Blood pressure and pulse wave velocity values in the institutionalized elderly aged 80 and over: baseline of the PARTAGE study

Systolic and diastolic blood pressure time in target range and cardiovascular outcomes in patients with hypertension and pre-frailty or frailty status

In patients with hypertension and pre-frailty or frailty, the influence of systolic (SBP) and diastolic blood pressure (DBP) time in target range (TTR) on clinical outcomes is unclear. Thus, we conducted a post hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT). Classifying 4208 participants into frail and non-frail groups using a frailty index, the study calculated blood pressure time in target range (BP-TTR) for the first three months using the Rosendaal method. The primary endpoint included a composite of nonfatal myocardial infarction (MI), acute coronary syndromes, stroke, acute decompensated heart failure (ADHF), and cardiovascular death. Relationships between BP-TTR and outcomes were analyzed using Kaplan-Meier curves, Cox models, and restricted cubic spline curves, with subgroup analysis for further insights. In a median follow-up of 3.17 years, primary outcomes occurred in 6.7% of participants. Kaplan-Meier analysis showed that a lower systolic blood pressure time in target range (SBP-TTR) (0%-25%) correlated with an increased cumulative incidence of the primary outcome (p < .001), nonfatal MI (P = .021), stroke (P = .004), and cardiovascular death (P = .002). A higher SBP-TTR (75%-<100%) was linked to a reduced risk of these outcomes. The restricted cubic spline (RCS) curve revealed a linear association between SBP-TTR and the primary outcome (non-linear P = .704). Similar patterns were observed for diastolic blood pressure time in target range (DBP-TTR). Subgroup analysis showed that the protective effect of higher SBP-TTR was less pronounced at low DBP-TTR levels (P for interaction = .023). In conclusion, this study highlights the importance of maintaining BP within the target range to mitigate cardiovascular risks in this population.

Medical Telemonitoring for the Management of Hypertension in Older Patients in Japan

Hypertension is the most frequent modifiable risk factor associated with cardiovascular disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has been recommended to reduce CVD event risks. However, caution should be exercised since older hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and older patients eligible for clinical trials may not represent the general population. Medical telemonitoring systems, which enable us to monitor a patient's medical condition remotely through digital communication, have become much more prevalent since the coronavirus pandemic. Among various physiological parameters, BP monitoring is well-suited to the use of such systems, which enable healthcare providers to deliver accurate and safe BP management, even in the presence of frailty and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable multi-professional team-based management of hypertension. However, the implementation of medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including the development of user-friendly devices, integration with existing clinical systems, data security, and cost of implementation and maintenance, need to be overcome. In this review, we focus on the potential of medical telemonitoring for the management of hypertension in older people in Japan.

Analysis of blood pressure and blood pressure variability pattern among older patients in long-term care hospitals: an observational study analysing the Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) dataset

OBJECTIVES

There are limited data regarding blood pressure (BP) variability among older adults living in long-term care hospitals (LTCHs). We aimed to collect data from LTCH and analyse BP characteristics and its variability among these patients using a novel platform.

METHODS

The Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) platform was used to construct a daily BP dataset using data of 394 older patients from 6 LTCHs. BP variability was expressed as coefficient of variation (CV = standard deviation/mean of BP × 100). Physical frailty and cognitive function were evaluated using the K-FRAIL questionnaire and the Cognitive Performance Scale of the interRAI Long-Term Care Facilities tool, respectively.

RESULTS

From September 2019 to September 2020, 151,092 BP measurements, 346.5 (IQR 290.8-486.3) measurements per patient, were included. The mean BP was 123.4 ± 10.8/71.3 ± 6.5 mmHg. BP was significantly lower in frail patients (122.2 ± 11.3/70.4 ± 6.8 mmHg) than in pre-frail/robust patients (124.4 ± 10.4/72.1 ± 6.1 mmHg, P < 0.05). However, CV of systolic (10.7 ± 2.3% versus 11.3 ± 2.3%, P = 0.005) and diastolic (11.6 ± 2.3% versus 12.4 ± 2.4%, P < 0.001) BP was higher in frail patients. The mean BP was lower, but BP variability was higher in patients with cognitive impairment. The mean BP, but not BP variability, was higher in treated hypertensive patients, as the number of antihypertensive medications increased.

CONCLUSION

Older patients with physical or cognitive frailty had lower BP but higher BP variability. Relationship among frailty, increased BP variability and adverse clinical outcomes should be investigated.

Mean arterial pressure estimated by brachial pulse wave analysis and comparison with currently used algorithms

OBJECTIVE

Mean arterial pressure (MAP) is usually calculated by adding one-third of pulse pressure (PP) to DBP. This formula assumes that the average value of pulse waveform is constant in all individuals and coincides with 33.3% of PP amplitude (MAP = DBP + PP × 0.333). Other formulas were lately proposed to improve the MAP estimation, adding to DBP an established percentage of PP: MAP = DBP + PP × 0.40; MAP = DBP + PP × 0.412; MAP = DBP + PP × 0.333 + 5 mmHg.

METHODS

The current study evaluated the integral of brachial pulse waveform recorded by applanation tonometry in 1526 patients belonging to three distinct cohorts: normotensive or hypertensive elderly, hypertensive adults, and normotensive adults.

RESULTS

The percentage of PP to be added to DBP to obtain MAP was extremely variable among individuals, ranging from 23 to 58% (mean: 42.2 ± 5.5%), higher in women (42.9 ± 5.6%) than men (41.2 ± 5.1%, P < 0.001), lower in the elderly cohort (40.9 ± 5.3%) than in the general population cohort (42.8 ± 6.0%, P < 0.001) and in the hypertensive patients (42.4 ± 4.8%, P < 0.001). This percentage was significantly associated with DBP (β = 0.357, P < 0.001) and sex (β = 0.203, P < 0.001) and significantly increased after mental stress test in 19 healthy volunteers (from 39.9 ± 3.2 at baseline, to 43.0 ± 4.0, P < 0.0001). The average difference between MAP values estimated by formulas, compared with MAP assessed on the brachial tonometric curve, was (mean ± 1.96 × SD): -5.0 ± 6.7 mmHg when MAP = DBP + PP × 0333; -1.2 ± 6.1 mmHg when MAP = DBP + PP × 0.40; -0.6 ± 6.1 mmHg when MAP = DBP + PP × 0.412; -0.4 ± 6.7 mmHg when MAP = DBP + PP × 0.333 + 5.

CONCLUSION

Due to high interindividual and intraindividual variability of pulse waveform, the estimation of MAP based on fixed formulas derived from SBP and DBP is unreliable. Conversely, a more accurate estimation of MAP should be based on the pulse waveform analysis.

Effects of a personalized physical exercise program in peripheral and central blood pressure in community dwelling old hypertensive adults: the AGA@4life intervention model

We aimed at testing the effect of a tailored physical exercise intervention program on brachial and central blood pressure (bBP and cBP, respectively) in a group of hypertensive old adults. Thirty-three participants (mean age: 82 ± 9 years) were divided into two groups (intervention group and control group) according to their adherence to the physical training program. The exercise program included aerobic and strength components, prescribed in a personalized approach, and implemented under a strict control of two experienced professionals. An oscillometric-based device was used to measure bBP and cBP, both at baseline ant 3 months after the intervention period. The groups had similar clinical and demographic characteristics at baseline. No significant changes were observed in any of the considered endpoints in the control group. Conversely, a significant reduction was depicted in the intervention group, for both bBP and cBP. The results demonstrate that physical exercise prescribed in a tailored approach is an effective nonpharmacological tool to reduce pBP and cBP in older adults.

Increased aortic stiffness in adults with chronic indeterminate Chagas disease

An ever-increasing number of patients with chronic indeterminate Chagas disease are diagnosed with early vascular and cardiac abnormalities, as cardiovascular imaging becomes more sensitive. However, the currently available information on aortic stiffness (a prognostic marker for adverse cardiovascular outcomes) in these patients is scarce. In this study, we consecutively recruited 21 asymptomatic Bolivian adult patients with chronic indeterminate Chagas disease and 14 Bolivian adults, who were seronegative for Trypanosoma cruzi infection. No participants had a prior history of heart disease, hypertension, diabetes, chronic kidney disease or atrial fibrillation. Carotid-femoral pulse wave velocity (cf-PWV), carotid-radial PWV (cr-PWV), carotid intima-media thickness and conventional echocardiographic measurements were recorded in all participants. Patients with chronic indeterminate Chagas disease had significantly higher cf-PWV (7.9±1.3 vs. 6.4±1.1 m/s, p = 0.003) and greater HOMA-estimated insulin resistance than subjects without Chagas disease. The two groups did not significantly differ in terms of age, sex, smoking, adiposity measures, blood pressure, plasma lipids, fasting glucose levels as well as cr-PWV, carotid intima-media thickness measurements, left ventricular mass and function. Presence of chronic indeterminate Chagas disease was significantly associated with increasing cf-PWV values (β coefficient: 1.31, 95% coefficient interval 0.44 to 2.18, p = 0.005), even after adjustment for age, sex, heart rate, systolic blood pressure and insulin resistance. In conclusion, asymptomatic Bolivian adult patients with chronic indeterminate Chagas disease have an early and marked increase in aortic stiffness, as measured by cf-PWV, when compared to Bolivian adults who were seronegative for Trypanosoma cruzi infection.

[Prevalence of carotid artery stenosis in nonagenarians: Survey in a primary care hospital]

AIM

Carotid artery stenosis increases with age and may cause brain ischemia if arterial hypotension occurs. We performed a monocentric pilot study to investigate its prevalence in the very elderly and to assess its potential influence on blood pressure (BP) goals during antihypertensive treatment.

METHODS

All patients≥90 years of a primary care medical ward were prospectively included over 15 months. Ultrasound exams of the precerebral arteries were offered to all elderly patients for routine evaluation of their cardiovascular risk. Frequencies of stenosed common, internal and external carotid arteries (CCA, ICA, ECA) were analyzed together with clinical BP and antihypertensive therapy. Patients with circulatory shock and readmissions were excluded.

RESULTS

Sixty-three patients aged 92±3 years (78% female) hospitalized for a median of 11 days were included. On admission, 76% were on antihypertensive drugs vs. 86% at discharge. Mean admission BP was 149/77 vs. 129/72mmHg at discharge; systolic BP<140mmHg 36% vs 64% (P<0.05). Mean intima-media thickness (ACC, right/left) was 8.7/9.4mm. Prevalence of plaque or stenosis<60% was: CCA 19.0%, ICA 19.0%, ECA 31.7%, bulb 74.6%; of stenosis≥60%: CCA 0%, ICA 7.9%, ECA 19.0%, ICA bilateral 1.6% (unilateral occlusion 3.1%, no bilateral). Coincidence of systolic BP<120mmHg and ACI stenosis≥60% had a probability of 1-2%.

CONCLUSION

Concerning the risk of brain ischemia due to carotid artery stenosis, a BP goal<140mmHg should be safe for most nonagenarians. If individual BP goals are lower, searching for significant stenosis by ultrasound may be useful.

Management of Hypertension in the Elderly and Frail Elderly

An elevated systolic but not diastolic blood pressure level represents a common finding in elderly patients and is associated with an increased risk for developing coronary artery disease, cerebrovascular disease, peripheral artery disease, progressive cognitive decline and renal failure. Although less frequently, elderly patients manifest not only with systolic but also diastolic hypertension. Also in this case, the elderly patient will present an increased risk for developing hypertension-related abnormalities. Based on several trials conducted in patients ≥65 years and one single trial in patients ≥80 years the most recent European guidelines recommend antihypertensive treatment in elderly hypertensive patients with a systolic blood pressure ≥60 mmHg, with a systolic target between 140 and 150 mmHg. In fit elderly patients <80 years treatment may be considered at a systolic level ≥140 mmHg with a target SBP <140 mmHg if treatment is well tolerated. Despite of the above, at least three issues related to antihypertensive drug treatment in aged individuals are still debated, particularly after the publication of a recent large scale clinical trial that included also 2.636 patients ≥75 years and a study in nursing home residents ≥80 years, i.e. the frailest oldest patients: (1) the blood pressure threshold at which antihypertensive drug should be initiated, (2) the blood pressure targets of the therapeutic intervention, and (3) the approach to frail elderly hypertensive patients. This review will critically review the evidence available so far on these important issues as well as the position of current guidelines and consensus statements.

Evidence for a Prognostic Role of Orthostatic Hypertension on Survival in a Very Old Institutionalized Population

In old individuals, regulation of blood pressure during postural changes is impaired. Several studies have assessed the clinical impact of orthostatic hypotension (OHypoT) during the aging process. By contrast, the prevalence and prognostic role of the increase in blood pressure in upright position (orthostatic hypertension, OHyperT) in old adults remain unknown. We investigated the association of OHyperT with cardiovascular morbidity and mortality in a population of old institutionalized subjects. A 2-year follow-up longitudinal study was conducted on 972 subjects (mean age [SD] 88 [5]) from the PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study, able to maintain a standing position. OHyperT was defined as an increase in systolic blood pressure ≥20 mm Hg during the first and third minute of standing. Three groups of subjects were compared: orthostatic normotension (n=540), OHypoT (n=157), and OHyperT (n=275). OHyperT prevalence (28%) was higher than OHypoT (16%). Sitting systolic blood pressure was higher in OHypoT compared with orthostatic normotension and OHyperT groups (146 [23] versus 136 [21] and 136 [20] mm Hg, respectively, P<0.001). The OHyperT group was associated with a greater risk of cardiovascular morbidity and mortality than orthostatic normotension (hazard ratio 1.51 [1.09-2.08], P<0.01) and remained unchanged after adjustment for age, sex, sitting systolic blood pressure, and comorbidities. No difference in cardiovascular morbidity and mortality was observed between OHyperT and OHypoT groups. In conclusion, in a old frail population, the increase in systolic blood pressure during upright position occurs frequently and is associated with higher cardiovascular morbidity and mortality independently of sitting blood pressure levels and major comorbidities. Health professional should take into account not only the decrease but also the increase in blood pressure when standing up.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00901355.

Elderly Algerian women lose their sex-advantage in terms of arterial stiffness and cardiovascular profile

OBJECTIVES

Several studies have shown lower carotid-femoral pulse wave velocity (cfPWV) levels in women compared to men, a difference that could partially explain the increased longevity in women. However, these studies have been performed in industrial countries while few data are available in emerging populations. We studied arterial stiffness, as evaluated by cfPWV, in elderly Algerian men and women.

METHODS

cfPWV was studied in 321 Algerian men (81.2 ± 5.3 years) and women (81.1 ± 4.4 years). An age-matched and sex-matched cohort of European individuals (n = 321) was used as a control group.

RESULTS

Comparatively to men, Algerian women exhibited higher BMI and heart rate (HR), higher prevalence of hypertension, and were more frequently treated for hypertension. cfPWV was not different between Algerian men (14.8 ± 3.3 m/s) and women (14.9 ± 3.4 m/s). By contrast, in Europeans, women had lower cfPWV (12.7 ± 2.7 m/s) than men (14.0 ± 3.3 m/s; P <0.001). Comparatively to European women, Algerian women had a higher cfPWV (P <0.01). In both ethnic groups, multivariate analyses revealed that age, mean blood pressure (BP), HR, and diabetes were positively associated with cfPWV, whereas female sex was associated with lower cfPWV only in Europeans.

CONCLUSION

Elderly Algerian women exhibit arterial stiffness similar to men, whereas European women display lower arterial stiffness than men. This loss of 'arterial sex advantage' in Algerians may be explained by higher BP, HR, and a worse metabolic profile in Algerian women. Interventions in emerging populations, especially in women, should be a priority in order to address these risk factors by acting on current lifestyle.

The control of blood pressure might be important in delaying progression of arterial aging in patients with type 2 diabetes mellitus

Objective

Arterial stiffness, as assessed by the brachial-ankle pulse wave velocity (baPWV), is associated with arterial aging and has been consistently linked to cardiovascular disease. The factors involved in reducing the progression of arterial stiffness in patients with type 2 diabetes mellitus (DM) have not yet been fully established.

Methods

Of 478 patients who underwent two baPWV measurements (at baseline and 1 year later) at the Department of Internal Medicine, St Vincent’s Hospital, from November 2009 to June 2011, 341 subjects were enrolled in this study (male to female ratio =150:191; mean age, 62.1±7.7 years). The 341 subjects were over the age of 50 with type 2 DM, were diagnosed without peripheral artery disease, and 170 if the subjects (50%) had hypertension.

Results

baPWV at baseline increased in a linear manner along with age (β=22.8, t=10.855; P<0.0001, R²=0.258). After 1 year follow-up, the change in baPWV (ΔbaPWV) was variable (median 32.7 cm/s [approximate range, −557 to ∼745]). In multiple linear regression, the change in systolic blood pressure (β=7.142, 95% confidence interval =4.557–9.727; P<0.0001, R²=0.305) was associated with ΔbaPWV during follow-up. The change in glycated hemoglobin (HbA_1c) and a glycemic control of keeping HbA_1c levels below 7.0% were not associated with ΔbaPWV.

Conclusion

We found that the variation of blood pressure was associated with the progression of vascular aging of the large- to middle-sized arteries in patients with type 2 DM. Therefore, control of blood pressure might be important in reducing arterial aging or PWV in patients with type 2 DM.

Fetal aortic distensibility, compliance and pulse pressure assessment during the second half of pregnancy

The objective of the study was to measure fetal aortic pulse wave velocity and lumen diameter waveforms and subsequently calculate local distensibility, compliance and pulse pressure. A dedicated algorithm for optimizing lumen diameter assessment from radiofrequency ultrasound data is described. Biplane raw data were obtained from a matrix array transducer. We evaluated 83 confirmed, normally developing pregnancies at 22-38 wk. Fetal aortic pulse wave velocity (PWV, m/s) = 0.047 × gestational age (wk) + 1.241, and the distensibility coefficient (1/kPa) = 1/(1.04 × PWV(2)). The logarithm of the local compliance index (mm(2)/kPa) and the pulse pressure (kPa) were both linearly related to gestational age as 0.022 × GA (wk) - 0.343 and 0.012 × GA (wk) + 0.931, respectively. In conclusion, fetal aortic elastic properties can be derived from phase-sensitive radiofrequency data and multiline diameter assessment. Future studies may shed further light on the developmental origins of vascular health and disease.

Left ventricular ejection time, not heart rate, is an independent correlate of aortic pulse wave velocity

Several studies showed a positive association between heart rate and pulse wave velocity, a sensitive marker of arterial stiffness. However, no study involving a large population has specifically addressed the dependence of pulse wave velocity on different components of the cardiac cycle. The aim of this study was to explore in subjects of different age the link between pulse wave velocity with heart period (the reciprocal of heart rate) and the temporal components of the cardiac cycle such as left ventricular ejection time and diastolic time. Carotid-femoral pulse wave velocity was assessed in 3,020 untreated subjects (1,107 men). Heart period, left ventricular ejection time, diastolic time, and early-systolic dP/dt were determined by carotid pulse wave analysis with high-fidelity applanation tonometry. An inverse association was found between pulse wave velocity and left ventricular ejection time at all ages (<25 years, r(2) = 0.043; 25-44 years, r(2) = 0.103; 45-64 years, r(2) = 0.079; 65-84 years, r(2) = 0.044; ≥ 85 years, r(2) = 0.022; P < 0.0001 for all). A significant (P < 0.0001) negative but always weaker correlation between pulse wave velocity and heart period was also found, with the exception of the youngest subjects (P = 0.20). A significant positive correlation was also found between pulse wave velocity and dP/dt (P < 0.0001). With multiple stepwise regression analysis, left ventricular ejection time and dP/dt remained the only determinant of pulse wave velocity at all ages, whereas the contribution of heart period no longer became significant. Our data demonstrate that pulse wave velocity is more closely related to left ventricular systolic function than to heart period. This may have methodological and pathophysiological implications.

Effect of a short-term intermittent exercise-training programme on the pulse wave velocity and arterial pressure: a prospective study among 71 healthy older subjects

AIMS OF THE STUDY

Stiffening of large arteries has been associated with increased cardiovascular outcomes among older subjects. Endurance exercises might attenuate artery stiffness, but little is known about the effects of intermittent training programme. We evaluate the effect of a short Intermittent Work Exercise Training Program (IWEP) on arterial stiffness estimated by the measure of the pulse wave velocity (PWV).

METHODS AND SUBJECTS

Seventy-one healthy volunteers (mean age: 64.6 years) free of symptomatic cardiac and pulmonary disease performed a 9-week IWEP that consisted of a 30-min cycling twice a week over a 9-week period. Each session involved six 5-min bouts of exercise, each of the latter separated into 4-min cycling at the first ventilatory threshold alternated with 1-min cycling at 90% of the pretraining maximal tolerated power. Before and after the IWEP, the following measurements were made: carotid-radial PWV and carotid-femoral PWV with a tonometer and systolic and diastolic blood pressure.

RESULTS

Training resulted in a non-significant decrease of the carotid-radial PWV, a significant decrease of the carotid-femoral PWV from 10.2 to 9.6 m/s (p < 0.001) (that was no longer significant after adjustment for mean arterial pressure) and a significant decrease in both systolic and diastolic blood pressure, respectively, from 129.6 ± 14.9 mmHg to 120.1 ± 14.1 mmHg (p < 0.001) and from 77.2 ± 8.8 mmHg to 71.4 ± 10.1 mmHg (p < 0.001).

CONCLUSION

The present results support the idea that a short-term intermittent aerobic exercise programme may be an effective lifestyle intervention for reducing rapidly blood pressure and probably central arterial stiffness among older healthy subjects.

Decentralized cardiovascular autonomic control and cognitive deficits in persons with spinal cord injury

Spinal cord injury (SCI) results in motor and sensory impairments that can be identified with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Although, SCI may disrupt autonomic neural transmission, less is understood regarding the clinical impact of decentralized autonomic control. Cardiovascular regulation may be altered following SCI and the degree of impairment may or may not relate to the level of AIS injury classification. In general, persons with lesions above T1 present with bradycardia, hypotension, and orthostatic hypotension; functional changes which may interfere with rehabilitation efforts. Although many individuals with SCI above T1 remain overtly asymptomatic to hypotension, we have documented deficits in memory and attention processing speed in hypotensive individuals with SCI compared to a normotensive SCI cohort. Reduced resting cerebral blood flow (CBF) and diminished CBF responses to cognitive testing relate to test performance in hypotensive non-SCI, and preliminary evidence suggests a similar association in individuals with SCI. Persons with paraplegia below T7 generally present with a normal cardiovascular profile; however, our group and others have documented persistently elevated heart rate and increased arterial stiffness. In the non-SCI literature there is evidence supporting a link between increased arterial stiffness and cognitive deficits. Preliminary evidence suggests increased incidence of cognitive impairment in individuals with paraplegia, which we believe may relate to adverse cardiovascular changes. This report reviews relevant literature and discusses findings related to the possible association between decentralized cardiovascular autonomic control and cognitive dysfunction in persons with SCI.

Correlation between peripheral blood pressure and pulse-wave velocity values in the institutionalized elderly persons 80 years of age and older: the PARTAGE study

BACKGROUND

Carotid-femoral pulse-wave velocity (PWV) provides a comprehensive noninvasive indication of arterial stiffness, and is now established as a strong marker of cardiovascular disease (CVD). The correlation between peripheral blood pressure (BP) and PWV and their respective influences on mortality have been poorly studied in the elderly. Our objective was to analyze this correlation in nursing-home residents over 80 years of age, with the view that the results of this could ultimately be helpful in implementing strategies for the diagnosis and long-term follow-up of CVD and mortality in the very elderly population.

METHODS

The Predictive Value of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population (PARTAGE) study is a 2-year cohort study of 1,130 subjects living in 72 nursing homes in France and Italy. The correlation between baseline systolic and diastolic blood pressure (SBP and DBP, respectively) and baseline PWV (measured with a PulsePen® tonometer) was studied in 1,071 subjects for whom PWV measurements were available.

RESULTS

Correlations between peripheral BP and PWV were significant but weak, with r = 0.24 for self-measured SBP, r = 0.30 for casual SBP, r = 0.11 for self-measured DBP, r = 0.14 for casual DBP, and r = 0.26 for casual pulse pressure (PP). A trend toward a weaker correlation was observed in the older age group for self-measured SBP and in the group with a lower level of activities of daily living (ADL) for self-measured SBP and DBP.

CONCLUSIONS

These findings suggest that SBP, DBP, and PWV provide different information in the very elderly. The results of the prospective, longitudinal, long-term PARTAGE study will allow further insight into this and provide additional in-depth information about the respective prognostic value of the measurement of peripheral BP and PWV.

Mortality and cardiovascular events are best predicted by low central/peripheral pulse pressure amplification but not by high blood pressure levels in elderly nursing home subjects: the PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study

OBJECTIVES

The aim of the longitudinal PARTAGE study was to determine the predictive value of blood pressure (BP) and pulse pressure amplification, a marker of arterial function, for overall mortality (primary endpoint) and major cardiovascular (CV) events, in subjects older than 80 years of age living in a nursing home.

BACKGROUND

Assessment of pulse indexes may be important in the evaluation of the CV risk in very elderly frail subjects.

METHODS

A total of 1,126 subjects (874 women) who were living in French and Italian nursing homes were enrolled (mean age, 88 ± 5 years). Central (carotid) to peripheral (brachial) pulse pressure amplification (PPA) was calculated with the help of an arterial tonometer. Clinical and 3-day self-measurements of BP were conducted.

RESULTS

During the 2-year follow-up, 247 subjects died, and 228 experienced major CV events. The PPA was a predictor of total mortality and major CV events in this population. A 10% increase in PPA was associated with a 24% (p < 0.0003) decrease in total mortality and a 17% (p < 0.01) decrease in major CV events. Systolic BP, diastolic BP, or pulse pressure were either not associated or inversely correlated with total mortality and major CV events.

CONCLUSIONS

In very elderly individuals living in nursing homes, low PPA from central to peripheral arteries strongly predicts mortality and adverse effects. Assessment of this parameter could help in risk estimation and improve diagnostic and therapeutic strategies in very old, polymedicated persons. In contrast, high BP is not associated with higher risk of mortality or major CV events in this population. (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population [PARTAGE]; NCT00901355).

Blood pressure control in Italy: analysis of clinical data from 2005-2011 surveys on hypertension

INTRODUCTION

Blood pressure (BP) control is poorly achieved in hypertensive patients, worldwide.

AIM

We evaluated clinic BP levels and the rate of BP control in hypertensive patients included in observational studies and clinical surveys published between 2005 and 2011 in Italy.

METHODS

We reviewed the medical literature to identify observational studies and clinical surveys on hypertension between January 2005 and June 2011, which clearly reported information on clinic BP levels, rates of BP control, proportions of treated and untreated patients, who were followed in different clinical settings (mostly in general practice, and also in outpatient clinics and hypertension centres).

RESULTS

The overall sample included 158 876 hypertensive patients (94 907 women, mean age 56.6 ± 9.6 years, BMI 27.2 ± 4.2 kg/m(2), known duration of hypertension 90.2 ± 12.4 months). In the selected studies, average SBP and DBP levels were 145.7 ± 15.9 and 87.5 ± 9.7 mmHg, respectively; BP levels were higher in patients followed in hypertension centres (n = 10 724, 6.7%; 146.5 ± 17.3/88.5 ± 10.3 mmHg) than in those followed by general practitioners (n = 148 152, 93.3%; 143.5 ± 13.9/84.8 ± 8.9 mmHg; P < 0.01). More than half of the patients were treated (n = 91 318, 57.5%); among treated hypertensive patients, only 31 727 (37.0%) had controlled BP levels.

CONCLUSION

The present analysis confirmed inadequate control of BP in Italy, independently of the clinical setting. Although some improvement was noted compared with a similar analysis performed between 1995 and 2005, these findings highlight the need for a more effective clinical management of hypertension.

Measuring aortic pulse wave velocity using high-field cardiovascular magnetic resonance: comparison of techniques

BACKGROUND

The assessment of arterial stiffness is increasingly used for evaluating patients with different cardiovascular diseases as the mechanical properties of major arteries are often altered. Aortic stiffness can be noninvasively estimated by measuring pulse wave velocity (PWV). Several methods have been proposed for measuring PWV using velocity-encoded cardiovascular magnetic resonance (CMR), including transit-time (TT), flow-area (QA), and cross-correlation (XC) methods. However, assessment and comparison of these techniques at high field strength has not yet been performed. In this work, the TT, QA, and XC techniques were clinically tested at 3 Tesla and compared to each other.

METHODS

Fifty cardiovascular patients and six volunteers were scanned to acquire the necessary images. The six volunteer scans were performed twice to test inter-scan reproducibility. Patient images were analyzed using the TT, XC, and QA methods to determine PWV. Two observers analyzed the images to determine inter-observer and intra-observer variabilities. The PWV measurements by the three methods were compared to each other to test inter-method variability. To illustrate the importance of PWV using CMR, the degree of aortic stiffness was assessed using PWV and related to LV dysfunction in five patients with diastolic heart failure patients and five matched volunteers.

RESULTS

The inter-observer and intra-observer variability results showed no bias between the different techniques. The TT and XC results were more reproducible than the QA; the mean (SD) inter-observer/intra-observer PWV differences were -0.12(1.3)/-0.04(0.4) for TT, 0.2(1.3)/0.09(0.9) for XC, and 0.6(1.6)/0.2(1.4) m/s for QA methods, respectively. The correlation coefficients (r) for the inter-observer/intra-observer comparisons were 0.94/0.99, 0.88/0.94, and 0.83/0.92 for the TT, XC, and QA methods, respectively. The inter-scan reproducibility results showed low variability between the repeated scans (mean (SD) PWV difference = -0.02(0.4) m/s and r = 0.96). The inter-method variability results showed strong correlation between the TT and XC measurements, but less correlation with QA: r = 0.95, 0.87, and 0.89, and mean (SD) PWV differences = -0.12(1.0), 0.8(1.7), and 0.65(1.6) m/s for TT-XC, TT-QA, and XC-QA, respectively. Finally, in the group of diastolic heart failure patient, PWV was significantly higher (6.3 +/- 1.9 m/s) than in volunteers (3.5 +/- 1.4 m/s), and the degree of LV diastolic dysfunction showed good correlation with aortic PWV.

CONCLUSIONS

In conclusion, while each of the studied methods has its own advantages and disadvantages, at high field strength, the TT and XC methods result in closer and more reproducible aortic PWV measurements, and the associated image processing requires less user interaction, than in the QA method. The choice of the analysis technique depends on the vessel segment geometry and available image quality.