Accuracy and meaning of vascular parameters - Pierre BOUTOUYRIE Département de Pharmacologie et INSERM UMRS 872 Hôpital Européen Georges Pompidou ...
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Accuracy and meaning of vascular
parameters
Pierre BOUTOUYRIE
Département de Pharmacologie et INSERM UMRS 872
Hôpital Européen Georges Pompidou,
Université Paris Descartes et Assistance Publique-Hôpitaux de Paris
ARTERIAL COMPLIANCE
Arterial
Compliance
Systole
Left
ventricu
le Peripheral
Resistance
SYSTOLArterial
E Compliance
Diastole
Left
ventricul
Peripheral
e Resistance
DIASTOLE
By courtesy of CARIM
ARTERIAL FUNCTION AND BP
Pure Conduit Function Conduit and Cushioning
Function
pressure
pressure
Mean
Blood
Blood
Mean
pressure
pressure
Systole Diastole Systole Diastole
Arterial function : definition of
parameters
Mechanical stresses in the blood vessel
σθ
flow Q
R
h
circumferential wall stress fluid shear stress
σθ = P x R τ=4µQ
h π R3
Carotid-femoral pulse wave velocity
PWV can be assimilated
to arterial stiffness
∆t
L
∆L dP V 1
PWV = = . ≈
∆t ρ . dV DIST
Algorithms for identifying the foot of the wave
A
Are not equivalent
Intersecting tangents A>B>C
B
1st derivative
C
2nd derivative
10% upstroke
Maximum upstroke of the second derivative
Complior ® SphygmoCor Vx ®
ARTECH-medical Atcor Medical
www.artechmedical.com www.atcormedical.com
immediate succession
simultaneous delay to QRS
Local arterial stiffness and central
pressure
How to assess local pulse pressure ?
estimated from radial
measurement through
probe a transfer function
SphygmoCor Vx ®
Atcor Medical
www.atcormedical.com
Intra-arterial
PP
=
PP measured
with tonometry
bonePRESSURE WAVES RECORDED along
the arterial tree
Maximum
150
Early Wave (mm Hg)
100
Reflection Age 68 years
50
150
(mm Hg)
100 Age 54 years
50
150
(mm Hg)
Maximum
Amplification 100 Age 24 years
50
Renal
artery Femoral artery
Iliac artery
Thoracic
aorta Abdominal aorta
Ascending aorta
Nichols WW, et al. Arterial Vasodilation. Philadelphia,1993;32.Pressure wave amplification toward periphery
in younger
youngerPressure wave amplification toward periphery
in younger and equalisation in older
olderYounger subjects Older patients
Central pressure
=
=
+
+
Late return Early return
Slow PWV Fast PWV
Reflexion sitesPressure wave analysis: quantification of
reflected waves with applanation tonometry
SphygmoCor Vx ®
Atcor Medical
www.atcormedical.com
radial measurement
+ transfer function
Augmentation index
AI = AP
PPRadial artery tonometry Calibration on brachial SBP and DBP Probe orthogonal to the long axis of the RA
Carotid tonometry Application of the probe with light pressure on the best palpated pulse. Probe orthogonal to the long axis of the CCA Calibration on MBP and DBP of the RA measure
Central pressure and arterial
stiffness
Added value for risk prediction ?First author (year, country) Events Follow-up Type of patient Mean age
(years) (number) at entry
Aortic PWV
Blacher (1999, Fr) CV mortality 6.0 ESRD (241) 51
Laurent (2001, Fr) CV mortality 9.3 Hypertension (1980) 50
Meaume (2001, Fr) CV mortality 2.5 Elderly (>70) (141) 87
Shoji (2001, Jp) CV mortality 5.2 ESRD (265) 55
Boutouyrie (2002, Fr) CHD events 5.7 Hypertension (1045) 51
Cruickshank (02, GB) All cause M. 10.7 Diabetes and MS (571) 51
Laurent (2003, Fr) Fatal strokes 7.9 Hypertension (1715) 51
Sutton-Tyrrell (2005, US) CV events 4.6 Elderly (2488) 74
Shokawa (2005, Jp) CV mortality 10 General pop. (492) 64
Mattace (2006, Nl) CV mortality 4.5 General pop. (2835) 72
Hansen (2006, Dk) CV mortality 9.5 General pop. (1678) 50?
Ascending aorta (invasive)
Stefanadis (2000, Gr) Rec. acute CHD 3 Acute CHD (54) 55
Aorto-brachial PWV
Gosse (2005, Fr) CV events 5.4 Hypertension (412) 53
Carotid distensibility
YES Blacher (1999, Fr) CV mortality 6.0 ESRD (241) 51
YES Roman (2007, US) CV mortality 4.8 General pop. (3250)
Central
58
PP
NO Bots (2005, Nl) CV mortality 6.0 CVD patients 70
NO Mattace (2006, Nl) CV mortality 4.5 General pop. (2835) 72Predictive value of central PP for CV events,
independent of brachial PP
First author (year, country) Events Follow-up Type of patient Mean age
(years) (number) at entry
YES
Safar (2002, Fr) All cause mortality 4.3 ESRD (180) 54
Roman (2007, US) CV mortality 4.8 General pop. (3250) 58
NO
Williams (2006, UK) CV events 3.4 HT, ASCOT study (2073) 63
Dart (2006, Aust.) Mortality 4.1 Elderly female, ANBP 2 (484) 72Aortic stiffness and all-cause mortality
in 1980 hypertensives
1.00
< 10 m/s
0.90 10 m/s < 12.3 m/s
Kaplan-Meier PAortic stiffness and all-cause mortality
in 241 End stage renal disease patients
1.00
< 9.4 m/s
0.60 9.4 m/s <Influence of changes in PWV on survival in
ESRD patients
• Standardized
treatment, based on
Proportion of survival ACEi
• Similar reduction in
MBP
Decrease in PWV
PPrediction of CHD by aortic stiffness above
classical CV risk factors
Boutouyrie P . et al. Hypertension, 2002
1.0
0
20 PPrediction of CHD by aortic stiffness above
classical CV risk factors ?
??
Boutouyrie P . et al. Hypertension, 2002
1.0 ?
20
0
G E
PArterial stiffness and central pressure Implementation in current guidelines
Eur Heart J, December 2006
Target organ damage (TOD)
2007
• Left ventricular hypertrophy
(electrocardiogram:
Sokolow–Lyons .38 mm; Cornell .2440 mmms;
echocardiogram:
LVMI M > 125, W> 110 g/m2)
• Ultrasound evidence of arterial wall thickening
(carotid IMT > 0.9 mm) or atherosclerotic
Plaque
• Carotid-femoral pulse wave velocity
> 12 m/s
• Slight increase in serum creatinine
(M 115–133,W 107– 124 mol/l;
M 1.3–1.5,W1.2–1.4 mg/dl)
• Microalbuminuria
(30–300 mg/24 h; albumin–creatinine
ratio M > 22,W >31 mg/g;
M > 2.5,W > 3.5 mg/mmol)Reference value project • 16 european centers • 23 950 patients • Measurement of – Carotid-femoral pulse wave velocity – Carotid distensibility – Central pressure
PWV according to 2007 ESH risk categories
Values in % (100% = PWV in subjects with normal BP / No CV risk factors)
Based on 13,919 subjects
without current antihypertensive therapy
Optima Normal High Grade 1 Grade 2 Grade 3
l normal HT HT HT
No CV
risk 94.4 100.0 104.8 114.3 121.8 143.2
factors
1-2 CV
risk 104.3 113.8 121.7 134.2 141.0 153.2
factors
3 CV risk
factors/di 123.0 132.5 140.7 152.9 161.0 176.9
abetes
CV/renal
disease 116.8 123.0 133.2 137.7 153.3 147.0
Risk factors: age/gender, smoking, dislipidemia
Background Objectives Methods Results Discussion ConclusionsInfluence of age and risk on PWV
Risk factors: SBP, smoking, dislipidemia – no antihypertensive
therapy
Boxplots: whiskers : 1.5 interquartile range ≈ 10-90 percentile
PWV [m/s]
AgeInfluence of age and risk on PWV
Risk factors: SBP, smoking, dislipidemia – no antihypertensive
therapy
Boxplots: whiskers : 1.5 interquartile range ≈ 10-90 percentile
PWV [m/s]
AgeInfluence of age and risk on PWV
Risk factors: SBP, smoking, dislipidemia – no antihypertensive
therapy
Boxplots: whiskers : 1.5 interquartile range ≈ 10-90 percentile
PWV [m/s]
AgeInfluence of age and risk on PWV
Risk factors: SBP, smoking, dislipidemia – no antihypertensive
therapy
Boxplots: whiskers : 1.5 interquartile range ≈ 10-90 percentile
PWV [m/s]
AgeInfluence of age and risk on PWV
Risk factors: SBP, smoking, dislipidemia – no antihypertensive
therapy
Boxplots: whiskers : 1.5 interquartile range ≈ 10-90 percentile
PWV [m/s]
AgeCentral pressure
and arterial stiffness : physiology and
pathophysiology
ASCOT-CAFE trialCAFE study : Williams B et al. Circulation 2006
Amlodipine ± perindopril
Atenolol ± thiazide
Atenolol ± thiazideEffect of atenolol or amlodipine+perindopril on
pressure wave morphology the CAFÉ trial
Atenolol+thiazide
Amlodipine+perindo
pril
Peripheral BP Central BP
+++ Central pulse pressure : independent predictor of CV outcomeRole of increased central aortic and pulse pressures
in the increase of cardiovascular events
Increase in the central pulse pressure
that drives cerebral blood flow
increased stroke risk
Increase chronic kidney disease.
Increase in left ventricular load (LV
load) accelerates increase in LV
PP mass
increased risk of LV
hypertrophy
Decreased Coronary Artery
Perfusion
Diastole Pressure in
increased risk of MIASCOT, CAFE and LIFE : higher efficacy
of vasodilators over beta-blockers on CV events
lumen of small and large arteries
+
COST
Reduction (1) arterial stiffness
stroke
wave reflection
CHD
aortic PP
1- Lindgren et al, Heart 2008Évaluation de la PA CENTrale en cardiologie Hospitalière généRALE
• Un partenariat avec les services de cardiologie des CHG sous l’égide du CNCHG 40 centres investigateurs pressentis répartis sur tout le territoire Coordination principal : Dr Claude Barnay Comité scientifique : experts CHG + CHU Promoteur : Servier Médical 2 phases : 1 registre + 1 cohorte Durée prévue : 2 ans
Objectifs
• REGISTRE
– Objectif primaire
• Recueillir les valeurs de pression centrale et de rigidité aortique d’une
population française hospitalière de patients à haut risque CV
• Mesurer l’impact de la connaissance de ces paramètres sur la prise
de décision thérapeutique
• SUIVI PROSPECTIF
– Objectif primaire
• Evaluer l’effet de la prise d’IEC sur les paramètres de pression
centrale et de rigidité aortique
• Mesurer l’impact de la connaissance de la PA centrale et de la rigidité
aortique sur le suivi des patients
• Mesurer la valeur prédictive de la PA centrale et de la rigidité aortique
sur les événements (valeur de base et baisse sous traitement)• Objectifs
Registre :
Décrire la population de patients suivis en CHG (hospitalisation et consultation)
Évaluer la pression et la rigidité artérielle centrales de cette population
Estimer la pertinence ce cette évaluation
Cohorte :
Décrire l’évolution des PA humérales, centrales et de la rigidité artérielle chez des patients
hypertendus et/ou à haut Risque CV traités par DHP et IEC (ASCOT/ACCOMPLISH)• Schéma prévisionnel de l’étude
T1
2008 T2
2009 T1
2010
février sept nov nov
Ouverture du registre Gel de la base du Suivi de la cohorte des patients
Centhrale registre et analyse à haut risque vasculaire sous
statistique DHP + IEC
Inclusion de patients à
haut risque vasculaire Nouvelle évaluation de la PA
centrale et de la rigidité
Evaluation de la PA artérielle
centrale et de la rigidité
artérielle
Communications des Communications des
premiers résultats du résultats définitifs registre +
registre aux Assises 2009 cohorte aux Assises 2010• Méthodologie
Évaluation des paramètres hémodynamiques centraux par tonométrie d’aplanation
(Sphygmocor®, Atcor Medical) :
- évaluation des valeurs de PA centrale à partir de l’onde de pression radiale (fonction
de transfert validée, méthodologie ASCOT Café)
- mesure de la VOP (carotido fémorale…)
A l’inclusion dans le registre et à la consultation de suivi sous traitement DHP+ IEC
Mise à disposition du matériel dans les centres investigateurs (session de formation,
hot line…)Thank you
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