Blood pressure parameters and pulse wave velocity for
Blood pressure parameters and pulse wave velocity for cardiovascular-renal prevention Jacques Blacher Unité HTA, prévention et thérapeutique cardiovasculaires Centre de diagnostic et de thérapeutique, Hôtel-Dieu, Paris May 2015
Disclosures Jacques Blacher ∙No financial participation in the capital of a healthcare company. ∙No permanent interest (work contract, regular remuneration. . . ) in a healthcare company. ∙Occasional direct and indirect interests (clinical trials, scientific work, scientific committees, expert reports, conferences, colloquia, training courses, participation at various symposia, writing of brochures. . . ), remunerated where appropriate, for most companies that market cardiovascular drugs or other medicinal products used in my areas of expertise (ARDIX-THERVAL, AMGEN, ASTRAZENECA, BAYER, BMS, BOUCHARA RECORDATI, DAÏCHI SANKYO, DANONE, EUTHERAPIE, GSK, IPSEN, MENARINI, MERCK SERONO, MSD, NOVARTIS, PIERRE FABRE, PILEJE, ROCHE, SANOFI, SERVIER, TAKEDA).
Risk assessment strategies
Risk assessment strategies • • • Systolic versus diastolic ? Pulse pressure versus systolic ? Young versus old ? Central versus peripheral ? PWV versus BP ? Comparison of different biomarkers problem of intercorrelations
Risk of CHD Death According to Systolic BP and Diastolic BP in MRFIT Adjusted Relative Risk 4 Decile Systolic BP (mm Hg) Diastolic BP (mm Hg) Systolic 3 Diastolic 2 1 0 1 2 (Lowest 10%) 3 4 5 6 7 8 9 10 (Highest 10%) <112 112 - 118 - 121 - 125 - 129 - 132 - 137 - 142 - ? 151 <71 71 - 76 - 79 - 81 - 84 - 86 - 89 - 92 - ? 98 Stamler et al. Arch Intern Med. 1993; 153: 598 -615.
Risk assessment strategies • • • Systolic versus diastolic ? Pulse pressure versus systolic ? Young versus old ? Central versus peripheral ? PWV versus BP ? Comparison of different biomarkers problem of intercorrelations
Darné B et al. Pulsatile versus steady component of blood pressure: a cross-sectional analysis and a prospective analysis on cardiovascular mortality. Hypertension 1989; 13: 392 -400 • Blood pressure divided into 2 components: pulse and mean, rather than systolic and diastolic • 18 336 men + 9351 women aged 40 -69 • Follow-up: 9. 5 years • Strong correlation between PP and MAP • Principal component analysis = 2 independent parameters • Relation between pulsatile component and LVH • Relation between steady component index and CV death in both sexes • Relation between pulsative component index and death from CHD in women > 55
Pulse Pressure Predicts Risk Best In Older Hypertensives - A Meta-Analysis 2 -Year Risk Of End Point EWPHE (N=840) Syst-Eur (N=4695) Syst-China (N=2394) Systolic Blood Pressure (mm Hg) Blacher et al. Arch Intern Med. 2000; 160. Diastolic Pressure (mm Hg)
Mortality Rates (per 10000 person-years) in the 9 groups of patients Benetos A. et al. Hypertens. 1999; 33: 44 -52. Cardiovascular Mortality
Risk assessment strategies • • • Systolic versus diastolic ? Pulse pressure versus systolic ? Young versus old ? Central versus peripheral ? PWV versus BP ? Comparison of different biomarkers problem of intercorrelations
Franklin S, et al. Hemodynamic Patterns of Age-Related Changes in Blood Pressure. The Framingham Heart Study. Circulation 1997; 96: 308 -315.
Relative cardiovascular risk associated with SBP, DBP and PP Franklin S. Does the relation of blood pressure to coronary heart disease risk change with aging ? Circulation. 2001; 103: 1245 -9. Single BP Components* Age < 50 y SBP DBP PP Age 50 -59 y SBP DBP PP Age 60 y SBP DBP PP HR (95 % CI)† 1. 14 1. 34 1. 02 (1. 06 -1. 24)++ (1. 18 -1. 51)+++ (0. 89 -1. 17) 1. 08 1. 11 (1. 02 -1. 15)+ (0. 99 -1. 24) (1. 02 -1. 22)+ 1. 17 1. 12 1. 24 (1. 11 -1. 24)+++ (0. 99 -1. 27) (1. 16 -1. 33)+++ * SBP, DBP and PP were entered in separate models, adjusted for age, sex, body mass index, cigarette smoking, diabetes mellitus, and ratio of total to HDL cholesterol † HR was associated with 10 mm Hg increase in BP + p<0. 05, ++p<0. 01, +++ p<0. 001
Risk assessment strategies • • • Systolic versus diastolic ? Pulse pressure versus systolic ? Young versus old ? Central versus peripheral ? PWV versus BP ? Comparison of different biomarkers problem of intercorrelations
Probabilities of survival in the study population according to the level of central PP divided into tertiles. Comparison between survival curves was highly significant (p<0. 001) Safar et al. Hypertension 2002
Cardiovascular survival Augmentation Index (AIX) and CV survival Duration of follow-up (months) London and al. Hypertension 2001
Jankowski P, et al. Hypertension 2008 ; 51 : 848 -55.
Risk assessment strategies • • • Systolic versus diastolic ? Pulse pressure versus systolic ? Young versus old ? Central versus peripheral ? PWV versus BP ? Comparison of different biomarkers problem of intercorrelations
Risk assessment strategies • • • Systolic versus diastolic ? Pulse pressure versus systolic ? Young versus old ? Central versus peripheral ? PWV versus BP ? Comparison of different biomarkers problem of intercorrelations
Systolic Diastolic Central Peripheral Mean Pulse
Area under ROC curves, crude and adjusted HRs per 1 SD increment Variable Mean±SD AUC Crude HR Adjusted HR Brachial SBP 156± 28 0. 64± 0. 10 1. 3 (1. 0 -1. 7) 1. 1 (0. 8 -1. 3) Carotid SBP 152± 29 0. 71± 0. 11 1. 6 (1. 2 -2. 1) 1. 2 (0. 8 -1. 4) DBP 83± 15 0. 65± 0. 10 0. 5 (0. 4 -0. 7) 0. 8 (0. 6 -1. 0) MBP 108± 17 0. 50± 0. 09 0. 8 (0. 7 -1. 1) 0. 7 (0. 9 -1. 2) Brachial PP 73± 23 0. 78± 0. 11 1. 8 (1. 5 -2. 3) 1. 2 (0. 9 -1. 5) Carotid PP 68± 25 0. 84± 0. 11 2. 2 (1. 7 -2. 7) 1. 4 (1. 1 -1. 8) Bra. /carot. PP 110± 16 0. 85± 0. 11 0. 2 (0. 1 -0. 4) 0. 5 (0. 3 -0. 8) Aortic PWV 11. 7± 3. 1 0. 83± 0. 11 2. 1 (1. 7 -2. 6) 1. 3 (1. 0 -1. 7) LV mass index 172± 46 0. 68± 0. 11 1. 5 (1. 2 -1. 8) 1. 2 (0. 9 -1. 6)
Hypertension 2009
Relative Integrated Discrimination Improvement (RIDI%) : major cardiovascular events 25 RIDI (%) 15 -13% 4% -7% 20% 7% 13% DBP vs SBP PP vs SBP MAP vs SBP PP vs DBP MAP vs DBP PP vs MAP 5 -5 -15
From risk assessment to risk reduction strategies
From risk assessment to risk reduction strategies • • • Residual risk Systolic versus diastolic ? BP versus PWV ? Peripheral BP versus central BP ? Young versus oldest old Prevention of CAD versus prevention of stroke ? • Prêt-à-porter versus haute couture
From risk assessment to risk reduction strategies • • • Residual risk Systolic versus diastolic ? BP versus PWV ? Peripheral BP versus central BP ? Young versus oldest old Prevention of CAD versus prevention of stroke ? • Prêt-à-porter versus haute couture
From risk assessment to risk reduction strategies • • • Residual risk Systolic versus diastolic ? BP versus PWV ? Peripheral BP versus central BP ? Young versus oldest old Prevention of CAD versus prevention of stroke ? • Prêt-à-porter versus haute couture
IMPACT OF AORTIC STIFFNESS ATTENUATION ON SURVIVAL OF PATIENTS IN END-STAGE RENAL FAILURE • 1 st step: dry weight • 2 nd step: ACE inhibitor or calcium antagonist • 3 rd step: calcium antagonist or ACE inhibitor (if not well tolerated) • 4 th step: ACE inhibitor or calcium antagonist + beta-blocker • 5 th step: ACE inhibitor + calcium antagonist + beta-blocker Guérin et al. Circulation 2001; 103: 987 -992
Changes of Mean Blood Pressure and aortic PWV (m/s) MBP (mm. Hg) 120 14 PWV (m/s) 120 14 13 13 12 110 11 10 100 9 Inclusion At target BP Survivors End of follow up 10 100 9 Inclusion At target BP End of follow up Non Survivors Guerin and al. Impact of aortic stiffness attenuation on survival of patient in end stage renal failure. Circulation. 2001; 103: 987 -992
From risk assessment to risk reduction strategies • • • Residual risk Systolic versus diastolic ? BP versus PWV ? Peripheral BP versus central BP ? Young versus oldest old Prevention of CAD versus prevention of stroke ? • Prêt-à-porter versus haute couture
From risk assessment to risk reduction strategies • • • Residual risk Systolic versus diastolic ? BP versus PWV ? Peripheral BP versus central BP ? Young versus oldest old Prevention of CAD versus prevention of stroke ? • Prêt-à-porter versus haute couture
Hypertension : complications Cerebral haemorrhage Chronic renal insufficiency Coronary artery disease LVH Ischemic stroke Dementia Myocardial infarction ARTERIAL HYPERTENSION Atrial fibrillation Heart failure Hypertensive encephalopathy Blindness Aortic aneurism Pre-eclampsia/ Peripheral arterial eclampsia disease
From risk assessment to risk reduction strategies • • • Residual risk Systolic versus diastolic ? BP versus PWV ? Peripheral BP versus central BP ? Young versus oldest old Prevention of CAD versus prevention of stroke ? • Prêt-à-porter versus haute couture
From risk assessment to risk reduction strategies • • • Residual risk Systolic versus diastolic ? BP versus PWV ? Peripheral BP versus central BP ? Young versus oldest old Prevention of CAD versus prevention of stroke ? • Prêt-à-porter versus haute couture
From risk assessment to risk reduction strategies CONCLUSION • Reliable BP measurements • Better understanding of the patho-physiology • Meta-analysis of observational studies and therapeutic trials (structural models): • Association of different BP parameters to CV risk reduction • Dedicated therapeutic trials • Focussing on one parameter versus another • Difficult to interpret because of collinearity
Systolic Diastolic Central Peripheral Mean Pulse
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