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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:

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.

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