Κεντρικές*πιέσεις*–Ανακλώμενα*κύματα** · Central hemodynamics...
Transcript of Κεντρικές*πιέσεις*–Ανακλώμενα*κύματα** · Central hemodynamics...
Η μελέτη των δεικτών αρτηριακής δομής και λειτουργίας: Από την κλινική έρευνα στην κλινική πράξη; Κεντρικές πιέσεις – Ανακλώμενα κύματα
Δημήτριος Στάκος, FESC, FSCAI Επίκουρος καθηγητης καρδιολογίας Δ.Π.Θ. Αλεξανδρούπολη
Peripheral not representative of central (especially in younger)
SBP -‐ DBP -‐ MP -‐ PPA
McEniery C M et al. Hypertension. 2008
McEniery C M et al. Hypertension. 2008
78% overlap in aortic systolic BP between high-normal BP and stage 1 hypertension
..32% between normal BP and stage 1 hypertension
Peripheral not representative of central
men women
Staessen JA, et al. Lancet. 2001 Agabiti-Rosei E, et al, Hypertension , 2007 Agabiti-Rosei E, et al, Hypertension , 2007
Central vs peripheral pressures plots and odds ratios with CV events (strokes) A direct relation between stroke and central pressure changes induced by antihypertensive treatment
Peripheral pressure Central pressure
SBP difference (Central -Per): amlodipin difference is greater
Despite insignificant differences in PSBP, derived CSBP is substantially lower with amlodipine-based therapy
Williams B, et al. Circulation, 2006
Differential effects of antihypertensives on peripheral and central pressures and CV outcomes
Adji A, et al. Am J Hypertens 2010
HOPE study
CAFE study
ACCOMPLISH study
+ Diuretic
+ Amlodipine
HOPE study
CAFE study
ACCOMPLISH study
Dahlöf B, et al. Lancet, 2005
Cardiovascular outcomes according to antihypertensive regiment
Stroke
and all-cause mortality
Cardiovascular events
CV mortality
Adji A, et al. Am J Hypertens. 2010
Comparison of ΔSBP2 across different antihypertensives class.
Central pressures guide CV benefits from antihypertensive drugs
The pressure wave contour Summation of forward and backward reflected waves during the same ejection cycle
Ventricular ejection Wave amplitude Wave velocity
Atenolol Amlodipine
Atenolol Amlodipine
Aortic waveforms from patients achieving equivalent brachial blood pressures
Williams B, et al. Circulation, 2006
Per
iphe
ral w
avef
orm
s
Cor
resp
ondi
ng d
eriv
ed
cent
ral a
ortic
wav
efor
ms
Central blood pressure (CBP)-related indexes obtained from radial pressure pulse waveform
* Tr: reflected wave arrival time
ΔSBP2 =rSBP2-pSBP
*
Ύψος πίεσης κατά τη σύµπτωση ΔSBP2
cPP/bPP
Central pressures and reflected waves : CARDIOVASCULAR DISEASE biomarkers of disease detection and events
Central BP measurements and subclinical organ damage in general population
Roman MJ, et al, Hypertension , 2007
The association between AIx and CVD is better in young male (angiography)
Weber T, et al. Circula(on. 2004
Central hemodynamics and risk of CAD
ORs in <60y
London MG, et al. Hypertension, 2001
CV and overall survival according to AIx quartiles in End-Stage Renal Failure
Log-rank test : P<0.0001
Log-rank test : P<0.0001
(~8 years)
Mitchell GF, et al. Circulation. 2010
Higher aortic stiffness assessed by PWV but not Aix or central PP is associated with cardiovascular risk in the general population (Framingham)
Temmar M, et al. Hypertension. 2010
Intraaortic BP anf PP Amplification in Subjects at High Coronary Risk
PPA
Increase in PP from central to peripheral arteries physiologically contributes to reduce the cardiac pulsatile load
Benetos A, et al. JACC, 2010
C/B ratio is less dependent on BP calibration
PPA
It seem logical that ..the prognostic impact of pulsatile arterial function is higher in the presence of coronary atherosclerosis, being the other major limiting factor of coronary perfusion.
Aix as determinant of clinical outcomes in non-CAD patients
Williams B, et al. Circulation. 2006
AIx
Augmentation pressure and AIx predicts major adverse CV outcomes in CAD male patients
Chirinos JA, et al. Hypertension. 2005
for each 10-mm Hg increase
for each 10% increase
AIx
Weber T, et al Eur Heart J. 2005
Aix and cardiovascular events in patients undergoing PCI
* Death, MI, and clinical restenosis
*
log-rank test: P=0.001
AIx@75 tertiles at baseline
88% males
70% males
60% males
AIx
Central PP predict CV events more strongly than brachial PP in the general population
Fatal and non-fatal CV events
Roman MJ, et al, Hypertension , 2007
cPP
HRs of the individual BP variables per 10 mmHg increment for all cause and CV mortality in 1272 participants
Wang KL,et al. J Hypertens. 2009
10-year
cPP
Myocardial oxygen demands and central pressure,
Tension time index (TTI) as a measure of myocardial oxygen demand per minute
Association with incident and reflected wave indices
*
*
Greater in women
RWTT: reflected wave transit time
Possible underestimation of the impact of wave reflection indices in predicting CV events -timing dependence-
Thus, high values of AI and Pa secondary to reduced RWTT do not necessarily indicate an increase in wave reflection intensity
Reflection index
Wang KL, et al. Hypertension. 2010
The carotid pressure waveform separation into its forward and reflected components to calculate the transit time–independent parameters of wave reflection intensity
Wang KL, et al. Hypertension. 2010
Hazard ratios per increment of 1-SD of Pi, Pa, Pf, and Pb for cardiovascular mortality
Central hemodynamics for the prediction of CV events
8.8% αύξηση κινδύνου για κάθε 10mmHg αύξησης της CSBP
Vlachopoulos C, et al. Eur Heart J, 2010
13.7% αύξηση κινδύνου για κάθε 10mmHg αύξησης της CPP
Central hemodynamics for the prediction of CV events
31.8% αύξηση κινδύνου για κάθε 10mmHg αύξησης του C AIx
Vlachopoulos C, et al. Eur Heart J, 2010
Central hemodynamics for the prediction of all-cause mortality
38.4% αύξηση κινδύνου για κάθε 10mmHg αύξησης του C AIx
Vlachopoulos C, et al. Eur Heart J, 2010
Conclusions: Non-invasive measurement of central pressures and central wave indices can be used in clinical practice
requires good knowledge of central hemodynamics physiology Although target values for radial artery AT are not well defined, age- and sex-specific ranges for central pressure measurements in normotensive individuals are known (central SBP of approximately 124 mm Hg or greater and a central PP of 50 mm Hg or greater are associated with a higher risk of CV events and mortality. Finally, the study of central waveform can provide new and better insight into the pathophysiology of cardiovascular disorders associated with ageing, hypertension, diabetes, CAD and ESRD.
Which population (CAD, HTN, general population, ESRD, men, women)
Temmar M, et al. Hypertension. 2010
Mitchell GF, et al. Circulation. 2010
Safar M, et al. Hypertension. 2002
CAD population
General population
ESRD population
Which parameter (evidence for a specific central pressure component or index does not necessarily apply to the others)
(HR, height, gender EF dependence)
ΔSBP2 =rSBP2-pSBP
*
cPP/pPP ratio
Nilsson PM, et al. Hypertension.2009
ADAM: aggressive decrease of atherosclerosis modifiers
Putting all currently available data together it appears certainly that there is an additional prognostic value of central pressure wave forms beyond peripheral blood pressure for early detection of CVD risk, monitor of /need
for antihypertensive therapy or re-stratification in specific disease groups
Central pressure wave indices ?
cBP and wave reflection indices may reveal the effects of CV risk factors before brBP measurements do