Jafar Al-Said, M.B. ChB. MD. FASN. FACP. Chair of I nternal Medicine. Nephrology and Internal Medicine Consultant. Bahrain Specialist Hospital

Jafar Al-Said, M.B. ChB. MD. FASN. FACP.Chair of Internal Medicine.Nephrology and Internal Medicine Consultant.Bahrain Specialist HospitalCENTRAL BLOOD PRESSUREAND ITS CLINICAL IMPLICATION EUROPEAN HYPERTENSION EXELLENCE CENTERBAHRAIN SPECIALIST HOSPITAL1

SchemeHistoric points.Pulse wave hemodynamics.Central Pressure. Incident wave & Reflected wave.Augmentation pressure. Pulse wave Velocity.How to Measure the Central pressure.Evidenced based clinical significance. PWA and Central BP research data from BSH European HTN excellence center data. Conclusion.

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History of Pulse wave and HTN3

First BP measures 1677-1761

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1897 Scipione Riva Rocci

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1905, Nikolai Korotkoff.

Korotkoff sounds

71- The first Korotkoff sound is the snapping sound first heard at the systolic pressure.

2- The second sounds are the murmurs heard between the systolic and diastolic pressures.

3- The third sound was described as a loud, crisp tapping sound.

4- The fourth sound, "thumping" and "muting".

5- The fifth Korotkoff sound is silent as the cuff pressure drops below the diastolic blood pressure.

Hypertension History1733 first BP measurement made Stephen Hales.1808 HTN as disease Thomas Young.1836 HTN as disease Richard Bright.1896 Cuff based Sphygmomanometer Scipione Riva-Rocci.1905 Korotkoff soundsNikolai Korotkoff.1911 Term: Essential HTN Ebrhard Frank.1928 Malignant HTNMayo clinic 8

Transportation in 1900

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Telecommunication and Mail 1900

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Measurement of the BP2015Korotkoff sounds of BP measurement.

Discovered By Nocolas Korotkoff 1905.

BP CUFF PICTURE.

en.wikipedia.org/wiki/Korotkoff_souWikipedia

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12How to measure BP?Office.Home.ABPM.Central BP measurement.

Central BP measuring Devices13

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Aortic Pressure

Arterial wall Composition

Peripheral vessels are muscular with high collagen.

Central arteries are predominantly made of elastin fibers.

Progressive Loss of elastin occurs:With ageHTN. Trudeau Luc. Central Blood Pressure as an Index of Antihypertensive Control: Determinants and Potential Value. Canadian Journal of Cardiology 30 (2014) S23eS2816

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18AORTAAPEX

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Aorta and Central Arteries

INCIDENT WAVEREFLECTIVE WAVE20Large Artery store:50% of stroke volume.10 % of the energy. ** Adrian Covic, Pulse Wave Velocity Ratio. Hypertension 2015;65:289-290

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23Arterial system is a closed system

Primary wave (blue) travels along the arteries generating reflected waves from bifurcations

These small reflected waves return to the heart, summing to create a reflected pressure wave as shown in grey, starting even before the end of systoleFigure 2

Physiology - Pressure Wave Reflection at the Heart

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Affect of Atherosclerosis on blood flow

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Augmentation pressure

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Aging and changes in the pulse wave

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Schematic representation of pulse pressure amplification.

Oliver J J , and Webb D J Arterioscler Thromb Vasc Biol. 2003;23:554-566Copyright American Heart Association, Inc. All rights reserved.27

Schematic representation of pulse pressure amplification. Typical pressure tracings from the brachial artery and central aorta are shown. When the large arteries are compliant, such as in a normal healthy young subject (waveforms on the left), the arterial waveform is amplified as it travels toward the periphery. As the large arteries stiffen, for example, with increasing age, diabetes, or other cardiovascular risk factors, this amplification is reduced (waveforms on the right). The two subjects have similar BP at the brachial artery despite striking differences at the aorta, demonstrating the importance of assessing central BP in individuals. The effect of peripheral wave reflection on the central aortic waveform is illustrated in the lower tracings. When the large arteries are compliant the initial systolic pressure wave, P1, traveling from the heart to the periphery, is responsible for peak SBP. Reflected pressure waves, P2, arrive at the central aorta in diastole, augmenting DBP and coronary artery filling. As large arteries stiffen, wave reflection occurs earlier so that SBP is augmented and DBP falls. AIx is calculated as the difference between the second (P2) and first (P1) systolic peaks (P) as a percentage of the PP. Thus, AIx is negative in healthy young people, but with aging or increasing cardiovascular risk, arteries stiffen and AIx becomes increasingly positive.

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Augmentation IndexAI = Augmentation Pressure Pulse Pressure

Is predictor of CV mortality and morbidity.Vlachopoulos C, Aznaouridis K, Stefanadis C. Prediction of cardiovascular events and all-cause mortality with arterial stiffness: a systematic review and meta-analysis. J Am Coll Cardiol. 2010;55(13): 13181327.

Jankowski P, Kawecka-Jaszcz K, Czarnecka D, et al. Pulsatile but not steady component of blood pressure predicts cardiovascular events in coronary patients. Hypertension. 2008;51:18.

Correlate with LV mass in normotensives. Marchais SJ, Guerin AP, Pannier BM, Levy BI, Safar ME, London GM. Wave reflections and cardiac hypertrophy in chronic uremia. Influence. of body size. Hypertension. 1993;22:87688329

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S PAPPPDP

Systolic pressure (SP) Diastolic pressure (DP) Central Pulse Pressure (PP) Augmented pressure (AP) measure of the energy wasted by the heart due to the reflected wave AIx (= AP/PP)composite measure of the magnitude of wave reflection and arterial stiffness

Key Central pressure parameters.P2

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R.R. Townsend et al. Central blood pressure measurementsan opportunity for efficacy and safety in drug development? Journal of the American Society of Hypertension 4(5) (2010) 21121431

Aortic Pulse wave Analysis

Figure 1: Aortic pulse pressure waveform. Systolic and diastolic pressures are the peak and trough of the waveform. Augmentation pressure is the additional pressure added to the forward wave by the reflected wave. Augmentation index is defined as the augmentation pressure as a percentage of pulse pressure. The dicrotic notch represents closure of the aortic valve and is used to calculate ejection duration. Time to reflection is calculated as the time at the onset of the ejected pulse waveform to the onset of the reflected wave.32

CENTRAL PRESSURE INCREASEAging.Smoking.Hyperlipidemia.HTN. ORourke MF. Pulsatile arterial hemodynamics in hypertension. Aus N Z Med 1976;6(suppl 2):40-8.

McEniery CM, Yasmin, McDonnell B, et al. Central pressure: variability and impact of cardiovascular risk factors: the Anglo-Cardiff Collaborative Trial II. Hypertension 2008;51:1476-82.33

Central BP represent more accurately the load on Coronary, cerebral circulation and Lt Vent. R.R. Townsend et al. Central blood pressure measurementsan opportunity for efficacy and safety in drug development? Journal of the American Society of Hypertension 4(5) (2010) 21121434

Central BP performs better than the Brachial BP in terms of CV mortality and outcome.

McEniery CM, Yasmin, McDonnell B, Munnery M, Wallace SM, Rowe CV, et al. Central pressure: variability and impact of cardiovascular risk factors. The Anglo-Cardiff Collaborative Trial II. Hypertension 2008;51:147682.

Townsend RR, Wimmer NJ, Chirinos JA, Parsa A, Weir M, Perumal K, et al. Aortic PWV in chronic kidney disease: a CRIC ancillary study. Am J Hypertens 2010;23:2829.

Roman MJ, Devereux RB, Kizer JR, Lee ET, Galloway JM, Ali T, et al. Central pressure more strongly relates to vascular disease and outcome thandoes brachial pressure: the Strong Heart Study. Hypertension 2007;50:197203.

Roman MJ, Devereux RB, Kizer JR, Okin PM, Lee ET, Wang W, et al. High central pulse pressure is independently associated with adverse cardiovascular outcome: the strong heart study. J Am Coll Cardiol 2009;54: 17304.

Pini R, Cavallini MC, Palmieri V, Marchionni N, Di BM, Devereux RB, et al. Central but not brachial blood pressure predicts cardiovascular events in an unselected geriatric population: the ICARe Dicomano Study. J Am Coll Cardiol 2008;51:24329.

Wang KL, Cheng HM, Sung SH, Chuang SY, Li CH, Spurgeon HA, et al.Wave reflection and arterial stiffness in the prediction of 15-year all-cause and cardiovascular mortalities: a community-based study. Hypertension 2010;55:799805.

Mitchell GF, Hwang SJ, Vasan RS, Larson MG, Pencina MJ, Hamburg NM, et al. Arterial stiffness and cardiovascular events: the Framingham Heart Study. Circulation 2010;121:50511.35

Central pressure a better predictor for target organ damage than Brachial BP.Better correlated with:Carotid internal diameter and intima-media thickness.Vascular Hypertrophy.Extent of atherosclerosis.

Augmentation pressure is associated with increased LVH. Independent of Age and MAP. Boutouyrie P, Bussy C, Lacolley P, et al. Association between local pulse pressure, mean blood pressure and large-artery remodelling. Circulation 1999;100:1987-93.Saba PS, Roman MJ, Pini R, et al. Relation of arterial pressure waveform to left ventricular and carotid anatomy in normotensive subjects. J Am Coll Cardiol 1993;22:1873-80.36

Associated with more age related macular denervation.

More progression of renal disease and all cause mortality, CV mortality

Carotid intema-media thickness and atherosclerosis plaque score. Central pressure a better predictor of target organ damage than Brachial BP.Sato E, Feke GT, Appelbaum EY, et al. Association between systemic arterial stiffness and age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 2006;244:963-71Cohen DL, Townsend RR. Central blood pressure and chronic kidney disease progression. Int J Nephrol 2011;2011:407801.

Safar ME, Blacher J, Pannier B, et al. Central pulse pressure and mortality in end-stage renal disease. Hypertension 2002;39:735-8.Roman MJ, Devereux RB, Kizer JR, et al. Central blood pressure more strongly relates to vascular disease and outcome than does brachial pressure: the Strong Heart Study. Hypertension 2007;50:197-203.37

Strong Heart study:

N =2403.With no CV risk.Follow up for 4.8 years.

Result:Central pressure predicted CV events ( MI, stroke, HF, cardiac death) better than brachial BP. Central pressure a better predictor of target organ damage than Brachial BP.Roman MJ, Devereux RB, Kizer JR, et al. Central blood pressure more strongly relates to vascular disease and outcome than does brachial pressure: the Strong Heart Study. Hypertension 2007;50:197-203.38

Individuals > 65 years. Some normotensive and untreated HTN.Follow up 8 years.

Results:Carotid central pressure was predictor of CV events and not brachial.

Central pressure a better predictor of target organ damage than Brachial BP.Pini R, Cavallini MC, Palmieri V, et al. Central but not brachial blood pressure predicts cardiovascular events in an unselected geriatric population. J Am Coll Cardiol 2008;51:2432-9.39

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ESC Stockholm. Central blood Pressure. To the heart of matter Sept 2010

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Williams B. ESC Stockholm. Central blood Pressure. To the heart of matter Sept. 2010

Distribution of central BP values in a Japanese general populationAim: Distribution of central BP in a general Japanese population.

Methodology:Cross sectional study.N= 10756.No overt CV disease.

Results: Central systolic was higher than brachial BP. Mean age 55.3 +12.5.Males 61 %.Mean central systolic was 112.6 +19.2 with no CV and optimal Brachial BP. 125.8 + 37.2 for HTN with no CV risk factors. Hiroyuki Takase, Yasuaki Dohi and Genjiro Kimura. Distribution of central blood pressure values estimated by Omron HEM-9000AI in the Japanese general population. Hypertension Research 36, 50-57 (January 2013) doi:10.1038/hr.2012.12242

Central BP Threshold< 130/90 mmHg.

Cheng HM, Chuang SY, Sung SH, Chen CH. Derivation and validation of diagnostic thresholds for central blood pressure measurements based on long-term cardiovascular risks. J Am Coll Cardiol 2013;62:1780-7.

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Pulse Wave VelocitySpeed of pulse wave propagation through the aorta.

Stiff artery = higher speed.

Elastic arteries = slowed speed.

Influenced by heart rate, Age and DM. ( Not smoking, gender and dyslipidemia)

ESH/ESC Task Force for the Management of Arterial Hypertension. 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology. J Hypertens 2013;31:1925-38.44

Mean PWV value for age < 30 years = 6.2m/s.

Mean PWV value for age > 70 years = 10.9 m/s.Pulse Wave VelocityReference value for arterial stiffness collaborative group in EuropeThe Reference Values for Arterial Stiffness Collaboration. Determinants of pulse wave velocity in healthy people and in the presence of cardiovascular risk factors: establishing normal and reference values. Eur Heart J 2010;31:2338-50.45

1 m/s increased aPWV was associated with 7% increased CV event risk.

Patients who are: 60 years. Male.Non smoker.Non Diabetic, Non HTN.T. Cholest. 5.5, LDL 1.3 46

Ben Shlomo. et.al. Journal of the American College of Cardiology; Vol 63, No 7, 2014

Best individual predictor for the first Major CV event.

Strong predictor of future CV events and all cause mortality. Carries higher prevalence risk for CV events in high risk patients. Pulse Wave VelocityMitchell GF, Hwang SJ, Vasan RS, et al. Arterial stiffness and cardiovascular events; the Framingham Heart Study. Circulation 2010;121: 505-11.Vlachopoulos C, Aznaouidis K, Stefanadis C. Prediction of cardiovascular events and all-cause mortality with arterial stiffness. J Am Coll Cardiol 2010;55:1318-2747

Mitchell GF, Hwang SJ, Vasan RS, et al. Arterial stiffness and cardiovascular events; the Framingham Heart Study. Circulation 2010;121: 505-11.48

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Better outcome in prediction of CV risk among:

Intermediate risk group.

Young population. 49

Ben Shlomo. et.al. Journal of the American College of Cardiology; Vol 63, No 7, 2014

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Ben Shlomo. et.al. Journal of the American College of Cardiology; Vol 63, No 7, 2014

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In the CAFE study of over 2,000 patients, brachial blood pressure was controlled in both study arms

But the ACE/ CCB arm had up lower central BP and 30% less CV events than the beta blocker arm.

Augmented Pressure was reduced by the ACE/ CCB but not by the beta blocker.

Brachial pressure does not measure arterial stiffnessCentral Pressure shows the effects of Drug therapy masked by Brachial Pressure

Williams B et al., Circulation 2006; 113: 1213-25

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Central Pulse Pressure is better than brachial pressure in determining CV risk.Strong Heart Study showed that central pulse pressure (CPP) defines a threshold for CV risk: Below 50 mmHg- Risk of heart attack or stroke was normal.Above 50 mmHg there were twice as many heart attacks and stokes when CPP exceeded 50mmHg.

* NS from Q1

** p