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Utility of central blood pressure in identifying adolescents and young adults with target organ damage
e42
Abstracts / Journal of the American Society of Hypertension 8(4S) (2014) e35–e43
artery stiffness and heart function in hypertensive patients has not been clarified. Methods: Two hundred and twenty hypertensive patients underwent transthoracic and carotid echocardiography. Measurements of local arterial stiffness were taken at the right common carotid artery level and stiffness parameter (ß), pressure-strain elasticity modulus (Ep) and intima-media thickness (IMT) were calculated. Brachial cuff BP was measured just before starting the carotid study. The patients with any cardiovascular disease, diabetes mellitus (DM), stroke, transient ischemic attack (TIA), or carotid stenosis were excluded. Results: Carotid artery stiffness parameter (ß) was correlated with age and left ventricular (LV) mass index (p<0.005). Even though ß was not correlated with LV systolic function, it was inversely well correlated with diastolic function. When the artery was stiffer, early mitral annular velocity (E’) decreased (p<0.001) and the index of left atrial (LA) pressure (early diastolic mitral inflow E velocity / E’) increased (p¼0.001). In logistic regression, diastolic dysfunction was affected by age (beta -0.385, p¼0.001), LA volume index (beta 0.175, p¼0.013) and ß (beta -0.273, p¼0.019). Conclusion: In hypertensive patients, changes in carotid artery stiffness can affect the diastolic function, independent of age and LA volume index. Therefore, measurements and control of carotid stiffness can play an important role in the prevention of diastolic heart failure. Keywords: carotid artery stiffness; heart function; hypertension
P-41 The hemodynamic effects on brachial and central blood pressure with the use of 5-hour ENERGYÒ drink in healthy adults Carolina Ojeda, Roshni Shah, Racheal Russell, Fernando Alcocer, Christian Machado, Susan Patricia Steigerwalt. Providence-St John Health, Southfield, MI, United States Introduction: Energy drinks have become one of the fastest growing beverage products in the US. Case reports of myocardial infarction, cardiac arrest, stroke and seizures have been linked to their use. Two common ingredients in energy drinks are caffeine and Taurine. Taurine is an amino acid and is thought to increase the effects of caffeine; it is present in high quantities in mammalian hearts where it is shown to increase cardiac stroke volume. It is unknown what effects Taurine has in combination with caffeine on the human heart. Our study was done to evaluate hemodynamic effects 5-hour ENERGYÒ Drink has on healthy individuals. Central blood pressure has been shown to be a better predictor of cardiac events than brachial readings. Studies have compared the effects of caffeine on central vs brachial blood pressure; however, this is the first one assessing the effects of energy drinks on central blood pressure. Methods and results: We are currently conducting a single center study that will involve a total of fifty healthy subjects between the ages of 2065 where each subject will be their own control. Measurements of brachial blood pressure and central blood pressure with an AtCorÔdevice on a 24hr caffeine free day and separate day with the usage of 5-hour ENERGYÒ Drink will be compared (central pressure 3 hours post consumption of energy drink). Preliminary data from initial 16 subjects reveal the use of 5-hour ENERGYÒ Drink widens central pulse pressure (p¼.002) with a mean of 27.94 to a 34.81 on energy drink day. We noted a decrease in heart rate by 6bpm (p¼.145) with a median of 72bpm on caffeine free day and 66bpm on energy drink day. Increase in central systolic pressure of 5mmHg (p¼.121) with a mean of 101.50mmHg vs 106.25mmHg, and a decrease in central diastolic pressure by 2mmHg (p¼.286) mean of 73.56mmHg vs 71.4mm Hg on energy drink day. Brachial systolic pressure was increased by 6mmHg (p¼.118). Brachial diastolic pressure was decreased by 1.5mmHg (p¼.178) and brachial pulse pressure was widened from a mean of 42.88 to 51.25 (p¼.008).
Conclusions: In a small group of patients the use of 5-hour ENERGYÒ Drink induces hemodynamic changes in both brachial and central blood pressures. Thus the use by patients with cardiac, renal, and cerebrovascular diseases warrants caution. Further investigation is needed to expand and confirm these results. Keywords: central blood pressure; energy drinks
P-42 Utility of central blood pressure in identifying adolescents and young adults with target organ damage Silvia Totaro,3 Connie E. McCoy,1 Lawrence M. Dolan,1 Thomas R. Kimball,1 Elaine M. Urbina.2 1Cincinnati Children’s Hospital, Cincinnati, OH, United States; 2Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States; 3University Hospital San Giovanni Battista, Turin, Italy Hypertensive (HTN) target organ damage (TOD) is a risk factor for CV events in adults and is associated with TOD in youth. Whether central BP is associated with TOD in young subjects is not known. We examined brachial and central BP patterns as related to TOD: composite (mean common, bulb, internal) carotid intima media thickness (cIMT), Augmentation Index (AIx), brachial distensibility (BrachD), carotidfemoral pulse wave velocity (PWVf) and left ventricular mass indexed to ht2.7 (LVMI). Anthropometrics, lab and 3 measures of mercury BP and central BP (SphygmoCor, AtCor Medical Sydney, Australia) were obtained on 493 subjects (16-24 years, 34% male, 39% Caucasian, 1/3 T2DM). BP categories (BPcat) were defined as HTN ¼elevated brachial BP (by 4th Report or JNC7) and elevated central BP ( 95% for our lean controls, N¼180). Masked HTN (MH) ¼ elevated central/ normal brachial BP and Spurious HTN (SH) ¼ elevated brachial/normal central BP. ANOVA was performed to determine differences in covariates and TOD by BPcat. Tukey’s ttest was used to adjust for multiple comparisons. General linear models were created to see if BPcat was an independent determinant of TOD after adjusting for CV risk factors. The full model contained BPcat, age, race, sex, presence of T2DM, BMI z-score, HR, Lipids, glucose, insulin and CRP. There were 397 normotensive (NT) (80 %), 8 SH (2 %), 77 MH (16 %) and 11 HTN (2 %) subjects. NT had superior levels of CVRF compared to other BPcat groups. HTN had more adverse levels of TOD compared to NT except for AIx which lost significance after correction for multiple comparisons. MH had adverse TOD compared to NT for all parameters except cIMT. SH only had higher LVMI compared to NT. LVMI was equal among SH, MH & HTN. The independent determinants of TOD (all model p<0.0001) were cIMT¼BPcat, age, race, sex, BMIz, T2DM (r2¼0.22), AIx¼BPcat, Ht, TG, HbA1c (r2¼0.19), BrachD¼BPcat, sex, BMIz, insulin (r2¼0.37), PWVf¼BPcat, age, race BMIz, HR, glucose, insulin (r2¼0.48), LVMI¼sex, BMIz, HbA1c (r2¼0.44). BP category entered all models except for LVMI. In addition to brachial HTN, central masked HTN and spurious HTN are related to TOD. Measurement of central BP may be useful in to identify young subjects at risk for TOD.
Abstracts / Journal of the American Society of Hypertension 8(4S) (2014) e35–e43 Keywords: central BP; pulse wave velocity; left ventricular mass; pediatrics
A greater AIx is independently associated with increased LV mass, suggesting that late systolic load from wave reflections promotes LV hypertrophy in aortic stenosis. Keywords: wave reflections; aortic stenosis; LV mass; arterial compliance
P-43 Wave reflections and left ventricular mass in aortic stenosis Prasad Konda,1 Payman Zamani,1 Scott Akers,1 Prithvi Shiva Kumar,1 Shivapriya Peddireddy,1 Sanjal Desai,1 Amin Vakilipour,1 Chandrahasa Sarabu,1 Deepa Rawat,2 Preston Broderick,1 Julio A. Chirinos.1 1Hospital of the University of Pennsylvania, Philadelphia, PA, United States; 2Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, United States Background: Aortic stenosis (AS) is associated with left ventricular (LV) hypertrophy. However, the determinants of LV mass in AS have not been fully characterized. In subjects with stenotic aortic valves, LV afterload depends on the severity of AS as well as the load imposed by the arterial system. Arterial load consists of both pulsatile and resistive components, both of which may impact the degree of LV hypertrophy. We assessed the relative importance of aortic valve area versus arterial load on LV mass. Methods: We studied 33 subjects (32 male) with mild (n¼6), moderate (n¼19) or severe (n¼8) AS. We measured LV mass, cardiac output and aortic valve area with cardiac MRI (steady-state free precessing cine imaging). We performed carotid and femoral tonometry to determine central (aortic) pressures, augmentation index (AIx, an index of wave reflections), and carotidfemoral pulse-wave velocity (PWV, a measure of aortic wall stiffness). We computed total arterial compliance as the ratio of stroke volume/central pulse pressure. We computed total peripheral resistance (TPR) as mean pressure / cardiac output. We used linear regression to assess the independent contributions of these arterial parameters and AS severity on LV mass. We then restricted our analyses to only subjects with moderate or greater AS (n¼27). Results: The table shows results of regression models in all subjects (left) as well as subjects with moderate or severe AS (right). In both analyses, AIx and total arterial compliance were independent predictors of LV mass. TPR was not associated with LV mass. AIx is influenced by heart rate, arterial stiffness, and wave reflections. The association between AIx and LV mass was independent of heart rate and large artery stiffness (i.e., carotid-femoral pulse wave velocity), indicating that wave reflections drive the association seen between AIx and LV mass. Conclusion: In subjects with AS, arterial pulsatile load is an independent determinant of LV mass, for any given severity of valvular stenosis.
Regression models predicting LV mass*
Total arterial compliance TPR AIx Aortic valve area
e43
All subjects (n¼33) b coefficient (P value)
Moderate or severe AS (n¼27) b coefficient (P value)
0.57 (p¼0.004) 0.29 (p¼0.09) 0.47 (p¼0.008) -0.21 (p¼0.13)
0.71 (p¼0.001) 0.09 (p¼0.64) 0.45 (p¼0.01) -0.12 (p¼0.42)
* Models adjusted for heart rate and PWV
P-44 What do we know about arterial hypertension - cross-section research in lithuanian doctors and patients Kristina Baronaite-Dudoniene, Gintare Sakalyte, Rasa Karaliute, Ruta Marija Babarskiene. Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania Objective: To evaluate patients and physicians knowledge about arterial hypertension (AH) and to determine factors that influence treatment adherence. Materials and methods: In this cross-sectional survey participants were enrolled from two separate studies that included 534 patients with arterial hypertension (project ‘‘Knowledge about arterial hypertension in society’’, 2009 November - 2010 February) and 235 doctors and 764 patients (project ‘‘Arterial hypertension treatment features in Lithuania’’), respectively. Knowledge on arterial hypertension was quantified using mean cumulative score (MCS). Treatment adherence and compliance with treatment recommendations was evaluated by means of Hill-Bone scale. Results: Patients with secondary educational level (n¼192) achieved MCS of 6.692.14 (means SD), compared with 7.212.14 and 8.942.04 in patients with college education (n¼160) or university degree (n¼180), respectively (p¼0.038). MCS was significantly higher in women vs. men (7.51 2.19 vs. 6.912.08; p¼0.002). Higher MCS was reported in patients with long-standing AH (n¼119), compared to respondents with less than 10 year history of AH (n¼193) (7.771.76 vs. 7.132.03, p¼0.005). MCS was higher if doctors were chosen as one of the primary information source (n¼278) compared to individuals who did not list doctor as primary information source (7.471.94 vs. 7.102.38; p¼0.048). 71.1% of doctors (n¼167) and 40.5% of patients (309) agreed that poor arterial hypertension control was caused by non-adherence to medication use. Overweight and obesity were listed as the cause for uncontrolled AH by 51.5% (n¼121) and 54.9% (n¼419) of doctors and patients respectively. 68.5% of doctors (n¼161) and 37.6% of patients (n¼287) indicated that poor hypertension control was associated with non-adherence to treatment recommendations. 336 (44.8 %) of surveyed patients indicated that they had difficulties taking several types of medications. Duration of AH correlated with adherence to treatment recommendations (Pearson correlation coefficient - 0.09, p¼0.014). The number of tablets was adversely associated with adherence to treatment (p¼0.014) Conclusions: Knowledge about AH is associated with educational attainment, sex and AH duration. Patients who got information directly from the doctor knew more compared to those who chose other sources. Longstanding AH and multiple medication use were associated with worse adherence to treatment recommendations. Keywords: arterial hypertension; doctors and patients knowledge; compliance with medications
Abstracts / Journal of the American Society of Hypertension 8(4S) (2014) e35–e43
artery stiffness and heart function in hypertensive patients has not been clarified. Methods: Two hundred and twenty hypertensive patients underwent transthoracic and carotid echocardiography. Measurements of local arterial stiffness were taken at the right common carotid artery level and stiffness parameter (ß), pressure-strain elasticity modulus (Ep) and intima-media thickness (IMT) were calculated. Brachial cuff BP was measured just before starting the carotid study. The patients with any cardiovascular disease, diabetes mellitus (DM), stroke, transient ischemic attack (TIA), or carotid stenosis were excluded. Results: Carotid artery stiffness parameter (ß) was correlated with age and left ventricular (LV) mass index (p<0.005). Even though ß was not correlated with LV systolic function, it was inversely well correlated with diastolic function. When the artery was stiffer, early mitral annular velocity (E’) decreased (p<0.001) and the index of left atrial (LA) pressure (early diastolic mitral inflow E velocity / E’) increased (p¼0.001). In logistic regression, diastolic dysfunction was affected by age (beta -0.385, p¼0.001), LA volume index (beta 0.175, p¼0.013) and ß (beta -0.273, p¼0.019). Conclusion: In hypertensive patients, changes in carotid artery stiffness can affect the diastolic function, independent of age and LA volume index. Therefore, measurements and control of carotid stiffness can play an important role in the prevention of diastolic heart failure. Keywords: carotid artery stiffness; heart function; hypertension
P-41 The hemodynamic effects on brachial and central blood pressure with the use of 5-hour ENERGYÒ drink in healthy adults Carolina Ojeda, Roshni Shah, Racheal Russell, Fernando Alcocer, Christian Machado, Susan Patricia Steigerwalt. Providence-St John Health, Southfield, MI, United States Introduction: Energy drinks have become one of the fastest growing beverage products in the US. Case reports of myocardial infarction, cardiac arrest, stroke and seizures have been linked to their use. Two common ingredients in energy drinks are caffeine and Taurine. Taurine is an amino acid and is thought to increase the effects of caffeine; it is present in high quantities in mammalian hearts where it is shown to increase cardiac stroke volume. It is unknown what effects Taurine has in combination with caffeine on the human heart. Our study was done to evaluate hemodynamic effects 5-hour ENERGYÒ Drink has on healthy individuals. Central blood pressure has been shown to be a better predictor of cardiac events than brachial readings. Studies have compared the effects of caffeine on central vs brachial blood pressure; however, this is the first one assessing the effects of energy drinks on central blood pressure. Methods and results: We are currently conducting a single center study that will involve a total of fifty healthy subjects between the ages of 2065 where each subject will be their own control. Measurements of brachial blood pressure and central blood pressure with an AtCorÔdevice on a 24hr caffeine free day and separate day with the usage of 5-hour ENERGYÒ Drink will be compared (central pressure 3 hours post consumption of energy drink). Preliminary data from initial 16 subjects reveal the use of 5-hour ENERGYÒ Drink widens central pulse pressure (p¼.002) with a mean of 27.94 to a 34.81 on energy drink day. We noted a decrease in heart rate by 6bpm (p¼.145) with a median of 72bpm on caffeine free day and 66bpm on energy drink day. Increase in central systolic pressure of 5mmHg (p¼.121) with a mean of 101.50mmHg vs 106.25mmHg, and a decrease in central diastolic pressure by 2mmHg (p¼.286) mean of 73.56mmHg vs 71.4mm Hg on energy drink day. Brachial systolic pressure was increased by 6mmHg (p¼.118). Brachial diastolic pressure was decreased by 1.5mmHg (p¼.178) and brachial pulse pressure was widened from a mean of 42.88 to 51.25 (p¼.008).
Conclusions: In a small group of patients the use of 5-hour ENERGYÒ Drink induces hemodynamic changes in both brachial and central blood pressures. Thus the use by patients with cardiac, renal, and cerebrovascular diseases warrants caution. Further investigation is needed to expand and confirm these results. Keywords: central blood pressure; energy drinks
P-42 Utility of central blood pressure in identifying adolescents and young adults with target organ damage Silvia Totaro,3 Connie E. McCoy,1 Lawrence M. Dolan,1 Thomas R. Kimball,1 Elaine M. Urbina.2 1Cincinnati Children’s Hospital, Cincinnati, OH, United States; 2Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States; 3University Hospital San Giovanni Battista, Turin, Italy Hypertensive (HTN) target organ damage (TOD) is a risk factor for CV events in adults and is associated with TOD in youth. Whether central BP is associated with TOD in young subjects is not known. We examined brachial and central BP patterns as related to TOD: composite (mean common, bulb, internal) carotid intima media thickness (cIMT), Augmentation Index (AIx), brachial distensibility (BrachD), carotidfemoral pulse wave velocity (PWVf) and left ventricular mass indexed to ht2.7 (LVMI). Anthropometrics, lab and 3 measures of mercury BP and central BP (SphygmoCor, AtCor Medical Sydney, Australia) were obtained on 493 subjects (16-24 years, 34% male, 39% Caucasian, 1/3 T2DM). BP categories (BPcat) were defined as HTN ¼elevated brachial BP (by 4th Report or JNC7) and elevated central BP ( 95% for our lean controls, N¼180). Masked HTN (MH) ¼ elevated central/ normal brachial BP and Spurious HTN (SH) ¼ elevated brachial/normal central BP. ANOVA was performed to determine differences in covariates and TOD by BPcat. Tukey’s ttest was used to adjust for multiple comparisons. General linear models were created to see if BPcat was an independent determinant of TOD after adjusting for CV risk factors. The full model contained BPcat, age, race, sex, presence of T2DM, BMI z-score, HR, Lipids, glucose, insulin and CRP. There were 397 normotensive (NT) (80 %), 8 SH (2 %), 77 MH (16 %) and 11 HTN (2 %) subjects. NT had superior levels of CVRF compared to other BPcat groups. HTN had more adverse levels of TOD compared to NT except for AIx which lost significance after correction for multiple comparisons. MH had adverse TOD compared to NT for all parameters except cIMT. SH only had higher LVMI compared to NT. LVMI was equal among SH, MH & HTN. The independent determinants of TOD (all model p<0.0001) were cIMT¼BPcat, age, race, sex, BMIz, T2DM (r2¼0.22), AIx¼BPcat, Ht, TG, HbA1c (r2¼0.19), BrachD¼BPcat, sex, BMIz, insulin (r2¼0.37), PWVf¼BPcat, age, race BMIz, HR, glucose, insulin (r2¼0.48), LVMI¼sex, BMIz, HbA1c (r2¼0.44). BP category entered all models except for LVMI. In addition to brachial HTN, central masked HTN and spurious HTN are related to TOD. Measurement of central BP may be useful in to identify young subjects at risk for TOD.
Abstracts / Journal of the American Society of Hypertension 8(4S) (2014) e35–e43 Keywords: central BP; pulse wave velocity; left ventricular mass; pediatrics
A greater AIx is independently associated with increased LV mass, suggesting that late systolic load from wave reflections promotes LV hypertrophy in aortic stenosis. Keywords: wave reflections; aortic stenosis; LV mass; arterial compliance
P-43 Wave reflections and left ventricular mass in aortic stenosis Prasad Konda,1 Payman Zamani,1 Scott Akers,1 Prithvi Shiva Kumar,1 Shivapriya Peddireddy,1 Sanjal Desai,1 Amin Vakilipour,1 Chandrahasa Sarabu,1 Deepa Rawat,2 Preston Broderick,1 Julio A. Chirinos.1 1Hospital of the University of Pennsylvania, Philadelphia, PA, United States; 2Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, United States Background: Aortic stenosis (AS) is associated with left ventricular (LV) hypertrophy. However, the determinants of LV mass in AS have not been fully characterized. In subjects with stenotic aortic valves, LV afterload depends on the severity of AS as well as the load imposed by the arterial system. Arterial load consists of both pulsatile and resistive components, both of which may impact the degree of LV hypertrophy. We assessed the relative importance of aortic valve area versus arterial load on LV mass. Methods: We studied 33 subjects (32 male) with mild (n¼6), moderate (n¼19) or severe (n¼8) AS. We measured LV mass, cardiac output and aortic valve area with cardiac MRI (steady-state free precessing cine imaging). We performed carotid and femoral tonometry to determine central (aortic) pressures, augmentation index (AIx, an index of wave reflections), and carotidfemoral pulse-wave velocity (PWV, a measure of aortic wall stiffness). We computed total arterial compliance as the ratio of stroke volume/central pulse pressure. We computed total peripheral resistance (TPR) as mean pressure / cardiac output. We used linear regression to assess the independent contributions of these arterial parameters and AS severity on LV mass. We then restricted our analyses to only subjects with moderate or greater AS (n¼27). Results: The table shows results of regression models in all subjects (left) as well as subjects with moderate or severe AS (right). In both analyses, AIx and total arterial compliance were independent predictors of LV mass. TPR was not associated with LV mass. AIx is influenced by heart rate, arterial stiffness, and wave reflections. The association between AIx and LV mass was independent of heart rate and large artery stiffness (i.e., carotid-femoral pulse wave velocity), indicating that wave reflections drive the association seen between AIx and LV mass. Conclusion: In subjects with AS, arterial pulsatile load is an independent determinant of LV mass, for any given severity of valvular stenosis.
Regression models predicting LV mass*
Total arterial compliance TPR AIx Aortic valve area
e43
All subjects (n¼33) b coefficient (P value)
Moderate or severe AS (n¼27) b coefficient (P value)
0.57 (p¼0.004) 0.29 (p¼0.09) 0.47 (p¼0.008) -0.21 (p¼0.13)
0.71 (p¼0.001) 0.09 (p¼0.64) 0.45 (p¼0.01) -0.12 (p¼0.42)
* Models adjusted for heart rate and PWV
P-44 What do we know about arterial hypertension - cross-section research in lithuanian doctors and patients Kristina Baronaite-Dudoniene, Gintare Sakalyte, Rasa Karaliute, Ruta Marija Babarskiene. Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania Objective: To evaluate patients and physicians knowledge about arterial hypertension (AH) and to determine factors that influence treatment adherence. Materials and methods: In this cross-sectional survey participants were enrolled from two separate studies that included 534 patients with arterial hypertension (project ‘‘Knowledge about arterial hypertension in society’’, 2009 November - 2010 February) and 235 doctors and 764 patients (project ‘‘Arterial hypertension treatment features in Lithuania’’), respectively. Knowledge on arterial hypertension was quantified using mean cumulative score (MCS). Treatment adherence and compliance with treatment recommendations was evaluated by means of Hill-Bone scale. Results: Patients with secondary educational level (n¼192) achieved MCS of 6.692.14 (means SD), compared with 7.212.14 and 8.942.04 in patients with college education (n¼160) or university degree (n¼180), respectively (p¼0.038). MCS was significantly higher in women vs. men (7.51 2.19 vs. 6.912.08; p¼0.002). Higher MCS was reported in patients with long-standing AH (n¼119), compared to respondents with less than 10 year history of AH (n¼193) (7.771.76 vs. 7.132.03, p¼0.005). MCS was higher if doctors were chosen as one of the primary information source (n¼278) compared to individuals who did not list doctor as primary information source (7.471.94 vs. 7.102.38; p¼0.048). 71.1% of doctors (n¼167) and 40.5% of patients (309) agreed that poor arterial hypertension control was caused by non-adherence to medication use. Overweight and obesity were listed as the cause for uncontrolled AH by 51.5% (n¼121) and 54.9% (n¼419) of doctors and patients respectively. 68.5% of doctors (n¼161) and 37.6% of patients (n¼287) indicated that poor hypertension control was associated with non-adherence to treatment recommendations. 336 (44.8 %) of surveyed patients indicated that they had difficulties taking several types of medications. Duration of AH correlated with adherence to treatment recommendations (Pearson correlation coefficient - 0.09, p¼0.014). The number of tablets was adversely associated with adherence to treatment (p¼0.014) Conclusions: Knowledge about AH is associated with educational attainment, sex and AH duration. Patients who got information directly from the doctor knew more compared to those who chose other sources. Longstanding AH and multiple medication use were associated with worse adherence to treatment recommendations. Keywords: arterial hypertension; doctors and patients knowledge; compliance with medications