Development and validation of optimal cut-off value in inter-arm systolic blood pressure difference for prediction of cardiovascular events

Prognostic value of brachial-ankle pulse wave velocity changes post-transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) offers a solution, especially for high-risk aortic stenosis (AS) patients. However, patient outcomes post-TAVR show variability, highlighting the need for reliable prognostic indicators. Brachial-ankle pulse wave velocity (baPWV), a measure of arterial stiffness, may predict outcomes post-TAVR. This study aims to explore baPWV's prognostic value in relation to all-cause mortality post-TAVR. This study prospectively enrolled 212 severe AS patients undergoing TAVR between September 2015 and December 2021, focusing on pre- and post-TAVR baPWV measurements to explore associations with all-cause mortality. Of the 212 patients (119 females, 93 males, mean age 85 years), post-TAVR baPWV increased significantly from 1589 ± 376 to 2010 ± 521 cm/s (p < 0.001). Aortic valve (AV) peak velocity and mean pressure gradient decreased, while AV area increased, indicating procedural success. Despite this, 88% of patients experienced an increase in baPWV, with higher pre-procedure AV peak velocity and mean pressure gradient identified as predictors of increased baPWV post-TAVR. Over 23 months, 29 patients (14%) reached the primary endpoint of all-cause mortality. Notably, changes in baPWV, rather than baseline values, were significantly associated with event-free survival (HR: 0.64 per 1SD increase, p = 0.009). The study highlights the prognostic value of baPWV changes post-TAVR in predicting patient outcomes. Elevated baPWV post-TAVR may reflect a beneficial adaptation to altered hemodynamics, suggesting the need for individualized patient evaluation and the integration of baPWV measurements into clinical practice for improved post-TAVR management.

The predictive value of interarm systolic blood pressure differences in patients with vascular disease: Sub-analysis of the COMPASS trial

BACKGROUND AND AIMS

Systolic blood pressure interarm difference (IAD) predicts cardiovascular morbidity and mortality in primary prevention populations. We examined the predictive value of IAD and the effects of treatment with the combination of rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily versus aspirin 100 mg once daily according to IAD in patients with chronic coronary artery disease or peripheral artery disease.

METHODS

COMPASS trial patients with IAD <15 mmHg and IAD >15 mmHg were compared with respect to thirty-month incidence risk of: 1) composite of stroke, myocardial infarction, or cardiovascular death (MACE), 2) composite of acute limb-ischemia or vascular amputation (MALE), 3) composite of MACE or MALE, and 4) effects of treatment with the combination versus aspirin alone on these outcomes.

RESULTS

24,539 patients had IAD<15 mmHg and 2,776 had IAD ≥15 mmHg. Relative to patients with IAD ≥15 mm Hg, those with IAD<15 mmHg had similar incidence rates for all measured outcomes including the composite of MACE or MALE (HR 1.12 [95% CI: 0.95 to 1.31], p = 0.19), with the exception of stroke (HR 1.38 [95% CI: 1.02 to 1.88], p = 0.04). Compared to aspirin alone, the combination consistently reduced the composite of MACE or MALE in both IAD <15 mmHg (HR 0.74 [95% CI: 0.65-0.85], p < 0.0001, ARR = -23.1) and IAD>15 mmHg (HR 0.65 [95% CI: 0.44-0.96], p = 0.03; ARR = -32.6, p interaction = 0.53) groups.

CONCLUSIONS

Unlike primary prevention populations, measuring IAD for risk stratification purposes does not appear to be useful in patients with established vascular disease.

Prevalence of inter-arm blood pressure difference among young healthy adults: Results from a large cross-sectional study on 3235 participants

More than 100 years ago, the difference in blood pressure (BP) between arms was first reported. Recent studies have shown that different blood pressure between the right and left arm leads to cardiovascular events. Three thousand and thirty volunteers participated in our cross-sectional study. The sIABP was equal in 163 of 3030 persons (5.37%), dIABP was equal in 222 out of 3030 persons (7.32%), from a total of 792/3030 persons (26.1%) sIAD >10 mmHg, and dIAD > or = 10 mmHg was found in 927 out of 3030 persons (33.5%) in the right arm, and 32.4% in the left arm. In 2692 of 3030 volunteers BP, initially recorded in the dominant hand (right arm), showing sIAD > or = 10 mmHg was found in 943 (37.1%) volunteers, and when the first measurement was done in 338 left-handed volunteers it showed sIAD > or = 10 mmHg in 112 of 338 (34.1%), P < .001; 95% confidence interval for systolic right hand were (115.73: 116.73), and for systolic left hand 95% confidence interval were (113.17:114.15). Furthermore, height, residential area, and heart rate above 90 bpm had a significant effect on IAD (P = . 041, 0.002, <001, respectively). In conclusion, significant inter-arm systolic and diastolic BP differences above (10 mm Hg) is common in the young, healthy population. Hand dominance is a significant consideration while measuring blood pressure. It is mandatory to measure blood pressure in both arms in a sitting position with a stable condition.

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Blood pressure should be measured in both arms due to differences in values between them to avoid under-diagnosis of hypertension.

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Accurate measurement of blood pressure is mandatory to prevent cardiovascular, cerebrovascular, and renal diseases.

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In this study, the prevalence of IAD among young, healthy adults was reported.

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Hand dominance is a significant consideration while measuring blood pressure.

Elevated Interarm Systolic Blood Pressure Difference Is Positively Associated with Increased Likelihood of Coronary Artery Disease

Background

Systolic interarm differences in blood pressure have been associated with all-cause mortality and cardiovascular disease. We investigated the relationship between interarm systolic blood pressure difference and coronary artery disease.

Methods

We retrospectively analyzed data for patients undergoing coronary angiography and brachial-ankle pulse wave velocity examination during hospitalization from 2013 to 2018. Patients underwent simultaneous upper arm blood pressure measurement. Interarm systolic blood pressure difference (IASBPD) was defined as the absolute value of the difference between the right and left upper limb systolic blood pressure. Patients with IASBPD ≥10 mmHg constituted the high group, and those with IASBPD <10 mmHg constituted the normal group. We also recorded data for cardiovascular risk factors. Coronary artery disease was defined as ≥50% vessel stenosis or having undergone interventional therapy according to coronary angiography results.

Results

Compared with the normal group, the number of patients with coronary artery disease was higher in the high group (86.1% vs. 74.6%, P=0.029). Multiple logistic regression showed that IASBPD ≥10 mmHg were positively correlated with coronary artery disease (odds ratio, 2.313; 95% confidence interval, 1.086-4.509; P=0.029), and as the IASBPD value increased, the correlation also gradually increased.

Conclusions

IASBPD ≥10 mmHg was positively related to coronary artery disease and increased IASBPD values were correlated with coronary artery disease severity.

Associations Between Systolic Interarm Differences in Blood Pressure and Cardiovascular Disease Outcomes and Mortality: Individual Participant Data Meta-Analysis, Development and Validation of a Prognostic Algorithm: The INTERPRESS-IPD Collaboration

Systolic interarm differences in blood pressure have been associated with all-cause mortality and cardiovascular disease. We undertook individual participant data meta-analyses to (1) quantify independent associations of systolic interarm difference with mortality and cardiovascular events; (2) develop and validate prognostic models incorporating interarm difference, and (3) determine whether interarm difference remains associated with risk after adjustment for common cardiovascular risk scores. We searched for studies recording bilateral blood pressure and outcomes, established agreements with collaborating authors, and created a single international dataset: the Inter-arm Blood Pressure Difference - Individual Participant Data (INTERPRESS-IPD) Collaboration. Data were merged from 24 studies (53 827 participants). Systolic interarm difference was associated with all-cause and cardiovascular mortality: continuous hazard ratios 1.05 (95% CI, 1.02-1.08) and 1.06 (95% CI, 1.02-1.11), respectively, per 5 mm Hg systolic interarm difference. Hazard ratios for all-cause mortality increased with interarm difference magnitude from a ≥5 mm Hg threshold (hazard ratio, 1.07 [95% CI, 1.01-1.14]). Systolic interarm differences per 5 mm Hg were associated with cardiovascular events in people without preexisting disease, after adjustment for Atherosclerotic Cardiovascular Disease (hazard ratio, 1.04 [95% CI, 1.00-1.08]), Framingham (hazard ratio, 1.04 [95% CI, 1.01-1.08]), or QRISK cardiovascular disease risk algorithm version 2 (QRISK2) (hazard ratio, 1.12 [95% CI, 1.06-1.18]) cardiovascular risk scores. Our findings confirm that systolic interarm difference is associated with increased all-cause mortality, cardiovascular mortality, and cardiovascular events. Blood pressure should be measured in both arms during cardiovascular assessment. A systolic interarm difference of 10 mm Hg is proposed as the upper limit of normal. Registration: URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015031227.

Systolic inter-arm blood pressure difference and risk of cognitive decline in older people: a cohort study

BACKGROUND

Systolic inter-arm difference in blood pressure (IAD) and cognitive decline are both associated with cardiovascular disease; therefore, it was hypothesised that IAD may be predictive of cognitive decline.

AIM

To examine associations of IAD with cognitive decline in a community population.

DESIGN AND SETTING

A prospective study of older Italian adults enrolled in the InCHIANTI study.

METHOD

Univariable and multivariable associations of IAD were explored with declines in mini mental state examination (MMSE) scores, Trail Making Test A and B scores, and a composite outcome representing substantial decline in any of these scores. Backward stepwise regression was used to adjust observed associations of IAD with cognitive decline.

RESULTS

The rate of decline for MMSE scores in 1133 participants was greater with IAD ≥5 mmHg or ≥10 mmHg. On univariable analyses continuous IAD was associated with the composite outcome (odds ratio [OR] 1.16 per 5 mmHg of IAD, 95% confidence interval [CI] = 1.02 to 1.31). Substantial decline in MMSE score was seen with IAD ≥5 mmHg (OR 1.41, 95% CI = 1.03 to 1.93), and in the composite outcome with IAD ≥5 mmHg (OR 1.44, 95% CI = 1.10 to 1.89) or ≥10 mmHg (OR 1.39, 95% CI = 1.03 to 1.88). After multivariable adjustment, an IAD ≥ 5 mmHg remained associated with reductions in the composite outcome, reflecting declining cognitive performance (OR 1.46, 95% CI = 1.05 to 2.03).

CONCLUSION

An IAD ≥5 mmHg is associated with cognitive decline in a representative older population. Given that systolic inter-arm differences in blood pressure are easily measured, confirmation of these findings could inform individualised treatment for the prevention of cognitive decline and dementia.

Value of a Machine Learning Approach for Predicting Clinical Outcomes in Young Patients With Hypertension

Risk stratification of young patients with hypertension remains challenging. Generally, machine learning (ML) is considered a promising alternative to traditional methods for clinical predictions because it is capable of processing large amounts of complex data. We, therefore, explored the feasibility of an ML approach for predicting outcomes in young patients with hypertension and compared its performance with that of approaches now commonly used in clinical practice. Baseline clinical data and a composite end point—comprising all-cause death, acute myocardial infarction, coronary artery revascularization, new-onset heart failure, new-onset atrial fibrillation/atrial flutter, sustained ventricular tachycardia/ventricular fibrillation, peripheral artery revascularization, new-onset stroke, end-stage renal disease—were evaluated in 508 young patients with hypertension (30.83±6.17 years) who had been treated at a tertiary hospital. Construction of the ML model, which consisted of recursive feature elimination, extreme gradient boosting, and 10-fold cross-validation, was performed at the 33-month follow-up evaluation, and the model’s performance was compared with that of the Cox regression and recalibrated Framingham Risk Score models. An 11-variable combination was considered most valuable for predicting outcomes using the ML approach. The C statistic for identifying patients with composite end points was 0.757 (95% CI, 0.660–0.854) for the ML model, whereas for Cox regression model and the recalibrated Framingham Risk Score model it was 0.723 (95% CI, 0.636–0.810) and 0.529 (95% CI, 0.403–0.655). The ML approach was comparable with Cox regression for determining the clinical prognosis of young patients with hypertension and was better than that of the recalibrated Framingham Risk Score model.

The ankle brachial index exhibits better association with cardiovascular outcomes than interarm systolic blood pressure difference in patients with type 2 diabetes

Increased interarm systolic blood pressure difference (IASBPD) is associated with cardiovascular prognosis in the general population. This study aimed to evaluate whether IASBPD or ankle brachial index (ABI) is strongly associated with cardiovascular outcomes in patients with type 2 diabetes.Total 446 type 2 diabetes followed up for a mean 5.8 years divided by ABI (<0.9 vs ≥0.9) or IASBPD (<10 vs ≥10 mm Hg). The primary outcome was a composite of all-cause mortality, hospitalization for coronary artery disease, nonfatal stroke, carotid, or peripheral revascularization, amputations, and diabetic foot syndrome. The secondary endpoint was all-cause mortality.Sixty-four composite events and 17 deaths were identified. The primary and secondary outcomes were higher than those in the group with ABI < 0.9 vs ABI ≥ 0.9 (32.8% vs 11.6%, P < .005 for primary outcome; 14.0% vs 2.3%, P < .005 for all-cause mortality) but IASBPD cannot exhibit a prognostic value. ABI < 0.9 was also the dominant risk factor of both endpoints demonstrated by multivariate Cox proportional analysis (composite events: adjusted hazard ratio [HR], 2.39; 95% confidence interval [CI], 1.26-4.53; P = .007; all-cause mortality: adjusted HR, 3.27: 95% CI, 1.91-5.60; P < .001).The ABI was more associated with cardiovascular outcomes in patients with diabetes than IASBPD.

Inter-arm systolic blood pressure dependence on hand dominance

Inter-arm systolic blood pressure differences (SBP-DIFF) ≥ 10 mmHg have been reported useful to predict future cardiovascular-related morbidities. Although well studied in patients, there is little information on healthy young adults and the role of hand-dominance as a factor affecting SBP-DIFF. As dominant arms (DOM) tend to have greater girth and muscle development than nondominant arms (NDOM) it was reasoned that cuff pressures needed to obtain SBP may be greater on DOM causing DOM SBP to be greater. To test this hypothesis and also provide typical values, SBP was measured in left and right-handers (29·4 ± 10·4 years) in whom handedness was clearly defined. Handedness was determined by a multi-question form in 90 young adults (45 male) and SBP-DIFF determined via simultaneous measurements done in triplicate on seated subjects. The percentage of left-handers in male and female sub-groups were equal at 37·8%. Results show that the absolute SBP-DIFF in left-handers (mean ± SD) was 4·4 ± 3·8 mmHg and for right-handers was 5·0 ± 4·2 mmHg (P = 0·362). There was also no statistically significant difference among 1st, 2nd and 3rd measured SBP-DIFF for either right or left-handers or differences between right and left-handers. Results show no evidence of a higher SBP in DOM and thus clarifies the hand-dominance issue as a factor not generally needing to be considered in clinical assessments. A potentially useful secondary outcome was the finding that 14·8% of this group had at least one measured SBP-DIFF ≥ 10 mmHg a fact that may have future relevance.