40
Inje University Busan Paik Hospital ARTERIAL STIFFNESS and HYPERTENSION 인제대학교 부산백병원 순환기내과 김동수

ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

  • Upload
    others

  • View
    3

  • Download
    0

Embed Size (px)

Citation preview

Page 1: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

ARTERIAL STIFFNESS and

HYPERTENSION

인제대학교부산백병원순환기내과

김동수

Page 2: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

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

Page 3: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

연령증가에 따른 혈압치의 의의

Franklin SS et al. Circulation 1997;96:308

Pulse pressureMean BP

Diastolic BP Systolic BP

Page 4: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 5: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 6: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

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)

Page 7: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

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)

Page 8: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

Pulse Pressure As a Risk Factor For

Cardiovascular Events

Risk associated with increasing SBP at fixed values of DBPJ Hypertens 2000;18:1527

Page 9: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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.

Page 10: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 11: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

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.

Page 12: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 13: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

고혈압에서 혈압상승요인

• 혈관벽의경화(arterial stiffness)

• 탄성동맥벽의신전성(distensibility) 저하

Page 14: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

The Arterial Wall

Page 15: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

Factors increasing arterial stiffness

Genetics of

the RAS

Page 16: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

Arterial

StiffnessHypertension

Cause

Consequence

Page 17: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

• Pulse Pressure

• Pulse Wave Velocity

• Augmentation Index

• Pulse Contour Analysis

Measurement of Arterial Stiffness

Page 18: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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 (?)

Page 19: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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.

Page 20: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

young

Middle-aged

elderly

normotension hypertension

Pulse wave in normotensive and hypertensive subjects

Normotensive Hypertensive

Page 21: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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.

Page 22: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 23: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

고혈압에있어서 PWV의임상적의의

Hypertension 1999;33:1111

Marker of CV Risk in Hypertensive Patients

Page 24: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 25: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

고혈압에 있어서 PWV의 임상적 의의

Lancet 1996;348:645

Page 26: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

Summary(1)

• 고혈압은연령의증가에따라확장기혈압우위부터수축기혈압우위로변화하고, 고령기에는맥압의의의가크다.

이것은탄성동맥벽의신전성저하로서 PWV는좋은 지표가된다.

• 고혈압에서는 PWV가높고수축기혈압과상관한다. 이것은동맥벽의 remodeling을시사한다.

• 정상혈압에서 PWV의높은값은장래고혈압을발현할가능성이높은것을시사한다.

Page 27: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

Summary(2)

• 고혈압에서 PWV값은총사망및심혈관질환발생과사망에대한중요한예측인자가된다.

• 고혈압에서심비대를평가하는것과같이 PWV를평가할필요가있다.

Page 28: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

혈압치료 시의 PWV 모니터의 임상적의의

• PWV는고혈압환자, 신부전환자및 70세이상의고령자에있어서혈압의정도와는독립된심혈관예후의예지인자이다.

• PWV는혈압정도와밀접하게관련되어있으며혈압치의상승과함께증가하고, 강압에의해감소한다.

• 강압요법등의치료가혈압강하뿐만아니라 PWV의개선을가져올수있다.

Page 29: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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.

Page 30: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 31: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

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

Page 32: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

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

Page 33: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

-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

Page 34: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

Therapeutic Aspect of Increased PP

• Nitrates

• ACE Inhibitor or ARB with Diuretics

• Spironolactone

• Other Drugs

- Drug to target collagen metabolism

- Hormone replacement therapy

Page 35: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

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

Page 36: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

PWV(맥파전파속도) 측정

혈관의 길이를 구하기 위해 신장(키)를 입력

Page 37: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

이 0 관, M/55

Ht: 170cm

Wt: 72kg BMI:

24.9

R-Bra

R-Ank

L-Ank

Page 38: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

정 0 옥, F/66

Ht: 158cm

Wt: 69kg BMI:

27.6

R-Bra

R-Ank

L-Ank

Page 39: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

김 0 자, F/64

Ht: 160cm

Wt: 57kg

BMI: 22.3

R-Bra

R-Ank

L-Ank

Page 40: ARTERIAL STIFFNESS and HYPERTENSION · 2015-07-07 · Hypertension 1998;32:560 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2.0 2.2 Normotensive women Normotensive men Hypertensive women Hypertensive

Inje University Busan Paik Hospital

김 0 홍, M/64

Ht: 170cm

Wt: 66kg BMI:

22.8

R-Bra

R-Ank

L-Ank