J Clin Hypertens. 2018;20:469–471. wileyonlinelibrary.com/journal/jch
©2018 Wiley Periodicals, Inc.
Peripheral arterial stiffness as a surrogate of central
hemodynamics: A new era for cardiovascular risk estimation?
Michael Doumas MD, PhD
| Konstantinos P. Imprialos MD
| Vasilios G. Athyros MD, PhD
Veterans Affairs Medical Center, George Washington University, Washington, DC, USA
Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
Vasilios G. Athyros, MD, PhD, Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
He who cures a disease may be the skill fullest, but he that
prevents it is the safest physician. —Thomas Fuller 1608-
1661, English Clergyman and Historian.
This comment, made by one of the most emblematic personalities of
the 17th century, highlights the widely accepted opinion of preventing,
rather than curing, a disease. Prevention of cardiovascular (CV) disease,
the leading cause of death worldwide,
remains a challenging aspect in
clinical practice and requires the timely recognition of patients at risk
for CV events. Arterial hypertension, diabetes mellitus, dyslipidemia, and
obesity, along with other traditional risk factors, have been identified as
strong and independent predictors of CV disease; however, even these
established risk factors fail to fully predict CV events.
have been emphasizing in unveiling novel CV risk factors that alone, or
in combination, could offer a better stratification of CV risk. For a marker
to be established as a valid risk factor, strong data indicating an indepen-
dent association between the marker and CV morbidity and mortality,
along with evidence supporting the marker’s ability to predict CV events
beyond traditional risk factors, is needed. More importantly, the manage-
ment of emerging risk factors should offer reduction in CV outcomes.
Arterial stiffness is emerging as a promising CV risk factor with
data supporting an independent association between arterial stiffness
and CV events, whereas several studies have shown ameliorating ef-
fects of various cardiovascular drugs on arterial stiffness.
or accelerated vascular aging, in the presence of vascular deteriorat-
ing conditions (hypertension, diabetes mellitus, obesity, dyslipidemia,
chronic kidney disease), result in arteriosclerosis. In turn, pulse waves
travel faster in the sclerotic vessels.
The calculation of the velocity
of these waves (pulse wave velocity [PWV]), along with other indi-
ces, such as augmentation index and pulse pressure (PP), are widely
used for the assessment of the arterial stiffness.
Arterial stiffness is
not caused by hypertension, diabetes, or kidney impairment (among
others), also is an independent predictor of the pathogenesis of the
The calculation of the velocity between 2 different sites of the ar-
terial tree is the most common non- invasive method for the estimation
of PWV. Carotid- femoral PWV represents the stiffening of the aorta,
while branchial- ankle PWV (baPWV) is indicative of the stiffening of
the peripheral arterial tree.
Carotid- femoral PWV has been thor-
oughly examined in the general population and patients with CV risk
factors or overt CV disease in several parts of the world. In contrast,
studies assessing arterial stiffness with baPWV are mostly originating
from Asian countries. In addition, it has been suggested that aortic
PWV is of higher predictive value (in terms of CV events) compared
with the stiffening of the peripheral arteries.
Nonetheless, a number of studies have demonstrated an associ-
ation between increased baPWV and CV morbidity and mortality in
several populations. The Hisayama study followed more than 2900
subjects free of CV disease for more than 7 years. It was found that a
20% increase in baPWV was associated with a 1.3- fold risk increase
for CV events after adjustment for potential risk factors.
other population- based prospective cohort study showed that among
4164 patients without a history of CV disease, baPWV was an inde-
pendent predictor of future CV events, and values >18 m/s were as-
sociated with a 1.7- fold risk increase for CV events compared with
patients with PWV lower than 18 m/s.
The J- TOPP trial evaluated the
association of baPWV with the incidence of CV disease in 662 hyper-
tensive subjects. Patients with high, compared with low, baPWV had
more CV events and less 8- year cardiovascular- free survival rates.
Similarly, a sub analysis of the CSPPT trial unveiled that among 3310
hypertensive patients, the risk for stroke was significantly higher in pa-
tients with baPWV at the highest quartile compared with those in the
Important information comes from a sub- analysis of
the IMPACT- ABI registry evaluating the association between baPWV