A generalized arterial transfer function derived at rest underestimates augmentation of central pressure after exercise

Wave reflection quantification analysis and personalized flow wave estimation based on the central aortic pressure waveform

Pulse wave reflections reflect cardiac afterload and perfusion, which yield valid indicators for monitoring cardiovascular status. Accurate quantification of pressure wave reflections requires the measurement of aortic flow wave. However, direct flow measurement involves extra equipment and well-trained operator. In this study, the personalized aortic flow waveform was estimated from the individual central aortic pressure waveform (CAPW) based on pressure-flow relations. The separated forward and backward pressure waves were used to calculate wave reflection indices such as reflection index (RI) and reflection magnitude (RM), as well as the central aortic pulse transit time (PTT). The effectiveness and feasibility of the method were validated by a set of clinical data (13 participants) and the Nektar1D Pulse Wave Database (4,374 subjects). The performance of the proposed personalized flow waveform method was compared with the traditional triangular flow waveform method and the recently proposed lognormal flow waveform method by statistical analyses. Results show that the root mean square error calculated by the personalized flow waveform approach is smaller than that of the typical triangular and lognormal flow methods, and the correlation coefficient with the measured flow waveform is higher. The estimated personalized flow waveform based on the characteristics of the CAPW can estimate wave reflection indices more accurately than the other two methods. The proposed personalized flow waveform method can be potentially used as a convenient alternative for the measurement of aortic flow waveform.

A systematic review on the effect of acute aerobic exercise on arterial stiffness reveals a differential response in the upper and lower arterial segments

The objective of this systematic review was to provide insight into the controversy that still abounds as to the impact of acute aerobic exercise on immediate changes in arterial stiffness. Electronic databases were searched to identify articles assessing the effects of acute aerobic exercise on parameters of arterial stiffness. Eligible studies included arterial stiffness measurements before and after acute aerobic exercise in healthy human subjects. Forty-three studies were included. The effect of acute aerobic exercise on arterial stiffness was found to be dependent on the anatomical segment assessed, and on the timing of the measurement post-exercise. Arterial stiffness of the central and upper body peripheral arterial segments was found to be increased relative to resting values immediately post-exercise (0-5 min), whereas, thereafter (>5 min), decreased to a level at or below resting values. In the lower limbs, proximal to the primary working muscles, arterial stiffness decreased immediately post-exercise (0-5 min), which persisted into the recovery period post-exercise (>5 min). This systematic review reveals a differential response to acute exercise in the lower and upper/central arterial segments in healthy adult subjects. We further showed that the effect of acute aerobic exercise on arterial stiffness is dependent on the timing of the measurements post-exercise. Therefore, when assessing the overall impact of exercise on arterial stiffness, it is important to consider the arterial segment being analyzed and measurement time point, as failure to contextualize the measurement can lead to conflicting results and misleading clinical inferences.

Evaluation of a brachial cuff and suprasystolic waveform algorithm method to noninvasively derive central blood pressure

BACKGROUND

Central blood pressure (BP) can be estimated noninvasively by analyzing brachial artery waveforms. In this study, our aim was to assess the validity of a brachial cuff-based (suprasystolic) technique for estimating central BP (CBPestimated) by comparison with invasive aortic BP (CBPinvasive).

METHODS

Eighty-four simultaneous CBPestimated (Pulsecor R7.0) and CBPinvasive measures were recorded in 47 patients (aged 63±10 years, 62% male) undergoing coronary angiography. Measures were captured at baseline and acutely following intravenous glyceryl trinitrate (GTN; 100-200 μg). Mean CBPinvasive systolic BP (SBP) and diastolic BP (DBP) were compared with CBPestimated SBP and DBP calibrated with brachial SBP and DBP recorded from the Pulsecor device. To test validity of the central BP algorithm, measures of CBPestimated SBP were also compared with CBPinvasive SBP following recalibration with invasive mean arterial pressure (MAP) and DBP.

RESULTS

At baseline, mean difference ± standard deviation between CBPestimated SBP and CBPinvasive SBP was -7±9mm Hg (intraclass correlation coefficient (ICC) = 0.86; P < 0.001) with similar underestimation post-GTN (-6±9mm Hg; ICC = 0.90; P < 0.001). Recalibration of CBPestimated SBP with invasive MAP and DBP resulted in closer mean difference to CBPinvasive SBP (-2±7mm Hg; ICC = 0.95; P < 0.001) at baseline but not post-GTN (-6±7mm Hg; ICC = 0.95; P < 0.001).

CONCLUSIONS

The Pulsecor algorithm to derive central BP has acceptable validity when calibrated with invasive pressures. However, accuracy is compromised when noninvasive brachial cuff BP calibration is used.

Effects of exercise on central aortic pressure before and after treatment with renin-angiotensin system blockade in patients with hypertension

INTRODUCTION

Brachial blood pressure increases with exercise and an excessive rise predicts increased cardiovascular risk. Measurement of brachial blood pressure alone may exaggerate the true blood pressure elevation due to exercise-induced change to pressure amplification. Whether blood pressure-lowering treatment modulates pressure amplification during exercise is unknown.

METHODS

Thirty-two participants with stage 1-2 hypertension (mean age 59.2 years) received eight weeks' blood pressure lowering with either aliskiren (300mg, n=16) or valsartan (320mg, n=16). Brachial and central aortic pressure (CASP) were measured non-invasively during treadmill exercise (Bruce protocol) at baseline, after eight weeks' treatment and 48 hours following treatment withdrawal.

RESULTS

The rise in brachial blood pressure with exercise exceeded the rise in CASP, indicative of enhanced pressure amplification. Eight weeks' treatment elicited similar reductions in brachial blood pressure and CASP which did not differ between rest and peak exercise (p>0.05). The exercise-induced increase in systolic pressure amplification did not differ between baseline and following eight weeks' treatment (p>0.05). These effects remained unchanged following treatment withdrawal.

CONCLUSION

Blood pressure lowering does not directly influence the relationship between aortic and brachial pressure either at rest or during exercise in patients with hypertension, other than through proportionate lowering of both pressures. These effects remained unchanged 48 hours after a simulated missed medication dose.

Assessment of arterial stiffness using applanation tonometry

Augmentation index (AIx) and pulse wave velocity (PWV) assess functional and structural aspects of the vascular wall and are independent markers of cardiovascular morbidity and mortality. Like blood pressure, many factors, genetic, structural, and physiological, affect AIx and PWV. AIx and PWV can be assessed noninvasively using applanation tonometry. The technique is simple, but comes with a number of practical and technical limitations that have not been well documented and (or) explored. This review considers pulse wave analysis in the context of cardiovascular disease, and considers its limitations. Data are presented indicating that the placement of the probe is critical, and that the amplitude of the obtained signal is related to the variability in measurements. On a more theoretical note, issues are discussed regarding the applied transfer functions that are built in the devices to assess central AIx from peripheral waveforms. Altogether, PWV and its analysis are useful additions to the arsenal of parameters that can be used to assess vascular health and to estimate vascular risk. Yet, our analysis underscores the necessity for precise operating procedures, and calls for transparency regarding the applied transfer functions of commercial devices.

Noninvasive studies of central aortic pressure

Our purpose is to review noninvasive methods for measuring central arterial pressure. Indices of central arterial pressure measured from central aortic and peripheral arterial waveforms have shown value in predicting cardiovascular events and death, as well as in guiding therapeutic management. This article reviews noninvasive techniques of measuring central arterial pressure that have been validated against intra-arterial pressure. This paper explains methods to derive central (aortic and carotid) pressure from radial and brachial sites. It focuses on specific issues of brachial calibration applied to carotid pressure waveforms, which were regarded as a surrogate of aortic pressures used in three major studies (Framingham, Asklepios, and Australian National Blood Pressure 2 studies). We explain why radial-based methods are superior to carotid-based methods for estimating central pressure. Physiological principles of pressure measurement need be satisfied to ensure accurate recording.

Arterial stiffness identification of the human carotid artery using the stress-strain relationship in vivo

Arterial stiffness is well accepted as a reliable indicator of arterial disease. Increase in carotid arterial stiffness has been associated with carotid arterial disease, e.g., atherosclerotic plaque, thrombosis, stenosis, etc. Several methods for carotid arterial stiffness assessment have been proposed. In this study, in vivo noninvasive assessment using applanation tonometry and an ultrasound-based motion estimation technique was applied in seven healthy volunteers (age 28±3.6years old) to determine pressure and wall displacement in the left common carotid artery (CCA), respectively. The carotid pressure was obtained using a calibration method by assuming that the mean and diastolic blood pressures remained constant throughout the arterial tree. The regional carotid arterial wall displacement was estimated using a 1D cross-correlation technique on the ultrasound radio frequency (RF) signals acquired at a frame rate of 505-1010Hz. Young's moduli were estimated under two different assumptions: (i) a linear elastic two-parallel spring model and (ii) a two-dimensional, nonlinear, hyperelastic model. The circumferential stress (σ(θ)) and strain (ɛ(θ)) relationship was then established in humans in vivo. A slope change in the circumferential stress-strain curve was observed and defined as the transition point. The Young's moduli of the elastic lamellae (E(1)), elastin-collagen fibers (E(2)) and collagen fibers (E(3)) and the incremental Young's moduli before ( [Formula: see text] ) and after the transition point ( [Formula: see text] ) were determined from the first and second approach, respectively, to describe the contribution of the complex mechanical interaction of the different arterial wall constituents. The average moduli E(1), E(2) and E(3) from seven healthy volunteers were found to be equal to 0.15±0.04, 0.89±0.27 and 0.75±0.29MPa, respectively. The average moduli [Formula: see text] and [Formula: see text] of the intact wall (both the tunica adventitia and tunica media layers) were found to be equal to 0.16±0.04MPa and 0.90±0.25MPa, respectively. The average moduli [Formula: see text] and [Formula: see text] of the tunica adventitia were found to be equal to 0.18±0.05MPa and 0.84±0.22MPa, respectively. The average moduli [Formula: see text] and [Formula: see text] of the tunica media were found to be equal to 0.19±0.05MPa and 0.90±0.25MPa, respectively. The stiffness of the carotid artery increased with strain during the systolic phase. In conclusion, the feasibility of measuring the regional stress-strain relationship and stiffness of the normal human carotid artery was demonstrated noninvasively in vivo.

Aortic pressure wave reconstruction during exercise is improved by adaptive filtering: a pilot study

Reconstruction of central aortic pressure from a peripheral measurement by a generalized transfer function (genTF) works well at rest and mild exercise at lower heart rates, but becomes less accurate during heavy exercise. Particularly, systolic and pulse pressure estimations deteriorate, thereby underestimating central pressure. We tested individualization of the TF (indTF) by adapting its resonance frequency at the various levels of exercise. In seven males (age 44–57) with coronary artery disease, central and peripheral pressures were measured simultaneously. The optimal resonance frequency was predicted from regression formulas using variables derived from the individual’s peripheral pressure pulse, including a pulse contour estimation of cardiac output (pcCO). In addition, reconstructed pressures were calibrated to central mean and diastolic pressure at each exercise level. Using a genTF and without calibration, the error in estimated aortic pulse pressure was −7.5 ± 6.4 mmHg, which was reduced to 0.2 ± 5.7 mmHg with the indTFs using pcCO for prediction. Calibration resulted in less scatter at the cost of a small bias (2.7 mmHg). In exercise, the indTFs predict systolic and pulse pressure better than the genTF. This pilot study shows that it is possible to individualize the peripheral to aortic pressure transfer function, thereby improving accuracy in central blood pressure assessment during exercise.

Renal Dysfunction Does Not Affect the Peripheral-to-Central Arterial Pressure Transfer Function

Arterial generalized transfer functions (GTFs) are increasingly used to estimate central pressure from peripheral measurements. Analysis of derived central waveforms may be valuable in the assessment of patients with chronic kidney disease. The aim of this study was to assess whether the GTF is affected by renal disease. Ninety-four subjects with varying degrees of renal function (Kidney Disease Outcomes Quality Initiative stages 1 to 5; 14 controls) had simultaneous measurements of carotid and radial waveforms made by applanation tonometry. GTFs were calculated by Fourier analysis for each subject group. Derived carotid waveforms were obtained by applying an independently generated GTF to the radial waveform. Glomerular filtration rate inversely correlated with central systolic ( R =−0.42; P <0.001), mean ( R =−0.34; P <0.01) and diastolic ( R =−-0.27, P <0.01) blood pressures, as well as central augmentation index ( R =−0.30; P <0.01) and carotid-femoral pulse wave velocity ( R =−0.33; P <0.001). Derived waveforms were not significantly different from measured waveforms in terms of systolic blood pressure, augmentation index, maximum slope, or the delay between the incident and reflected waves, although the derived waveforms slightly underestimated the systolic ejection period (−4.4±0.9 ms; P <0.001). Overall root-mean-square error was 2.4±0.1 mm Hg. No significant relationship existed between the degree of bias of any derived waveform measure and glomerular filtration rate or chronic kidney disease stage ( P >0.16). No significant differences between chronic kidney disease stages were observed in transfer function gain or phase ( P >0.05). We conclude that the peripheral-to-central GTF is not affected by degree of renal dysfunction and can be used with equivalence in patients with varying degrees of chronic kidney disease.

The impact of exercise on derived measures of central pressure and augmentation index obtained from the SphygmoCor device

The purpose of this study was to investigate whether measures derived from the SphygmoCor device and its associated transfer function are influenced by exercise-induced alterations in vascular tone. Measurements were taken from either the exercised or the contralateral nonexercised limb during repeated and identical incremental hand-grip protocols. Eight male subjects performed three 3-min bouts of hand-grip exercise on two occasions. The exercise intensities were set at 3 kg, 5 kg, with a final 1.5-kg bout performed during cuff ischemia (1.5Isch). Blood pressure waveforms were recorded from the radial artery of either the exercised or nonexercised limb using applanation tonometry (SphygmoCor) during a 90-s rest period immediately after each exercise bout. Central blood pressures and augmentation indexes (AIx), an index of arterial stiffness, were derived using the peripheral waveform and the inbuilt SphygmoCor transfer function (TF). AIx was consistently ∼10% higher in the exercised arm during all trials compared with the nonexercised limb. Similarly, there was a consistent and significant difference (∼3 mmHg; P < 0.05) between exercised and nonexercised arms for the derived central systolic and mean arterial blood pressures. Despite identical bouts of exercise, AIx and central systolic and mean arterial blood pressures derived from applanation tonometry at the peripheral radial artery were statistically different when assessed at the exercising arm vs. the nonexercising arm. Changes in vascular tone with exercise may modify the intrinsic characteristics of the vessel wall and could compromise the assumptions underlying transfer functions used to derive central measures using applanation tonometry.