Annie Rudnichi

Pulse Pressure A Predictor of Long-term Cardiovascular Mortality in a French Male Population

Studies on the usefulness of blood pressure as a prognostic factor in cardiovascular disease have more often involved investigations of the levels of diastolic or systolic blood pressure. However, blood pressure may be divided into two other components: steady (mean pressure) and pulsatile (pulse pressure). In this study, the relationship of pulse pressure to cardiovascular mortality was investigated in 19 083 men 40 to 69 years old who were undergoing a routine systematic health examination and were being followed up after a mean period of 19.5 years. Subjects were divided into four groups according to age (40 to 54 and 55 to 69 years) and mean arterial pressure (<107 and > or =107 mm Hg). Each group was further divided into four subgroups according to the pulse pressure level. A wide pulse pressure (evaluated according to the quartile group or as a continuous quantitative variable) was an independent and significant predictor of all-cause, total cardiovascular, and, especially, coronary mortality in all age and mean pressure groups. No significant association between pulse pressure and cerebrovascular mortality was observed. In conclusion, in a large population of men with a relatively low cardiovascular risk, a wide pulse pressure is a significant independent predictor of all-cause, cardiovascular, and, especially, coronary mortality.

Pulse Pressure and Cardiovascular Mortality in Normotensive and Hypertensive Subjects

There is now increasing evidence that high pulse pressure, which is an indicator of large artery stiffness, is an independent risk factor for cardiovascular mortality, especially coronary mortality, in different populations. We have recently shown in a large French population that in male subjects aged 40 to 69 years, increased pulse pressure was a strong predictor of cardiovascular mortality, especially coronary mortality. In the present report, we analyzed the effect of pulse pressure in men and women of the same cohort after classifying them as normotensive (systolic blood pressure [SBP] <140 mm Hg and DBP <90 mm Hg) or hypertensive (SBP >/=160 mm Hg or DBP >/=95 mm Hg). After adjustment for age, mean blood pressure, and other risk factors, the relative risk (95% confidence limits) for cardiovascular mortality for an increase of 10 mm Hg of pulse pressure was 1.20 (1.01 to 1.44) in normotensives and 1.09 (1.03 to 1.14) in hypertensives. Cardiovascular and coronary death rates were similar in the group of normotensive men with a pulse pressure >50 mm Hg and in the group of hypertensive men with a pulse pressure <45 mm Hg. No association between cardiovascular mortality and pulse pressure was observed in either normotensive or hypertensive women (0.85 [0.60 to 1.21] and 1.0 [0. 91 to 1.11], respectively). Low mortality rates could explain this observation in normotensive but not in hypertensive women, in whom cardiovascular mortality rates were relatively high. Because a high pulse pressure in men is an independent predictor of cardiovascular mortality in both hypertensives and in those considered as having normal blood pressure, this parameter could aid in evaluating cardiovascular risk.

Pulse pressure and aortic pulse wave are markers of cardiovascular risk in hypertensive populations

BACKGROUND Pulse pressure (PP) and aortic pulse wave velocity (PWV) are significant markers of cardiovascular risk, but a similar role for central wave reflections has never been investigated. PROCEDURES To determine the factors influencing PP, PWV, and carotid wave reflections, a cohort of 1087 patients with essential hypertension either treated or untreated was studied cross-sectionally. Atherosclerotic alterations (AA) were defined on the basis of clinical events and PWV evaluated from an automatic device. The carotid amplification index (CAI), a quantitative estimation of the magnitude of central wave reflections, was measured noninvasively from pulse wave analysis using radial and carotid aplanation tonometry. RESULTS In the overall population, age and mean arterial pressure represented 30.4%, 32.3%, and 5.6% of the variance of, respectively PP, PWV, and CAI. For the latter, body weight and heart rate represented 22.9% of variability. On the basis of logistic regression, AA were associated, in addition to age, plasma creatinine and HDL cholesterol levels, and tobacco consumption to three mechanical factors, increased PP, increased PWV, and low diastolic blood pressure, but not by CAI (adjusted odds ratio: 1.00; 95% confidence intervals: 0.99-1.01). CONCLUSION In cross-sectional hypertensive populations, PP and PWV, but not CAI, are significantly and independently associated with cardiovascular amplications.

Aortic pulse wave velocity as a marker of cardiovascular disease in subjects over 70 years old.

Background Aortic pulse wave velocity (PWV) is a significant and independent predictor of cardiovascular diseases (CVD) in hypertensive subjects and in patients with end-stage renal disease, but its contribution to cardiovascular risk in subjects between 70 and 100 years old has never been tested. Patients A cohort of 124 subjects (mean age: 87 ± 7 years) was studied in two geriatric departments in a Paris suburb. Together with sphygmomanometric blood pressure measurements, aortic PWV was measured using a validated automatic device. Results Blood pressure, heart rate and body mass index, but not age, explained 48% of the PWV variability in this cohort. Furthermore, PWV was the major factor predicting the presence of CVD. The adjusted odds ratio was 17.44 (95% confidence intervals: 2.52–120.55). Antihypertensive drug therapy and low plasma albumin level had only an additive role. Blood pressure, particularly pulse pressure, had no predictive value. Conclusion In 70–100-year-old subjects, aortic PWV is a strong independent marker of CVD, a finding that remains to be to confirmed by long-term longitudinal studies.

Cardiovascular Mortality in Hypertensive Men According to Presence of Associated Risk Factors

Abstract—To evaluate the risk of cardiovascular disease (CVD) mortality in hypertensive men according to the presence of associated risk factors (ARFs). The population was composed of 29640 normotensive men without ARFs (reference group) and 60343 hypertensive men (with and without ARFs) who had a standard health checkup at the Centre d’Investigations Préventives et Cliniques between 1978 and 1988. Mortality data for a mean period of 14 years were analyzed. The following ARFs were considered: total cholesterol ≥2.5 g/L, personal history of diabetes, smoking (current smokers), body mass index >28 kg/m2, and heart rate >80 bpm. CVD risk related to the presence of isolated hypertension (assessed in hypertensive subjects without ARFs versus the reference group) increased linearly from 15% at the age of 30 years to 134% at the age of 80 years. In hypertensive subjects, one additional ARF increased CVD risk by 56% (47% to 65%, P <0.01) in younger subjects but only by 4% (−8% to 17%, P =NS) in older subjects. The role of hypercholesterolemia and tobacco smoking in CVD mortality was significantly higher in hypertensive subjects aged <55 years than in hypertensive subjects aged ≥55 years (P <0.01), whereas the roles of tachycardia and obesity were not affected by age. In younger hypertensive subjects, evaluation of CVD risk and therapeutic strategies should target ARFs. In older subjects, the presence of high blood pressure levels seems to be the major determinant of CVD risk.

Heart rate and pulse pressure amplification in hypertensive subjects

BACKGROUND Although mean blood pressure (MBP) remains unmodified along the arterial tree, pulse pressure (PP) increases physiologically from the central to the peripheral arteries. Amplification of PP is known to be influenced by heart rate (HR), but the impact of this alteration has never been tested in patients with hypertension. METHODS A total of 712 hypertensive subjects, either treated or untreated, were divided into three classes of HR level. Carotid and brachial systolic blood pressure (SBP), carotid augmentation index, a marker of wave reflections, and carotid-brachial PP amplification were measured using applanation tonometry. RESULTS Independent of age, sex, and antihypertensive drugs, subjects with HR >80 beats/min were characterized, in comparison with those with lower HR, by reduced carotid SBP, PP, and augmentation index, resulting in a significant increase in PP amplification. In men but not in women, this pattern was associated with higher values of brachial SBP and DBP and by higher incidences of elevated glycemia and atherosclerotic alterations. In the male population, PP amplifications was, independent of HR, associated with the presence of beta blocking agents (negative association) and elevated plasma glucose. CONCLUSIONS Hypertensive men and women with high HR have significant PP amplifications, principally because of reduced central SBP and disturbed wave reflections. beta-blocking agents and plasma glucose independently alter PP amplification in men but not in women. Whether these opposite patterns influence the gender difference in cardiovascular risk should be prospectively studied.

Angiotensin-Converting Enzyme D/I Gene Polymorphism and Age-Related Changes in Pulse Pressure in Subjects with Hypertension

Background—Few studies have examined the possible influence of gene polymorphisms on the increase of systolic blood pressure (SBP) and pulse pressure (PP) with age, although in older populations, SBP>160 mm Hg or PP>60 mm Hg are strong mechanical factors predicting cardiovascular mortality. Methods and Results—This cross-sectional study involved 315 men and 154 women with either systolic–diastolic or isolated systolic hypertension. Using polymerase chain reaction, the angiotensin-converting enzyme (ACE) D/I gene polymorphism was investigated separately in men and women, enabling us to determine the relationships between age and PP, SBP, and diastolic blood pressure (DBP) for each genotype in each population. In men, most of which were under 50 years of age, the slope of the age–PP and age–SBP (but not age–DBP) relationships differed significantly between genotypes (P =0.0096 and 0.0175). The interslope difference was unmodified after adjustments involving all of the following factors together: plasma glucose, cholesterol, creatinine, potassium, body weight, tobacco consumption, mean blood pressure, and previous antihypertensive therapy. Adjustment of the two latter parameters alone significantly attenuated the interslope difference. Based on logistic regressions, the DD genotype was shown to independently predict a PP>60 mm Hg but not a SBP>160 mm Hg. Conclusions—In men, the ACE D/I gene polymorphism independently modulates age-related increase of PP, and potentially modulates the resulting cardiovascular risk. This finding requires the development of long-term follow-up.

Drug treatment of hypertension: the reduction of pulse pressure does not necessarily parallel that of systolic and diastolic blood pressure

Drug treatment of hypertension reduces systolic and diastolic blood pressure according to a well-established dose-response curve. Whether there is a parallel decrease in mean blood pressure and pulse pressure has not been investigated in the past Recent analysis of the literature and personal work indicates that, during drug treatment of hypertension, a significant decrease in systolic and diastolic blood pressure may be associated with an unchanged pulse pressure, a situation that might contribute to maintaining cardiovascular risk.