CENTRAL VERSUS BRACHIAL BLOOD PRESSURE IN PREDICTION OF CVS EVENTS

1. Central Aortic Pressure in
management Hypertension
state of the art
BY
ASHRAF OKBA
PROF. OF INTERNAL MEDICINE
AIN SHAMS UNIVERSITY

2. “A man is as old as his
arteries.”Thomas Sydenham, 1624-1689

3. “Arterial aging”
• Every heart beat generates a pulse wave, which disperses in the
human body. Young and healthy vessels are absorbing the energy of
the wave – vascular walls are cushioning.
• Vessels are ageing. Over time they are getting stiff – vascular walls
are not cushioning anymore. The travel speed of the pulse wave is
increasing (pulse wave velocity – PWV).
• Early detection of vascular aging is important to prevent CVD and
Hypertension.
Blood pressure 137/91 mmHg
Blood pressure 137/91 mmHg – What is the
difference?

4. Why Measure Arterial Stiffness?
• Reflects the true arterial wall damage
• Has an independent predictive value for CV events
, independent of the traditional risk factors
• A marker of earlier TOD compared to LVH and
albuminuria

5. Increased Arterial Stiffness
cause
• Increases vascular afterload with a propensity to develop LVH
• Decreases coronary perfusion pressure
• Increases myocardial oxygen demand and sub-endocardial
ischemia
• Increases flow turbulence, endothelial dysfunction &
atherogenesis

6. APWV measured was a significant predictor of cardiovascular
complications, above and beyond mean arterial pressure.
Prognostic Value of Aortic Pulse Wave Velocity as
Index of Arterial Stiffness in the General Population
(Circulation. 2006)
Vascular Stiffness Measurements as
a Prognostic Indicator
A increase in PWV by 1.0 m/sec increases the
risk of CV events by 14%

7. Speed of the wave is related to the stiffness of the
artery it is traveling in
The stiffer the artery;
the higher the wave speed
Wave speed is proportional to the square
root of arterial stiffness

8. Assessment of Arterial Stiffness
• Pulse wave velocity (PWV)
The gold standard measurement of arterial stiffness
• Central aortic pressure
• Augmentation index

9. Pulse Wave Velocity (PWV)
• In young adults, arteries are distensible, thus wave travel
velocity is relatively low. The reflected wave is seen in
diastole.
• In older people and in arteriosclerosis, the pulse wave
velocity is high, the reflected wave is fater &
superimposed on the systolic wave leading to higher
systolic pressure and shorter diastolic time.

10. Pulse wafeform
of 25 year
Pulse wafeform
of 47 year
Pulse wafeform
of 85year
Central aortic pulse waveform in different age groups

11. PWV predicts overall survival in end-
stage renal disease patients
Blacher et al. 1999
Probability of
survival (all-cause
mortality) in end-
stage renal
disease patients
according to the
level of aortic
pulse wave
velocity (PWV)
divided in tertiles
(P< .0001).

12. What creates central BP?
• Stroke volume
• Aortic stiffness (compliance / Windkessel)
• Systemic vascular resistance (“runoff”)
• Reflected pressure wave

13. The major organs (brain, heart, and kidney) see
central arterial BP and not brachial BP.
Therefore, brachial systolic and pulse BPs
measured with a sphygmomanometer in the
arm are not always reliable measures of central
aortic systolic and pulse BPs.
Central BP & PP

15. • Among 3520 participants, central and brachial pulse pressures
were more strongly related to vascular hypertrophy and
extent of atherosclerosis than were systolic pressures.
• Central pulse pressure was more strongly related to all 3
arterial measures than was brachial pulse pressure .
• central pulse pressure predicted cardiovascular events more
strongly than brachial pulse pressure
• In conclusion, central pulse pressure is more strongly related
to vascular hypertrophy, extent of atherosclerosis, and
cardiovascular events than is brachial blood pressure.

16. Beta-blockers not effectively protect against cardiovascular events as
it’s central systolic pressure

17. BP 142/88 mmHg
ABPM 136/86
COL-LDL 135 mg/dl
Waist 104 cm
ECG, UAE: negative
Guidelines ESH - ESC 2013
Searching for TOD modifies treatment decisions!
BP 142/88
mmHg
ABPM
136/86
COL-LDL 135
mg/dl
Waist 104 cm
LVM 126
g/m2
PWV 10,5
m/s
NO Treatment with drugs
Treatment: YES, BP and LDL !!
Patient with recently diagnosed HT, no previous treatment

18. Cardioalex 2015
ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE
ESH - ESC CHARTS
BP 185/105 mmHg
COL-LDL 135 mg/dl
LVM 125 g/m2
PWV 10,5 m/s
Waist 104 cm
BP 135/88 mmHg
COL-LDL 135 mg/dl
LVM 116 g/m2
PWV 10,1 m/s
Waist 104 cm
BP 135/88 mmHg
COL-LDL 98 mg/dl
LVM 105 g/m2
PWV 8,8 m/s
Waist 101 cm
BP 185/105 mmHg
COL-LDL 135 mg/dl
LVM 125 g/m2
PWV 10,5 m/s
Waist 104 cm
Guidelines ESH - ESC 2013
Treatment of BP ALONE does not
necessarily reduce risk !!

19. ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE
ESH - ESC CHARTS
BP 142/88 mmHg
ABPM 136/86
COL-LDL 135 mg/dl
Waist 104 cm
ECG, UAE: negative
Guidelines ESH - ESC 2013
Searching for TOD modifies treatment
decisions !!
BP 142/88
mmHg
ABPM
136/86
COL-LDL 135
mg/dl
Waist 104 cm
LVM 126
g/m2
PWV 10,5
m/s
NO Treatment with drugs
Treatment: YES, BP and LDL !!
Patient with recently diagnosed HT, no previous treatment

20. ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE
ESH - ESC CHARTS
Guidelines ESH - ESC 2013
What is our target? Blood Pressure? TOD?
How often?
BP 142/88
mmHg
ABPM
136/86
COL-LDL 135
mg/dl
LVM 126
g/m2
PWV 10,5
m/s
Patient with Stage 1 HT, treatment
Valsartan is added
statin is added
BP 138/85
mmHg
ABPM ?
COL-LDL 98
mg/dl
LVM ?
PWV 10,1
m/s
3 months later, treatment Amlodipine/Valsartan 10/160 , statin

21. WHEN YOU UNDERSTAND
SMILE AND CUSTOMIZE
ASHRAF OKBA
22

22. • At least 75% of patients
will require combination
therapy to achieve
contemporary BP targets.
.1Gradman AH, Basile JN, Carter BL, et al. Combination therapy
in hypertension. J Am Soc Hypertens 2010; 4 (2): 90-8.

23. Valsartan &amlodipine combination achieve An optimal control of BP with
different degree of hypertension included isolated systolic hypertension
Real-Life Safety and Effectiveness Adv Ther (2011) 28(2):134-149.

24. Amlodipin based therapy achieve control of BP 24 hrs
without much variability
Rothwell PM, et al. Lancet Neurol. 2010;9:469-480.
RAS BLOKER
RAS BLOKER

25. VAL /AMLOD
VAL /AMLOD

26. Boutouyrie et al J Hypertens 2014; 32: 108-114
Effect of B.blocker/Amlodipine versus Valsartan/Amlodipine
on aPWV Adjusted for Changes in MAP and Heart Rate

27. Rev. 1.0
19.05.2016
Pulse Wave Analysis (PWA)

28. ARTERIAL STIFFNESS IN DAILY CLINICAL PRACTICE
CONCLUSIONS
1. Measuring TOD as an intermediate stage in the
continuum improves stratification of cardiovascular risk
2. Treatment-induced changes in subclinical organ
damage relate to cardiovascular outcomes
3. Arterial stiffness appears to be the most useful
candidate TOD to be used for monitoring patients
4. The effect of drugs on arterial stiffness seems to be
stronger for newer treatments, including ARB and CBB