Steno-Stiffness Approach for Cardiovascular Disease Risk Assessment in Primary Prevention

Vascular function: a key player in hypertension

The major functions of the arterial system are to "efficiently deliver blood to the peripheral organs and maintain vascular homeostasis". Both the endothelial and medial layer contribute to the three major functions, namely, conversion of pulsatile to steady blood flow, appropriate distribution of blood flow to the target organs, and vascular protection and homeostasis. Vascular dysfunction contributes to the development of cardiovascular diseases through a combination of several mechanisms, including impaired coronary perfusion, cardiac systolic/diastolic dysfunction, microvascular damage, and abnormal hemodynamics in the arterial tree. The representative marker of endothelial function is flow-mediated vasodilatation and that of the medial layer function is pulse wave velocity, and that of the blood supply function of the arterial tree is the ankle-brachial pressure index. In hypertension, vascular dysfunction could also lead to the development of isolated systolic hypertension, isolated diastolic hypertension, and systolic/diastolic hypertension. Vascular dysfunction is involved in a vicious cycle with abnormal blood pressure variability. Furthermore, a vicious cycle may also exist between vascular dysfunction and hypertension. While the significances of vascular function tests to predict future cardiovascular events has been established in cases of hypertension, their usefulness in assessing the effectiveness of management of the vascular functions in hypertension on the cardiovascular outcomes has not yet been fully clarified. Thus, vascular dysfunction plays crucial roles in the pathophysiology of hypertension, and further research is warranted to establish strategies to improve vascular dysfunction in cases of hypertension. Vascular functions in the pathophysiology of hypertension. Vascular dysfunction and elevation of blood pressure are components of a vicious cycle even from their early stages, which including abnormal blood pressure variabilities. This vicious cycle is associated with hypertensive organ damage and also adverse cardiovascular outcomes. Strategies to break this vicious cycle have not yet been fully established.

Evaluation of Carotid Artery Atherosclerosis and Arterial Stiffness in Cardiovascular Disease Risk: An Ongoing Prospective Study From the Kailuan Cohort

Objective

To assess whether carotid artery ultrasonography and brachial-ankle pulse wave velocity (baPWV) measurement can accurately predict cardiovascular and cerebrovascular events, and all-cause mortality in patients with cardiovascular diseases (CVD).

Methods

Patients from the Kailuan Study Stroke Cohort (Tangshan, China) who underwent carotid artery ultrasonography and baPWV measurement between June 2010 and June 2011 were included in this study. The effects of carotid plaque, baPWV, and their combination on cardiovascular events, including myocardial infarction (MI), cerebral ischemic stroke, cerebrovascular events, and all-cause mortality, were evaluated using Kaplan-Meier analysis and Cox proportional hazards regression.

Results

A total of 4,899 participants (59.7% males; 54.18 ± 11.52 years old) were analyzed. During a mean follow-up of 5.68 ± 0.66 years, the incidence of cardiovascular events and all-cause mortality were 4.94‰ person-years and 7.02‰ person-years, respectively; 32.8% of participants had both carotid artery atherosclerosis and increased arterial stiffness. A high baPWV alone was associated with an increased risk of CVD events [hazard ratio (HR): 2.68; 95% confidence interval (95% CI): 1.20–6.00; P = 0.007] and cerebral infarction (HR: 5.92; 95% CI: 1.76–19.93; P = 0.004), but not with MI or all-cause death. The presence of both carotid plaque and high baPWV was highly associated with an increased risk of CVD events (HR: 4.65; 95% CI: 2.06–10.45; P < 0.001) and cerebral infarction (HR: 9.21; 95% CI: 2.71–31.19; P < 0.001), but not with MI or all-cause death. Similar results were obtained by the Kaplan-Meier analyses.

Conclusion

The presence of carotid plaque and high baPWV were associated with a high risk of CVD events and ischemic stroke. Moreover, the combination of carotid artery ultrasonography and baPWV measurement could predict the risk for CVD ability more accurately than a single measurement alone.

State of the Art Review: Brachial-Ankle PWV

The brachial-ankle pulse wave velocity (brachial-ankle PWV), which is measured simply by wrapping pressure cuffs around the four extremities, is a simple marker to assess the stiffness of the medium- to large- sized arteries. The accuracy and reproducibility of its measurement have been confirmed to be acceptable. Risk factors for cardiovascular disease, especially advanced age and high blood pressure, are reported to be associated with an increase of the arterial stiffness. Furthermore, arterial stiffness might be involved in a vicious cycle with the development/progression of hypertension, diabetes mellitus and chronic kidney disease. Increase in the arterial stiffness is thought to contribute to the development of cardiovascular disease via pathophysiological abnormalities induced in the heart, brain, kidney, and also the arteries themselves. A recent independent participant data meta-analysis conducted in Japan demonstrated that the brachial-ankle PWV is a useful marker to predict future cardiovascular events in Japanese subjects without a previous history of cardiovascular disease, independent of the conventional model for the risk assessment. The cutoff point may be 16.0 m/s in individuals with a low risk of cardiovascular disease (CVD), and 18.0 m/s in individuals with a high risk of CVD and subjects with hypertension. In addition, the method of measurement of the brachial-ankle PWV can also be used to calculate the inter-arm systolic blood pressure difference and ankle-brachial pressure index, which are also useful markers for cardiovascular risk assessment.

Noninvasive vascular function tests for the future prediction of primary cardiovascular diseases

OBJECTIVES

Cardiovascular diseases (CVDs) still remain the main causes of death and disability in the US and worldwide, and the prediction for their future incidence is not well established. The utilization of the new cardiovascular risk score (CVRS) developed by the new ACC/AHA blood pressure treatment guidelines has improved the 10-year prediction of CVDs. However, its predictive value could be further increased with the addition of other risk factors identified with the use of several noninvasive vascular tests. These tests include, the older tests such as flow-mediated dilation (FMD), pulse wave velocity (PWV), pulse pressure (PP), and the newly developed noninvasive vascular tests of, reactive hyperemia-peripheral arterial tonometry (RH-PAT), cardio-ankle vascular index (CAVI), and the inter-arm/inter-leg pressure difference (IAPD/ILPD).

METHODS

In order to get a current perspective regarding the usefulness of these new noninvasive vascular tests for the future prediction of CVDs, a Medline search of the English language literature was conducted between 2014 and 2019 using the terms cardiovascular disease, coronary heart disease, noninvasive vascular tests, risk factors, and 26 pertinent papers were retrieved.

RESULTS

The analysis of results from these papers showed that these noninvasive vascular tests have an independent predictive value for the future incidence of CVDs and hypertension. However, their long-term predictive value is not well established, since there are no currently, available data from long-term clinical outcome studies.

CONCLUSION

The analysis of data from the retrieved papers demonstrated that the new noninvasive vascular tests have an independent predictive value for the future incidence of CVDs and hypertension. However, their long-term predictive value is not established as yet for the lack of long-term outcome studies. When the currently ongoing long-term trials are completed, it is quite possible that the data from these tests added to CVRS could enhance its predictive value.

The HOPE Asia Network activity for "zero" cardiovascular events in Asia: Overview 2020

The impact of hypertension-related cardiovascular disease and target organ damage, and therefore the benefits of blood pressure (BP) control, is greater in Asian than in Western countries. Asia-specific features of hypertension and its effective management are important and active areas of research. The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was formed in 2016 and is now a member of the World Hypertension League. The main goal of the HOPE Asia Network is to improve the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia. Considerable work has already been done on the journey to achieving this goal. We have shown that BP control status in Asia differs between countries, and even between regions within the same country. Several expert panel consensus recommendations and clinical guidance papers are available to support the use of home and ambulatory BP monitoring in the region. In addition, the AsiaBP@Home study prospectively investigated home BP control status across 15 specialist centers using the same validated device and measurement schedule. We have also proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), a vicious cycle of BP variability and vascular disease on cardiovascular events and organ damage, and suggested a SHATS score for risk stratification for clinical practice. This special issue of the journal collates Asia-specific resources and data, contributing to advances in hypertension management and cardiovascular disease prevention in the region.