Central Aortic Pressure in management Hypertension state of the art

BY ASHRAF OKBA

PROF. OF INTERNAL MEDICINE AIN SHAMS UNIVERSITY

“A man is as old as his arteries.”Thomas Sydenham, 1624-1689

“Arterial aging”• Every heart beat generates a pulse wave, which disperses in the human body.

Young and healthy vessels are absorbing the energy of the wave – vascular walls are cushioning.

• Vessels are ageing. Over time they are getting stiff – vascular walls are not

cushioning anymore. The travel speed of the pulse wave is increasing (pulse wave velocity – PWV).

• Early detection of vascular aging is important to prevent CVD and Hypertension.

Blood pressure 137/91 mmHg

Blood pressure 137/91 mmHg – What is the difference?

Why Measure Arterial Stiffness?

• Reflects the true arterial wall damage

• Has an independent predictive value for CV events , independent of the traditional risk factors

• A marker of earlier TOD compared to LVH and albuminuria

Increased Arterial Stiffness cause

• Increases vascular afterload with a propensity to develop LVH

• Decreases coronary perfusion pressure

• Increases myocardial oxygen demand and sub-endocardial

ischemia

• Increases flow turbulence, endothelial dysfunction &

atherogenesis

APWV measured was a significant predictor of cardiovascular complications, above and beyond mean arterial pressure.

Prognostic Value of Aortic Pulse Wave Velocity as Index of Arterial Stiffness in the General Population

(Circulation. 2006)

Vascular Stiffness Measurements asa Prognostic Indicator

A increase in PWV by 1.0 m/sec increases the risk of CV events by 14%

Speed of the wave is related to the stiffness of the artery it is traveling in

The stiffer the artery; the higher the wave speed

Wave speed is proportional to the square root of arterial stiffness

Assessment of Arterial Stiffness

• Pulse wave velocity (PWV) The gold standard measurement of arterial

stiffness

• Central aortic pressure• Augmentation index

Pulse Wave Velocity (PWV)

• In young adults, arteries are distensible, thus wave travel velocity is relatively low. The reflected wave is seen in diastole.

• In older people and in arteriosclerosis, the pulse wave velocity is high, the reflected wave is fater & superimposed on the systolic wave leading to higher systolic pressure and shorter diastolic time.

Pulse wafeform of 25 year

Pulse wafeform of 47 year

Pulse wafeform of 85year

Central aortic pulse waveform in different age groups

PWV predicts overall survival in end-stage renal disease patients

Blacher et al. 1999

Probability of survival (all-cause mortality) in end-stage renal disease patients according to the level of aortic pulse wave velocity (PWV) divided in tertiles (P< .0001).

What creates central BP?

• Stroke volume

• Aortic stiffness (compliance / Windkessel)

• Systemic vascular resistance (“runoff”)

• Reflected pressure wave

The major organs (brain, heart, and kidney) see central arterial BP and not brachial BP.

Therefore, brachial systolic and pulse BPs measured with a sphygmomanometer in the arm are not always reliable measures of central aortic systolic and pulse BPs.

Central BP & PP

• Among 3520 participants, central and brachial pulse pressures were more strongly related to vascular hypertrophy and extent of atherosclerosis than were systolic pressures.

• Central pulse pressure was more strongly related to all 3 arterial measures than was brachial pulse pressure .

• central pulse pressure predicted cardiovascular events more strongly than brachial pulse pressure

• In conclusion, central pulse pressure is more strongly related to vascular hypertrophy, extent of atherosclerosis, and cardiovascular events than is brachial blood pressure.

Beta-blockers not effectively protect against cardiovascular events as it’s central systolic pressure

BP 142/88 mmHgABPM 136/86 COL-LDL 135 mg/dlWaist 104 cmECG, UAE: negative

Guidelines ESH - ESC 2013

Searching for TOD modifies treatment decisions!

BP 142/88 mmHgABPM 136/86 COL-LDL 135 mg/dlWaist 104 cmLVM 126 g/m2

PWV 10,5 m/s

NO Treatment with drugs

Treatment: YES, BP and LDL !!

Patient with recently diagnosed HT, no previous treatment

Cardioalex 2015

ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE

ESH - ESC CHARTS

BP 185/105 mmHgCOL-LDL 135 mg/dlLVM 125 g/m2

PWV 10,5 m/sWaist 104 cm

BP 135/88 mmHgCOL-LDL 135 mg/dlLVM 116 g/m2

PWV 10,1 m/sWaist 104 cm

BP 135/88 mmHgCOL-LDL 98 mg/dlLVM 105 g/m2

PWV 8,8 m/sWaist 101 cm

BP 185/105 mmHgCOL-LDL 135 mg/dlLVM 125 g/m2

PWV 10,5 m/sWaist 104 cm

Guidelines ESH - ESC 2013

Treatment of BP ALONE does not necessarily reduce risk !!

ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE

ESH - ESC CHARTS

BP 142/88 mmHgABPM 136/86 COL-LDL 135 mg/dlWaist 104 cmECG, UAE: negative

Guidelines ESH - ESC 2013

Searching for TOD modifies treatment decisions !!

BP 142/88 mmHgABPM 136/86 COL-LDL 135 mg/dlWaist 104 cmLVM 126 g/m2

PWV 10,5 m/s

NO Treatment with drugs

Treatment: YES, BP and LDL !!

Patient with recently diagnosed HT, no previous treatment

ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE

ESH - ESC CHARTS

Guidelines ESH - ESC 2013

What is our target? Blood Pressure? TOD? How often?

BP 142/88 mmHgABPM 136/86 COL-LDL 135 mg/dlLVM 126 g/m2

PWV 10,5 m/s

Patient with Stage 1 HT, treatment

Valsartan is addedstatin is added

BP 138/85 mmHgABPM ? COL-LDL 98 mg/dlLVM ?PWV 10,1 m/s

3 months later, treatment Amlodipine/Valsartan 10/160 , statin

WHEN YOU UNDERSTAND SMILE AND CUSTOMIZE

ASHRAF OKBA

22

•At least 75% of patients

will require combination therapy to achieve

contemporary BP targets.

.1Gradman AH, Basile JN, Carter BL, et al. Combination therapy in hypertension. J Am Soc Hypertens 2010; 4 (2): 90-8 .

Valsartan &amlodipine combination achieve An optimal control of BP with different degree of hypertension included isolated systolic hypertension Real-Life Safety and Effectiveness Adv Ther (2011) 28(2):134-149.

Amlodipin based therapy achieve control of BP 24 hrs without much variability

Rothwell PM, et al. Lancet Neurol. 2010;9:469-480.

RAS BLOKER

RAS BLOKER

VAL /AMLOD

VAL /AMLOD

Boutouyrie et al J Hypertens 2014; 32: 108-114

Effect of B.blocker/Amlodipine versus Valsartan/Amlodipine on aPWV Adjusted for Changes in MAP and Heart Rate

Rev. 1.0 03.05.2023

Pulse Wave Analysis (PWA)

ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE

CONCLUSIONS

1. Measuring TOD as an intermediate stage in the continuum improves stratification of cardiovascular risk

2. Treatment-induced changes in subclinical organ damage relate to cardiovascular outcomes

3. Arterial stiffness appears to be the most useful candidate TOD to be used for monitoring patients

4. The effect of drugs on arterial stiffness seems to be stronger for newer treatments, including ARB and CBB