Arterial stiffness, pulse pressure, and cardiovascular disease—Is it possible to break the vicious circle?

Genetic Complexities of Cerebral Small Vessel Disease, Blood Pressure, and Dementia

Importance

Vascular disease is a treatable contributor to dementia risk, but the role of specific markers remains unclear, making prevention strategies uncertain.

Objective

To investigate the causal association between white matter hyperintensity (WMH) burden, clinical stroke, blood pressure (BP), and dementia risk, while accounting for potential epidemiologic biases.

Design, Setting, and Participants

This study first examined the association of genetically determined WMH burden, stroke, and BP levels with Alzheimer disease (AD) in a 2-sample mendelian randomization (2SMR) framework. Second, using population-based studies (1979-2018) with prospective dementia surveillance, the genetic association of WMH, stroke, and BP with incident all-cause dementia was examined. Data analysis was performed from July 26, 2020, through July 24, 2022.

Exposures

Genetically determined WMH burden and BP levels, as well as genetic liability to stroke derived from genome-wide association studies (GWASs) in European ancestry populations.

Main Outcomes and Measures

The association of genetic instruments for WMH, stroke, and BP with dementia was studied using GWASs of AD (defined clinically and additionally meta-analyzed including both clinically diagnosed AD and AD defined based on parental history [AD-meta]) for 2SMR and incident all-cause dementia for longitudinal analyses.

Results

In 2SMR (summary statistics-based) analyses using AD GWASs with up to 75 024 AD cases (mean [SD] age at AD onset, 75.5 [4.4] years; 56.9% women), larger WMH burden showed evidence for a causal association with increased risk of AD (odds ratio [OR], 1.43; 95% CI, 1.10-1.86; P = .007, per unit increase in WMH risk alleles) and AD-meta (OR, 1.19; 95% CI, 1.06-1.34; P = .008), after accounting for pulse pressure for the former. Blood pressure traits showed evidence for a protective association with AD, with evidence for confounding by shared genetic instruments. In the longitudinal (individual-level data) analyses involving 10 699 incident all-cause dementia cases (mean [SD] age at dementia diagnosis, 74.4 [9.1] years; 55.4% women), no significant association was observed between larger WMH burden and incident all-cause dementia (hazard ratio [HR], 1.02; 95% CI, 1.00-1.04; P = .07). Although all exposures were associated with mortality, with the strongest association observed for systolic BP (HR, 1.04; 95% CI, 1.03-1.06; P = 1.9 × 10-14), there was no evidence for selective survival bias during follow-up using illness-death models. In secondary analyses using polygenic scores, the association of genetic liability to stroke, but not genetically determined WMH, with dementia outcomes was attenuated after adjusting for interim stroke.

Conclusions

These findings suggest that WMH is a primary vascular factor associated with dementia risk, emphasizing its significance in preventive strategies for dementia. Future studies are warranted to examine whether this finding can be generalized to non-European populations.

Early Cardiac Rehabilitation Improves Carotid Arterial Stiffness in Patients with Myocardial Infarction

Background

Little is known about the effect of cardiac rehabilitation (CR) on carotid arterial stiffness (CAS) in patients with myocardial infarction (MI).

Patients and Methods

Rehabilitation group (B) included 90 patients with MI subjected to CR, control group (K) consisted of 30 patients with MI not participating in CR, and healthy group comprised 38 persons without cardiovascular risk factors. CAS was determined using echo-tracking before and after CR.

Results

At baseline, patients with MI (B+K) presented with significantly higher mean values of CAS parameters: beta-stiffness index (7.1 vs 6.4, p = 0.004), Peterson's elastic modulus (96 kPa vs 77 kPa, p < 0.001) and PWV-beta (6.1 m/s vs 5.2 m/s, p < 0.001) than healthy persons. Age (beta: r = 0.242, p = 0.008; EP: r = 0.250, p = 0.006; PWV-beta: r = 0.224, p = 0.014) and blood pressure: SBP (EP: r = 0.388, PWV-beta: r = 0.360), DBP (AC: r = 0.225) and PP (PWV-beta: r = 0.221) correlated positively with the initial parameters of CAS. Beta-stiffness index (Rho=-0.26, p = 0.04) and PWV-beta (Rho = 0.29, p = 0.03) correlated inversely with peak exercise capacity expressed in METs. After CR, mean values of beta-stiffness index (6.2 vs 7.1, p = 0.016), EP (78 kPa vs 101 kPa, p = 0.001) and PWV-beta (5.4 m/s vs 6.2 m/s, p = 0.001) in group B were significantly lower than in group K. In group B, CAS parameters decreased significantly after CR. Univariate analysis demonstrated that the likelihood of an improvement in CAS after CR was significantly higher in patients with baseline systolic blood pressure <120 mm Hg (OR = 2.74, p = 0.009) and left ventricular ejection fraction <43% (OR = 5.05, p = 0.005).

Conclusion

In patients with MI, CR exerted a beneficial effect on CAS parameters. The improvement in CAS was predicted by lower SBP and LVEF at baseline.

Relationship between Pulse Pressure and Handgrip Strength in the Korean Population: A Nationwide Cross-Sectional Study

Background: Sarcopenia is defined as the loss of muscle mass and strength and low physical performance, and it is closely related to the risk of cardiovascular disease and mortality. Pulse pressure (PP) is a biomarker of arterial stiffness and compliance. Elevated PP levels increase the risk of cardiovascular diseases and all-cause mortality. Nevertheless, the association between PP and sarcopenia has not yet been clearly established. Methods: Participant data were extracted from the Korea National Health and Nutrition Examination Survey conducted from 2014 to 2020. The study population was classified into three groups (PP < 40 mmHg, 40 mmHg ≤ PP < 60 mmHg, and PP ≥ 60 mmHg). PP was calculated by deducting the diastolic blood pressure from the systolic blood pressure. For handgrip strength, the maximum value measured with a grip dynamometer was adopted (weak handgrip strength: <28 kg for men, <18 kg for woman; normal handgrip strength: ≥28 kg for men, ≥18 kg for women). To determine the relationship between PP and the prevalence of weak handgrip strength, multiple logistic regression analysis was performed after adjusting for possible confounding factors. Results: The higher PP group had a higher age, body mass index; systolic blood pressure, prevalence of hypertension, diabetes, hyperlipidemia, and metabolic syndrome, and maximum handgrip strength. In all models, the prevalence of weak handgrip strength was significantly higher in the group with PP ≥ 60 mmHg compared to the control group (PP < 40 mmHg). Conclusions: Elevated PP was significantly associated with a higher prevalence of weak muscle strength. Thus, PP monitoring may be used to identify individuals at risk of sarcopenia and is helpful in improving health outcomes.

John J, Van Iterson EH, Laffin LJ. Association of pulse pressure with death, myocardial infarction, and stroke among cardiovascular outcome trial participants

Background

Prior evidence demonstrates that pulse pressure (PP), a surrogate marker of arterial stiffness, is an independent risk factor for mortality and major adverse cardiovascular (CV) events.

Objectives

The study aimed to identify the association of PP with death, myocardial infarction, and stroke among participants enrolled in large CV outcome clinical trials and determine if this association was impacted by pre-existing CV disease, or specific CV risk factors.

Methods

A total of 65,382 individuals, ages 19 to 98 years, that were enrolled in one of five CV outcome trials were analyzed. Baseline demographics, history, blood pressures, and medications were collected. Univariate and multivariable analyses were conducted to explore temporal patterns, risks, and adjusted survival rates.

Results

Mean baseline PP was 52 ± 12 mmHg. For every 10 mmHg increase in PP, there was an increased risk of death, stroke, or myocardial infarction (hazard ratio (HR) 1.11, 95 % CI 1.08 to 1.14, p < 0.001). Similarly, a PP ≥ 60 mmHg demonstrated an HR of 1.27 (95 % CI 1.19 to 1.36, p < 0.001) compared with PP < 60 mmHg. A similar association existed for all subgroups analyzed except for participants with a history of stroke where increasing PP did not increase risk (HR 1.02, 95 % CI 0.95 to 1.10, p = 0.53). PP was a better predictor of adverse outcomes when compared to both systolic and diastolic blood pressures using the AIC and C-index.

Conclusions

Among participants enrolled in CV outcome trials, baseline PP is associated with increased risk of death, myocardial infarction, and stroke for those with pre-existing CV disease and risk factors with the exception of a prior history of stroke.

Age and vascular aging: an unexplored frontier

Vascular age is an emerging field in cardiovascular risk assessment. This concept includes multifactorial changes in the arterial wall, with arterial stiffness as its most relevant manifestation, leading to increased arterial pressure and pulsatile flow in the organs. Today, the approved test for measuring vascular age is pulse wave velocity, which has been proven to predict cardiovascular events. Furthermore, vascular phenotypes, such as early vascular aging and "SUPERNOVA," representing phenotypic extremes of vascular aging, have been found. The identification of these phenotypes opens a new field of study in cardiovascular physiology. Lifestyle interventions and pharmacological therapy have positively affected vascular health, reducing arterial stiffness. This review aims to define the concepts related to vascular age, pathophysiology, measurement methods, clinical signs and symptoms, and treatment.

Evaluation of the effect of obesity, dietary glycemic index and metabolic profiles on the cardiovascular risk in children with classical phenylketonuria

OBJECTIVES

To compare the glycemic index(GI),obesity,echocardiographic,and arterial stiffness measurements with the healthy control group to evaluate the cardiovascular risk of pediatric classical phenylketonuria(PKU).

METHODS

The study was a prospective observational,involving 104 pediatric volunteers between 2019 and 2020.Two groups were formed:the PKU patient group and the healthy control group.These two groups were further divided into three subgroups:obese,overweight,and normal weight.The patients' anthropometric measurements,body fat analysis,biochemical analysis, GI and glycemic load(GL),arterial stiffness measurements,and echocardiographic findings were recorded.

RESULTS

The PKU patient group's glucose,total cholesterol,LDL,and HDL values were significantly lower than the healthy control group(p = 0.010 for glucose and p = 0.001 for total cholesterol,LDL and HDL).Triglyceride levels were higher in the PKU patient group than in the healthy controls(109.6 vs. 76.7 mg/dl,p = 0.001). GI and GL were significantly lower in the PKU patient group than in the healthy control group(GI 453 vs. 392.9,p = 0.017 and GL 101.1 vs. 85.5,p = 0.036).Left ventricular mass(LVM)-z-score and LVM index were significantly higher in the PKU group than in the healthy control group(LVM z-score 0.9 vs. 0.5,p = 0.014 and LVM index 38.9 vs. 32.7 g/m2.7,p = 0.001). A moderately statistically significant positive correlation was found between the mean phenylalanine(phe) value and pulse wave velocity(PWV) among the PKU patient groups(R: 0.477,p < 0.001).A moderately statistically significant positive correlation was also found between waist circumference and PWV in the PKU patient group(R:0.541, p < 0.001).

CONCLUSIONS

Our study found that close follow-up of phe levels and PWV is more critical than obesity, GI, and GL in the cardiovascular evaluation of classical PKU patients.A large number of multicenter pediatric studies are needed in this area.

Complexities of cerebral small vessel disease, blood pressure, and dementia relationship: new insights from genetics

Importance

There is increasing recognition that vascular disease, which can be treated, is a key contributor to dementia risk. However, the contribution of specific markers of vascular disease is unclear and, as a consequence, optimal prevention strategies remain unclear.

Objective

To disentangle the causal relation of several key vascular traits to dementia risk: (i) white matter hyperintensity (WMH) burden, a highly prevalent imaging marker of covert cerebral small vessel disease (cSVD); (ii) clinical stroke; and (iii) blood pressure (BP), the leading risk factor for cSVD and stroke, for which efficient therapies exist. To account for potential epidemiological biases inherent to late-onset conditions like dementia.

Design Setting and Participants

This study first explored the association of genetically determined WMH, BP levels and stroke risk with AD using summary-level data from large genome-wide association studies (GWASs) in a two-sample Mendelian randomization (MR) framework. Second, leveraging individual-level data from large longitudinal population-based cohorts and biobanks with prospective dementia surveillance, the association of weighted genetic risk scores (wGRSs) for WMH, BP, and stroke with incident all-cause-dementia was explored using Cox-proportional hazard and multi-state models. The data analysis was performed from July 26, 2020, through July 24, 2022.

Exposures

Genetically determined levels of WMH volume and BP (systolic, diastolic and pulse blood pressures) and genetic liability to stroke.

Main outcomes and measures

The summary-level MR analyses focused on the outcomes from GWAS of clinically diagnosed AD (n-cases=21,982) and GWAS additionally including self-reported parental history of dementia as a proxy for AD diagnosis (ADmeta, n-cases=53,042). For the longitudinal analyses, individual-level data of 157,698 participants with 10,699 incident all-cause-dementia were studied, exploring AD, vascular or mixed dementia in secondary analyses.

Results

In the two-sample MR analyses, WMH showed strong evidence for a causal association with increased risk of ADmeta (OR, 1.16; 95%CI:1.05-1.28; P=.003) and AD (OR, 1.28; 95%CI:1.07-1.53; P=.008), after accounting for genetically determined pulse pressure for the latter. Genetically predicted BP traits showed evidence for a protective association with both clinically defined AD and ADmeta, with evidence for confounding by shared genetic instruments. In longitudinal analyses the wGRSs for WMH, but not BP or stroke, showed suggestive association with incident all-cause-dementia (HR, 1.02; 95%CI:1.00-1.04; P=.06). BP and stroke wGRSs were strongly associated with mortality but there was no evidence for selective survival bias during follow-up. In secondary analyses, polygenic scores with more liberal instrument definition showed association of both WMH and stroke with all-cause-dementia, AD, and vascular or mixed dementia; associations of stroke, but not WMH, with dementia outcomes were markedly attenuated after adjusting for interim stroke.

Conclusion

These findings provide converging evidence that WMH is a leading vascular contributor to dementia risk, which may better capture the brain damage caused by BP (and other etiologies) than BP itself and should be targeted in priority for dementia prevention in the population.

Supplementation of antihypertensive drug regimen with vitamin E ameliorates alterations of primary haemodynamic parameters and total antioxidant capacity in ovariectomised rats

OBJECTIVES

Ovariectomy induces heightened response to vasoconstrictors, alters vasorelaxation and consequently causes hypertension due to increased oxidative stress in rats.

METHODS

This study evaluated the ameliorative effects of ramipril and vitamin E, on primary haemodynamic parameters and cardiac antioxidant defence status, in ovariectomised rats using 64 adult female rats of the Wistar strain randomly divided as follows: Control (sham); Ovariectomised (OVX); OVX plus Ramipril; OVX plus vitamin E; and OVX plus Ramipril plus vitamin E.

RESULTS

The plasma level of oestrogen was significantly lower (p<0.05), in the ovariectomised rats compared with the sham. The systolic, diastolic and mean arterial blood pressure of ovariectomised rats increased significantly (p<0.05), but the alteration was significantly reduced by the administration of ramipril alone or in combination with vitamin E. Significant decrease (p<0.05) was observed in the serum level of nitric oxide in OVX group compared with Sham. Also, analysed markers of oxidative stress: Malondialdehyde (MDA) contents and hydrogen peroxide (H2O2) generated decreased significantly (p<0.05), but systemic antioxidants: reduced glutathione (GSH) contents; glutathione peroxidase (GPx) and superoxide dismutase (SOD) activities increased significantly (p<0.05) in the ovariectomised rats treated with ramipril and vitamin E compared with untreated ovariectomised rats. The study concludes that alteration, in the primary haemodynamic parameters, associated with ovariectomy in rats is potently ameliorated by co-administration of the antihypertensive drug ramipril and vitamin E.

CONCLUSIONS

The supplementation of antihypertensive regimen with antioxidants such as vitamin E in the treatment of hypertension is therefore justifiable especially in ovariectomised or hypogonadal patients.

The relationship between pulse pressure with plasma PCSK9 and interleukin-6 among patients with acute ischemic stroke and dyslipidemia

BACKGROUND AND PURPOSE

A high plasma concentration of proprotein convertase subtilisin/kexin type 9 is characteristic of a prothrombotic state in cardiovascular diseases. Elevated inflammatory markers, such as interleukin-6, are associated with worse outcomes after ischemic stroke. We aimed to study the role of plasma PCSK9 and IL-6 in acute ischemic stroke with dyslipidemia.

METHODS

We divided 123 enrolled patients with first-ever acute ischemic stroke into normotensive and high blood pressure groups and further into high and low pulse pressure subgroups. Clinical characteristics and inflammatory and metabolic parameters, including plasma PCSK9 and IL-6, were recorded.

RESULTS

After the analysis of the normotensive and BP groups, there were positive correlations between PP and carotid stenosis (P = 0.031) and plaque numbers (P = 0.013) and between National Institute of Health Stroke Scale scores (P = 0.019) and carotid stenosis severity (P = 0.021) and resistance index (P = 0.04). There was a significant association between plasma cholesterol and PCSK9 (P = 0.044) in the low PP subgroup and IL-6 (P = 0.042) in the high PP subgroup.

CONCLUSIONS

Our findings indicated that plasma PCSK9 levels were associated with the low PP subgroup, while IL-6 was associated with the high PP subgroup. Dyslipidemia control is also necessary for those who had a stroke and who have high PP. Further investigation to assess the role of PCSK9 and IL-6 in patients with stroke is required for early treatment and secondary prevention.

Association Between Pulse Pressure With All-Cause and Cardiac Mortality in Acute Coronary Syndrome: An Observational Cohort Study

Background

Pulse pressure (PP) is a surrogate of aortic stiffness, and reflects cardiac performance and stroke volume. Previous studies have indicated that PP was a robust predictor of cardiovascular outcomes and mortality. However, results have been mixed, and very few studies have focused on the association of PP with mortality in acute coronary syndrome (ACS). Thus, we aimed to investigate the relationship between admission PP and the prognosis of patients with ACS.

Methods

This cohort study included 10,824 patients diagnosed with ACS from the Cardiovascular Center Beijing Friendship Hospital Database Bank (CBDBANK) from January 2013 to October 2018. Patients with cardiogenic shock, malignancy, severe trauma and, no PP at admission were excluded. Restricted cubic spline and Cox proportional hazards regression were used to evaluate the association between PP and 1-year all-cause and cardiac mortality.

Results

In the whole cohort, a total of 237 (2.19%) all-cause deaths were reported at 1-year follow-up. Restricted cubic spline analysis suggested a J-shaped relationship between PP and mortality. Among patients with ACS, both lower and higher PP levels were related to an increased risk of mortality (Pnon–linear &lt; 0.001); with a PP level of 30 or 80 mmHg, as compared with 50 mmHg, the adjusted hazard ratios for 1-year all-cause mortality were 2.02 (95% CI, 1.27–3.22) and 1.62 (95% CI, 1.13–2.33), respectively, after adjustments for potential confounders. Similar results were observed for cardiac deaths. The J-shaped relationship between PP and mortality remained in a series of subgroup analyses.

Conclusion

Our results suggested that both low and high PP were associated with an increased risk of mortality in patients with ACS.

The Relationship between Pulse Pressure and Periodontal Disease in Korean Populations with or without Hypertension

Aims: This study evaluated the relationship between pulse pressure (PP) and periodontal disease in Korean adults with or without hypertension (classified as HTN and non-HTN, respectively). Methods: Data on 3496 adults (≥20 years) were obtained from the Korean National Health and Nutrition Examination Survey (2015). We classified those with HTN as SBP ≥ 140 mmHg, DBP ≥ 90 mmHg, or current use of anti-hypertensive medications. Results: There were a few key findings: when logistic regression analysis was applied for periodontal disease (community periodontal index score ≥ 3), the odds ratios (OR) were significantly higher in the high PP (PP > 60 mmHg) than in the normal PP (PP ≤ 60 mmHg) in the HTN group (OR, 2.131; 95% confidence interval (CI), 1.579–2.876). However, periodontal disease was not associated with high PP in the non-HTN group and was not significant (OR, 0.866; 95% CI, 0.494–1.518). Conclusions: In Korean adults, periodontal disease was positively associated with PP in the HTN group but not in the non-HTN group.

Pulsatile Hemodynamics and Coronary Artery Disease

Coronary artery disease (CAD) is the leading cause of human death and has a high prevalence throughout the world. Therefore, it is important to detect CAD early and to apply individualized therapy according to the patients' risk. There is an increasing interest in pulsatile arterial hemodynamics in the cardiovascular area. Widely used measurements of arterial pulsatile hemodynamics include pulse pressure, pulse wave velocity and augmentation index. Here, we will review underlying pathophysiology linking the association of arterial pulsatile hemodynamics with CAD, and the usefulness of the measurements of pulsatile hemodynamics in the prediction of future cardiovascular events of CAD patients. Clinical and therapeutic implications will be also addressed.

Higher habitual dietary flavonoid intake associates with lower central blood pressure and arterial stiffness in healthy older adults

Flavonoids have shown anti-hypertensive and anti-atherosclerotic properties: the impact of habitual flavonoid intake on vascular function, central haemodynamics and arterial stiffness may be important. We investigated the relationship between habitual flavonoid consumption and measures of central blood pressure and arterial stiffness. We performed cross-sectional analysis of 381 non-smoking healthy older adults (mean age 66·0 (sd 4·1) years; BMI, 26·4 (sd 4·41) kg/m2; 41 % male) recruited as part of the Australian Research Council Longevity Intervention study. Flavonoid intake (i.e. flavonols, flavones, flavanones, anthocyanins, isoflavones, flavan-3-ol monomers, proanthocyanidins, theaflavins/thearubigins and total consumption) was estimated from FFQ using the US Department of Agriculture food composition databases. Measures of central haemodynamics and arterial stiffness included systolic blood pressure (cSBP), diastolic blood pressure (cDBP), mean arterial pressure (cMAP) and augmentation index (cAIx). After adjusting for demographic and lifestyle confounders, each sd/d higher intake of anthocyanins ((sd 44·3) mg/d) was associated with significantly lower cDBP (-1·56 mmHg, 95 % CI -2·65, -0·48) and cMAP (-1·62 mmHg, 95 % CI -2·82, -0·41). Similarly, each sd/d higher intake of flavanones ((sd 19·5) mg/d) was associated with ~1 % lower cAIx (-0·93 %, 95 % CI -1·77, -0·09). These associations remained significant after additional adjustment for (1) a dietary quality score and (2) other major nutrients that may affect blood pressure or arterial stiffness (i.e. Na, K, Ca, Mg, n-3, total protein and fibre). This study suggests a possible benefit of dietary anthocyanin and flavanone intake on central haemodynamics and arterial stiffness; these findings require corroboration in further research.

Investigation on Pulse Wave Forward Peak Detection and Its Applications in Cardiovascular Health

OBJECTIVE

The contours of the pulse wave vary greatly, which affect the accuracy of pulse wave peak detection and the reliability of subsequent peak-based cardiovascular health analyses. We proposed an algorithm to reliably detect the peak of forward pulse wave (forward peak) and proposed to use it for improving the accuracy in cardiovascular health analysis.

METHODS

A method based on Gaussian fitting was proposed to detect the forward peak. Then, the forward peak was utilized for instantaneous heart rate (HR), heart rate variability (HRV), and augmentation index (a cardiovascular risk marker reflecting arterial stiffness) estimations. The accuracy of HR/HRV obtained by forward peak was compared with that obtained by other photoplethymogram (PPG) characteristic points previously reported, using electrocardiogram-derived HR/HRV as gold standard. The correlation between augmentation index and age was calculated. The performance was verified using PPG-based pulse wave data with different contours while they were recorded at different locations from subjects with a wide range of age.

RESULTS

The proposed forward peak detection method had smaller estimation error when compared with the gold standard, than other PPG characteristic points in estimating HR/HRV. The augmentation index extracted from the proposed forward peak method was significantly correlated with age (p < 0.01).

CONCLUSIONS

The proposed algorithm can relatively reliably detect the forward peak and has a wide application prospect in cardiovascular health.

SIGNIFICANCE

Due to the convenience of PPG measurements, this proposed forward peak detection method has the potential to be widely used in the fields of wearable devices and telemedicine.

Cardiovascular Outcomes in the Acute Phase of COVID-19

The cumulative number of cases in the current global coronavirus disease 19 (COVID-19) pandemic, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has exceeded 100 million, with the number of deaths caused by the infection having exceeded 2.5 million. Recent reports from most frontline researchers have revealed that SARS-CoV-2 can also cause fatal non-respiratory conditions, such as fatal cardiovascular events. One of the important mechanisms underlying the multiple organ damage that is now known to occur during the acute phase of SARS-CoV-2 infection is impairment of vascular function associated with inhibition of angiotensin-converting enzyme 2. To manage the risk of vascular dysfunction-related complications in patients with COVID-19, it would be pivotal to clearly elucidate the precise mechanisms by which SARS-CoV-2 infects endothelial cells to cause vascular dysfunction. In this review, we summarize the current state of knowledge about the mechanisms involved in the development of vascular dysfunction in the acute phase of COVID-19.

Role of increased central arterial stiffness in macro and microvascular damage in patients with coronary artery disease

BACKGROUND

Patients with heart disease frequently have renal dysfunction manifested by a decrease in glomerular filtration rate (GFR) and / or increase of albuminuria.

OBJECTIVES

The objective was to study the possible role of increased aortic stiffness in the presence and extent of coronary artery disease (CAD) and kidney dysfunction in a group of patients with suspected CAD.

PATIENTS AND METHODS

We studied forty-eight patients undergoing coronariography for suspected coronary disease (CAD). Using applanation tonometry on the radial artery and applying a transfer function, central blood pressure values were calculated. The study of aortic stiffness was done by determining the carotid-femoral pulse velocity (Pv_c-f).

RESULTS

Of the 48 patients, 11 had no significant coronary lesions, 24 showed significant lesions in 1 or 2 coronary arteries and 13 in ≥ 3 arteries. The group with a higher degree of CD had significantly higher cPP values than the group without CD. The Pv_c-f increased progressively and significantly with the degree of CD. The logistic regression showed that Pv_c-f independently predicted the presence of CD. The relative risk of CD increased 2.5 times for each meter of increase in Pv_c-f. The GFR was negatively and significantly correlated with age and Pv_c-f was associated with albuminuria.

CONCLUSIONS

In patients with stable CD, Pv_c-f, expression of aortic stiffness, is independently associated with the existence of CD and its degree of extension. The increase in arterial stiffness also participates in the decrease in GFR and in the increase in albuminuria.

Association of Low-BMI with Aortic Stiffness in Young Healthy Individuals

BACKGROUND

Increased arterial stiffness is an independent predictor of cardiovascular morbidity and mortality. It is not known whether low-BMI has any detrimental effect on arterial wall early during young age.

OBJECTIVES

The present study was aimed to determine if low-BMI can increase arterial stiffness in young healthy individuals.

METHODS

A cross-sectional study was conducted on young healthy subjects (n=100) with low-BMI <18.5 (n=50) and normal-BMI: 18.5-24.9 (n=50) with age ranging between 15-23 years. BMI, heart rate, blood pressure and arterial stiffness indices such as regional pulse wave velocity (PWV) between brachial-ankle (baPWV), carotid-femoral (cfPWV), heart-ankle (haPWV), heart-brachial (hbPWV) were measured.

RESULTS

A significantly increased pulse pressure (p=0.014), baPWV (1059.2 ± 140.26 cm/s Vs 994.66 ± 129.23 cm/s; p=0.019) and cfPWV (641.03 ± 113.83 cm/s Vs 583.96 ± 120.48 cm/s; p=0.017) was found in individuals with low-BMI than normal-BMI group. There was a significant negative correlation between BMI and central arterial PWV. Further multiple regression analysis showed that BMI was robustly associated with cf-PWV (p=0.004) and baPWV (p=0.016) even after multiple adjustments with potential confounders using several models.

CONCLUSIONS

These findings show a significant increased aortic stiffness and pulse pressure in low-BMI subjects compared to those with normal BMI. Low-BMI was inversely and independently associated with central arterial or aortic stiffness. These findings suggest that low-BMI may be a risk factor for aortic stiffness in young healthy individuals.

Subclinical cardiovascular dysfunction in children and adolescents with asthma

BACKGROUND

There is close association between asthma and cardiovascular functions as both diseases share common inflammatory pathways. The current study was aimed at investigating the risk factors, associated with endothelial and cardiac functions in children with newly-diagnosed mild-persistent asthma.

METHODS

A total of 33 steroid-naive asthmatic children [median(interquartile-range); 9.1 years(7.8-13.5)] and 16 healthy controls [11.5 years(9.9-13.6)] were included. Their demographic, clinical and laboratory findings were recorded. Carotid Artery intima-media thickness (CIMT), stiffness, distensibility and strain were measured as atheroclerosis markers. Conventional and tissue Doppler imaging was performed to evaluate ventricular function.

RESULTS

The patients with asthma had higher CIMT and stiffness and lower strain and distensibility compared to controls (p < 0.001 for all). There was a significant correlation between the duration of asthmatic symptoms and subclinical-atherosclerosis as well as peripheral eosinophil count (p < 0.001, p < 0.05). The patients had lower tricuspid-annular-plane-systolic-excursion (TAPSE), ejection time, and higher isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and left ventricle myocardial performance index (LVMPI) than the control subjects (p < 0.001 for all). A positive correlation was also observed between the duration of asthmatic-symptoms and cardiac-function parameters.

CONCLUSION

Children with mild persistent asthma had subclinical atherosclerosis and ventricular dysfunction even in the early stage of disease. Symptom duration was closely associated with both subclinical atherosclerosis and ventricular dysfunction. Myocardial performance index was abnormal in the asthmatic children when assessed by tissue Doppler Imaging even though they had normal ejection fraction in conventional echocardiography. Future prospective studies with larger sample sizes are needed to confirm these findings and to assess the possible protective effect of ICSs in the prevention of subclinical atherosclerosis.

Immediate effects of a single session of physical exercise on cognition and cerebral blood flow: A randomized controlled study of older adults

BACKGROUND

Regular physical activity is beneficial for cognitive performance in older age. A single bout of aerobic physical exercise can transiently improve cognitive performance. Researchers have advanced improvements in cerebral circulation as a mediator of long-term effects of aerobic physical exercise on cognition, but the immediate effects of exercise on cognition and cerebral perfusion are not well characterized and the effects in older adults are largely unknown.

METHODS

Forty-nine older adults were randomized to a 30-min aerobic exercise at moderate intensity or relaxation. Groups were matched on age and cardiovascular fitness (VO2 max). Average Grey Matter Blood Flow (GMBF), measured by a pulsed arterial-spin labeling (pASL) magnetic resonance imaging (MRI) acquisition, and working memory performance, measured by figurative n-back tasks with increasing loads were assessed before and 7 min after exercising/resting.

RESULTS

Accuracy on the n-back task increased from before to after exercising/resting regardless of the type of activity. GMBF decreased after exercise, relative to the control (resting) group. In the exercise group, higher n-back performance after exercise was associated with lower GMBF in the right hippocampus, left medial frontal cortex and right orbitofrontal cortex, and higher cardiovascular fitness was associated with lower GMBF.

CONCLUSION

The decrease of GMBF reported in younger adults shortly after exercise also occurs in older adults and relates to cardiovascular fitness, potentially supporting the link between cardiovascular fitness and cerebrovascular reactivity in older age.

Evaluation of pulse pressure and proportional pulse pressure as predictors of severity among patients having heart failure with reduced ejection fraction

Introduction:

Proportional Pulse Pressure (PPP) is a significant risk indicator in heart failure. PPP is a simple, inexpensive and easily measurable clinical index. This non-invasive test provides useful prognostic information for patients with heart failure with reduced ejection fraction (EF) particularly in those with an EF < 30% where lower proportional pulse pressure independently predicts mortality.

Methods:

A prospective observational study involving 150 patients with reduced ejection fraction was done. Detailed history, clinical examination and parameters like pulse pressure, proportional pulse pressure were evaluated and correlated with ejection fraction.

Results:

The mean age of the patients was 58.99 ± 11.03 years and the majority of the study participants (57.33 %) were between 45 and 65 years of age. The most common etiology of heart failure (HF) was coronary heart disease in this study (76%). Proportional Pulse pressure showed significant association with ejection fraction. The specificity for detecting heart failure was more for proportional pulse pressure and systolic blood pressure (95 % each).

Conclusion:

Proportional Pulse Pressure may help to identify HF patients who present with low cardiac output, low ejection fraction, and worse prognosis. Our current observations reinforce the importance of clinically based skills that must not be forgotten when managing HF.

State of the Art Review: Brachial-Ankle PWV

The brachial-ankle pulse wave velocity (brachial-ankle PWV), which is measured simply by wrapping pressure cuffs around the four extremities, is a simple marker to assess the stiffness of the medium- to large- sized arteries. The accuracy and reproducibility of its measurement have been confirmed to be acceptable. Risk factors for cardiovascular disease, especially advanced age and high blood pressure, are reported to be associated with an increase of the arterial stiffness. Furthermore, arterial stiffness might be involved in a vicious cycle with the development/progression of hypertension, diabetes mellitus and chronic kidney disease. Increase in the arterial stiffness is thought to contribute to the development of cardiovascular disease via pathophysiological abnormalities induced in the heart, brain, kidney, and also the arteries themselves. A recent independent participant data meta-analysis conducted in Japan demonstrated that the brachial-ankle PWV is a useful marker to predict future cardiovascular events in Japanese subjects without a previous history of cardiovascular disease, independent of the conventional model for the risk assessment. The cutoff point may be 16.0 m/s in individuals with a low risk of cardiovascular disease (CVD), and 18.0 m/s in individuals with a high risk of CVD and subjects with hypertension. In addition, the method of measurement of the brachial-ankle PWV can also be used to calculate the inter-arm systolic blood pressure difference and ankle-brachial pressure index, which are also useful markers for cardiovascular risk assessment.

Predictors of Acute Kidney Injury After Hip Fracture in Older Adults

INTRODUCTION

This study aimed to investigate the prevalence of acute kidney injury (AKI) following hip fracture surgery in geriatric patients and to identify predictors for development of AKI with a focus on possible preventable risk factors.

METHODS

In this retrospective cohort study, we reviewed electronic medical records of all patients above 65 years of age who underwent hip fracture surgery at Copenhagen University Hospital, Bispebjerg, Denmark, in 2018. Acute kidney injury was assessed according to the Kidney Disease Improving Global Outcomes guidelines. Multivariate logistic regression analyses were used to identify independent risk factors for AKI.

RESULTS

Postoperative AKI developed in 28.4% of the included patients (85/299). Acute kidney injury was associated with increased length of admission (11.3 vs 8.7 days, P < .001) and 30-day mortality (18/85 vs 16/214, P = .001). In multivariable analysis, higher age (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.08, P = .004), heart disease (OR: 1.78, 95% CI: 1.01-3.11, P = .045), and postoperative blood transfusion (OR: 1.84, 95% CI: 1.01-3.36, P = .048) were associated with AKI. Moreover, a higher postoperative C-reactive protein (199.0 ± 99.9 in patients with AKI, 161.3 ± 75.2 in patients without AKI) and lower postoperative diastolic blood pressure were observed in patients developing AKI.

DISCUSSION AND CONCLUSION

Acute kidney injury was common following hip fracture surgery and associated with longer admissions and increased mortality. Patients developing AKI were older and showed several postoperative similarities, including higher C-reactive protein, lower postoperative diastolic pressure, and the need for blood transfusion.

Can routine perioperative haemodynamic parameters predict postoperative morbidity after major surgery?

Background

Postoperative morbidity occurs in 10–15% of patients undergoing major noncardiac surgery. Predicting patients at higher risk of morbidity may help to optimize perioperative prevention. Preoperative haemodynamic parameters, systolic arterial pressure (SAP) < 100 mmHg, pulse pressure (PP) > 62 mmHg or < 53 mmHg, and heart rate (HR) > 87 min^-1 are associated with increased postoperative morbidity. We evaluated the correlation between these and other routine haemodynamic parameters, measured intraoperatively, with postoperative morbidity. Postoperative morbidity was measured using the Comprehensive Complication Index (CCI) and length of stay (LOS). Additionally we correlated CCI with the cardiac risk biomarker, preoperative NT-ProBNP.

Methods

This is a retrospective analysis of patients in MET-REPAIR, a European observational study correlating self-reported physical activity with postoperative morbidity. Patients’ electronic anaesthetic records (EARs) including perioperative haemodynamic data were correlated with 30-day postoperative morbidity, CCI and LOS parameters. Statistical analysis to assess for correlation was by Kendall’s Correlation Coefficient for tied ranks (Tau-B) or Spearman’s Correlation Coefficient. Blood for N-terminal prohormone of brain natriuretic peptide (NT-proBNP) measurement was collected < 31 days before surgery.

Results

Data from n = 50 patients were analysed. When stratified according to age > 70 years and ASA > 3, the duration of MAP < 100 mmHg, < 75 mmHg or < 55 mmHg were associated with a higher CCI (tau = 0.57, p = 0.001) and duration < 75 mmHg was associated with prolonged LOS (tau = 0.39, p = 0.02). The intraoperative duration of PP > 62 mmHg was associated with LOS (tau = 0.317, p = 0.007). There was no correlation between preoperative NT-proBNP and either CCI or LOS.

Conclusions

In older and higher risk patients, duration of intraoperative hypotension by a variety of definitions, or PP > 62 mmHg, are associated with increased postoperative CCI and LOS. These findings warrant confirmation in larger databases with evaluation of whether real-time intraoperative intervention could reduce postoperative morbidity.

Good advice for endothelial cells: Get in line, relax tension, and go with the flow

Endothelial cells (ECs) are continuously subjected to fluid wall shear stress (WSS) and cyclic strain caused by pulsatile blood flow and pressure. It is well established that these hemodynamic forces each play important roles in vascular disease, but their combined effects are not well understood. ECs remodel in response to both WSS and cyclic strain to align along the vessel axis, but in areas prone to atherogenesis, such an alignment is absent. In this perspective, experimental and clinical findings will be reviewed, which have revealed the characteristics of WSS and cyclic strain, which are associated with atherosclerosis, spanning studies on whole blood vessels to individual cells to mechanosensing molecules. Examples are described regarding the use of computational modeling to elucidate the mechanisms by which EC alignment contributes to mechanical homeostasis. Finally, the need to move toward an integrated understanding of how hemodynamic forces influence EC mechanotransduction is presented, which holds the potential to move our currently fragmented understanding to a true appreciation of the role of mechanical stimuli in atherosclerosis.

From Endothelial Dysfunction to Arterial Stiffness in Diabetes Mellitus

Prevalence of diabetes mellitus has increased drastically over time, especially in more populous countries such as the United States, India, and China. Patients with diabetes have an increased risk of major cardiovascular events such as acute myocardial infarction, cerebrovascular disease, and peripheral vascular disease. Arterial stiffness is a process related to aging and vascular, metabolic, cellular and physiological deterioration. In recent years, it has been described as an independent predictor of cardiovascular mortality and coronary artery disease. Additionally, it plays an important role in the measurement of chronic disease progression. Recent studies have suggested a strong relationship between diabetes mellitus and arterial stiffness since they share a similar pathophysiology involving endothelial dysfunction. The literature has shown that microvascular and macrovascular complications in diabetic patients could be screened and measured with arterial stiffness. Additionally, new evidence proposes that there is a relationship between blood glucose levels, microalbuminuria, and arterial stiffness. Moreover, arterial stiffness predicts cardiovascular risk and is independently associated with mortality in diabetic patients. Abnormal arterial stiffness values in diabetic patients should alert the clinician to the presence of vascular disease, which merits early study and treatment. We await more studies to determine if arterial stiffness could be considered a routine useful non-invasive tool in the evaluation of diabetic patients. There is enough evidence to conclude that arterial stiffness is related to the progression of diabetes mellitus.

Ankle pulse pressure to diastole ratio as a novel non-invasive costless screening tool for subclinical atherosclerosis

Atherosclerosis develops gradually as a subclinical condition and eventually becomes clinically apparent as heart disease or stroke. The degree of decreased arterial compliance affects both pulse pressure (PP) and diastolic blood pressure (DBP). These relations would be clear in the distal periphery. We propose that the ankle PP/ankle DBP ratio (APPD) can uncover the ongoing subclinical vascular risk. Based on the elastic chamber theory, APPD = (Cs-Cd)/(Cd-C0) in which Cs, Cd, and C0 represent arterial compliance at systolic pressure, diastolic pressure, and zero-pressure. For a given ventricular ejection, the value of Cs-Cd (i.e. PP) positively differs in the same person from brachium to ankle based on the distance from the heart, degree of arterial stiffness, and the local arterial function. On the other hand, the decreased arterial compliance increases the speed of reflected pulse waves to the heart resulting in earlier ventricular ejection by which the value of Cd-C0 (i.e. DBP) decreases over the arterial tree. In the same person, studies of ankle-brachial blood pressure (BP) differences revealed that PP greatly differed from brachium to ankle while DBPs were of minimal change or almost equivalent. However, DBP would be lower in those with arterial stiffness compared to others of the same age. Accordingly, APPD increases as arterial compliance decreases. Moreover, decreased APPD after a certain limit would reflect either local arterial stenosis or a compromised left ventricular function. When we divided ankle PP by ankle DBP, we could control the diversity of ankle PP as being not related to the BP level and possibly fluctuates in the same person. Additionally, APPD will indicate the extra rapid reflected pulse wave given in decreased DBP. Since increased common carotid artery intima-media thickness (CIMT) is a well-established marker of atherosclerosis, we initially studied 115 subjects apparently free form vascular diseases and had not taken a drug that can affect BP on the day of the study, aged 40-60 years, without a history of stroke, coronary heart disease or peripheral vascular disease to evaluate the relation between APPD and CIMT. The association was statistically significant even after adjusting for age, sex and important covariates and the area under the receiver operating characteristic curve was 0.902 ± 0.031. Therefore, the potential applicability of APPD as a tool for subclinical atherosclerosis was greatly proven.

Association of Pulse Pressure With Clinical Outcomes in Patients Under Different Antiplatelet Strategies After Percutaneous Coronary Intervention: Analysis of GLOBAL LEADERS

BACKGROUND

We evaluated the association of pulse pressure (PP) and different antiplatelet regimes with clinical and safety outcomes in an all-comers percutaneous coronary intervention (PCI) population.

METHODS

In this analysis of GLOBAL LEADERS (n = 15,936) we compared the experimental therapy of 23 months of ticagrelor after 1 month of dual-antiplatelet therapy (DAPT) vs standard DAPT for 12 months followed by aspirin monotherapy in subjects who underwent PCI and were divided into 2 groups according to the median PP (60 mm Hg). The primary end point (all-cause death or new Q-wave myocardial infarction) and the composite end points: patient-oriented composite end points (POCE), Bleeding Academic Research Consortium (BARC) 3 or 5, and net adverse clinical events (NACE) were evaluated.

RESULTS

At 2 years, subjects in the high-PP group (n = 7971) had similar rates of the primary end point (4.3% vs 3.9%; P = 0.058), POCE (14.9% vs 12.7%; P = 0.051), and BARC 3 or 5 (2.5% vs 1.7%; P = 0.355) and higher rates of NACE (16.4% vs 13.7%; P = 0.037) compared with the low-PP group (n = 7965). Among patients with PP < 60 mm Hg, the primary end point (3.4% vs 4.4%, adjusted hazard ratio [aHR] 0.77, 95% confidence interval [CI] 0.61-0.96), POCE (11.8% vs 13.5%, aHR 0.86, 95% CI 0.76-0.98), NACE (12.8% vs 14.7%, aHR 0.85, 95% CI 0.76-0.96), and BARC 3 or 5 (1.4% vs 2.1%, aHR 0.69, 95% CI 0.49-0.97) were lower with ticagrelor monotherapy compared with DAPT. The only significant interaction was for BARC 3 or 5 (P = 0.008).

CONCLUSIONS

After contemporary PCI, subjects with high PP levels experienced high rates of NACE at 2 years. In those with low PP, ticagrelor monotherapy led to a lower risk of bleeding events compared with standard DAPT.

Association between blood pressure components and the presence of carotid plaque among adults aged 45 years and older: a population-based cross-sectional study in rural China

OBJECTIVE

Pulse pressure is strongly associated with the early development of large-vessel atherosclerotic disease. However, the relationship between pulse pressure and carotid plaque in China is unknown. Thus, we investigated the associations of pulse pressure and mean arterial pressure with the presence of carotid plaques in a low-income population in rural China.

PARTICIPANTS AND METHODS

Residents, aged ≥45 years, without histories of stroke or cardiovascular disease were enrolled. Participant demographics, previous medical histories, and lifestyle information were collected; anthropometric measures, serum profiles, and B-mode ultrasonographic investigations were also performed.

RESULTS

The mean age of participants (n = 3789) was 59.9 years overall (men 61.1 years; women, 59.1 years). The mean SBP (146.42 mmHg) and DBP (86.81 mmHg), pulse pressures (59.61 mmHg), and mean arterial pressures (106.68 mmHg) were high in this population. The odds ratio (95% confidence interval) for the association of pulse pressure with the presence of carotid plaques was 1.028 (1.023-1.033), in the univariate analysis. After gradual adjustment for demographic features, risk factors, and serum profile measurements, this positive association remained statistically significant (all, P < 0.001). However, there was no significant relationship between mean arterial pressure and the presence of carotid plaques.

CONCLUSION

These findings suggest that an elevated pulse pressure is an independent risk factor for the presence of carotid plaque. These results suggest that enhanced monitoring of blood pressure components, among low-income residents, is crucial for decreasing the risk of stroke and other cardiovascular disease in China.

Novel Biomarkers of Early Atherosclerotic Changes for Personalised Prevention of Cardiovascular Disease in Cervical Cancer and Human Papillomavirus Infection

Cervical cancer is associated with a causative role of human papillomavirus (HPV), which is a highly prevalent infection. Recently, women with a genital HPV infection were found to have increased incidence of cardiovascular diseases (CVD), including severe cardiovascular events such as myocardial infarction and stroke. The pathomechanisms of this relation are not yet fully understood, and may significantly affect the health of a large part of the population. Accelerated atherosclerosis is assumed to play a key role in the pathophysiology of this relationship. To identify high-risk groups of the population, it is necessary to stratify the CVD risk. Current algorithms, as widely used for the estimation of CVD risk, seem to be limited by the individual misclassification of high-risk subjects. However, personalised prediction of cardiovascular events is missing. Regarding HPV-related CVD, identification of novel sensitive biomarkers reflecting early atherosclerotic changes could be of major importance for such personalised cardiovascular risk prediction. Therefore, this review focuses on the pathomechanisms leading to HPV-related cardiovascular diseases with respect to atherosclerosis, and the description of potential novel biomarkers to detect the earliest atherosclerotic changes important for the prevention of CVD in HPV infection and cervical cancer.

Increased Arterial Stiffness in Adolescents With Obesity

Increased arterial stiffness (AS) is an early sign of cardiovascular disease. Influence of weight, puberty, and insulin resistance (IR) on AS in adolescents is unclear. Therefore, this study compared AS, assessed with pulse wave velocity (PWV) and augmentation index (AIx), of adolescents with and without obesity and evaluated the influence of puberty and IR on AS. Sixty-two lean and 61 adolescents with obesity were included. Significantly higher PWV was observed in adolescents with obesity (4.1 ms⁻¹ [2.4 to 5.6 ms⁻¹] vs 3.6 ms⁻¹ [0.4 to 6.1 ms⁻¹]; P = .01), while AIx was not significant different. However, significantly higher AIx was observed in adolescents with obesity and IR (3.0 [−17.5% to 28.5%] vs −3.0 [−19.0% to 13.0%]; P = .01). For Tanner stages, no differences were observed. The higher PWV in adolescents with obesity and higher AIx in adolescents with obesity and IR both indicate an increased AS. Consequently, measurement of AS should be considered in adolescents with obesity and IR as part of cardiovascular risk assessment.

U-shaped association of central pulse pressure with long-term prognosis after ST-segment elevation myocardial infarction

The relationship between central pulse pressure (CPP) measured at the time of primary percutaneous coronary intervention (PPCI) and long-term prognosis after ST-segment elevation myocardial infarction (STEMI) has not been investigated. CPP measurements were performed in 1348 patients with STEMI (327 women; mean age 62.5 ± 12.1 years) undergoing PPCI. Aortic systolic and diastolic blood pressure was measured before intervention. The primary outcome was 8-year all-cause mortality. The median [25-75th percentile] CPP value was 55.0 [43.0-70.0] mmHg. CPP correlated negatively with heart rate (P < 0.001), body mass index (P = 0.007), Killip class (P < 0.001) and initial area at risk (P < 0.001) and positively with age (P < 0.001), female sex (P < 0.001), diabetes (P = 0.012), arterial hypertension (P < 0.001) and glomerular filtration rate (P = 0.004). There were 181 deaths over the follow-up. In patients with CPP within the 1st, 2nd and 3rd tertiles, the Kaplan-Meier estimates of mortality were 17.3%, 10.8% and 24.2%, respectively; univariable hazard ratio [HR] =1.52, 95% confidence interval [CI] 0.99 to 2.32; P = 0.055 for tertile 1 vs. tertile 2 and HR =2.09 [1.36-3.21]; P < 0.001 for tertile 3 vs. tertile 2. For CPP values lower than 35 mmHg and higher than 71 mmHg, the association between CPP and all-cause mortality was significant (HR =1.276 [1.004-1.621] for the 35 mmHg value and HR =1.289 [1.003-1.657] for the 71 mmHg value) compared with the CPP reference value (54 mmHg). After adjustment, the association between CPP and all-cause mortality was attenuated (P = 0.304). In patients with STEMI undergoing PPCI there is a U-shaped association between CPP and mortality up to 8 years after PPCI.

Angiotensin II type 1 receptor blockers prevent aortic arterial stiffness in elderly patients with hypertension

Backgrounds and aims: Increased arterial stiffness may increase cardiovascular morbidity and mortality. Angiotensin II type 1 receptor blockers (ARBs) are potentially useful in controlling the central blood pressure and arterial stiffness in mild to moderate essential hypertension, while the effects of ARBs in aged patients with essential hypertension are not entirely investigated. Methods: The carotid-femoral arterial pulse wave velocity (PWV) was measured in aged patients with essential hypertension. Results: In a cross-sectional study, PWV value was significantly higher in these old patients with essential hypertension, compared to patients without essential hypertension. In correlation analysis, PWV was associated positively with age, hypertension duration, and carotid atherosclerosis. However, there was no relationship between PWV and gender in aged patients with essential hypertension. In a perspective study, 6-12 months administration of ARBs (losartan, 50 mg/day; telmisartan, 40 mg/day; valsartan 80 mg/day; irbesartan, 150 mg/day) remarkably reduced PWV in aged patients with essential hypertension. Regression analyses of multiple factors indicated that the effects of ARBs on arterial stiffness were not associated with the reduction of blood pressure. Conclusion: ARB treatment is a negative risk factor of arterial stiffness in aged patients with essential hypertension.

Analyzing the association between aortic regurgitation and atherosclerosis: is pulse pressure a cause of atherosclerosis?

If pulse pressure, one of the mechanical stresses, is a risk factor for atherosclerotic cardiovascular disease, then atherosclerosis should be progressive in aortic regurgitation which is a representative disease with increased pulse pressure. This cross-sectional study included 1,149 patients. We examined the influence of aortic regurgitation on maximum intima-media thickness or brachial-ankle pulse wave velocity. The degree of aortic regurgitation was classified into 4 grades by color Doppler examination. There were 177 patients with aortic regurgitation. Pulse pressure was significantly higher in patients with aortic regurgitation than in those without it. On multiple regression analysis, aortic regurgitation was not found to be a significant independent variable for maximum intima-media thickness [standard partial regression coefficient: aortic regurgitation = grade 1, 0.011, P = 0.7635; aortic regurgitation ≥ grade 2, -0.034, P = 0.3289] and brachial-ankle pulse wave velocity [standard partial regression coefficient: aortic regurgitation = grade1, -0.043, P = 0.1197; aortic regurgitation ≥ grade2, 0.002, P = 0.9358] after adjusting for age, sex, body mass index, presence or absence of cardiovascular disease, antihypertensive treatment, diabetes, dyslipidemia, and smoking. These results found no causal association between aortic regurgitation and atherosclerosis, and were a contradiction to the opinion that pulse pressure was a risk factor of atherosclerosis.

Predictive Value of Pulse Pressure in Acute Ischemic Stroke for Future Major Vascular Events

Background and Purpose—

This study aimed to investigate whether pulse pressure (PP) obtained during the acute stage of ischemic stroke can be used as a predictor for future major vascular events.

Methods—

Using a multicenter prospective stroke registry database, patients who were hospitalized for ischemic stroke within 48 hours of onset were enrolled in this study. We analyzed blood pressure (BP) data measured during the first 3 days from onset. Primary and secondary outcomes were time to a composite of stroke recurrence, myocardial infarction, all-cause death, and time to stroke recurrence, respectively.

Results—

Of 9840 patients, 4.3% experienced stroke recurrence, 0.2% myocardial infarction, and 7.3% death during a 1-year follow-up period. In Cox proportional hazards models including both linear and quadratic terms of PP, PP had a nonlinear J-shaped relationship with primary (for a quadratic term of PP, P =0.004) and secondary ( P <0.001) outcomes. The overall effects of PP and other BP parameters on primary and secondary outcomes were also significant ( P <0.05). When predictive power of BP parameters was compared using a statistic of −2 log-likelihood differences, PP was a stronger predictor than systolic BP (8.49 versus 5.91; 6.32 versus 4.56), diastolic BP (11.42 versus 11.05; 10.07 versus 4.56), and mean atrial pressure (8.75 versus 5.91; 7.03 versus 4.56) for the primary and secondary outcomes, respectively.

Conclusions—

Our study shows that PP when measured in the acute period of ischemic stroke has nonlinear J-shaped relationships with major vascular events and stroke recurrence, and may have a stronger predictive power than other commonly used BP parameters.

Lysyl Oxidase Induces Vascular Oxidative Stress and Contributes to Arterial Stiffness and Abnormal Elastin Structure in Hypertension: Role of p38MAPK

AIMS

Vascular stiffness, structural elastin abnormalities, and increased oxidative stress are hallmarks of hypertension. Lysyl oxidase (LOX) is an elastin crosslinking enzyme that produces H2O2 as a by-product. We addressed the interplay between LOX, oxidative stress, vessel stiffness, and elastin.

RESULTS

Angiotensin II (Ang II)-infused hypertensive mice and spontaneously hypertensive rats (SHR) showed increased vascular LOX expression and stiffness and an abnormal elastin structure. Mice over-expressing LOX in vascular smooth muscle cells (TgLOX) exhibited similar mechanical and elastin alterations to those of hypertensive models. LOX inhibition with β-aminopropionitrile (BAPN) attenuated mechanical and elastin alterations in TgLOX mice, Ang II-infused mice, and SHR. Arteries from TgLOX mice, Ang II-infused mice, and/or SHR exhibited increased vascular H2O2 and O2.- levels, NADPH oxidase activity, and/or mitochondrial dysfunction. BAPN prevented the higher oxidative stress in hypertensive models. Treatment of TgLOX and Ang II-infused mice and SHR with the mitochondrial-targeted superoxide dismutase mimetic mito-TEMPO, the antioxidant apocynin, or the H2O2 scavenger polyethylene glycol-conjugated catalase (PEG-catalase) reduced oxidative stress, vascular stiffness, and elastin alterations. Vascular p38 mitogen-activated protein kinase (p38MAPK) activation was increased in Ang II-infused and TgLOX mice and this effect was prevented by BAPN, mito-TEMPO, or PEG-catalase. SB203580, the p38MAPK inhibitor, normalized vessel stiffness and elastin structure in TgLOX mice.

INNOVATION

We identify LOX as a novel source of vascular reactive oxygen species and a new pathway involved in vascular stiffness and elastin remodeling in hypertension.

CONCLUSION

LOX up-regulation is associated with enhanced oxidative stress that promotes p38MAPK activation, elastin structural alterations, and vascular stiffness. This pathway contributes to vascular abnormalities in hypertension. Antioxid. Redox Signal. 27, 379-397.

The effect of high altitude on central blood pressure and arterial stiffness

Central arterial systolic blood pressure (SBP) and arterial stiffness are known to be better predictors of adverse cardiovascular outcomes than brachial SBP. The effect of progressive high altitude (HA) on these parameters has not been examined. Ninety healthy adults were included. Central BP and the augmentation index (AI) were measured at the level of the brachial artery (Uscom BP⁺ device) at <200 m and at 3619, 4600 and 5140 m. The average age of the subjects (70% men) were 32.2±8.7 years. Compared with central arterial pressures, brachial SBP (+8.1±6.4 mm Hg; P<0.0001) and pulse pressure (+10.9±6.6 mm Hg; P<0.0001) were significantly higher and brachial diastolic BP was lower (-2.8±1.6 mm Hg; P<0.0001). Compared with <200 m, HA led to a significant increase in brachial and central SBP. Central SBP correlated with AI (r=0.50; 95% confidence interval (CI): 0.41-0.58; P<0.0001) and age (r=0.32; 95% CI: 21-0.41; P<0.001). AI positively correlated with age (r=0.39; P<0.001) and inversely with subject height (r=-0.22; P<0.0001), weight (r=-0.19; P=0.006) and heart rate (r=-0.49; P<0.0001). There was no relationship between acute mountain sickness scores (Lake Louis Scoring System (LLS)) and AI or central BP. The independent predictors of central SBP were male sex (coefficient, t=4.7; P<0.0001), age (t=3.6; P=0.004) and AI (t=7.5; P<0.0001; overall r²=0.40; P<0.0001). Subject height (t=2.4; P=0.02), age (7.4; P<0.0001) and heart rate (t=11.4; P<0.0001) were the only independent predictors of AI (overall r²=0.43; P<0.0001). Central BP and AI significantly increase at HA. This rise was influenced by subject-related factors and heart rate but not independently by altitude, LLS or SpO₂.

Favorable Pulse Wave Augmentation Indices and Left Ventricular Diastolic Profile in β-Thalassemia Minor

β-Thalassemia minor (β-Τm) is associated with rheological and biochemical alterations that can affect cardiovascular function. We aimed to evaluate the elastic arterial properties and the pulse wave augmentation indices in a population of patients with β-Τm. Seventy-five individuals with β-Τm (age 55.5 [42.75-65.25], women 48%) and 127 controls (age 57 years [48-63], women 55.1%) underwent comprehensive echocardiographic evaluation and applanation tonometry of the radial and femoral artery. Pulse wave analysis revealed that augmentation pressure, augmentation index (AIx), and heart rate-corrected AIx were significantly lower (median [interquartile range]: 8.75 [4.625-13] vs 11 [6.5-14.5], P = .017; 26.5 [17.5-33.375] vs 30.5 [20.75-37.5], P = .014; and 22.25 [15.125-29.5] vs 27 [20.5-33], P = .008, respectively) in the β-Τm group compared to controls. The left atrial active emptying volume was significantly lower and the isovolumic relaxation time was shorter in the β-Τm group compared to the control group (10.2 [7.4-14.4] vs 12.0 [8.6-15.8], P = .040 and 78 [70-90] vs 90 [70-104], P = .034, respectively). β-Thalassemia minor is associated with favorable pulse wave augmentation indices and left ventricular diastolic function profile in asymptomatic individuals with cardiovascular risk factors.

Pulse pressure in acute coronary syndromes: Comparative prognostic significance with systolic blood pressure

Background:

Pulse pressure is a readily available vital sign that has been shown to independently predict outcomes in several cardiovascular disease states. We investigated the prognostic significance of pulse pressure (PP) and systolic blood pressure (SBP) among patients with acute coronary syndromes (ACS).

Methods:

A total of 14,514 patients with ACS in the prospective, multicentre Global Registry of Acute Coronary Events (GRACE), expanded GRACE (GRACE-2) and Canadian Registry of Acute Coronary Events (CANRACE) were stratified by initial PP on presentation. Patient characteristics and in-hospital outcomes were compared by PP quartiles and the independent prognostic significance of PP for in-hospital mortality was quantified. We compared the discriminative ability (c-statistic) of models incorporating either PP or SBP.

Results:

Patients with higher PPs were older, more frequently female and had higher prevalence rates of conventional cardiovascular risk factors (all p < 0.01). Lower PP was associated with ST-segment elevation myocardial infarction presentation, higher GRACE risk scores and higher rates of adverse in-hospital outcomes ( p < 0.001). PP was strongly correlated with SBP (Pearson’s correlation coefficient = 0.79, p < 0.001). After adjustment for other GRACE risk model predictors, lower PP was independently associated with in-hospital mortality (first vs. fourth quartile [reference]: adjusted odds ratio 2.57, 95% confidence interval 1.80–3.67). The c-statistic was slightly higher for the multivariable model incorporating SBP as compared to the model with PP (0.868 vs. 0.864, respectively, p = 0.028) for in-hospital mortality.

Conclusion:

Higher presenting PP is associated with increased age and more prevalent cardiovascular risk factors, whereas patients with lower PP present with worse clinical characteristics and in-hospital outcomes. Lower PP is an independent adverse prognosticator in ACS. However, PP did not improve the discriminatory performance of the GRACE risk score compared with SBP.

Arterial stiffness and stroke: de-stiffening strategy, a therapeutic target for stroke

Stroke is the second leading cause of mortality and morbidity worldwide. Early intervention is of great importance in reducing disease burden. Since the conventional risk factors cannot fully account for the pathogenesis of stroke, it is extremely important to detect useful biomarkers of the vascular disorder for appropriate intervention. Arterial stiffness, a newly recognised reliable feature of arterial structure and function, is demonstrated to be associated with stroke onset and serve as an independent predictor of stroke incidence and poststroke functional outcomes. In this review article, different measurements of arterial stiffness, especially pressure wave velocity, were discussed. We explained the association between arterial stiffness and stroke occurrence by discussing the secondary haemodynamic changes. We reviewed clinical data that support the prediction role of arterial stiffness on stroke. Despite the lack of long-term randomised double-blind controlled therapeutic trials, it is high potential to reduce stroke prevalence through a significant reduction of arterial stiffness (which is called de-stiffening therapy). Pharmacological interventions or lifestyle modification that can influence blood pressure, arterial function or structure in either the short or long term are promising de-stiffening therapies. Here, we summarised different de-stiffening strategies including antihypertension drugs, antihyperlipidaemic agents, chemicals that target arterial remodelling and exercise training. Large and well-designed clinical trials on de-stiffening strategy are needed to testify the prevention effect for stroke. Novel techniques such as modern microscopic imaging and reliable animal models would facilitate the mechanistic analyses in pathophysiology, pharmacology and therapeutics.

Development of Coronary Pulse Wave Velocity: New Pathophysiological Insight Into Coronary Artery Disease

Background

Although aortic stiffness assessed by pulse wave velocity (PWV) is a strong predictor of coronary artery disease, the significance of local coronary stiffness has never been tackled. The first objective of this study was to describe a method of measuring coronary PWV (CoPWV) invasively and to describe its determinants. The second objective was to assess both CoPWV and aortic PWV in patients presenting with acute coronary syndromes or stable coronary artery disease.

Methods and Results

In 53 patients, CoPWV was measured from the delay in pressure wave and distance traveled as a pressure wire was withdrawn from the distal to the proximal coronary segment. Similarly, aortic PWV was measured invasively when the wire was pulled across the ascending aorta; carotid–femoral PWV was also measured noninvasively using the SphygmoCor system (AtCor Medical). Mean CoPWV was 10.3±6.1 m/s. Determinants of increased CoPWV were fractional flow reserve, diastolic blood pressure, and previous stent implantation in the recorded artery. CoPWV was lower in patients with acute coronary syndromes versus stable coronary artery disease (7.6±3 versus 11.5±6.4 m/s; P=0.02), and this persisted after adjustment for confounders. In contrast, aortic stiffness, assessed by aortic and carotid–femoral PWV, did not differ significantly.

Conclusions

CoPWV seems associated with acute coronary events more closely than aortic PWV. High coronary compliance, whether per se or because it leads to a distal shift in compliance mismatch, may expose vulnerable plaques to high cyclic stretch. CoPWV is a new tool to assess local compliance at the coronary level; it paves the way for a new field of research.

The Pressure of Aging

Significant hemodynamic changes ensue with aging, leading to an ever-growing epidemic of hypertension. Alterations in central arterial properties play a major role in these hemodynamic changes. These alterations are characterized by an initial decline in aortic distensibility and an increase of diastolic blood pressure, followed by a sharp increase in pulse wave velocity (PWV), and an increase in pulse pressure (PP) beyond the sixth decade. However, the trajectories of PWV and PP diverge with advancing age. There is an increased prevalence of salt-sensitive hypertension with advancing age that is, in part, mediated by marinobufagenin, an endogenous sodium pump ligand.