Association of left ventricular structural and functional abnormalities with aortic and brachial blood pressure variability in hypertensive patients: the SAFAR study

Short-Term Variability of Both Brachial and Aortic Blood Pressure is Increased in Patients with Immune-mediated Chronic Inflammation

INTRODUCTION

Blood pressure (BP) variability (BPV) has emerged as an indicator of subclinical organ damage and an independent predictor of cardiovascular disease (CVD) morbidity and mortality in high-risk populations.

AIM

We aimed to assess short-term variability of both brachial and aortic BP in psoriasis, a common immune-mediated inflammatory disorder characterized by increased CVD risk.

METHODS

Psoriasis patients and non-psoriasis individuals had their BP assessed throughout a 24 h period (Mobil-O-Graph device). Brachial and aortic BPV during the 24 h and the respective daytime and nighttime periods was calculated from relevant ambulatory BP profiles. In-house software was applied to automatically calculate average real variability (ARV) of brachial and aortic systolic (bSBP, aSBP) and diastolic BP (bDPB, aDBP), and the weighted standard deviation (wSD) of 24 h bSBP/aSBP. 24 h pulse wave velocity (PWV) and augmentation index (AIx) were used as widely applied markers of arterial stiffness.

RESULTS

Psoriasis patients (n = 74) presented increased ARV of 24 h and daytime bSBP/aSBP, and increased ARV of 24 h and daytime bDBP/aDBP, compared to controls (n = 40). PWV and AIx correlated with ARV of 24 h bSBP/aSBP, daytime bSBP/aSBP, while PWV further correlated with ARV of nighttime aSBP. The observed associations with PWV, yet not AIx, with indices of BPV remained significant after adjusting for CVD risk factors.

CONCLUSIONS

This is the first study reporting increased 24 h variability of both brachial and aortic BP in psoriasis. The association of short-term BPV with arterial stiffness implies a potential role of BPV in terms of CVD risk stratification in patients with chronic immune-mediated inflammation.

Pharmacological treatment of hypertension guided by peripheral or central blood pressure: a comparison between the two strategies

Background

Arterial hypertension treatment guided by central blood pressures (CPB) rather than peripheral blood pressures (PBP) measurement has the potential to show greater effectiveness in preventing or even regressing stiffness and target organ damage (TOD).

Objective

This study aimed to compare the parameters of CBP and PBP measurements, arterial stiffness, TOD and renal profile in patients with anti-hypertensive treatment guided by CBP or PBP targets.

Methods

A randomized clinical trial was conducted in central group (CG) and peripheral group (PG). Patients were randomized, evaluated every 3 months for BP and antihypertensive adjustments during a one-year follow up. The procedures in V1 and V5: anthropometric assessment; CBP/PBP measurements, carotid ultrasound; echocardiography; laboratory tests. Paired and unpaired t-tests and the χ2 were used (significance level: 5%).

Results

The study evaluated 59 participants (30CG/29PG). The augmentation index (AIx) was higher in the CG (27.3% vs. 20.3%, p = 0.041). Intergroup analysis has found central diastolic BP lower in the CG (78.9 vs. 84.3 mmHg, p = 0.024) and the Alx difference between groups ceased to exist after a one-year follow-up. Intragroup comparisons, after intervention, showed a lower frequency of changed PWV (p < 0.001) and LVMI (p = 0.018) in the CG. The PG showed a higher frequency of changed PWV (p < 0.001) and LVMI (p = 0.003).

Conclusion

The intervention guided by central BP reduced the central diastolic BP and AIx compared to the PG. There was a reduction in the frequency of changed PWV and LVMI in the CG.

Blood pressure and its variability: classic and novel measurement techniques

Current hypertension guidelines recommend using the average values of several blood pressure (BP) readings obtained both in and out of the office for the diagnosis and management of hypertension. In-office BP measurement using an upper-arm cuff constitutes the evidence-based reference method for current BP classification and treatment targets. However, out-of-office BP evaluation using 24 h ambulatory or home BP monitoring is recommended by all major medical associations for obtaining further insights into the BP profile of an individual and how it relates to their daily activities. Importantly, the highly variable nature of office and out-of-office BP readings has been widely acknowledged, including the association of BP variability with cardiovascular outcomes. However, to date, the implications of BP variability on cardiovascular outcomes have largely been ignored, with limited application in clinical practice. Novel cuffless wearable technologies might provide a detailed assessment of the 24 h BP profile and behaviour over weeks or months. These devices offer many advantages for researchers and patients compared with traditional BP monitors, but their accuracy and utility remain uncertain. In this Review, we outline and compare conventional and novel methods and techniques for assessing average BP levels and BP variability, and reflect on the utility and potential of these methods for improving the treatment and management of patients with hypertension.

The most commonly available blood pressure (BP) monitoring devices are useful for capturing a snapshot BP value, but most have limited utility in measuring BP variability. In this Review, Schutte and colleagues outline the advantages and disadvantages of conventional and novel techniques to measure average BP levels and BP variability.

Although the dynamic nature of blood pressure (BP) is well-known, hypertension guidelines recommend using the average values of static BP readings (office or out-of-office), specifically aiming to level the fluctuations and peaks in BP readings.

All current BP measurement methods have imperfect reproducibility owing to the continuous fluctuation in BP readings, making it difficult to accurately diagnose hypertension.

Accumulating evidence from clinical trials, large registries and meta-analyses shows that increased BP variability predicts cardiovascular outcome, independently of the average BP values.

To date, BP variability is overlooked, with limited application in clinical practice, probably owing to a variety of complex non-standardized BP variability assessment methods and indices, and uncertain thresholds and clinical usefulness.

Novel cuffless wearable BP technologies can provide very large numbers of readings for days and months without the discomfort of traditional BP monitoring devices, and have the potential to replace current BP methods, once accuracy issues are resolved and their clinical usefulness is proved.

The Impact of High Dietary Sodium Consumption on Blood Pressure Variability in Healthy, Young Adults

BACKGROUND

High sodium (Na+) intake augments blood pressure variability (BPV) in normotensive rodents, without changes in resting blood pressure (BP). Augmented BPV is associated with end-organ damage and cardiovascular morbidity. It is unknown if changes in dietary Na+ influence BPV in humans. We tested the hypothesis that high Na+ feeding would augment BPV in healthy adults.

METHODS

Twenty-one participants (10 F/11 M; 26 ± 5 years; BP: 113 ± 11/62 ± 7 mm Hg) underwent a randomized, controlled feeding study that consisted of 10 days of low (2.6 g/day), medium (6.0 g/day), and high (18.0 g/day) salt diets. On the ninth day of each diet, 24-h urine samples were collected and BPV was calculated from 24-h ambulatory BP monitoring. On the tenth day, in-laboratory beat-to-beat BPV was calculated during 10 min of rest. Serum electrolytes were assessed. We calculated average real variability (ARV) and standard deviation (SD) as metrics of BPV. As a secondary analysis, we calculated central BPV from the 24-h ambulatory BP monitoring.

RESULTS

24-h urinary Na+ excretion (low = 41 ± 24, medium = 97 ± 43, high = 265 ± 92 mmol/24 h, P < 0.01) and serum Na+ (low = 140.0 ± 2.1, medium = 140.7 ± 2.7, high = 141.7 ± 2.5 mmol/l, P = 0.009) increased with greater salt intake. 24-h ambulatory ARV (systolic BP ARV: low = 9.5 ± 1.7, medium = 9.5 ± 1.2, high = 10.0 ± 1.9 mm Hg, P = 0.37) and beat-to-beat ARV (systolic BP ARV: low = 2.1 ± 0.6, medium = 2.0 ± 0.4, high = 2.2 ± 0.8 mm Hg, P = 0.46) were not different. 24-h ambulatory SD (systolic BP: P = 0.29) and beat-to-beat SD (systolic BP: P = 0.47) were not different. There was a trend for a main effect of the diet (P = 0.08) for 24-h ambulatory central systolic BPV.

CONCLUSIONS

Ten days of high sodium feeding does not augment peripheral BPV in healthy, adults.

CLINICAL TRIALS REGISTRATION

NCT02881515.

Relation of blood pressure variability to left ventricular function and arterial stiffness in hypertensive patients

INTRODUCTION

Variability of blood pressure (BP) has been reported to be related to worse cardiovascular outcomes. We examined the impact of daytime systolic BP variability on left ventricular (LV) function and arterial stiffness in hypertensive patients.

METHODS

Ambulatory BP monitoring (ABPM) and echocardiography were performed in 116 hypertensive patients. We assessed BP variability as standard deviations of daytime systolic BP on 24-hour ABPM. Conventional echocardiographic parameters, area strain and three-dimensional diastolic index (3D-DI) using 3D speckle tracking were measured. Arterial stiffness was evaluated by acquiring pulse wave velocity (PWV) and augmentation index.

RESULTS

Patients with higher BP variability showed significantly increased left ventricular mass index (LVMI) and late mitral inflow velocity, as well as decreased E/A (early mitral inflow velocity/late mitral inflow velocity) ratio, area strain and 3D-DI than those with lower BP variability (LVMI: p = 0.02; A velocity: p < 0.001; E/A ratio: p < 0.001; area strain: p = 0.02; 3D-DI: p = 0.04). In addition, increased BP variability was associated with higher PWV and augmentation index (p < 0.001). Even among patients whose BP was well controlled, BP variability was related to LV mass, diastolic dysfunction and arterial stiffness.

CONCLUSION

Increased BP variability was associated with LV mass and dysfunction, as well as arterial stiffness, suggesting that BP variability may be an important determinant of target organ damage in hypertensive patients.

Arterial Stiffness Use for Early Monitoring of Cardiovascular Adverse Events due to Anthracycline Chemotherapy in Breast Cancer Patients. A Pilot Study

BACKGROUND

Chemotherapy with doxorubicin and cyclophosphamide, although efficient for treating breast cancer, is associated with cardiovascular complications. Recent studies seek to identify methods that can early detect cardiological and vascular changes as a strategy to decrease the incidence of cardiovascular comorbidities.

OBJECTIVE

To evaluate the role of arterial stiffness measurement in the monitoring of doxorubicin and cyclophosphamide-induced cardiotoxicity in breast cancer patients.

METHODS

Prospective longitudinal study in 24 breast cancer patients undergoing treatment with doxorubicin and cyclophosphamide. Patients underwent an indirect evaluation of arterial stiffness through non-invasive measurement of hemodynamic parameters such as pulse wave velocity with the Mobil-O-Graph® 24H PWA device at three different times of the chemotherapy treatment (pre-chemotherapy, after the first and the fourth cycle). The left ventricular ejection fraction was also evaluated by Doppler echocardiography (pre-chemotherapy and after the fourth chemotherapy cycle). Data were considered significant when p ≤ 0.05.

RESULTS

Patients had a mean age of 52.33 ± 8.85 years and body mass index of 31 ± 5.87 kg/m2. There was no significant difference between the hemodynamic parameters evaluated by the oscillometric method or in the left ventricular ejection fraction in the different evaluated periods.

CONCLUSION

Evaluations of arterial stiffness by oscillometry and measurement of left ventricular ejection fraction by Doppler echocardiography showed equivalence in the values found, suggesting that the evaluation method of arterial stiffness studied could be used as a marker for cardiovascular adverse events associated with doxorrubicin-based chemotherapy drugs.

Mechanisms of pulse pressure amplification dipping pattern during sleep time: the SAFAR study

The difference in pulse pressure (PP) between peripheral arteries and the aorta, called pulse pressure amplification (PPamp), is a well-described physiological phenomenon independently associated with cardiovascular events. Recent studies suggest that it exhibits circadian variability. Our aim was to detect the factors associated with the circadian variability of PPamp. In 497 consecutive subjects (aged 54 years, 56.7% male, 79.7% hypertensives), we assessed the circadian pattern of peripheral and central arterial hemodynamics by 24-hour evaluation of brachial and aortic blood pressure (BP), augmentation index (AI), and pulse wave velocity (PWV) using a validated oscillometric device (Mobil-O-Graph). All parameters exhibited a circadian variation. Sleep dipping (decrease) pattern was observed for PPamp, brachial and aortic systolic BP, mean BP, and PWV, whereas a rising pattern (higher sleep than wake values) was observed for brachial PP, aortic PP, and AI. The factors independently associated with the less sleep dipping in PPamp were older age, lower height, the use of antihypertensive medication, and sleep decrease in arterial stiffness (PWV), whereas female gender, the presence of hypertension, sleep increase of pressure wave reflections (AI), sleep decrease in heart rate, and mean BP were associated with a greater sleep-dipping in PPamp. These data provide further pathophysiological understanding of the mechanisms leading to PPamp dipping. Several implications regarding the clinical use of the aortic and brachial BP, especially during sleep time, are raised that should be addressed in future research.