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Lempiäinen PA, Ylitalo A, Huikuri H, Kesäniemi YA, Ukkola OH. Nighttime ambulatory pulse pressure predicts cardiovascular and all-cause mortality among middle-aged participants in the 21-year follow-up. J Clin Hypertens (Greenwich) 2021; 23:1547-1555. [PMID: 34216537 PMCID: PMC8678805 DOI: 10.1111/jch.14317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/04/2021] [Accepted: 06/20/2021] [Indexed: 11/27/2022]
Abstract
Office pulse pressure (PP) is a predictor for cardiovascular (CV) events and mortality. Our aim was to evaluate ambulatory PP as a long‐term risk factor in a random cohort of middle‐aged participants. The Opera study took place in years 1991–1993, with a 24‐h ambulatory blood pressure measurement (ABPM) performed to 900 participants. The end‐points were non‐fatal and fatal CV events, and deaths of all‐causes. Follow‐up period, until the first event or until the end of the year 2014, was 21.1 years (mean). Of 900 participants, 22.6% died (29.6% of men/15.6% of women, p<.001). A CV event was experienced by 208 participants (23.1%), 68.3% of them were male (p<.001). High nighttime ambulatory PP predicted independently CV mortality (hazard ratio [HR] 2.60; 95% confidence interval [CI 95%] 1.08–6.31, p=.034) and all‐cause mortality in the whole population (HR 1.72; Cl 95% 1.06–2.78, p=.028). In males, both 24‐h PP and nighttime PP associated with CV mortality and all‐cause mortality (24‐h PP HR for CV mortality 2.98; CI 95% 1.11–8.04, p=.031 and all‐cause mortality HR 2.40; CI 95% 1.32–4.37, p=.004). Accordingly, nighttime PP; HR for CV mortality 3.13; CI 95% 1.14–8.56, p=.026, and for all‐cause mortality HR 2.26; CI 95% 1.29–3.96, p=.004. Cox regression analyses were adjusted by sex, CV risk factors, and appropriate ambulatory mean systolic BP. In our study, high ambulatory nighttime PP was detected as a long‐term risk factor for CV and all‐cause mortality in middle‐aged individuals.
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Affiliation(s)
- Päivi A Lempiäinen
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Antti Ylitalo
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Heikki Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Y Antero Kesäniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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Dahle N, Skau E, Leppert J, Ärnlöv J, Hedberg P. Poorly controlled ambulatory blood pressure in outpatients with peripheral arterial disease. Ups J Med Sci 2021; 126:7609. [PMID: 33995892 PMCID: PMC8098705 DOI: 10.48101/ujms.v126.7609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients with peripheral arterial disease (PAD) are generally less intensively managed than patients with coronary heart disease (CHD), despite that their risk of complications is believed to be equivalent. Identification of PAD patients at risk of poorly controlled blood pressure (BP) could lead to improved treatment, thus lowering the risk of cardiovascular (CV) complications. We aimed to describe the prevalence of poorly controlled cardiovascular (CV) risk factors, focusing on BP, in outpatients with PAD diagnosed in a vascular ultrasound laboratory. METHODS Consecutive outpatients with carotid and/or lower extremity PAD were included (n = 402) and examined with blood sampling, clinical BP, and 24-h ambulatory BP measurements. A poorly controlled clinical BP was defined as ≥140/90 mmHg, ambulatory BP ≥130/80 mmHg, low-density lipoprotein (LDL)-cholesterol level ≥2.5 mmol/L, and glycated hemoglobin (HbA1c) level >53 mmol/mol in those with diabetes. RESULTS Most of the patients had poorly controlled clinical (76.6%) and ambulatory BP (51.7%) profiles. Antihypertensive medications were prescribed in 84% of the patients. However, >40% of them used only 0-1 medication, and <25% of them used three or more agents. Clinical BP, a low number of medications, body mass index, and the presence of diabetes independently predicted a poorly controlled ambulatory BP. Nearly one-third of the patients were smokers, and most of the cohort had an LDL-cholesterol level of ≥2.5 mmol/L. An HbA1c level of >53 mmol/mol was present in 55% of diabetic patients. CONCLUSION Poorly controlled clinical and ambulatory systolic BP profiles were common. In addition, suboptimal control of other important CV risk factors was detected. The findings of this study highlight the need for better preventive efforts against CV risk factors in outpatients with PAD.
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Affiliation(s)
- Nina Dahle
- Centre for Clinical Research, Uppsala University, Falun, Sweden
- Primary Health Care Center Britsarvet-Grycksbo, County of Dalarna, Falun, Sweden
| | - Emma Skau
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Jerzy Leppert
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
| | - Johan Ärnlöv
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
- School of Health and Social Studies, Dalarna University, Falun, Sweden
| | - Pär Hedberg
- Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
- Department of Clinical Physiology, Västmanland County Hospital, Västerås, Sweden
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Increased preoperative pulse pressure predicts procedural complications and mortality in patients who undergo tibial interventions for critical limb ischemia. J Vasc Surg 2015; 63:673-677. [PMID: 26577658 DOI: 10.1016/j.jvs.2015.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 09/15/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pulse pressure is a noninvasive measure of arterial stiffness. Increased pulse pressure is associated with an increased risk of cardiovascular events and death. The effects of pulse pressure on outcomes after endovascular interventions for critical limb ischemia (CLI), however, are unknown. We thus evaluated whether increased preoperative pulse pressure was associated with adverse outcomes and mortality in patients who underwent endovascular tibial artery intervention. METHODS All patients who underwent endovascular tibial intervention for CLI at a single institution from 2004 to 2014 were included in this study. Preoperative pulse pressure was derived from measurements obtained in the holding area before the procedure. Patients were divided into two groups on the basis of pulse pressure, <80 or ≥80 mm Hg. Patient demographic characteristics and comorbidities were documented, and outcomes including procedural complications, repeat intervention, amputation, and mortality were recorded. Multivariable logistic regression was used to account for patient demographic characteristics and comorbidities. RESULTS Of 371 patients, 186 patients had a preoperative pulse pressure <80 mm Hg and 185 had a preoperative pulse pressure ≥80 mm Hg. No significant differences in patient demographic characteristics or comorbidities were identified; however, there was a trend toward older age in patients with increased pulse pressure (70 vs 72; P = .07). In univariate analysis, procedural complications (21% vs 13%; P = .02), reinterventions (26% vs 17%; P < .01), and restenosis (32% vs 23%; P = .03) were more common among patients with pulse pressure ≥80. Procedural complications remained significant in multivariate analysis (odds ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). There was no difference in 30-day mortality; however, increased mortality was seen at 5 years of follow-up (odds ratio, 1.6; 95% confidence interval, 1.0-2.5; P = .04) in multivariable analysis. CONCLUSIONS Increased preoperative pulse pressure is associated with procedural complications and increased mortality in patients who undergo endovascular tibial intervention for CLI. It is a marker of increased risk, and might be a suitable target for interventions aimed at improving outcomes in this high-risk population.
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Del Brutto OH, Mera RM, Sedler MJ, Gruen JA, Phelan KJ, Cusick EH, Zambrano M, Brown DL. The Relationship Between High Pulse Pressure and Low Ankle-Brachial Index. Potential Utility in Screening for Peripheral Artery Disease in Population-Based Studies. High Blood Press Cardiovasc Prev 2015; 22:275-80. [PMID: 25986077 DOI: 10.1007/s40292-015-0103-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/12/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION The ankle-brachial index (ABI) is a reliable screening procedure for peripheral artery disease detection. However, ABI testing is time-consuming and requires trained personnel, which may preclude its routine use in population-based surveys. Preliminary data suggest a relationship between ABI values and pulse pressure (PP) levels. AIM To assess whether PP calculation might help to detect persons who need ABI screening in population-based studies. METHODS All Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo ABI testing. Non-consented persons and those with ABI ≥1.4 were excluded. Using generalized linear and logistic regression models adjusted for demographics and cardiovascular risk factors, as well as receiver operator characteristics curve analysis, we evaluated the association between PP values and ABI, as well as the reliability of PP to identify candidates for ABI testing. RESULTS Out of 239 participants (mean age 70 ± 8 years, 62 % women), 46 (19 %) had an ABI ≤0.9 and 136 (57 %) had PP >65 mmHg, with a negative relationship between them (R = -0.386, p < 0.0001). A PP >65 mmHg was associated with an ABI ≤ 0.9 in the logistic regression model (OR 3.46, 95 % CI 1.07-11.2, p = 0.038). Continuous PP levels also correlated negatively with ABI (β -0.0014, 95 % CI -0.0024 to -0.0004, p = 0.005). The sensitivity of a PP >65 mmHg to predict a low ABI was 85 %, and the specificity was 50 %. In contrast, the sensitivity of blood pressure ≥140/90 mmHg was 27 % and the specificity was 10 %. The area under the curve for the predictive value of a PP >65 mmHg was 0.673 (95 % CI 0.609-0.736), and that of a blood pressure ≥140/90 mmHg was 0.371 (95 % CI 0.30-0.443), with a significant difference between them (p < 0.0001). CONCLUSIONS PP calculation may be a simple tool to detect candidates for ABI testing in population-based studies.
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Affiliation(s)
- Oscar H Del Brutto
- School of Medicine, Universidad Espíritu Santo, Ecuador, Guayaquil, Ecuador,
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Roseguini BT, Hirai DM, Alencar MC, Ramos RP, Silva BM, Wolosker N, Neder JA, Nery LE. Sildenafil improves skeletal muscle oxygenation during exercise in men with intermittent claudication. Am J Physiol Regul Integr Comp Physiol 2014; 307:R396-404. [DOI: 10.1152/ajpregu.00183.2014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Endothelial dysfunction caused by defective nitric oxide (NO) signaling plays a pivotal role in the pathogenesis of intermittent claudication (IC). In the present study, we evaluated the acute effects of sildenafil, a phosphodiesterase type 5 inhibitor that acts by prolonging NO-mediated cGMP signaling in vascular smooth muscle, on blood pressure (BP), skeletal muscle oxygenation, and walking tolerance in patients with IC. A randomized, double-blind, crossover study was conducted in which 12 men with stable IC received two consecutive doses of 50 mg of sildenafil or matching placebo and underwent a symptom-limited exercise test on the treadmill. Changes in gastrocnemius deoxy-hemoglobin by near-infrared spectroscopy estimated peripheral muscle O2delivery-to-utilization matching. Systolic BP was significantly lower during the sildenafil trial relative to placebo during supine rest (∼15 mmHg), submaximal exercise (∼14 mmHg), and throughout recovery (∼18 mmHg) ( P < 0.05). Diastolic BP was also lower after sildenafil during upright rest (∼6 mmHg) and during recovery from exercise (∼7 mmHg) ( P < 0.05). Gastrocnemius deoxygenation was consistently reduced during submaximal exercise (∼41%) and at peak exercise (∼34%) following sildenafil compared with placebo ( P < 0.05). However, pain-free walking time (placebo: 335 ± 42 s vs. sildenafil: 294 ± 35 s) and maximal walking time (placebo: 701 ± 58 s vs. sildenafil: 716 ± 62 s) did not differ between trials. Acute administration of sildenafil lowers BP and improves skeletal muscle oxygenation during exercise but does not enhance walking tolerance in patients with IC. Whether the beneficial effects of sildenafil on muscle oxygenation can be sustained over time and translated into positive clinical outcomes deserve further consideration in this patient population.
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Affiliation(s)
- Bruno T. Roseguini
- Pulmonary Function and Clinical Exercise Physiology Unit, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Daniel M. Hirai
- Pulmonary Function and Clinical Exercise Physiology Unit, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Maria C. Alencar
- Pulmonary Function and Clinical Exercise Physiology Unit, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Roberta P. Ramos
- Pulmonary Function and Clinical Exercise Physiology Unit, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Bruno M. Silva
- Department of Physiology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Nelson Wolosker
- Department of Surgery, Division of Vascular Surgery, University of Sao Paulo, Sao Paulo, Brazil; and
| | - J. Alberto Neder
- Pulmonary Function and Clinical Exercise Physiology Unit, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
- Queen's University and Kingston General Hospital, Laboratory of Clinical Exercise Physiology, Department of Medicine, Kingston, Ontario, Canada
| | - Luiz E. Nery
- Pulmonary Function and Clinical Exercise Physiology Unit, Department of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
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Trapp M, Trapp EM, Egger JW, Domej W, Schillaci G, Avian A, Rohrer PM, Hörlesberger N, Magometschnigg D, Cervar-Zivkovic M, Komericki P, Velik R, Baulmann J. Impact of mental and physical stress on blood pressure and pulse pressure under normobaric versus hypoxic conditions. PLoS One 2014; 9:e89005. [PMID: 24817135 PMCID: PMC4015896 DOI: 10.1371/journal.pone.0089005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 01/13/2014] [Indexed: 11/23/2022] Open
Abstract
Objective Hypobaric hypoxia, physical and psychosocial stress may influence key cardiovascular parameters including blood pressure (BP) and pulse pressure (PP). We investigated the effects of mild hypobaric hypoxia exposure on BP and PP reactivity to mental and physical stress and to passive elevation by cable car. Methods 36 healthy volunteers participated in a defined test procedure consisting of a period of rest 1, mental stress task (KLT-R), period of rest 2, combined mental (KLT-R) and physical task (bicycle ergometry) and a last period of rest both at Graz, Austria (353 m asl) and at the top station Dachstein (2700 m asl). Beat-to-beat heart rate and BP were analysed both during the test procedures at Graz and at Dachstein and during passive 1000 m elevation by cable car (from 1702 m to 2700 m). Results A significant interaction of kind of stress (mental vs. combined mental and physical) and study location (Graz vs. Dachstein) was found in the systolic BP (p = .007) and PP (p = .002) changes indicating that during the combined mental and physical stress task sBP was significantly higher under hypoxic conditions whereas sBP and PP were similar during mental stress both under normobaric normoxia (Graz) and under hypobaric hypoxia (Dachstein). During the passive ascent in cable car less trivialization (psychological coping strategy) was associated with an increase in PP (p = .004). Conclusion Our data show that combined mental and physical stress causes a significant higher raise in sBP and PP under hypoxic conditions whereas isolated mental stress did not affect sBP and PP under hypoxic conditions. PP-reaction to ascent in healthy subjects is not uniform. BP reactions to ascent that represents an accumulation of physical (mild hypobaric hypoxia) and psychological stressors depend on predetermined psychological traits (stress coping strategies). Thus divergent cardiovascular reactions can be explained by applying the multidimensional aspects of the biopsychosocial concept.
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Affiliation(s)
- Michael Trapp
- Research Unit of Behavioural Medicine, Health Psychology and Empirical Psychosomatics, Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Eva-Maria Trapp
- Research Unit of Behavioural Medicine, Health Psychology and Empirical Psychosomatics, Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria; University Clinic of Psychiatry. Medical University of Graz, Graz, Austria
| | - Josef W Egger
- Research Unit of Behavioural Medicine, Health Psychology and Empirical Psychosomatics, Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Wolfgang Domej
- Department of Pneumology, Medical University of Graz, Graz, Austria
| | - Giuseppe Schillaci
- Department of Medicine, University of Perugia and Terni University Hospital, Terni, Italy
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Peter M Rohrer
- Research Unit of Behavioural Medicine, Health Psychology and Empirical Psychosomatics, Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Nina Hörlesberger
- Research Unit of Behavioural Medicine, Health Psychology and Empirical Psychosomatics, Department of Medical Psychology and Psychotherapy, Medical University of Graz, Graz, Austria
| | | | - Mila Cervar-Zivkovic
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Peter Komericki
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | | | - Johannes Baulmann
- UKSH Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Skoglund PH, Arpegård J, Ostergren J, Svensson P. Amino-terminal pro-B-type natriuretic peptide and high-sensitivity C-reactive protein but not cystatin C predict cardiovascular events in male patients with peripheral artery disease independently of ambulatory pulse pressure. Am J Hypertens 2014; 27:363-71. [PMID: 24470529 DOI: 10.1093/ajh/hpt278] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with peripheral arterial disease (PAD) are at high risk for cardiovascular (CV) events. We have previously shown that ambulatory pulse pressure (APP) predicts CV events in PAD patients. The biomarkers amino-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), and cystatin C are related to a worse outcome in patients with CV disease, but their predictive values have not been studied in relation to APP. METHODS Blood samples and 24-hour measurements of ambulatory blood pressure were examined in 98 men referred for PAD evaluation during 1998-2001. Patients were followed for a median of 71 months. The outcome variable was CV events defined as either CV mortality or any hospitalization for myocardial infarction, stroke, or coronary revascularization. The predictive values of log(NT-proBNP), log(hs-CRP), and log(cystatin C) alone and together with APP were assessed by multivariable Cox regression. Area under the curve (AUC) and net reclassification improvement (NRI) were calculated compared with a model containing other significant risk factors. RESULTS During follow-up, 36 patients had at least 1 CV event. APP, log(NT-proBNP), and log(hs-CRP) all predicted CV events in univariable analysis, whereas log(cystatin C) did not. In multivariable analysis log(NT-proBNP) (hazard ratio (HR) = 1.62; 95% confidence interval (CI) = 1.05-2.51) and log(hs-CRP) (HR = 1.63; 95% CI = 1.19-2.24) predicted events independently of 24-hour PP. The combination of log(NT-proBNP), log(hs-CRP), and average day PP improved risk discrimination (AUC = 0.833 vs. 0.736; P < 0.05) and NRI (37%; P < 0.01) when added to other significant risk factors. CONCLUSIONS NT-proBNP and hs-CRP predict CV events independently of APP and the combination of hs-CRP, NT-proBNP, and day PP improves risk discrimination in PAD patients.
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Affiliation(s)
- Per H Skoglund
- Karolinska Institutet, Department of Medicine, Solna, Internal Medicine Unit and Emergency Department, Karolinska University Hospital Solna, Stockholm, Sweden
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