- Central blood pressure provides different information than peripheral blood pressure
- Central blood pressure better defines hypertension
- Central blood pressure has a stronger association with cardiovascular outcomes
- Central blood pressure predicts risk
- Central blood pressure responds to hypertensive management
- Central blood pressure outcomes
http://www.dialogues-cvm.com/document/77/DCVM77_02.pdf
Central blood pressure provides different information than peripheral blood pressure
Blood pressure (BP) measured in the upper arm is different from central blood pressure and the relationship shows considerable variation amongst individuals. Central blood pressure and left ventricular load are determined not only by cardiac output and peripheral vascular resistance but also the stiffness of conduit arteries which is measured by the timing and magnitude of pressure wave reflections.
Sharman, J, Stowasser, M, Fassett, R, Marwick, T, Franklin, S 2008, ‘Central blood pressure measurement may improve risk stratification’ J Hum Hypertens, vol. 22, No 12, pp. 838-44.
The CAFE Investigators, for the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Investigators, CAFE Steering Committee and Writing Committee, Williams, B, Lacy, PS, Thom, SM, Cruickshank, K, Stanton, A, Collier, D, Hughes, A.D, Thurston, H, O’Rourke, M 2006, ‘Differential Impact of Blood Pressure-Lowering Drugs on Central Aortic Pressure and Clinical Outcomes: Principal Results of the Conduit Artery Function Evaluation (CAFE) Study. Circulation, vol. 113, pp. 1213–1225.
Central blood pressure better defines hypertension
New values for defining hypertension based on risk analysis have demonstrated that optimal cBP is 110/80 mmHg. Hypertension is defined as > 130/90 mmHg, and above this level the risk of cardiovascular mortality and morbidity increases significantly.
Cheng, H-M, MD, Chuang, S-Y, Sung, S-H, Yu, W-C, Pearson, A, Lakatta, EG, Pan, W-H, Chen, C-H 2013, ‘Derivation and Validation of Diagnostic Thresholds for Central Blood Pressure Measurements Based on Long-Term Cardiovascular Risks’, J Am Coll Cardiol, vol. 62, no. 19, pp. 1780-1787.
Central blood pressure has a stronger association with cardiovascular outcomes
The difference between central blood pressure and peripheral blood pressure is significant because central blood pressure predicts cardiovascular outcomes better than brachial blood pressure.
Safar, ME, Jankowski, P 2009 ‘Central blood pressure and hypertension: role in cardiovascular risk assessment’, Clinical Science, vol. 116, no. 4, pp. 273–282.
Central blood pressure is more strongly associated with coronary artery disease, hypercholesterolemia, renal disease and cardiovascular complications in pregnancy.
Lazdam, M, de la Horra, A, Pitcher, A, Mannie, Z, Diesch, J, Trevitt, C, Kylintireas, I, Contractor, H, Singhal, A, Lucas, A, Neubauer, S, Kharbanda, R, Alp, N, Kelly, B, Leeson, P 2010, ‘Elevated blood pressure in offspring born premature to hypertensive pregnancy: is endothelial dysfunction the underlying vascular mechanism?’ Hypertension, vol. 56, no. 1, pp. 159-65.
Yinon, Y, Kingdom, JCP, Odutayo, A, Moineddin, R, Drewlo, S, Lai, V, Cherney, DZI, Hladunewich, MA 2010, ‘Vascular Dysfunction in Women With a History of Preeclampsia and Intrauterine Growth Restriction Clinical Perspective Insights Into Future Vascular Risk’, Circulation, vol. 122, pp. 1846-1853.
Central blood pressure predicts risk
Central hypertension predicts cardiovascular mortality
Optimal central blood pressure is 110/80 mmHg with >130/90 mmHg defining hypertension. Comparing to optimal blood pressure, the risk of cardiovascular mortality increased significantly in subjects with hypertension.
1272 normotensive and untreated hypertensive (Systolic BP ≥ 140 or Diastolic BP ≥ 90 mmHg without any previous antihypertensive medication) were included. 674 Taiwanese men, aged 30–79 years.
Cheng, H-M, MD, Chuang, S-Y, Sung, S-H, Yu, W-C, Pearson, A, Lakatta, EG, Pan, W-H, Chen, C-H 2013, ‘Derivation and Validation of Diagnostic Thresholds for Central Blood Pressure Measurements Based on Long-Term Cardiovascular Risks’, J Am Coll Cardiol, vol. 62, no. 19, pp. 1780-1787.
Central blood pressure better predicts cardiovascular events
Central blood pressure more strongly predicts vascular hypertrophy, extent of atherosclerosis, and cardiovascular events than did brachial blood pressure.
Among 2403 participants free of clinical CVD at baseline, 319 suffered fatal or nonfatal cardiovascular events during mean follow-up of 4.8 years. After adjustment for age, gender, current smoking, body mass index, cholesterol:HDL ratio, creatinine, fibrinogen, diabetes, and heart rate, noninvasively-determined central blood pressure more strongly predicted, vascular hypertrophy, extent of atherosclerosis, and cardiovascular events than did brachial blood pressure.
Roman, MJ, Devereux, RB, Kizer, JR, Lee, ET, Galloway, JM, Ali, T, Umans, JG & Howard, BV 2007, ‘Central pressure more strongly relates to vascular disease and outcome than does brachial pressure: the Strong Heart Study’, Hypertension, vol. 50, pp. 197-203.
Office central blood pressure is more predictive of all cause cardiovascular mortality than office peripheral blood pressure
In a community-based population of 1014 healthy participants, central & 24 hour systolic and pulse pressures, were obtained and associations with all-cause and cardiovascular mortalities over a median follow-up of 15 years were examined. Out-of-office 24 hour peripheral blood pressure may be superior to central blood pressure in the prediction of cardiovascular mortality, but central blood pressure may better predict all-cause mortality than 24 hour blood pressure.
Huang, C-M, Wang, K-L, Cheng, H-M, Chuang, S-Y, Sung, S-H, Yu, W-C, Ting, C-T, Lakatta, EG, Yin, FC, Chou, P, Chen, C-H 2011. ‘Central versus ambulatory blood pressure in the prediction of all-cause and cardiovascular mortalities’ J Hypertens, vol. 29, no. 3, pp. 454-9.
Lower risk of stage 1 hypertension needing treatment
9.5 years of follow-up of 354 mainly male participants screened for stage 1 hypertension and 34 normotensive controls data demonstrated that young-to-middle-age isolated systolic hypertensive individuals with low central blood pressure have a lower risk of hypertension needing treatment than those with high central blood pressure.
Saladini, F, Santonastaso, M, Mos, L, Benetti, E, Zanatta, N, Maraglino, G & Palatini, P, HARVEST Study Group 2011, ‘Isolated systolic hypertension of young-to-middle-age individuals implies a relatively low risk of developing hypertension needing treatment when central blood pressure is low’, J Hypertens, vol. 29, no. 7, pp. 1311-9.
Central blood pressure has predictive values independent of blood pressure
Central blood pressure values demonstrate that vasodilatory antihypertensives lower central blood pressure independently of peripheral blood pressure without evident class-specific differences, whereas non vasodilators may raise central blood pressure.
Miyashita H, Aizawa A, Hashimoto J et al. 2010, ‘Cross-sectional characterization of all classes of antihypertensives in terms of central blood pressure in Japanese hypertensive patients’ Am. J. Hypertens, vol. 23, no. 3, pp. 260–268.
Central blood pressure is an independent predictor of AF
SAFFIHRE is a study of AF in persons aged ≥65 years with ≥ 2 other risk factors for AF (hypertension, coronary artery disease, heart failure, diabetes), and without any history of AF or stroke at baseline. Of 800 enrolled participants central pulse pressure was stronger than peripheral pulse pressure as an independent predictor of AF. It dominated the model for prediction of first AF, eclipsing well-established clinical and echocardiographic risk factors.
Tsang, T, Verzosa, G, Barnes, M, Al-Omari, M, Bailey, K, Cha, S, Seward, J, Pellikka, P, Gersh, B & O’Rourke, MF 2008, Central Pulse Pressure As A Robust Predictor Of First Atrial Fibrillation: Study Of Atrial Fibrillation In High Risk Elderly (SAFFIHRE)’, Circulation, vol. 118, no, 18.
Central blood pressure responds to hypertensive management
Different classes of antihypertensive medication have similar effects on central blood pressure and brachial blood pressure but profoundly different effects on pulse wave morphology and thus central hemodynamic parameters.
Dahlöf et al., 2002; London et al., 2004; The CAFE Investigators et al., 2006; Jamerson et al., 2008; Mackenzie et al., 2009; McEniery, 2009; Protogerou, Papaioannou, et al., 2009; Protogerou, Stergiou, et al., 2009; Boutouyrie et al., 2010; Ferdinand et al., 2011; Takami and Saito, 2011
Significant association with amlodipine
Despite similar brachial systolic blood pressures between treatment groups, there were substantial reductions in central blood pressure with the amlodipine regimen. Central blood pressure was significantly associated with total cardiovascular events.
Preliminary evidence suggests that achievement of a lower central blood pressure for a given level of brachial blood pressure may be more effective in reducing CV organ damage and morbidity and mortality.
The CAFE Investigators, for the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Investigators, CAFE Steering Committee and Writing Committee, Williams, B, Lacy, PS, Thom, SM, Cruickshank, K, Stanton, A, Collier, D, Hughes, A.D, Thurston, H, O’Rourke, M 2006, ‘Differential Impact of Blood Pressure-Lowering Drugs on Central Aortic Pressure and Clinical Outcomes: Principal Results of the Conduit Artery Function Evaluation (CAFE) Study. Circulation, vol. 113, pp. 1213–1225.
Central blood pressure outcomes
High brachial blood pressure and low central blood pressure risk profile comparable to normotensives
Spurious systolic hypertension is characterized by high brachial blood pressure and low central blood pressure. CV risk profiles of both groups (spurious systolic hypertension and normotensives) were found to be comparable in a population aged 26–31 years. This suggests central blood pressure more accurately predicts normotension as well as hypertension.
Cheng, H-M, MD, Chuang, S-Y, Sung, S-H, Yu, W-C, Pearson, A, Lakatta, EG, Pan, W-H, Chen, C-H 2013, ‘Derivation and Validation of Diagnostic Thresholds for Central Blood Pressure Measurements Based on Long-Term Cardiovascular Risks’, J Am Coll Cardiol, vol. 62, no. 19, pp. 1780-1787.
Current evidence suggests that achieving a normal central blood pressure may produce better outcomes than achieving normal brachial blood pressure targets and may reduce morbidity and mortality and organ damage.
Pulse pressure (PP) was more strongly related to vascular hypertrophy and extent of atherosclerosis than was systolic pressure and that central PP was more strongly related to these subclinical manifestations of CVD than was brachial PP.
Central Pulse pressure >50mm Hg (compared with <50mm Hg) was significantly related to outcome in both men and women, in participants with and without diabetes, and in individuals older and younger than the ages 60 and 65 years.
Roman, MJ, Devereux, RB, Kizer, JR, Okin, PM, Lee, ET, Wang, W, Umans, JG, Calhoun, D, Howard, BV 2009, ‘High Central Pulse Pressure Is Independently Associated With Adverse Cardiovascular Outcome: The Strong Heart Study’, J Am Coll Cardiol, vol. 54, no. 18, pp. 1730-4.
Significantly less medication needed
Central blood pressure guided hypertension treatment requires significantly reduced medication to achieve healthy blood pressure than if treatment decisions were based on brachial blood pressure.
Twelve month study of 286 hypertensive patients being treated with 1-3 medications.
1:1 randomization; best-practice brachial blood pressure management +/- central aortic pressure assessment as an adjunct.
Sharman, JE, Marwick, TH, Gilroy, D, Otahal, P, Abhayaratna, WP & Stowasser, M 2013 ‘Randomized Trial of Guiding Hypertension Management Using Central Aortic Pressure Compared with Best-Practice Care: Principle Findings of the BP GUIDE Study’, Hypertension, vol. 62, pp. 1138-45.