The aim of this study was to evaluate the relative value of baseline and follow-up echocardiographic assessment of pulmonary artery systolic pressure (PASP) and right ventricular (RV) function in ...assessing response to vasodilator therapy in pulmonary arterial hypertension (PAH).
Routine follow-up of PASP and RV function is widely obtained in patients undergoing treatment for PAH, but the value of this reassessment is uncertain.
Of 162 prospectively recruited patients with PAH, 96 were included in this analysis of patients with ≥3 sequential echocardiographic studies. PASP and RV function (including right ventricular free wall strain RVFWS) were measured at baseline and on follow-up 2-dimensional echocardiography. Univariate and multivariate Cox regression with nested models was used to determine incremental and independent predictors of all-cause mortality.
Changes between visits were minimal for all parameters (RVFWS, p = 0.46; RV end diastolic area, p = 0.48; tricuspid annular plane systolic excursion, p = 0.32; PASP, p = 0.66; right atrial area, p = 0.39; and inferior vena cava, p = 0.25). Over 3 years of follow-up, 29 patients died. Baseline RVFWS was an independent predictor of outcome (hazard ratio HR: 0.90; 95% confidence interval CI: 0.83 to 0.97; p = 0.007), incremental to PASP and other clinical covariates (C statistic = 0.74, p = 0.001). Those who died showed no differences in RVFWS (p = 0.50), PASP (p = 0.90), and tricuspid annular plane systolic excursion (p = 0.83) between visits. When baseline measures and follow-up time were accounted for, mean changes in RVFWS (HR: 0.78; 95% CI: 0.63 to 0.96; p = 0.002), right atrial area (HR: 1.20; 95% CI: 1.07 to 1.40; p = 0.003), and inferior vena cava (HR: 66.5; 95% CI: 8.5 to 520.5; p < 0.001) over follow-up were significant in predicting outcome.
In PAH, baseline RV function (RVFWS) is a strong predictor of outcome, independent of PASP. Changes throughout therapy appear minimal, and only changes in RVFWS, inferior vena cava, size, and right atrial area were associated with outcome.
Display omitted
Accurate blood pressure (BP) measurement is critical for optimal cardiovascular risk management. Age-related trajectories for cuff-measured BP accelerate faster in women compared with men, but ...whether cuff BP represents the intraarterial (invasive) aortic BP is unknown. This study aimed to determine the sex differences between cuff BP, invasive aortic BP, and the difference between the 2 measurements.
Upper-arm cuff BP and invasive aortic BP were measured during coronary angiography in 1615 subjects from the Invasive Blood Pressure Consortium Database. This analysis comprised 22 different cuff BP devices from 28 studies.
Subjects were 64±11 years (range 40-89) and 32% women. For the same cuff systolic BP (SBP), invasive aortic SBP was 4.4 mm Hg higher in women compared with men. Cuff and invasive aortic SBP were higher in women compared with men, but the sex difference was more pronounced from invasive aortic SBP, was the lowest in younger ages, and the highest in older ages. Cuff diastolic blood pressure overestimated invasive diastolic blood pressure in both sexes. For cuff and invasive diastolic blood pressure separately, there were sex*age interactions in which diastolic blood pressure was higher in younger men and lower in older men, compared with women. Cuff pulse pressure underestimated invasive aortic pulse pressure in excess of 10 mm Hg for both sexes in older age.
For the same cuff SBP, invasive aortic SBP was higher in women compared with men. How this translates to cardiovascular risk prediction needs to be determined, but women may be at higher BP-related risk than estimated by cuff measurements.
Blood pressure (BP) is a leading global risk factor. Increasing age is related to changes in cardiovascular physiology that could influence cuff BP measurement, but this has never been examined ...systematically and was the aim of this study. Cuff BP was compared with invasive aortic BP across decades of age (from 40 to 89 years) using individual-level data from 31 studies (1674 patients undergoing coronary angiography) and 22 different cuff BP devices (19 oscillometric, 1 automated auscultation, 2 mercury sphygmomanometry) from the Invasive Blood Pressure Consortium. Subjects were aged 64±11 years, and 32% female. Cuff systolic BP overestimated invasive aortic systolic BP in those aged 40 to 49 years, but with each older decade of age, there was a progressive shift toward increasing underestimation of aortic systolic BP (
<0.0001). Conversely, cuff diastolic BP overestimated invasive aortic diastolic BP, and this progressively increased with increasing age (
<0.0001). Thus, there was a progressive increase in cuff pulse pressure underestimation of invasive aortic PP with increasing decades of age (
<0.0001). These age-related trends were observed across all categories of BP control. We conclude that cuff BP as an estimate of aortic BP was substantially influenced by increasing age, thus potentially exposing older people to greater chance for misdiagnosis of the true risk related to BP.
Abstract Individual patient response to effective therapies for pulmonary hypertension (PAH) is variable and difficult to quantify. Consequently, management decisions regarding initiation and ...continuation of therapy are highly dependent on the results of investigations. Registry data show that changes in cardiac index, mean right atrial pressure, and mean pulmonary artery pressure have the greatest influence on survival. It is recognized that pulmonary artery pressure (PASP) responses to PAH-specific drugs are heterogeneous. However, follow-up testing is strongly focused on assessing changes in PASP and functional status (6-min walk). The goals of therapy, which should be highlighted in follow-up imaging, include not only reduction of PASP, decrease in pulmonary vascular resistance, and improvements in right ventricular function, cardiac output, and tricuspid regurgitation. This paper reviews the echocardiographic follow-up of pulmonary hypertension, and especially focuses on right ventricular function—a major determinant of outcome, for which reliable echocardiographic assessment has become more feasible.
Abstract
BACKGROUND
Automated office blood pressure (AOBP) involving repeated, unobserved blood pressure (BP) readings during one clinic visit is recommended for in-office diagnosis and assessment of ...hypertension. However, the optimal AOBP protocol to determine BP control in the least amount of time with the fewest BP readings is yet to be determined and was the aim of this study.
METHODS
One hundred and eighty-nine patients (mean age 62.8 ± 12.1 years; 50.3% female) with treated hypertension referred to specialist clinics at 2 sites underwent AOBP in a quiet room alone. Eight BP measurements were taken starting immediately after sitting and then at 2-minute intervals (15 minutes total). The optimal AOBP protocol was defined by the smallest mean difference and highest intraclass correlation coefficient (ICC) compared with daytime ambulatory BP (ABP). The same BP device (Mobil-o-graph, IEM) was used for both AOBP and daytime ABP.
RESULTS
Average 15-minute AOBP and daytime ABP were 134 ± 22/82 ± 13 and 137 ± 17/83 ± 11 mm Hg, respectively. The optimal AOBP protocol was derived within a total duration of 6 minutes from the average of 2 measures started after 2 and 4 minutes of seated rest (systolic BP: mean difference (95% confidence interval) 0.004(−2.21, 2.21) mm Hg, P = 1.0; ICC = 0.81; diastolic BP: mean difference 0.37(−0.90, 1.63) mm Hg, P = 0.57; ICC = 0.86). AOBP measures taken after 8 minutes tended to underestimate daytime ABP (whether as a single BP or the average of more than 1 BP reading).
CONCLUSIONS
Only 2 AOBP readings taken over 6 minutes (excluding an initial reading immediately after sitting) may be needed to be comparable with daytime ABP.
Background
Postconditioning is a potential cardioprotective strategy that has demonstrated conflicting and variable reductions in infarct size in human trials.
Objectives
To determine whether ...postconditioning could increase the extent of myocardial salvage in patients with acute ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PPCI).
Methods
One hundred two patients (aged 57 ± 11 years; 88% male) were randomly assigned to a postconditioning or standard protocol. Cardiovascular magnetic resonance imaging was performed 3 days after PPCI to measure the volumetric extent of myocardial necrosis and the area at risk.
Results
With similar time‐to‐reperfusion (170 ± 84 minutes in the postconditioning group vs. 150 ± 70 minutes in the standard group, P = 0.22), the myocardial salvage index was not significantly different between the postconditioned group and the control group, averaging 42 ± 22% vs. 33 ± 21%, respectively (P = 0.08). Furthermore, postconditioning was not associated with a smaller infarct size compared to controls (13 ± 7 g/m2 vs. 15 ± 8 g/m2, respectively, P = 0.18).
Conclusions
Postconditioning does not significantly increase myocardial salvage or reduce infarct size in patients with STEMI undergoing PPCI. However, the possibility of a more modest impact of postconditioning cannot be excluded with our sample size. (J Interven Cardiol 2013;26:482‐490)
The purpose of this study was to determine whether ischemic postconditioning (IPC) could improve peripheral endothelial function in patients with acute ST-segment elevation myocardial infarction ...(STEMI) undergoing primary percutaneous coronary intervention (PCI). Of 102 patients randomly assigned to an IPC or standard protocol to study infarct size utilizing cardiovascular magnetic resonance imaging, 84 patients had peripheral endothelial function assessed with brachial ultrasound measures and peripheral arterial tonometry (PAT) during reactive hyperemia 3 days after PCI. Overall IPC was not associated with a smaller infarct size compared to controls, though there was a trend towards greater myocardial salvage with IPC. Patients randomized to IPC (n=43; age 56 ± 11 years; 85% male) and standard protocol (n=41; age 56 ± 10 years; 88% male) underwent endothelial function assessment. Flow mediated vasodilatation was not significantly greater in the IPC group than in the standard group (7.4 ± 4.9% versus 6.6 ± 4.0% respectively, p=0.40) nor was peak hyperemic velocity-time integral (78 ± 26 cm versus 71 ± 30 cm respectively, p=0.28). Similarly, the PAT hyperemic ratio was not significantly greater in the IPC group than in the standard group (2.0 ± 0.9 versus 1.8 ± 0.6 respectively, p=0.14). In conclusion, IPC did not improve early peripheral endothelial function in patients with STEMI undergoing primary PCI.
The aim of this study was to re-evaluate wave reflection in the healthy pulmonary arteries of sheep utilizing the time-domain-based method of wave intensity analysis. A thorough understanding of ...patterns of wave reflection during health and disease may provide future sensitive markers of early pulmonary vascular disease. Wave intensity was calculated from the simultaneous acquisition of proximal pulmonary arterial pressure and velocity in 12 anesthetized open-chest sheep. Normal pulmonary arterial wave speed was 2.1 ± 0.3 m s(-1). The incident forward compression wave generated by right ventricular systole was reflected in an open-end manner as a backward expansion wave from a site 3 cm downstream, corresponding to the main pulmonary bifurcation, and in a closed-end manner as a backward compression wave from a site 21 cm downstream, corresponding to the pulmonary microcirculation. The proximal open-end reflection site was not present throughout the entire cardiac cycle. Wave reflection was minimal with only 1% of the incident forward compression wave energy reflected as a backward expansion wave and 2% as a backward compression wave. The normal pulmonary artery in open-chest sheep is characterized by variable proximal open-end reflection from the main pulmonary bifurcation and fixed closed-end reflection from the microcirculation, generating backward-travelling waves of minimal intensity.
Background
Numerous devices purport to measure central aortic BP as distinct from conventional brachial BP. This study aimed to determine the accuracy (validation) of the Sphygmocor Xcel-cuff device ...(AtCor Medical, Sydney, Australia) for measuring central BP.
Methods
330 patients (mean age 61.3 ± 10.6 years) undergoing coronary angiography had simultaneous measurement of invasive aortic BP and non-invasive cuff-derived central BP using the Xcel device (total
n
= 552 individual comparisons). Methods were undertaken according to Artery Society guidelines and several calibration techniques to derive central SBP were examined.
Results
Central SBP was significantly underestimated, and with wide variability, when using the default calibration of brachial cuff SBP/DBP (−7.7 ± 11.0 mmHg). Similar wide variability was observed using other calibration methods (cuff 33% form-factor MAP/DBP, −4.4 ± 11.5 mmHg; cuff 40% form-factor MAP/DBP, 4.7 ± 11.9 mmHg; cuff oscillometric MAP/DBP, −18.2 ± 12.1 mmHg). Only calibration with invasive aortic integrated MAP/DBP resulted in a mean difference ± SD (3.3 ± 7.5 mmHg) within the minimum tolerable error of ≤5 ± ≤8 mmHg. The difference between brachial cuff SBP and invasive aortic SBP was 3.3 ± 10.7 mmHg. A subsample (
n
= 151) analysis to determine the accuracy of central-to-brachial SBP amplification, showed this to be over-estimated by the Xcel device (4.3 ± 9.1 mmHg,
p
= 0.02).
Conclusion
Irrespective of calibration technique, the Sphygmocor Xcel-cuff device does not pass the Artery Society accuracy (validation) criteria for non-invasive measurement of central BP. Further accuracy refinements of this device are required.
PDF
