Secondary Logo

Share this article on:

How to assess central arterial blood pressure?

Giannattasio, Cristina

Editorial Commentaries

Clinica Medica, Università Milano-Bicocca and Ospedale S. Gerardo, Monza, Milano, Italy.

See original paper on page 571

Correspondence and requests for reprints to Professor Cristina Giannattasio, Clinica Medica, Ospedale S. Gerardo, Via Donizetti 106, 20152, Monza, Milano, Italy. E-mail: cristina.giannattasio@unimib.it

In the past 20 years, a number of investigators have devoted a major part of their research activity to the relationship between peripheral and central arterial blood pressure [1–18]. Their work has shown that blood pressure in the brachial artery may be noticeably different from aortic blood pressure. It has also shown that this is due to the wave reflection phenomenon, which leads the forward pressure wave to variably summate with the backward one at the level of the ascending aorta in relation to the distensibility of the arterial system and the resulting speed of the pressure wave transmission along the arterial tree. It has finally, and correctly, been emphasized that the inability of brachial blood pressure to accurately reflect aortic blood pressure and its change by treatment has important clinical implications. This is because central blood pressure before and during treatment determines cardiac afterload, coronary perfusion and the degree of intravascular trauma that favours, along with other factors, the initiation and progression of atherosclerosis [19–32].

How to obtain aortic blood pressure values without invasive measurements, which are inapplicable to the hypertension population at large, is thus an important issue. This is why those studies reporting that non-invasive procedures, such as applanation tonometry on the radial artery and conventional brachial blood pressure measurements, could, with the use of a transfer function (Sphygmocor), achieve this purpose [33] are met with considerable interest. In this issue of the journal, Davies et al. [34] challenge this conclusion. In 28 subjects, the Sphygmocor system gave an estimate of central blood pressure that was closely related to the blood pressure values measured directly in the ascending aorta. However, the Bland–Aldman approach showed that aortic systolic and diastolic blood pressure were markedly underestimated and overestimated, respectively. Furthermore, it showed that the calculated values were no more precise than those obtained by conventional brachial measurements. Indeed, the latter technique performed better than the former because the underestimation of systolic blood pressure was less evident.

It remains to be discussed by those investigators specifically working in this field whether some of the study procedures may have reduced the accuracy of central blood pressure estimation and made the results less favourable than those of previous studies [1–18]. The authors, for example, note that brachial measurements were obtained through an oscillometric device (rather than through mercury sphygmomanometry), but they also point out that the device employed had passed through international validation protocols and was regarded as accurate. However, it cannot be denied that the data obtained lead to some disappointment. This is because, for investigation of large artery mechanical properties such as distensibility, the Sphygmocor promised to offer a simple, non-invasive method to obtain central arterial blood pressure values, and excursions on which to assess ultrasonographic systo-diastolic excursions of central artery diameter. There was the widely held hope that the problem of non-invasively obtaining central arterial blood pressure values had been overcome, and that the related techniques could be used in an epidemiological and large trial setting to more accurately describe the relationship of the blood pressure ‘which matters’ with cardiovascular disease.

To our disappointment, the paper by Davies et al. [34] suggests that further evidence is needed before this stage is reached.

Back to Top | Article Outline

References

1.Borow KM, Newburger JW. Non-invasive estimation of central aortic pressure using the oscillometric method for analyzing systemic artery pulsatile blood flow: comparatives of in direct systolic, diastolic, and mean brachial artery pressure with simultaneous direct ascending aortic pressure measurements. Am Heart J 1982; 103:879–886.
2.Merrilon JP, Lebras Y, Chastre J, Lerallut JF, Motte G, Fontenier G, et al. Forward and backward in the arterial system, their relationship to pressure waves form. Eur Heart J 1983; 4(suppl G):13–20.
3.Gravlee GP, Wong AB, Adkins TG, Case LD, Pauca AL. A comparison of radial, brachial, and aortic pressures after cardiopulmonary bypass. J Cardiothorac Anesth 1989; 3:20–26.
4.VanBeck JO, White RD, Abenstein JP, Mullany CJ, Orszulak TA. Comparison of axillary artery or brachial artery pressure with aortic pressures cardiopolmunary bypass using a long radial artery catheter. J Cardiothorac Vasc Anesth 1993; 7:312–315.
5.Aakhus S, Torp H, Haugland T, Hatle L. Non-invasive estimates of aortic root pressures: external subclavian arterial pulse tracing calibrated by oscillometrically determined brachial arterial pressures Clin Physiol 1993; 13:573–586
6.Karamanogul M, O'Rourke MF, Avolio AP, Kelly RP. An analysis of the relationship between central aortic and peripheral upper limb pressure waves in man. Eur Heart J 1993; 14:160–167.
7.Berger DS, Li JK, Noordergraaf A. Differential effect of wave reflections and peripheral resistance on aortic blood pressure: a model-based study. Am J Physiol 1994; 266:1626–1642.
8.Karamanoglu M, Feneley MP. Derivation of the ascending aortic-carotid pressure transfer function with arterial model. Am J Physiol 1996; 271:2399–2404.
9.Bos WJ, Imholz BP, van Goudoever J, Wesseling KH, van Montfrans GA. The reliability of noninvasive continuous finger blood pressure measurement in patients with both hypertension and vascular disease. Am J Hypertens 1992; 5:529–535.
10.Bos WJ, van Goudoever J, van Montfrans GA, van den Meiracker AH, Wesseling KH. Reconstruction of brachial artery pressure from noinvasive finger pressure measurements. Circulation 1996; 94:1870–1875.
11.Chen CH, Nevo E, Fetics B, Pak P, Maughan WL, Yin FCP, et al. Estimation of central aortic pressure waveform by mathematical transformation of radial tonometry pressure. Validation of generalized transfer function. Circulation 1997; 95:1827–1836.
12.Karamanoglu M, Feneley MP. On-line synthesis of the human ascending aortic pressure pulse from the finger pulse. Hypertension 1997; 30:1416–1424.
13.Stergiopulos N, Westerhof BE, Westerhof N. Physical basis of pressure transfer from periphery to aorta: a model-based study. Am J Physiol 1998; 274:H1386–H1392.
14.O’ Rourke MF. Mechanical principles. Arterial stifness and wave reflection. Pathol Bol (Paris) 1999; 47:623–633.
15.Segers P, Carlier S, Pasquet A, Rabben SI, Hellevik LR, Remme E, et al. Individualizing the aorto-radial pressure transfer function: feasibility of a model-based approach. Am J Physiol Heart Cric Physiol 2000; 279: H542–H549.
16.Sugimachi M, Shishido T, Miyatake K, Sunagawa K. A new model-based method of reconstructing central aortic pressure from peripheral arterial pressure. Jpn J Physiol 2001; 51:217–222.
17.McVeigh GE, Hamilton PK, Morgan DR. Evaluation of mechanical arterial properties: clinical, experimental and therapeutic aspects. Clin Sci (London) 2002; 102:51–56.
18.Van Bortel LM, Balkestein EJ, Van der Heijden-Spek JJ, Vanmolkot FH, Staessen JA, Kragten JA, et al. Non invasive assessment of local arterial pulse pressure: comparison of applanation tonometry and echo-tracking. J Hypertens 2001; 19:1037–1044.
19.Bots Ml, Dijk JM, Oren A, Grobbee DE. Carotid intima-madia thickness, arterial stiffness and risk of cardiovascular disease: current evidence. Hypertension 2002; 20:2317–2325.
20.Sugioka K, Hozumi T, Sciacca RR, Miyake Y, Titova I, Gaspard G, et al. Impact of aortic stiffness on ischemic stroke in elderly patients. Stroke 2002; 33:2077–2081.
21.London GM, Marchais SJ, Guerin AP, Metivier F. Impairment of arterial function in chronic renal disease: prognostic impact and therapeutic approach. Nephrol Dial Transplant 2002; 17(suppl 11):13–15.
22.Komai N, Ohishi M, Moriguchi A, Ayanagitani Y, Jnno T, Matsumoto K, et al. Low-dose doxazosin improved aortic stiffness and endothelial dysfunction measured by noninvasive evalutation. Hypertens Res 2002; 25:5–10.
23.Wu JH, Hagaman J, Kim S, Reddick RL, Maeda N. Aortic constriction exacerbates atherosclerosis and induces cardiac dysfunction in mice lacking apolipoprotein E. Arterioscler Thromb Vasc Biol 2002; 22:469–475.
24.Mullan BA, Young IS, Fee H, McCance DR. Ascorbic acid reduces blood pressures and arterial stiffness in type 2 diabetes. Hypertension 2002; 40:804–809.
25.Raison J, Rudnichi A, Safar ME. Effects of atorvastatin on aortic pulse wave velocity in patients with hypertension and hypercholesterolaemia: a preliminary study. J Hum Hypertens 2002; 16:705–710.
26.Mitchell GF, Izzo JL jr, Lacourciere Y, Ouellet JP, Neutel J. Omapatrilat reduces pulse pressure and proximal aortic stiffness in patients with systolic hypertension: results of the Conduit Hemodynamics of Omapatrilat International Research Study. Circulation 2002; 105:2955–2961.
27.Wilkinson IB, Prasad K, Hall IR, Thomas A, MacCallum H, Webb DJ, et al. Increased central pulse pressure and augmentation index in subjects with hypercholesterolaemia. J Am Coll Cardiol 2002; 39: 1005–1011.
28.Benetos A, Adamopoulos C, Bureau JM, Temmar M, Labat C, Bean K, et al. Determinants of accelerated progression of arterial stiffness in normotensive subjects and in treated hypertensive subjects over a 6-year period. Circulation 2002; 105:1202–1207.
29.Kingwell BA, Waddel TK, Medley TL, Cameron JD, Dart AM. Large artery stiffness predicts ischemic threshold in patients with coronary artery disease. J Am Coll Cardiol 2002; 40:773–779.
30.Benetos A, Waeber B, Izzo J, Mitchell G, Resnik L, Asmar R, et al. Influence of age, risk factors, and cardiovascular and renal disease on arterial stiffness: clinical applications. Am J Hypertens 2002; 15: 1101–1108.
31.Blacher J, Safar ME, Pannier B, Guerin AP, Marchais SJ, London GM. Prognostic significance of arterial stiffness measurements in end-stage renal disease patients. Curr Opin Nephrol Hypertens 2002; 11: 629–634.
32.Vlachopoulos C, Hirata K, Stefanadis C, Toutouzas P, O'Rourke MF. Caffeine increases aortic stiffness in hypertensive patients. Am J Hypertens 2003; 16:63–66.
33.Takazawa K, O'Rourke MF, Fujita M, Tanaka K, Kurosu F, Ibukiyama C. Estimation of ascending aortic pressure from radial arterial pressure using a generalised transfer function. Z Kardiol 1996; 85(suppl 3):137–139.
34.Davies JI, Band MM, Pringle S, Ogstron S, Struthers AD et al. Peripheral blood pressure measurement is as good as applanation tonometry at predicting ascending aortic blood pressure. J Hypertens 2003; 21: 561–566.
Copyright © 2003 Wolters Kluwer Health, Inc. All rights reserved.