Hypertension in pregnancy Tom Archer, MD, MBA UCSD Anesthesia.
Tom Archer, MD, MBA UCSD Anesthesiology May 9, 2011
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Transcript of Tom Archer, MD, MBA UCSD Anesthesiology May 9, 2011
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Radial pulse analysis, central blood pressure and cardiovascular health:
an historical curiosity makes a comeback.
Tom Archer, MD, MBA
UCSD Anesthesiology
May 9, 2011
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http://www.itmonline.org/image/pulse2.jpg
Pulse analysis was practiced in Chinese medicine thousands of years ago.
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Pulse analysis was also serious business in the 19th century
in Europe and the USA
• Sphygmographs in common use.
• Insurance companies relied on their results.
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http://www.mamweb.org/modules.php?name=Content&pa=showpage&pid=32000
Etienne-Jules Marey (1830-1904) invented the sphygmograph to record the arterial pulse on smoked paper. It was used by Engelmann, Mackenzie and Wenckebach.
Sphygmograph 1876
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Life insurance examination manual from 1891 discussed pulse analysis by sphygmography.
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Tom Archer, 58 y.o., good general health. Takes Crestor for high cholesterol.
Radial and predicted ascending aortic pressure waveform when subject is cold.
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Scipione Riva-Rocci introduced the mercury sphygmo-manometer in 1896.
Measured systolic BP only.
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history.library.ucsf.edu/.../chapter2_03.html
Harvey Cushing used it.
Korotkoff introduced auscultation for diastolic pressure in 1905.
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In the 20th century, Riva-Rocci and Korotkoff’s sphygmomanometer
eclipsed pulse analysis
• Two simple numbers: systolic / diastolic.
• Easy to use.
• Pulse analysis fell into disuse.
• 20th century saw tremendous gains from simple sphygmomanometry: dangers of high BP.
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But simple sphygmomanometry ignores valuable information within
the pulse trace.• Extra information can be extracted from the pulse
using high fidelity transducers, computers and a “generalized transfer function”, which has been validated.
• Specifically, the Central Blood Pressure (CBP) can be calculated using the radial pulse contour and the non-invasive brachial blood pressure.
• CBP is the pressure in the ascending aorta.
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health.yahoo.com/topic/heart/overview/article...
LV “sees” the SBP in the ascending aorta.
With normal aortic valve, LV wall tension depends on pressure in ascending aorta
(and diameter of LV chamber).
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SphygmoCor system for measuring central blood pressures
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Central blood pressure (CBP)
• Diastolic and mean pressures are very similar at radial / brachial and central sites, but
• Systolic CBP is not the same as brachial or radial systolic BP!
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AIR
BLOOD
#3 Systemic vascular resistance (resistance arterioles)
#2 Stiffness of aorta (“windkessel”)
heart
veins
arteries
#1 SV
#4 Wave reflection–
timing and amount
Muscular arteries
Central BP
What creates central BP?
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Kozo Hirata, MD; Masanobu Kawakami, MD; Michael F O’Rourke, MD, DSc*Circ J 2006; 70: 1231–1239
Augmentation Index (AIx) =
Augmentation Pressure /
Pulse Pressure
If reflected wave travels fast and arrives during systole it creates “augmentation pressure”, extra pressure work for the heart during systole.
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A high augmentation index is a deadly backdraft of pressure which exhausts the heart over time.
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Run animation
• Wave reflection animation can be found at:
• http://atcormedical.com/wave_reflection.html
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Augmentation Index (AIx)
• High AIx = unnecessary heart work.
• High AIx leads to LVH and cardiomyopathy.
• Lower AIx is better.
• Treatments that lower AIx help the patient.
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When is AIx high-- chronically?
• Normal aging
• Obesity
• Atherosclerosis
• Diabetes
• Pre-eclampsia
• Inflammatory arthritis
• Renal failure
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WW Nichols Curr Opin Cardiol 2002, 17:543–551
As healthy individuals age, reflected wave arrives at ascending aorta earlier and increases augmentation index and central pulse pressure. Three members of same family.
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Central BPs– ASCOT / CAFE study
• Lower central BPs are associated with better CV outcomes.
• Amlodipine achieved lower central BPs and had better CV outcomes than atenolol, despite achieving the same brachial artery BPs.
CAFE / ASCOT study, M. O’Rourke (Circulation. 2006;113:1213-1225.)
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Four months Rx with lisinopril decreased central aortic pulse pressure and augmentation index.
WW Nichols Curr Opin Cardiol 2002, 17:543–551
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6 months Rx with atorvastatin decreased central aortic pulse pressure and augmentation index.
WW Nichols Curr Opin Cardiol 2002, 17:543–551
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Adams KF, Am J Health-Syst Pharm—Vol 61 May 1, 2004 Suppl 2
ACE inhibitors and aldosterone antagonists reverse LV hypertrophy– via central BP effects?.
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ACE inhibitors, statins and aldosterone antagonists
can reverse LV hypertrophy—
is this due to decreased AIx and strain on the heart?
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What makes AIx go down-- chronically?
• Exercise
• Weight loss
• Red wine
• Statins
• Control of blood pressure (ACEI and CCB)
• NTG
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Ultra-marathon runner, 30 yo, at rest, seated. AIx = -14%. Note high diastolic radial and CBP.
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When is AIx high– acutely?
• Arterial compression in legs (squatting)
• Cold body temperature.
• Nicotine ingestion
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Tom Archer, 58 y.o., while squatting.
AIx = 21%
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Tom Archer, seated, very cold from being outside in winter.
AIx = 27%
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David G. Edwards,1 Amie L. Gauthier,2 Melissa A. Hayman,2 Jesse T. Lang,2 and Robert W. Kenefick2J Appl Physiol 100: 1210–1214, 2006.
Exposure of healthy young adults to cold air for 30 min increases augmentation index.
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What makes AIx decrease-- acutely?
• Exercise
• Alcohol
• Lowering blood pressure
• NTG
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Tom Archer, 58 yo, after work, seated comfortably. AIx = 11%.
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Tom Archer, 58 yo, after exercise and wine.
AIx = 1%
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Perioperative hypothermia increases cardiac event rate.
Is this due to increased AIx with hypothermia?
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Could AIx guide therapies in anesthesia and intensive care?
• NTG in low doses may work by decreasing wave reflection, CBP and afterload.
• First trial of AIx guided treatment would seem to be afterload reduction for the depressed LV– as in coming off CPB.
• SphygmoCor Mx does analysis on arterial line tracing, so it is continuous and hands-free.
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Is this an area which deserves more attention in Critical Care
Medicine?
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The End