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Four-limb blood pressure measurement could improve mortality prediction in the elderly. However, there was no study to evaluate whether such measurement was still useful in predicting overall and cardiovascular (CV) mortality in acute myocardial infarction (AMI). Two hundred AMI patients admitted to cardiac care unit were enrolled. The 4-limb blood pressures, inter-limb blood pressure differences, and ankle brachial index (ABI) were measured using an ABI-form device. The median follow-up to mortality was 64 months (25th-75th percentile: 5-174 months). There were 40 and 138 patients documented as CV and overall mortality, respectively. After multivariable adjustment, the ankle diastolic blood pressure (DBP) on the lower side, ABI value, ABI < 0.9, interarm DBP difference, interankle systolic blood pressure (SBP) and DBP differences, interankle SBP difference ≥ 15 mmHg, and interankle DBP difference ≥ 10 mmHg could predict overall mortality (P ≤ 0.025). The ankle DBP on the lower side, interankle DBP difference, and interankle DBP difference ≥ 10 mmHg could predict CV mortality (P ≤ 0.031). In addition, in the Nested Cox model, the model including the ankle DBP on the lower side and the model including interankle DBP difference had the best value for overall and CV mortality prediction, respectively (P ≤ 0.031). In AMI patients, 4-limb blood pressure measurement could generate several useful parameters in predicting overall and CV mortality. Furthermore, ankle DBP on the lower side and interankle DBP difference were the most powerful parameters in prediction of overall and CV mortality, respectively., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

A large interarm and interleg systolic blood pressure (SBP) difference and ankle-brachial index (ABI) <0.9 were associated with peripheral artery disease and left ventricular hypertrophy. These 3 parameters were derived from 4-limb SBP data. However, there is no study to assess clinical significance of SBP heterogeneity in 4 limbs. The aim of this study was to evaluate the association of 4-limb SBP standard deviation (SD) with peripheral vascular parameters and echocardiographic data in patients with or without clinical findings of peripheral artery disease.A total of 1240 patients were included, of whom 1020 had no clinical evidence of overt peripheral artery disease. The 4-limb blood pressures, brachial-ankle pulse wave velocity, and ABI were measured simultaneously by an ABI-form device.In the multivariable linear regression analysis, increased left ventricular mass index (LVMI), ABI < 0.9, interarm SBP difference >10 mm Hg, and interleg SBP difference >15 mm Hg (P ≤ .030) were associated with increased 4-limb SBP SD. Additionally, a subgroup multivariable linear regression analysis in 1020 patients without ABI < 0.9, interarm SBP difference >10 mm Hg, and interleg SBP difference >15 mm Hg found 4-limb SBP SD still had a positive correlation with LVMI (P < .001).In addition to significant association with ABI < 0.9, interarm SBP difference >10 mm Hg, and interleg SBP difference >15 mm Hg, 4-limb SBP SD was positively correlated with LVMI in the multivariable linear regression analysis in all study patients. Furthermore, in the subgroup of patients without clinical evidence of peripheral artery disease, 4-limb SBP SD still had a positive correlation with LVMI. Hence, assessment of 4-limb SBP heterogeneity is useful in identification of high-risk group of peripheral artery disease and/or increased LVMI, irrespective of the presence of overt peripheral artery disease.

Background: Tricuspid regurgitation pressure gradient (TRPG) is reportedly a predictor of cardiovascular (CV) mortality in patients without atrial fibrillation (AF); its relationship with cardiac outcomes in patients with AF has never been evaluated. This study aimed to examine the ability of TRPG to predict CV events and all-cause mortality in patients with AF., Materials and Methods: Comprehensive echocardiography was performed in 155 patients with persistent AF. Combined CV events were defined as CV mortality, stroke and hospitalization for heart failure., Results: During an average follow-up period of 27 months, 57 CV events and 31 all-cause deaths occurred. According to multivariate analysis, predictors of CV events included diuretic use, decreased left ventricular ejection fraction (LVEF), increased ratio of transmitral E velocity (E) to early diastolic mitral annular velocity (E') and TRPG. Predictors of all-cause mortality included old age, decreased LVEF, increased E/E' and TRPG. Notably, the addition of TRPG to a model containing clinical significant parameters, LVEF and E/E' significantly improved the values in predicting adverse CV events and all-cause mortality., Conclusions: The TRPG is not only a useful predictor of adverse CV events and all-cause mortality in patients with AF, it may also provide additional prognostic values for CV outcome and all-cause mortality over conventional parameters in such patients., (Copyright © 2018 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Patients with chronic kidney disease (CKD) often have poor vascular compliance and poor left ventricular diastolic dysfunction (LVDD). The pulse pressure index (PPI) defined as ((systolic blood pressure - diastolic blood pressure)/systolic blood pressure) reflects vascular compliance. Vascular compliance is reportedly associated with left ventricular diastolic function. This study of CKD patients investigated whether PPI correlates with the ratio of transmitral E wave velocity (E) to early diastole mitral annulus velocity (Ea) or with LVDD., Methods: This study enrolled 511 CKD patients who had been referred for echocardiographic examination. Blood pressure was automatically measured with an ABI-form device. The LVDD was defined as E-to-transmitral A wave velocity ratio of ≥0.9, Ea <8 cm/s, or E/Ea ≥15., Results: Compared with those with E/Ea <15, patients with E/Ea ≥15 had significantly higher systolic blood pressure, pulse pressure, and PPI (all P < 0.001). Multivariable analysis showed that PPI was independently associated with E/Ea (unstandardized coefficient β = 1.348; P < 0.001) and with LVDD (odds ratio = 1.441 per 0.064 increase; P < 0.001)., Conclusions: This study showed that increased PPI significantly correlates with elevated E/Ea and LVDD in CKD patients. Because PPI can be rapidly acquired during blood pressure measurement, it may be helpful for identifying CKD patients with a high left ventricular filling pressure and LVDD.

Background: An interankle systolic blood pressure (SBP) difference has been associated with overall and cardiovascular mortality. We investigated whether an association existed between this difference and ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and echocardiographic parameters., Methods: A total of 1,059 patients referred for echocardiographic examination were included in the study. The 4 limb blood pressures were measured simultaneously using an ABI-form device., Results: We performed multivariate forward analysis to determine the factors associated with an interankle SBP difference ≥ 15mm Hg. An ABI < 0.9 (P < 0.001), high baPWV (P < 0.001), and increased left ventricular mass index (LVMI; P = 0.004) were associated with an interankle SBP difference ≥ 15mm Hg. Also, the addition of an interankle SBP difference ≥ 15mm Hg to a model of clinical features could significantly improve the value in predicting ABI < 0.9 (P < 0.001) and increased LVMI (P = 0.036)., Conclusions: Our study demonstrated that ABI < 0.9, high baPWV, and increased LVMI were independently associated with an interankle SBP difference ≥ 15mm Hg. Also, an interankle SBP difference ≥ 15mm Hg could offer an extra benefit in identifying patients with ABI < 0.9 and increased LVMI beyond conventional clinical features. Hence, calculation of interankle SBP difference may provide additional information for identifying patients with peripheral vascular disease and increased LVMI.

An interarm systolic blood pressure (SBP) difference of 10 mmHg or more have been associated with peripheral artery disease and adverse cardiovascular outcomes. We investigated whether an association exists between this difference and ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and echocardiographic parameters. A total of 1120 patients were included in the study. The bilateral arm blood pressures were measured simultaneously by an ABI-form device. The values of ABI and baPWV were also obtained from the same device. Clinical data, ABI<0.9, baPWV, echocariographic parameters, and an interarm SBP difference ≥10 mmHg were compared and analyzed. We performed two multivariate forward analyses for determining the factors associated with an interarm SBP difference ≥10 mmHg [model 1: significant variables in univariate analysis except left ventricular mass index (LVMI); model 2: significant variables in univariate analysis except ABI<0.9 and baPWV]. The ABI<0.9 and high baPWV in model 1 and high LVMI in model 2 were independently associated with an interarm SBP difference ≥10 mmHg. Female, hypertension, and high body mass index were also associated with an interarm SBP difference ≥10 mmHg. Our study demonstrated that ABI<0.9, high baPWV, and high LVMI were independently associated with an interarm SBP difference of 10 mmHg or more. Detection of an interarm SBP difference may provide a simple method of detecting patients at increased risk of atherosclerosis and left ventricular hypertrophy.

Previous studies which included patients with preserved left ventricular (LV) systolic function demonstrated that arterial stiffness progressively increased as LV diastolic function decreased. However, it was unknown whether this correlation was still present in a heterogeneous study population involving patients with a wide range of LV systolic function. Seventy-five patients with depressed LV systolic function were consecutively included and 192 patients with preserved LV systolic function were randomly selected from subjects arranged for echocardiography examination. Brachial-ankle pulse wave velocity (baPWV) was measured using an ABI-form device. Of the 267 subjects (mean age 58 ± 14 years) included in the study, 105 had normal diastolic function, 74 had impaired relaxation, and 60 had pseudonormal and 28 restrictive diastolic dysfunction. BaPWV was only lower in patients with normal diastolic function than in those with abnormal diastolic function (p ≤ 0.001). It did not gradually rise as diastolic dysfunction grade increased. Multivariate analysis showed that increased age and systolic blood pressure and decreased LV ejection fraction, transmitral A velocity, and left atrial volume index (p ≤ 0.039) were correlated with increased baPWV. Our study showed that there were no positive correlation between echocardiographic LV diastolic parameters and baPWV. BaPWV did not progressively rise with increasing LV diastolic dysfunction grade. Therefore, patients with advanced LV diastolic dysfunction may not have increased arterial stiffness.

A low ankle-brachial index (ABI) calculated using systolic blood pressure (SBP) (ABIsbp) is associated with poor cardiovascular outcome in patients with acute myocardial infarction (AMI). ABI is always calculated using SBP clinically. However, there was no study investigating ABI calculated using mean artery pressure (MAP)(ABImap) and diastolic blood pressure (DBP)(ABIdbp) for mortality prediction in AMI patients. Therefore, our study was aimed to investigate the issue. 199 AMI patients were enrolled. Different ABIs were measured by an ABI-form device. The median follow-up to mortality was 64 months. There were 40 cardiovascular and 137 all-cause mortality. The best cutoff values of ABImbp and ABIdbp for mortality prediction were 0.91 and 0.78, respectively. After multivariate analysis, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular mortality (P ≤ .047). However, all of six ABI parameters, including ABIsbp, ABImap, ABIdbp, ABIsbp < 0.90, ABImap < 0.91, and ABIdbp < 0.78, could predict all-cause mortality (P ≤ .048). In a direct comparison of six ABI models for prediction of all-cause mortality, basic model + ABIdbp <0.78 had the highest predictive value (P ≤ .025). In conclusion, only ABIdbp and ABIdbp < 0.78 could predict cardiovascular and all-cause mortality after multivariate analysis in our study. Furthermore, when adding into a basic model, ABIdbp < 0.78 had the highest additively predictive value for all-cause mortality in the six ABI parameters. Hence, calculation of ABI using DBP except SBP might provide an extra benefit in prediction of cardiovascular and all-cause mortality in AMI patients. [ABSTRACT FROM AUTHOR]

Low ankle-brachial index (ABI) calculated using systolic blood pressure (SBP) is associated with poor prognosis. However, there is no study assessing ABI calculated using mean artery pressure (MAP) and diastolic blood pressure (DBP) in predicting mortality. Two cohort populations were enrolled. The first population comprised 379 patients (106 patients with angiography-proved peripheral artery disease (PAD) and 273 relative normal patients) to evaluate the best cutoff values of ABImbp and ABIdbp for prediction of PAD. The second population included 941 patients undergoing echocardiographic examinations to assess the ability of different ABIs in predicting mortality. ABIs were measured using an ABI-form device. The best cutoff values of ABImbp and ABIdbp for prediction of PAD were 0.92 and 0.88. In our second population, median follow-up to mortality was 93 months. There were 87 cardiovascular and 228 overall deaths. Multivariable analysis showed ABIsbp, ABImap, ABIdbp, ABIsbp <0.9, and ABImap <0.92 could predict overall and cardiovascular mortality (all p < 0.001). ABIdbp <0.88 could only predict CV mortality (p = 0.033). In a direct comparison of 6 multivariable models, the basic model consisting of significant variables in the univariable analysis plus ABImap <0.92 had the highest predictive value for overall and cardiovascular mortality (all p < 0.001). In a direct comparison of 6 multivariable models, the basic model + ABImap < 0.92 was the best model in predicting overall and cardiovascular mortality. Hence, calculation of ABI using MAP except SBP might provide extra benefit in survival prediction. Image 1 • Usefulness of ABI using mean arterial pressure (MAP) and diastolic blood pressure (DBP) to predict mortality is unknown. • We found the best cutoff values of ABImap and ABIdbp for prediction of peripheral artery disease were 0.92 and 0.88l. • Basic model + ABImap < 0.92 had the highest predictive value for overall and CV mortality than other models. • Calculation of ABImap except ABIsbp might provide an extra benefit in survival prediction. [ABSTRACT FROM AUTHOR]

The ratio of early mitral inflow velocity (E) to the global diastolic strain rate (E’sr) has been correlated with left ventricular filling pressure and predicts adverse cardiac outcomes in atrial fibrillation (AF). The relationship between the E/E’sr ratio and renal outcomes in AF has not been evaluated. This study examined the ability of the E/E’sr ratio in predicting progression to the renal endpoint, which is defined as a ≥ 25% decline in the estimated glomerular filtration rate in patients with AF. Comprehensive echocardiography was performed on 149 patients with persistent AF, and E’sr was assessed from three standard apical views using the index beat method. During a median follow-up period of 2.3 years, 63 patients (42.3%) were reaching the renal endpoint. Multivariate analysis showed that an increased E/E’sr ratio (per 10 cm) (hazard ratio, 1.230; 95% confidence interval, 1.088 to 1.391; p = 0.001) was associated with an increased renal endpoint. In a direct comparison, the E/E’sr ratio outperformed the ratio of E to early diastolic mitral annular velocity (E’) in predicting progression to the renal endpoint in both univariate and multivariate models (p ≤ 0.039). Moreover, adding the E/E’sr ratio to a clinical model and echocardiographic parameters provided an additional benefit in the prediction of progression to the renal endpoint (p = 0.006). The E/E’sr ratio is a useful parameter and is stronger than the E/E’ ratio in predicting the progression to the renal endpoint, and it may offer an additional prognostic benefit over conventional clinical and echocardiographic parameters in patients with AF. [ABSTRACT FROM AUTHOR]

BackgroundCardiovascular dysfunction was associated with progression of renal function decline. This study was to assess whether combination of brachial-ankle pulse wave velocity (baPWV) and the ratio of brachial pre-ejection period (bPEP) to brachial ejection time (bET) was independently associated with progression of renal function decline.MethodsWe included 363 patients and classified them into four groups according to median values of bPEP/bET and baPWV. Groups 1, 2, 3, and 4 were patients with bPEP/bET and baPWV below the median, bPEP/bET above but baPWV below the median, bPET/bET below but baPWV above the median, and bPET/bET and baPWV above the median, respectively. The decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope and the renal end points were defined as commencement of dialysis or ≥25% decline in eGFR. The relative risk of renal end points was analyzed by Cox regression method.ResultsThe eGFR slope was significantly associated with baPWV, bPEP/bET, and patients in groups 2, 3, and 4 (vs. group 1) (P < 0.006). Multivariate forward Cox regression analysis showed that high baPWV, high bPEP/bET, and patients in groups 2, 3, and 4 (vs. group 1) (P ≤ 0.047) were independent predictors of renal end points.ConclusionsOur results demonstrated higher baPWV and bPEP/bET were associated with faster renal function decline and adverse renal end points. Dividing patients into four groups using these two parameters might be useful in risk stratification for progression of renal function decline.American Journal of Hypertension 2012; doi:10.1038/ajh.2012.77 [ABSTRACT FROM AUTHOR]

Background. Patients with chronic kidney disease (CKD) are associated with increased cardiovascular morbidity and mortality. An increase in the ratio of pre-ejection period (PEP) to ejection time (ET) is correlated with an increase in left ventricular mass index (LVMI) and a decrease in left ventricular ejection fraction (LVEF). Brachial PEP (bPEP) and brachial ET (bET) can be automatically determined by an ankle-brachial index (ABI)-form device. The aims of this study were to assess whether bPEP/bET is a useful parameter in evaluation of LVMI and LVEF in patients with CKD and to evaluate the diagnostic value of bPEP/bET in the prediction of LVEF < 50%.Methods. We consecutively enrolled 234 CKD patients from our Outpatient Department of Internal Medicine. Both bPEP and bET were measured using an ABI-form device. Clinical and echocardiographic parameters were compared and analysed.Results. Multivariate analysis results show that bPEP/bET, systolic blood pressure, and body mass index were positively while albumin was negatively associated with LVMI. In addition, increased bPEP/bET, coronary artery disease, decreased albumin, and increased triglyceride were independent factors associated with decreased LVEF. The area under the curve for bPEP/bET in the prediction of LVEF < 50% was 0.859.Conclusions. Our findings show that bPEP/bET is an important determinant of LVMI and LVEF in CKD patients. It is also helpful in identification of CKD patients with LVEF < 50%. Screening CKD patients by means of bPEP/bET may help identify a high risk group of increased LVMI and decreased LVEF. [ABSTRACT FROM AUTHOR]

Upstroke time (UT), measured from the foot-to-peak peripheral pulse wave, is a merged parameter used to assess arterial stiffness and target vascular injuries. In this study, we aimed to investigate UT for the prediction of cardiovascular and all-cause mortality in patients with chronic kidney disease (CKD). This longitudinal study enrolled 472 patients with CKD. Blood pressure, brachial pulse wave velocity (baPWV), and UT were automatically measured by a Colin VP-1000 instrument. During a median follow-up of 91 months, 73 cardiovascular and 183 all-cause mortality instances were recorded. Multivariable Cox analyses indicated that UT was significantly associated with cardiovascular mortality (hazard ratio (HR) = 1.010, p = 0.007) and all-cause mortality (HR = 1.009, p < 0.001). The addition of UT into the clinical models including traditional risk factors and baPWV further increased the value in predicting cardiovascular and all-cause mortality (both p < 0.001). In the Kaplan–Meier analyses, UT ≥ 180 ms could predict cardiovascular and all-cause mortality (both log-rank p < 0.001). Our study found that UT was a useful parameter in predicting cardiovascular and all-cause mortality in CKD patients. Additional consideration of the UT might provide an extra benefit in predicting cardiovascular and all-cause mortality beyond the traditional risk factors and baPWV. [ABSTRACT FROM AUTHOR]

Background: Left ventricular ejection fraction (LVEF) is a good indicator of cardiac function, and brachial-ankle pulse wave velocity (baPWV) is a good indicator of vascular function. Both of them can predict cardiovascular (CV) outcomes. Objectives: There is scarce literature discussing the impact of simultaneous consideration of cardiac and vascular function on overall and CV mortality. Methods: We included 958 patients and classified them into four groups. Groups 1 to 4 were patients with LVEF ≥ 50% and baPWV below the median, LVEF < 50% but baPWV below the median, LVEF ≥ 50% but baPWV above the median, and LVEF < 50% and baPWV above the median, respectively. Results: The median follow-up to mortality was 93 (25th–75th percentile: 69–101) months. There were 91 cases of CV mortality and 238 cases of all-cause mortality. After multivariable analysis, age, gender, diabetes, mean blood pressure, group 2 versus group 1, and group 4 versus group 1 were significant predictors of all-cause mortality (P ≤ 0.038) and age, diabetes, mean blood pressure, group 2 versus group 1, and group 4 versus group 1 were significant predictors of CV mortality (P ≤ 0.008). Conclusions: Patients with higher LVEF and lower baPWV had a similar overall and CV mortality as patients with higher LVEF and baPWV. Patients with lower LVEF and higher baPWV had the highest overall and CV mortality among the four study groups. In addition, patients with lower LVEF alone had a higher CV mortality than the patients with higher baPWV alone. Therefore, simultaneous consideration of cardiac and vascular function may be useful in predicting overall and CV mortality. [ABSTRACT FROM AUTHOR]