Elevated BNP and High Brachial Pulse Pressure in Patients with Diabetes

Background Heart failure (HF) is frequent in patients with diabetes mellitus (DM), and early detection improves prognosis. We investigated whether analysis of brachial blood pressure (BP) in daily practice can identify patients with DM and high risk for subsequent HF, as defined by brain natriuretic peptide (BNP) > 50 pg/ml. Methods 3,367 Outpatients with DM without a history of cardiovascular disease were enrolled in a prospective study. Results Age (mean±SD) was 56±14 years, 57% were male, 78% had type 2 DM and HbA1C was 7.4%±1.4%. A history of hypertension was recorded in 43% of patients and uncontrolled BP was observed in 13%. BNP concentration (mean±SD) was 21±21 ng/L and 9% of patients had high risk of incident HF. Brachial pulse pressure (PP) was the best BP parameter associated with high risk of incident HF compared to diastolic, systolic or mean BP (area under the ROC curve: 0.70, 0.65, 0.57 and 0.57 respectively). A multivariate analysis demonstrated that elevated PP was independently associated with high risk of incident HF (odds ratio [95%CI]: 2.1 [1.5–2.8] for PP ≥65mmHg). Study of central aortic BP and pulse wave velocity on 117 patients demonstrated that high risk of incident HF was associated with increased arterial stiffness and subendocardial ischemia. After a mean follow-up of 811days, elevated PP was associated with increased all-cause mortality (hazard ratio [95%CI]: 1.7 [1.1–2.8]). Conclusions Brachial PP is powerful and independent “easy to record” BP parameter associated with high risk of incident HF in diabetic patients.

The Association of Cardio-Ankle Vascular Index and Ankle-Brachial Index in Patients with Peripheral Arterial Disease

<b><i>Introduction:</i></b> The cardio-ankle vascular index (CAVI) is a well-known index to evaluate arterial stiffness and predict cardiovascular risk. <b><i>Methods:</i></b> We investigated whether CAVI can predict severity and extent of peripheral arterial disease. This study was a single-center, retrospective, observational study approved by the Ethics Committee of Yokohama Shintoshi Neurosurgical Hospital. A total of 96 patients (males, 63) with an abnormal ankle-brachial blood pressure index (ABI) of &#x3c;0.9 and who underwent extremity arteriography at our hospital from 2015 to 2018 were enrolled in this study. We defined that CAVI with a range of &#x3c;8.0 was normal. <b><i>Results:</i></b> Coronary angiography and extremity arteriography were performed for patients who had intermittent claudication and abnormal ABI. We divided the affected limbs into 3 categories: above-the-knee artery stenosis, above-the-knee artery chronic total occlusion, and only below-the-knee artery stenosis/occlusion groups. CAVI pseudonormalization was seen in 28, 76, and 19%, respectively. The above-the-knee artery stenosis and the only below-the-knee artery stenosis/occlusion groups had a high odds ratio of abnormalization of CAVI (3.1, 95% confidence interval [CI]: 1.39–7.22; <i>p</i> = 0.05, 4.56, 95% CI: 1.64–14.7). <b><i>Discussion/Conclusion:</i></b> In the presence of the above-the-knee artery chronic total occlusion, CAVI pseudonormalization was likely to be seen. The presence of CTO in the above-the-knee artery is one cause of pseudonormalized CAVI. In the range of ABI, in which stenotic lesions and obstructive lesions coexist, it may be possible to detect the existence of CTO by a combination of both ABI and CAVI.

Angioplasty of Flow‐Limiting Stenosis Reduces Aortic and Brachial Blood Pressure in Patients With Peripheral Artery Disease

Background Arterial hypertension affects cardiovascular outcome in patients with peripheral artery disease (PAD). We hypothesized that angioplasty of peripheral arterial stenoses decreases aortic (aBP) and brachial blood pressure (bBP). Methods and Results In an index cohort (n=30), we simultaneously measured aBP, bBP, augmentation index (AIx), and aortic pulse wave velocity (PWV) before and after angioplasty of the iliac and femoropopliteal arteries; diagnostic angiography served as a control. In an all‐comer registry cohort (n=381), we prospectively measured bBP in patients scheduled for angioplasty of the iliac, femoral, and crural arteries or diagnostic angiography. Systolic aBP decreased after iliac (Δ−25 mmHg; 95% CI, −30 to −20; P <0.0001) and femoropopliteal angioplasty (Δ−12 mmHg; 95% CI, −17 to −5; P <0.0001) as compared with diagnostic angiography. Diastolic aBP decreased after iliac (Δ−9 mmHg; 95% CI, −13 to −1; P =0.01) but not femoropopliteal angioplasty. In parallel, AIx significantly dropped, whereas PWV remained stable. In the registry cohort, systolic bBP decreased after angioplasty of the iliac (Δ−17 mmHg; 95% CI, −31 to −8; P =0.0005) and femoropopliteal arteries (Δ−10 mmHg; 95% CI, −23 to −1; P =0.04) but not the crural arteries, as compared with diagnostic angiography. Diastolic bBP decreased after iliac (Δ−10 mmHg; 95% CI, −17 to −2; P =0.01) and femoropopliteal angioplasty (Δ−9 mmHg; 95% CI, −15 to −1; P =0.04). Multivariate analysis identified baseline systolic bBP and site of lesion as determinants of systolic bBP drop after endovascular treatment. Conclusions Angioplasty of flow‐limiting stenoses in patients with peripheral artery disease lowers aortic and brachial blood pressure with more pronounced effects at more proximal lesion sites and elevated baseline systolic blood pressure. These data indicate a role of endovascular treatment to acutely optimize blood pressure in patients with peripheral artery disease. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02728479.

Pulse Wave Calibration and Implications for Blood Pressure Measurement

Central aortic systolic pressure (CASP) can be estimated via filtering of the peripheral pulse wave (PPW) following calibration to brachial blood pressure. Recent studies suggest PPW calibration to mean arterial pressure (MAP) and diastolic BP (DBP) provides more accurate CASP estimates (CASP MD ) versus conventional calibration to systolic BP (SBP) and DBP (CASP SD ). However, the peak of the MAP-DBP calibrated PPW, that is, SBP MD , is rarely reported or used for BP amplification calculations, despite CASP MD being derived from it. We aimed to calculate the unreported SBP MD from studies using MAP-DBP calibration for estimation of CASP MD and compared it with oscillometric brachial SBP (brSBP). Medline database was searched to March 18, 2020. Meta-analysis includes studies reporting noninvasive CASP SD , CASP MD , brSBP, and brachial DBP. SBP MD was calculated using linear function equations. Data from 21 studies used 8 different BP monitors (13 460 participants, mean age: 54±10 years, 57% female, brachial blood pressure: 130±14/79±9 mm Hg). Weighted mean difference between SBP MD and brSBP was 10 mm Hg (range, −2 to 17 mm Hg) and appeared device specific. Calibration of brachial versus radial PPWs to brachial blood pressure showed a greater disparity between SBP MD and brSBP (14 versus 2 mm Hg). BP amplification was similar comparing SBP-DBP versus MAP-DBP calibrations (brSBP-CASP SD versus SBP MD -CASP MD : 9 versus 11 mm Hg), with no instances of reverse BP amplification. PPWs calibrated to MAP-DBP to derive CASP MD generates SBP MD that differs markedly from brSBP with some oscillometric BP monitors. These findings have important implications for BP monitor accuracy, BP amplification, PPW calibration recommendations, and studies of associations between CASP versus SBP and outcomes.