Orsolya Cseprekál

Reference Values of Pulse Wave Velocity in Healthy Children and Teenagers

Carotid-femoral pulse wave velocity is an established method for characterizing aortic stiffness, an individual predictor of cardiovascular mortality in adults. Normal pulse wave velocity values for the pediatric population derived from a large data collection have yet to be available. The aim of this study was to create a reference database and to characterize the factors determining pulse wave velocity in children and teenagers. Carotid-femoral pulse wave velocity was measured by applanation tonometry. Reference tables from pulse wave velocities obtained in 1008 healthy subjects (aged between 6 and 20 years; 495 males) were generated using a maximum-likelihood curve-fitting technique for calculating SD scores in accordance with the skewed distribution of the raw data. Effects of sex, age, height, weight, blood pressure, and heart rate on pulse wave velocity were assessed. Sex-specific reference tables and curves for age and height are presented. Pulse wave velocity correlated positively (P<0.001) with age, height, weight, and blood pressure while correlating negatively with heart rate. After multiple regression analysis, age, height, and blood pressure remained major predictors of pulse wave velocity. This study, involving >1000 children, is the first to provide reference values for pulse wave velocity in children and teenagers, thereby constituting a suitable tool for longitudinal clinical studies assessing subgroups of children who are at long-term risk of cardiovascular disease.

Pulse Wave Velocity in End-Stage Renal Disease: Influence of Age and Body Dimensions

Arterial stiffness increases with age. This process is accelerated by end-stage renal disease (ESRD). Pulse wave velocity (PWV) increases with arterial stiffness. In this study, PWV of 133 healthy individuals (6–23 y of age) and 11 patients on dialysis was measured to establish the normal values of PWV and to compare them with those in ESRD. Age-matched (A-C) and height- and weight-matched (H/W-C) control groups were used. Thereafter, PWV was indexed to height and the data were reevaluated. The role of the risk factors including serum calcium, phosphate, parathyroid hormone (PTH), and the time on dialysis was analyzed using a score system. PWV correlated with age, weight, height, blood pressure, and heart rate. ESRD patients were smaller than A-C and older than H/W-C. PWV of patients with ESRD did not differ from A-C; however, it was elevated in comparison to H/W-C. In both healthy and ESRD patients, the PWV/height ratio was independent of age. PWV/height was increased in ESRD. There was a correlation between PWV/height and the risk factor score. Controls matched for height and weight or PWV/height should be used in cases of growth failure. A number of risk factors responsible for increased arterial stiffness are present in ESRD.

Measurement of pulse wave velocity in children and young adults: a comparative study using three different devices

To estimate the value of pulse wave velocity (PWV) in pediatric cardiovascular disease, prospective studies are needed. Various instruments based on different measurement principles are proposed for use in children, hence the need to test the comparability of these devices in this younger population. The objective of this study was to compare PWV measured by oscillometry (Vicorder (VIC)) with the gold standard of applanation tonometry (PulsePen (PP), Sphygmocor (SC)). PWV was measured in 98 children and young adults (age: 16.7(6.3–26.6) years (median(range)) with the above three devices at the same visit under standardized conditions. Mean PWV measured by VIC was significantly lower than that measured by SC and PP. There was no difference following path length correction of the VIC measurement (using the distance between the jugular notch and the center of the femoral cuff), (PP: 6.12(1.00), SC: 5.94(0.91), VIC: 6.14(0.75) m s−1). Velocities measured by the three devices showed highly significant correlations. Bland–Altman analysis revealed excellent concordance between all three devices, however, there was a small but significant proportional error in the VIC measurements showing a trend toward lower PWV measured by VIC at higher PWV values. Our study provides data on the three most frequently used instruments in pediatrics. Following path length correction of the VIC, all three devices provided comparable results. Thus, our work allows extrapolating data between previously established normal PWV values for children and forthcoming studies using these instruments to assess children at long-term risk of cardiovascular disease. The small proportional error of VIC needs additional technical development to improve the accuracy of the measurements.

Cardiovascular risk assessment in children with chronic kidney disease.

Chronic kidney disease (CKD) is a major factor contributing to cardiovascular (CV) morbidity and mortality with the highest risk in patients on dialysis. An estimation of CV risk is important not only to identify potential modifiable risk factors but also to evaluate the effect of treatments aimed to reduce the risk. Non-invasive methods of measuring vascular changes and circulating biomarkers are available to assess the presence and severity of cardiovascular damage. These include measures of structural (carotid intima-media thickness and coronary artery calcification score) and functional (aortic pulse wave velocity, 24-h ambulatory blood pressure monitoring, ambulatory arterial stiffness index, heart rate variability and flow-mediated dilatation) changes in the vessel wall. In addition, a number of circulating biomarkers of vascular damage and its progression have been studied. Many of these tests are well validated as surrogate markers of future cardiovascular events and death in adult CKD patients, but need technical adaptation, standardization and validation for use in children. With our current state of knowledge, these are best reserved for research studies and scarce clinical resources may be better utilized for preventative strategies to reduce the modifiable risk factors for calcification from early CKD stages.

Pulse wave velocity in children following renal transplantation

BACKGROUND Arterial stiffness (ASt) increases with age, a process accelerated by uraemia and reversed by transplantation (Tx). Increased ASt results in an elevated pulse wave velocity (PWV). METHODS To compare the PWV of Tx patients (n = 25, age = 15.1/95% CI = 13.5-16.7/year) and healthy controls, three control groups were formed: matched for age (A), for height and weight (H/W) and for age and height (A/H), respectively. To avoid bias from the growth deficit of Tx, firstly Z-scores of PWV were calculated (PWV-Z). Second, the PWV/height (PWV/h) ratio was assessed. Pre-Tx serum Ca, P, PTH and the cumulative dose of calcitriol (cCTL) were also analysed. Finally, Tx patients were compared to ESRD patients (n = 11). PWV was measured by applanation tonometry. RESULTS Tx were smaller than A and older than H/W. The PWV of Tx differed only from H/W and A/H. PWV-Z and PWV/h of Tx were increased compared to all control groups. They correlated with the CaxP and cCTL before Tx and were independent of age. Patients with creatinine clearance >90 ml/min/1.73 m(2) or <1 year on dialysis had lower PWV-Z and PWV/h than ESRD. CONCLUSION Controls that matched for both age and height should be used to assess PWV in children with growth failure. PWV-Z is a universal age-independent parameter of PWV in cases of growth retardation; PWV/h is a simple alternative of PWV-Z. CaxP and cCTL are major determinants of ASt after Tx. PWV may be reduced after Tx suggesting that the uraemia-induced cardiovascular changes might be reversible.

Cardiovascular risk assessment in children following kidney transplantation

Dégi A, Kerti A, Kis É, Cseprekál O, Tory K, Szabó AJ, Reusz GS. Cardiovascular risk assessment in children following kidney transplantation.

Ambulatory arterial stiffness index in children after kidney transplantation

Given the increase in CV morbidity after RTx and the scarcity of CV events in pediatrics, surrogate markers should be assessed to characterize CV damage in this population. AASI is a marker of arterial stiffness in adults, predicting cardio‐ and cerebrovascular morbidity. Our aim was to assess the determinants of AASI in RTx children (n = 54, 15.5 ± 3.5 yr) and to examine its relationship to central PWV. AASI was calculated from 24 h ABPM. PWV was determined by applanation tonometry, body composition by multifrequency bioimpedance measurement. The dipping state, volume overload, and time on dialysis were the main predictors of AASI (p < 0.05). Children with established HT (n = 34) had increased AASI, extracellular body water, and BNP (p < 0.05). In contrast to AASI, PWV did not differ between HT and normotensive RTx patient groups. There was no correlation between AASI and PWV. PWV was increased in children who spent more than one yr on dialysis prior to RTx. In conclusion, increased AASI in HT RTx children better characterizes the actual volume‐ and pressure‐dependent arterial rigidity rather than long‐term morphological changes in large arteries as reflected by PWV.

Reference values of aortic pulse wave velocity in a large healthy population aged between 3 and 18 years.

G rowing evidence has shown the inferiority in efficacy and outcomes of beta-blockers compared with other agents for the management of hypertension [1–3]. Consequently, when overtreatment of hypertension is suspected, tapering beta-blockers appears plausible. Dynamic left ventricular outflow tract obstruction (LVOTO) resulting from the systolic anterior motion (SAM) of the mitral valve over a thickened septal wall has been described in conditions with an abnormal left ventricle (LV) geometry and is alleviated with beta-blocker therapy. Dynamic LVOT is seen in various conditions, including hypertrophic obstructive cardiomyopathy (HOCM), acute coronary syndrome of the left anterior descending (LAD) coronary artery, Takotsubo syndrome, positive inotropic use, mitral valve apparatus abnormalities and postaortic valve surgery [3–6]. However, the pathogenesis of left ventricular hypertrophy (LVH) [7], which presents with LVOTO, remains unclear. Is this is a distinct diagnosis from classical HOCM or a combination of HOCM and LVH? We present a case of a patient with resistant hypertension and hypertrophied septal wall who developed LVOTO after beta-blocker cessation resulting in an acute coronary event. A 54-year-old man with a history of resistant hypertension presented to the hospital after collapsing and losing consciousness while walking. This event was preceded by an episode of dizziness without chest discomfort, shortness of breath or palpitations. He was on multiple antihypertensive agents, including losartan, hydrochlorothiazide, metoprolol succinate and amlodipine. The preceding week, his primary care physician discontinued the metoprolol because of a gradually developing hypotension on the aforementioned regimen. An echocardiogram done 5 years ago was reported to be normal. He had no family history of sudden death or structural heart disease. On initial physical examination, he was asymptomatic with a heart rate of 98 beats/minute, and his blood pressure was 124/82 mmHg without orthostatic hypotension. Cardiovascular examination revealed an apically displaced apex with a grade 3/6 systolic murmur, without signs of heart failure. Electrocardiogram demonstrated septal and lateral wall T wave inversion. The initial cardiac enzymes were mildly elevated. His initial echocardiogram showed decreased LV ejection fraction (25%), mid and apical severe hypokinesis, asymmetric septal hypertrophy (2 cm septal width) and a SAM of the mitral valve with mitral-septal contact. There was a resting LVOTO gradient of 60–80 and 100 mmHg with Valsalva manoeuver (Fig. 1). An urgent cardiac catheterization showed subtotal occlusion of the

Captopril-enhanced renal scintigraphy in the diagnosis of pediatric hypertension

Hypertension in childhood is no longer a rare condition mainly secondary to renal, or renovascular diseases, as a growing proportion of children are obese and hypertensive, with the phenotype of metabolic syndrome. Thus, we need to reconsider our practice in the examination of the hypertensive child and redefine the place of non-invasive methods for screening of renovascular hypertension, and specifically, to evaluate the value of captopril-enhanced renal scintigraphy at the two ends of the palette: the obese child with hypertension and the severely hypertensive prepubertal child. Renal artery stenosis in children is mainly due to fibromuscular dysplasia and stenoses associated with syndromes involving single or multiple smaller branch vessels. This explains the low specificity and sensitivity of the color-Doppler ultrasound method and captopril renal scintigraphy. Even the more sophisticated computed tomography (CT) and magnetic resonance imaging (MRI) angiographic techniques are, at present, not sensitive enough to exclude stenoses of the small branches definitely. Thus, children in whom there is a strong suggestion of renovascular hypertension should undergo angiography with a view to endovascular treatment, as non-invasive imaging has no significant benefit and might lead to a delay in treatment. In the cases when the probability of renovascular disease is moderate a basic assessment of renal function and structure is sufficient. In the neonate, catheter-associated thromboembolic disease is among the most common causes hypertension. It should be controlled medically until the patient is old enough to undergo angiography and angioplasty successfully. Thus, in this age group, there is a place for functional imaging with renal sonography and angiotensin-converting enzyme inhibitor (ACEI) renography to detect hemodynamically significant renovascular disease, with the limitations mentioned above. However, the rapid technical evolution of non-invasive methods requires periodic re-consideration of the actual standpoints.

Association of affective temperaments with blood pressure and arterial stiffness in hypertensive patients: a cross-sectional study

BackgroundAffective temperaments (anxious, depressive, cyclothymic, irritable and hyperthymic) measure subclinical manifestations of major mood disorders. Furthermore, cumulating evidence suggests their involvement in somatic disorders as well. We aimed to assess associations between affective temperament scores and blood pressure and arterial stiffness parameters in hypertensive patients.MethodsIn this cross-sectional study, 173 patients with well-controlled or grade 1 chronic hypertension, with no history of depression, completed the TEMPS-A, Beck Depression Inventory (BDI) and Hamilton Anxiety Scale (HAM-A) questionnaires in three GP practices. Arterial stiffness was measured with tonometry (PulsePen).ResultsAccording to multiple linear regression analysis, cyclothymic temperament score was positively associated with brachial systolic blood pressure independently of age, sex, total cholesterol, brachial diastolic blood pressure, BDI, HAM-A and the use of alprazolam (β = 0.529, p = 0.042), while hyperthymic temperament score was negatively related to augmentation index independent of age, sex, smoking, heart rate, BDI, HAM-A and the use of alprazolam (β = -0.612, p = 0.013). A significant interaction was found between cyclothymic temperament score and sex in predicting brachial systolic blood pressure (p = 0.025), between irritable and anxious temperament scores and sex in predicting pulse wave velocity (p = 0.021, p = 0.023, respectively) and an interaction with borderline significance between hyperthymic temperament score and sex in predicting augmentation index (p = 0.052).ConclusionsThe present findings highlight elevated blood pressure among subjects with high cyclothymic temperament as well as an increased level of arterial stiffening in subjects with low hyperthymic scores suggesting that affective temperaments may play a role in the development of hypertension and arterial stiffening and may thus represent markers of cardiovascular risk. Sex differences were also present in these associations.