of such ratios after time interval of several month up to several years. For CSBP estimation, we used the Arteriograph (Tensiomed Ltd.), based on blood pressure measurements by cuff on oscillometric principle, using pulse wave analysis (PWA) for assessment of CSBP. RESULTS: The proportion of patients retained the same characteristics (either higher central or higher peripheral SBP) between the fi rst and second measurement was 71.1 %. The association between 1st and 2nd measurement, was statistically signifi cant, p < 0.001. CONCLUSION: In our study, a high proportion (60 %) of treated hypertensive patients had CSBP higher than brachial SBP, which may adversely infl uence their prognosis. This characteristic is highly reproducible. Taking into the account these differences may increase the exactness of CV risk estimation and may contribute to explanation of residual risk of individual patient (Tab.
Journal of Cardiovascular Disease Research, 2019
Background: Non-invasively measured brachial arterial pressure is accepted as the standard method for blood pressure measurement. However, systolic pressure varies throughout the arterial tree such that central systolic pressure is actually lower than corresponding brachial pressure. The aim of the study was to evaluate the differential effects of commonly used antihypertensive drugs on central aortic pressure measured invasively. Methods and Results: This was a prospective, single-centre and observational study. During the time period November 2009 to November 2010, a total of 170 patients with chronic stable angina and systemic hypertension were enrolled. Detailed medical history and physical examinations were performed. Laboratory investigations were noted. Brachial and central aortic pressures were recorded and compared. Demographic and clinical parameters were comparable among patients in different antihypertensive therapy groups. Mean systolic blood pressure (SBP) difference and mean pulse pressure (PP) ratio values between beta blocker and non-beta blocker groups were significantly different, (p<0.0001) and (p=<0.0001) respectively. Mean central SBP difference and mean pulse pressure ratio values between beta blocker arm and beta blocker combination groups arm were significantly different too, (p <0.0001 and p=0.0005 respectively). Mean SBP difference and mean PP ratio were also significantly different for beta blocker monotherapy as compared with non-beta blocker drugs individually. In each antihypertensive therapy group, moderate and severe coronary artery disease groups had significantly higher central PP levels. Conclusion: Different classes of antihypertensives have differential impact on central blood pressures. Central systolic and pulse pressures cannot be inferred accurately from brachial blood pressures. Thus, there is potential for under treatment or overtreatment of hypertension based on brachial blood pressure targets.
Baseline predictors of central aortic blood pressure: A PEAR substudy
Journal of the American Society of Hypertension, 2014
Elevated central systolic blood pressure (BP) increases the risk of cardiovascular events and appears superior to peripheral BP for long term risk prediction. The objective of this study was to identify demographic and clinical factors associated with central pressures in patients with uncomplicated hypertension. We prospectively examined peripheral BP, central aortic BP, and arterial wall properties and wave reflection in 57 subjects with uncomplicated essential hypertension in the Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR) Study. Significant predictors of central SBP included height, smoking status, heart rate (HR), and peripheral systolic BP (SBP), while central diastolic BP (DBP) was explained by peripheral DBP and HR. These variables accounted for nearly all of the variability in central SBP and central DBP (R 2 ¼ 0.94 and R 2 ¼ 0.98, respectively). Central pulse pressure variability was largely explained by gender, ex-smoking status, HR, peripheral SBP, and peripheral DBP (R 2 ¼ 0.94). Central augmented pressure had a direct relationship with smoking status, peripheral SBP, and duration of hypertension, whereas it was indirectly related to height, HR, and peripheral DBP. Easily obtainable demographic and clinical factors are associated with central pressures in essential hypertensive persons. These relationships should be considered in future studies to improve assessment of BP to reduce cardiovascular risk and mortality. J Am Soc Hypertens 2014;8(3):152-158.