H igh blood pressure (BP) is an established modifiable risk factor for cardiovascular disease and mortality. However, the association between BP and cardiovascular risk weakens in the elderly.1 A major confounding factor is atherosclerotic peripheral arterial disease (PAD). 2,3 When PAD is present in subclavian and brachial arteries, arm BP cannot be accurately measured, and hypertension therefore cannot be timely diagnosed and properly managed in clinical practice. 4,5 Current technology allows simultaneous BP measurement in 4 limbs, 6,7 which may provide a comprehensive evaluation of BP and generate accurate BP differences between 4 limbs, such as ankle-brachial BP index (ABI) and the interarm and interankle BP differences. ABI is a well-documented diagnostic tool for PAD in lower extremities. 8 The interarm BP difference is also being recognized as an indicator of PAD in the subclavian or brachial arteries. [2][3][4][5][9][10][11] To the best of our knowledge, the diagnostic and prognostic significances of the interankle BP difference have not been investigated in prospective studies.We performed simultaneous BP measurement in 4 limbs in an elderly Chinese population, which was prospectively followed up for mortality. In the present study, we investigated total and cardiovascular mortality in relation to the level of arm BP, ABI, and the interarm and interankle BP differences. Methods Study PopulationOur study was conducted in the framework of the Chronic Disease Detection and Management in the Elderly (≥60 years) Program supported by the municipal government of Shanghai. In a newly urbanized suburban town, 30 kilometers from the city center, we invited all residents of 60 years or older to take part in comprehensive examinations of cardiovascular disease and risk. The Ethics Committee of Ruijin Hospital, Shanghai Jiaotong University School of Medicine approved the study protocol. All subjects gave written informed consent.A total of 3263 subjects (participation rate 90%) were enrolled in the period from 2006 to 2008, and followed up for vital status and cause of death till June 30, 2011. We excluded 130 subjects from the present analysis, because 4-limb BP measurement was not performed (n=45) or because of missing other information (n=85). Thus, the number of participants included in the present analysis was 3133. See Editorial Commentary, pp 1146-1147Abstract-The predictive value of blood pressure (BP) for cardiovascular morbidity and mortality diminishes in the elderly, which may be confounded and compensated by the BP differences across the 4 limbs, markers of peripheral arterial disease. In a prospective elderly (≥60 years) Chinese study, we performed simultaneous 4-limb BP measurement using an oscillometric device in the supine position, and calculated BP differences between the 4 limbs. At baseline, the mean age of the 3133 participants (1383 men) was 69 years. During 4 years (median) of follow-up, all-cause and cardiovascular deaths occurred in 203 and 93 subjects, respectively. In multiple regression...
P ulse wave velocity (PWV) is a measure of arterial stiffness and can be measured by recording pulse waves on 2 superficial arterial sites and measuring the distance between the 2 arterial sites.1 PWV is usually measured using the applanatation technique between carotid and femoral arteries, 2 between carotid and brachial arteries, 3 or between femoral and tibial or dorsalis arteries. 4 Carotid-femoral PWV is considered as a measure of aortic arterial stiffness and mostly studied for cardiovascular prediction.1 Several studies have demonstrated that carotid-femoral PWV predicts cardiovascular events and mortality in the general population 5,6 and in various patient cohorts. 7,8 Carotid-femoral PWV is, therefore, recommended by several recent hypertension guidelines as a measure of target-organ damage. 9,10 Current technology allows automatic detection of pulse waves using cuffs on the limb arterial sites, such as the brachial and posterior tibial arteries. With the time difference between the pulse waves of these arterial sites and an estimated travel path of the pulse waves according to body height, brachialankle PWV can then be calculated.11 Previous studies have shown that brachial-ankle PWV is closely correlated with carotid-femoral PWV 12 and is also predictive of cardiovascular events and mortality in the general population [13][14][15][16] and in various patient cohorts. [17][18][19][20][21][22][23][24][25] Nonetheless, brachial-ankle PWV measures stiffness of mixed elastic with muscular arteries, 26 instead of the elastic aorta alone, and hence quantitatively differs from carotid-femoral PWV and may have distinct values of cardiovascular prediction. In the present study, we investigated the predictive value of brachial-ankle PWV for mortality in an elderly Chinese population. Methods Study PopulationOur study was conducted in the framework of the Chronic Disease Detection and Management in the Elderly (≥60 years) Program supported by the municipal government of Shanghai. 27,28 In a newly urbanized suburban town, 30 km from the city center, we invited all residents ≥60 years to take part in comprehensive examinations of cardiovascular disease and risk. The Ethics Committee of Ruijin Hospital, Shanghai Jiaotong University School of Medicine, approved the study protocol. All subjects gave written informed consent.A total of 4140 subjects (participation rate 90%) were enrolled in the period from 2006 to 2011 and followed up for vital status and cause of death till June 30, 2013. We excluded 101 subjects from the present analysis, because brachial-ankle PWV was not measured (n=63) or because of missing other information (n=38). We further excluded 163 subjects with an ankle-brachial index <0.90 (n=107) or Abstract-Pulse wave velocity (PWV) is a measure of arterial stiffness and predicts cardiovascular events and mortality in the general population and various patient populations. In the present study, we investigated the predictive value of brachial-ankle PWV for mortality in an elderly Chinese population. Ou...
Background: Whether cardiovascular risk is more tightly associated with central (cSBP) than brachial (bSBP) systolic pressure remains debated, because of their close correlation and uncertain thresholds to differentiate cSBP into normotension versus hypertension. Methods: In a person-level meta-analysis of the International Database of Central Arterial Properties for Risk Stratification (n=5576; 54.1% women; mean age 54.2 years), outcome-driven thresholds for cSBP were determined and whether the cross-classification of cSBP and bSBP improved risk stratification was explored. cSBP was tonometrically estimated from the radial pulse wave using SphygmoCor software. Results: Over 4.1 years (median), 255 composite cardiovascular end points occurred. In multivariable bootstrapped analyses, cSBP thresholds (in mm Hg) of 110.5 (95% CI, 109.1–111.8), 120.2 (119.4–121.0), 130.0 (129.6–130.3), and 149.5 (148.4–150.5) generated 5-year cardiovascular risks equivalent to the American College of Cardiology/American Heart Association bSBP thresholds of 120, 130, 140, and 160. Applying 120/130 mm Hg as cSBP/bSBP thresholds delineated concordant central and brachial normotension (43.1%) and hypertension (48.2%) versus isolated brachial hypertension (5.0%) and isolated central hypertension (3.7%). With concordant normotension as reference, the multivariable hazard ratios for the cardiovascular end point were 1.30 (95% CI, 0.58–2.94) for isolated brachial hypertension, 2.28 (1.21–4.30) for isolated central hypertension, and 2.02 (1.41–2.91) for concordant hypertension. The increased cardiovascular risk associated with isolated central and concordant hypertension was paralleled by cerebrovascular end points with hazard ratios of 3.71 (1.37–10.06) and 2.60 (1.35–5.00), respectively. Conclusions: Irrespective of the brachial blood pressure status, central hypertension increased cardiovascular and cerebrovascular risk indicating the importance of controlling central hypertension.
We studied the prevalence, awareness, treatment and control of hypertension in an elderly Chinese population. The study subjects (age ≥60 years) were recruited from a suburban town of Shanghai from 2006 to 2008. We administered a standardized questionnaire to collect information on medical history, the use of medications and lifestyle. We measured blood pressure three times consecutively using a validated Omron 7051 oscillometric device (Kyoto, Japan) after the subjects had rested for at least 5 min in the sitting position. We defined hypertension as a blood pressure of at least 140 mm Hg systolic or 90 mm Hg diastolic or as the use of antihypertensive drugs. The 3949 participants (mean age of 68.3 years) included 2185 (55.3%) women, 182 (4.6%) obese subjects (body mass index ≥30 kg m(-2)) and 366 (9.3%) diabetic patients. The prevalence of hypertension was 59.4%. In the 2345 hypertensive patients, the awareness, treatment and control (<140/90 mm Hg) rates were 72.5%, 65.8% and 24.4%, respectively. In the 1542 treated hypertensive patients, 1196 (77.6%) used fixed-dose combinations of thiazide and reserpine or clonidine (n=1157, 75.0%) or of an angiotensin receptor blocker and hydrochlorothiazide (n=1) or free combinations (n=38, 2.5%), and 346 (22.4%) used a monotherapy of short-acting calcium channel blockers (n=217, 14.1%) or other classes of antihypertensive drugs (n=129, 8.3%). The corresponding control rates were 37.3% and 36.4%, respectively. In a stepwise logistic regression, the risk of uncontrolled hypertension was higher with older age (+10 years, odds ratio (OR) 1.19, P=0.03), female sex (OR 1.40, P=0.01), obesity (OR 2.35, P=0.0002) and heavy drinking (≥300 g per week, OR 2.18, P=0.0007). In conclusion, in elderly Chinese, the prevalence of hypertension is high. In spite of reasonably high awareness and treatment rates, the control rate remains low, most likely due to an unhealthy lifestyle and the underuse and/or underdose of antihypertensive drugs.
Pulsatile blood pressure (BP) confers cardiovascular risk. Whether associations of cardiovascular end points are tighter for central systolic BP (cSBP) than peripheral systolic BP (pSBP) or central pulse pressure (cPP) than peripheral pulse pressure (pPP) is uncertain. Among 5608 participants (54.1% women; mean age, 54.2 years) enrolled in nine studies, median follow-up was 4.1 years. cSBP and cPP, estimated tonometrically from the radial waveform, averaged 123.7 and 42.5 mm Hg, and pSBP and pPP 134.1 and 53.9 mm Hg. The primary composite cardiovascular end point occurred in 255 participants (4.5%). Across fourths of the cPP distribution, rates increased exponentially (4.1, 5.0, 7.3, and 22.0 per 1000 person-years) with comparable estimates for cSBP, pSBP, and pPP. The multivariable-adjusted hazard ratios, expressing the risk per 1-SD increment in BP, were 1.50 (95% CI, 1.33–1.70) for cSBP, 1.36 (95% CI, 1.19–1.54) for cPP, 1.49 (95% CI, 1.33–1.67) for pSBP, and 1.34 (95% CI, 1.19–1.51) for pPP ( P <0.001). Further adjustment of cSBP and cPP, respectively, for pSBP and pPP, and vice versa, removed the significance of all hazard ratios. Adding cSBP, cPP, pSBP, pPP to a base model including covariables increased the model fit ( P <0.001) with generalized R 2 increments ranging from 0.37% to 0.74% but adding a second BP to a model including already one did not. Analyses of the secondary end points, including total mortality (204 deaths), coronary end points (109) and strokes (89), and various sensitivity analyses produced consistent results. In conclusion, associations of the primary and secondary end points with SBP and pulse pressure were not stronger if BP was measured centrally compared with peripherally.
BackgroundA new simple technique based on iontophoresis technology (EZSCAN, Impeto Medical, Paris, France) has recently been developed for the screening of diabetes. In the present study, we investigated the accuracy of this system for the diagnosis of diabetes mellitus in Chinese.MethodsWe performed the EZSCAN test in diabetic and non-diabetic subjects. EZSCAN measures electrochemical conductance (EC) at forehead, hands and feet, and derives a diabetes index with a value ranging from 0 to 100. Diabetes mellitus was defined as a plasma glucose concentration of at least 7 mmol/l at fasting or 11.1 mmol/l at 2 hours after glucose load, or as the use of antidiabetic drugs.ResultsThe 195 study participants (51% men, mean age 52 years) included 75 diabetic patients (use of antidiabetic drugs 81%) and 120 non-diabetic subjects. EC (micro Siemens, μSi) was significantly (P < 0.001) lower in diabetic patients at the hands (44 vs. 61) and feet (51 vs. 69) locations, but not at the forehead (15 vs. 17, P = 0.39). When a diabetes index of 40 (suggested by the manufacturer) was used as the threshold, the sensitivity and specificity for the diagnosis of diabetes mellitus was 85% and 64%, respectively. In 80 patients who underwent an oral glucose tolerance test, EC at hands and feet and the diabetes index were significantly (P < 0.001) associated with both 2-hour post-load plasma glucose and serum glycosylated haemoglobin.ConclusionsEZSCAN might be useful in screening diabetes mellitus with reasonable sensitivity and specificity.
Abstract-No previous study has addressed the relative contributions of environmental and genetic cues to the diurnal blood pressure rhythmicity. From 24-hour ambulatory recordings of systolic blood pressure obtained in untreated patients (51% women; mean age, 51 years), we computed the night-to-day ratio in 897 and morning surge in 637. Environmental cues included season, mean daily outdoor temperature, atmospheric pressure, humidity and weekday, and the genetic cues 14 single nucleotide polymorphisms in 10 clock genes. Systolic blood pressure averaged (±SD) 126.7±11.9 mm Hg, night-to-day ratio 0.86±0.07, and morning surge 24.8±10.7 mm Hg. In adjusted analyses, night-to-day ratio was 2.4% higher in summer and 1.8% lower in winter (P<0.001) compared with the annual average with a small effect of temperature (P=0.079); morning surge was 1.7 mm Hg lower in summer and 1.1 mm Hg higher in winter (P<0.001). The other environmental cues did not add to the night-to-day ratio or morning surge variance (P≥0.37). Among the 14 genetic variations, only CLOCK rs180260 was significantly associated with morning surge after adjustment for season, temperature, and other host factors and after Bonferroni correction (P=0.044). In CLOCK rs1801260 C allele carriers (n=83), morning surge was 3.7 mm Hg higher than in TT homozygotes (n=554). Of the night-to-day ratio and morning surge variance, season and temperature explained ≈8% and ≈3%, while for genetic cues, these proportions were ≈1% or less. In conclusion, environmental compared with genetic cues are substantially stronger drivers of the diurnal blood pressure rhythmicity. Methods Study PopulationAs described elsewhere, 24,25 we recruited consecutive patients referred for ambulatory BP monitoring to the Hypertension Outpatient Clinic of Ruijin Hospital, Shanghai, China. We adhered to the principles of the Declaration of Helsinki. The Ethics Committee of Ruijin Hospital, Shanghai Jiaotong University School of Medicine, approved the study protocol. All patients gave informed written consent.Of patients referred from December 2008 until November 2012, 929 were eligible for inclusion in the present analysis because they were not on antihypertensive drug treatment or off antihypertensive medication for at least 2 weeks because they had both their clinic and 24-hour ambulatory BP measured and because they had been genotyped for the SNPs of interest. For analysis of the night-to-day BP ratio, we excluded 32 participants because their ambulatory BP recording was unsuccessful (n=24) or because of missing genotypes (n=8). For analysis of the morning surge, we discarded an additional 260 participants because they had not completed a diary, so that reliably differentiating between the awake and asleep periods of the day was impossible. Thus, the number of participants analyzed totaled 897 for the night-to-day BP ratio and 637 for the morning BP surge. BP MeasurementPhysicians measured the office BP after the patients had rested in the sitting position for at least 5 minutes. They obtained ...
Abstract-Patients with peripheral arterial disease may have elongated upstroke time in pulse waves in the lower extremities.We investigated upstroke time as a diagnostic tool of peripheral arterial disease and predictor of mortality in an elderly (≥60 years) Chinese population. We recorded pulse waves at the left and right ankles by pneumoplethysmography and calculated the percentage of upstroke time per cardiac cycle. Diagnostic accuracy was compared with the conventional ankle-brachial index method (n=4055) and computed tomographic angiography (34 lower extremities in 17 subjects). Upstroke time per cardiac cycle at baseline (mean±SD, 16.4%±3.1%) was significantly (P<0.0001) associated with ankle-brachial index in men (n=1803; r=−0.44) and women (n=2252; r=−0.32) and had an overall sensitivity and specificity of 86% and 80%, respectively, for the diagnosis of peripheral arterial disease (upstroke time per cardiac cycle, ≥21.7%) in comparison with computed tomographic angiography. During 5.9 years (median) of follow-up, all-cause and cardiovascular deaths occurred in 366 and 183 subjects, respectively. In adjusted Cox regression analyses, an upstroke time per cardiac cycle ≥21.7% (n=219; 5.4%) significantly (P<0.0001) predicted total and cardiovascular mortality. The corresponding hazard ratios were 1.98 (95% confidence interval, 1.48-2.65) and 2.29 (1.58-3.32), respectively, when compared with that of 2.10 (1.48-3.00) and 2.44 (1.57-3.79), respectively, associated with an ankle-brachial index of ≤0.90 (n=115; 2.8%). In conclusion, pulse waves in the lower extremities may behave as an accurate and ease of use diagnostic tool of peripheral arterial disease and predictor of mortality in the elderly. (Hypertension. 2016;67:527-534.
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