Κεντρικές*πιέσεις*–Ανακλώμενα*κύματα** · Central hemodynamics...

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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

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  

The value of pSBP in the estimation of absolute CVD risk over 5 years

It is Aortic systolic pressure that the left ventricle encounters during systole (afterload)

The Aortic pressure during diastole is a determinant of coronary perfusion.

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

Normal values according to age and gender in normotensives

Nelson M, et al. Mayo Clin Proc, 2010

Normal values in hypertensives vs normotensives

Nelson M, et al. Mayo Clin Proc, 2010

Measurement of central pulse pressure waveform

Tonometry of the radial artery

Invasive measurement

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

Central hemodynamic indices in End-Stage Renal Failure

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 and CV events in the general population

Pini R,et al. JACC. 2008

cPP

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

(~8 years)

Mitchell GF, et al. Circulation. 2010

Criticism

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

Stakos DA, et al. Hellenic J Cardiol. 2013

Aortic stiffness and chest pain in non-CAD HTN patients

Stakos DA, et al. Hellenic J Cardiol. 2013

Aortic stiffness and chest pain in non-CAD HTN patients

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

Comparison between central and peripheral BP

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

Benetos A, et al. JACC. 2012

Which age

Mean age: 88±5 years

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