ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2...
Transcript of ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2...
Inje University Busan Paik Hospital
ARTERIAL STIFFNESS and
HYPERTENSION
인제대학교부산백병원순환기내과
김동수
Inje University Busan Paik Hospital
Increase In SBP and
Decrease in DBP with Age
0 25 50 75 1000
50
100
150
Age, y/o
Blo
od P
ress
ure
, m
mH
g
SBP
DBP
Pulse pressure
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연령증가에 따른 혈압치의 의의
Franklin SS et al. Circulation 1997;96:308
Pulse pressureMean BP
Diastolic BP Systolic BP
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Three Blood Pressure Subtypes
Isolated diastolic hypertension(IDH):
• common to younger age
• SBP<140 and DBP 90mmHg
Combined systolic and diastolic hypertension(SDH):
• essential hypertension common to middle age
• SBP 140 and DBP 90 mmHg
Isolated systolic hypertension(ISH):
• the more frequent form in older age
• SBP 140mmHg and DBP <90mmHg
JNC V - Systolic hypertension; SBP 160mmHg and
DBP <90mmHg, borderline; SBP 140-159 mmHg
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CompliantSystole Diastole
Non-CompliantSystole Diastole
Constant Stroke Volume
Aorta
Pulse pressure
Systolic BP
Diastolic BP
Central Arterial Damping and
Peripheral Pulse Pressure
Curr Opin Cardiol 2004;19:341
Inje University Busan Paik Hospital
Increased PP Appears to Be More Powerful
Measure to Predict CHD Than SBP or DBP
The Framingham Heart Study
Adjusted for age, sex, body mass index, cigarettes smoked per day, glucose intolerance, and total cholesterol/HDL.
Circulation 1999;100:354
CH
D H
azard
Rati
o
DPP (mmHg)
Inje University Busan Paik Hospital
Increased PP Appears to Be More Powerful
Measure to Predict CHD Than SBP or DBP
The Framingham Heart Study
Adjusted for age, sex, body mass index, cigarettes smoked per day, glucose intolerance, and total cholesterol/HDL.
Circulation 1999;100:354
CH
D H
azard
Rati
o
PP (mmHg)
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Pulse Pressure As a Risk Factor For
Cardiovascular Events
Risk associated with increasing SBP at fixed values of DBPJ Hypertens 2000;18:1527
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Pulse Pressure and Cardiovascular Mortality in Normotensive and Hypertensive Subjects
Hypertension 1998;32:560
0.4 0.6 0.8 1 1.2 1.61.4 1.8 2.22.0
Normotensive women
Normotensive men
Hypertensive women
Hypertensive men
95% confidence interval
Odds ratio
Total C-V mortality in subjects with PP >50 mm Hg compared with subjects with PP< or=to
50 mm Hg in the 4 groups of subjects according to gender and presence of hypertension.
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The increase in SBP and fall in DBP
(↑ Pulse pressure) reflects stiffening of the
blood vessels and reduced arterial
compliance.
Systolic BP and pulse pressure are reliable
markers of age-related vascular target
organ damage.
Pulse Pressure: A predictor of long-term
CV mortality
Inje University Busan Paik Hospital
↑PP Vascular endothelial damage
& mechanical fatigue
Atherosclerosis
↑Aortic stiffness
↑Central wave
reflection
Schematic diagram illustrating the concept of bidirectionality in the
relationship between pulse pressure (PP) and atherosclerosis.
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Integrated Hemodynamic
Model of Hypertension
Systolic blood pressure
Diastolic blood pressure
Cardiac stroke volume
Central arterial stiffness
Systemic Vascular Resistance
Raises Lowers
Curr Opin Cardiol 2004;19:341
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고혈압에서 혈압상승요인
• 혈관벽의경화(arterial stiffness)
• 탄성동맥벽의신전성(distensibility) 저하
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The Arterial Wall
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Factors increasing arterial stiffness
Genetics of
the RAS
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Arterial
StiffnessHypertension
Cause
Consequence
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• Pulse Pressure
• Pulse Wave Velocity
• Augmentation Index
• Pulse Contour Analysis
Measurement of Arterial Stiffness
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맥파전파속도 (Pulse Wave Velocity)
* *a b
Distance (혈관길이)A B
A
B
t (맥파전파시간)
The speed with which the pulse wave travels along a length of artery
(Distance/t)
a classic marker of arterial stiffness might be an
independent predictor of CV mortality (?)
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Effects of hypertension on aortic pressure wave contour and on aortic impedance modulus
1. ↑Peripheral resistance
2. ↓Distensibility
3. Early wave reflection
Increased peripheral resistance
causes increased mean pressure
and an increased zero-frequency
component of impedance.
Decreased arterial distensibility
causes increased amplitude of the
initial pressure peak and increased
characteristic impedance. Earlier
return of reflected waves from
arterial terminations causes the late
systolic pressure peak and
impedance curve to shift to the
right.
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young
Middle-aged
elderly
normotension hypertension
Pulse wave in normotensive and hypertensive subjects
Normotensive Hypertensive
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맥파속도와고혈압과의관계
J Hypertens 1997;15(suppl 2):S89
PWV(m/s)=0.07×SBP(mmHg)+0.09×연령-4.3
For any given age,
carotid–femoral pulse
wave velocity is higher
in hypertensives
compared with
normotensive controls,
indicating increased
aortic stiffness in the
hypertensives.
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Atherosclerosis Risk in Communication
(ARIC) StudyArterial Stiffness and 6 Year Incidence of Hypertension
(BP ≥ 160/95 or meds)
*adjusted for age, race,gender, education, smoking, heart rate, obesity
0
2
4
6
8
10
1st 2nd 3rd 4th
Quartile of Arterial Stiffness Index
% w
ho d
evelo
p H
BP
p < 0.01 (trend)
Hypertension 1999;34:201
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고혈압에있어서 PWV의임상적의의
Hypertension 1999;33:1111
Marker of CV Risk in Hypertensive Patients
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Multivariate Logistic Analysis by Laurent et al.
Hypertension 2001;37:1236
Previous CVD, yes/no
Age, 10 yr
PWV, 5 m/s
-2 0 2 4 6 108 12 1614
p< 0.0001
P< 0.001
P = 0.03
Aortic Stiffness Is an Independent Predictor of
C-V Mortality in Hypertensive Patients
95% confidence interval
Odds ratio
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고혈압에 있어서 PWV의 임상적 의의
Lancet 1996;348:645
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Summary(1)
• 고혈압은연령의증가에따라확장기혈압우위부터수축기혈압우위로변화하고, 고령기에는맥압의의의가크다.
이것은탄성동맥벽의신전성저하로서 PWV는좋은 지표가된다.
• 고혈압에서는 PWV가높고수축기혈압과상관한다. 이것은동맥벽의 remodeling을시사한다.
• 정상혈압에서 PWV의높은값은장래고혈압을발현할가능성이높은것을시사한다.
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Summary(2)
• 고혈압에서 PWV값은총사망및심혈관질환발생과사망에대한중요한예측인자가된다.
• 고혈압에서심비대를평가하는것과같이 PWV를평가할필요가있다.
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혈압치료 시의 PWV 모니터의 임상적의의
• PWV는고혈압환자, 신부전환자및 70세이상의고령자에있어서혈압의정도와는독립된심혈관예후의예지인자이다.
• PWV는혈압정도와밀접하게관련되어있으며혈압치의상승과함께증가하고, 강압에의해감소한다.
• 강압요법등의치료가혈압강하뿐만아니라 PWV의개선을가져올수있다.
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Impact of Aortic Stiffness Attenuation on Survival of Patients in End-Stage Renal Failure
Circulation 2001;103:987
생존율
Probability of all-cause
survival according to
PWV under
antihypertensive
therapy. Comparison
between BP
responders (negative
PWV) and
nonresponders
(positive PWV) was
highly significant.
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Impact of Aortic Stiffness Attenuation on Survival of Patients in End-Stage Renal Failure
Circulation 2001;103:987
혈압
혈압
PWV
PWV
Changes of MBP (solid circle) and aortic PWV (open circle) from inclusion to
end of follow-up for survivors and nonsurvivors
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Improvement of arterial stiffness with antihypertensive drugs
For the same blood
pressure reduction,
arterial distensibility may
be increased to a greater
or lesser extent
depending on the
antihypertensive
compound.
Inhibition of the RAS or
SNS seems to be able to
modify arterial stiffness
J Hypertens 1997;15(suppl2):S89
Inje University Busan Paik Hospital
0
10
20
30 * *
+
**,++
Cen
tra
l au
gm
en
tati
on
in
dex
,%
Disparate effects of antihypertensive drugs
on Vascular Stiffness : 6 months trial
Park JB
*; p<0.05 vs NT
**;p<0.01 vs NT+;p<0.05 vs HT++;p<0.01 vs HT
NT HT atenolol irbesartan
lercanipine
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-600
-500
-400
-300
-200
-100
0
Valsartan Temocapril Cilnidipine Nifedipine CR
ba/PWV
cm/sec
Changes in the brachial-ankle pulse wave velocity
between baseline and 3 months after drugs in
elderly hypertensive patients
**
****
****
** p<0.01
Takami T, 2002 Hypertens Res
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Therapeutic Aspect of Increased PP
• Nitrates
• ACE Inhibitor or ARB with Diuretics
• Spironolactone
• Other Drugs
- Drug to target collagen metabolism
- Hormone replacement therapy
Inje University Busan Paik Hospital
Conclusions
• Arterial stiffening might be a precursor to
hypertension
• Arterial stiffening is a independent risk
factor for cardiovascular disease
• The decrease in arterial stiffness should be
another target of anti-hypertensive
therapy
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PWV(맥파전파속도) 측정
혈관의 길이를 구하기 위해 신장(키)를 입력
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이 0 관, M/55
Ht: 170cm
Wt: 72kg BMI:
24.9
R-Bra
R-Ank
L-Ank
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정 0 옥, F/66
Ht: 158cm
Wt: 69kg BMI:
27.6
R-Bra
R-Ank
L-Ank
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김 0 자, F/64
Ht: 160cm
Wt: 57kg
BMI: 22.3
R-Bra
R-Ank
L-Ank
Inje University Busan Paik Hospital
김 0 홍, M/64
Ht: 170cm
Wt: 66kg BMI:
22.8
R-Bra
R-Ank
L-Ank