brahial artery in hyperternsion
TRANSCRIPT
ULTRASONOGRAFIA DOPPLER A ULTRASONOGRAFIA DOPPLER A ARTEREI BRAHIALE IN ARTEREI BRAHIALE IN
EVALUAREA PACIENTULUI EVALUAREA PACIENTULUI HIPERTENSIVHIPERTENSIV
Alexandru AndritoiuAlexandru Andritoiu
SCUM CraiovaSCUM Craiova
ABAB
• Locul de masurare a TALocul de masurare a TA• TA periferica vs TA centrala?TA periferica vs TA centrala?• Evaluarea US – recentaEvaluarea US – recenta• Scop de cercetare fiziologicaScop de cercetare fiziologica
TehnicaTehnica
• B-scanB-scan• Color Doppler USColor Doppler US• Power-angioPower-angio• Spectral analysisSpectral analysis
Remodelarea ABRemodelarea AB
• ADAPTATIVAHTA• Obezitate• Hiper-Col• ATS
• MALADAPTATIVA• imbatranirea
Chung WB et al. Arterioscl Thromb Vasc Biol 2009
Rol compensator!
Cauze de remodelareCauze de remodelare
PatologicePatologice• HTA• Ateroscleroza (placi)• Hipercolesterolemie• Diabet zaharat• Obezitate • Sdr. Metabolic• Uremie-dializa
FiziologiceFiziologice• Antrenament fizic• Imbatranirea
Remodelarea AB in HTARemodelarea AB in HTA
• Proces compensator/adaptativ
• Prezervarea D/A luminale
• Shear-stress mentinut la un nivel scazut
Modificarile morfologiceModificarile morfologice
Cresterea D si A• Mecanism adaptativ (proces compensator)• Semn de ATS• Marker de risc CV• Relatia cu ATS carotidiana, BOAP
Grosimea peretelui ABGrosimea peretelui AB
Simon A CH, Safar ME - Br J Cl Pharmac 1984;18:243-246
Brachial artery haemodynamics in arterial hypertension
D creste in HTAD creste in HTA
• Normotensivi (N=25)
D = 3.2+/-0.2 mm• HTA (N=32)
D = 4.1+/0.2 mm
p <0.001
D = 4.2 mm
Andritoiu A 2000
D = 3.5 mm
NormoTA
HTA
Diametrul AB - Diametrul AB - relatia cu FR-CVrelatia cu FR-CV
Holubkov R et al. Am Heart J 143(5):802-807, 2002
Ultrasound image of the brachial artery (longitudinally) at 8× magnification, 11-MHz transducer frequency annotated for anatomic landmarks.
Grosimea peretelui ABGrosimea peretelui AB
Profilul anvelopei spectraleProfilul anvelopei spectrale
Profilul fiziologic trifazic
,,de rezistivitate crescuta,,
1
2
3 4
Parametrii spectraliParametrii spectrali
• S• D• Vmean• TAMx• IP• IR• Q (ml/min)
Modificari spectrale in HTAModificari spectrale in HTA
• Largirea spectrala• Atenuarea undei
reflectate• Disparitia ferestrei
spectrale• Unda tele-sistolica
Spectral Spectral broadening broadening
gradinggrading
(A) 1 p.
(B) 2 p.
(C) 3 p.
A
B
CAndritoiu A, 2008
Modificarile anvelopei spectrale la o pacienta in varsta de 51 ani,cu HTA si hipercolesterolemie:
disparitia ferestrei spectrale, largirea spectrala, cu pastrarea profilului trifazic, cu atenuarea undelor reflectate.
D = 3.6 mm (normal)
Modificari functionaleModificari functionale
%FMD – tonusul vasomotorVasodilatatia:• Mediata de endoteliu (Acetilcolina, metacolina)• Independenta de endoteliu (nitroprusiat, NTG-sl)• Mediata de flux (compresie)
Vascular Health and Risk management 2008;4(3);647-652
Cardiovascular Risk Factors Hypercholesterolemia Atherosclerosis Type I and II diabetes mellitus and
insulin resistance Male sex Smoking Systemic hypertensionSystemic hypertension Family history of CAD Homocysteine concentrations Aging Postmenopausal Hypertriglyceridemia Chronic Infections/Inflammation Vasculitic conditions C-reactive protein concentrations Herpes viruses Cytomegaloviruses Chlamydia pneumoniae and
Helicobacter pylori
Disease-based Conditions Chagas disease Post-Kawasaki disease Pulmonary hypertension Heart failure and dilated
cardiomyopathy Syndrome X and variant
angina Transplantation
atherosclerosis End-stage renal disease Miscellaneous conditions Pregnancy-induced
hypertension/preeclampsia Methionine loading Mental stress Environmental Factors Passive smoking Turbulent vessel flow Oxidants
Conditions Associated With Impairment in Conditions Associated With Impairment in
Endothelium-dependent VasodilationEndothelium-dependent Vasodilation
Kevin M. Sowinsk - Medscape Pharmacists 2000
Disfunctia endoteliala (AB)Disfunctia endoteliala (AB)
• Relatie cu FR-CV• Relatie cu BCI• Relatie cu ATS carotidiana• Relatie cu IxGB• Relatie cu D-AB
Risk factors and ET dysfunction
• Importance of risk factors and endothelial dysfunction in early life for atherosclerosis development and later cardiovascular outcome.
• A) Impact of cardiovascular risk factor profile at age 50 years on subsequent clinical events in the Framingham Study.
• B) Association between risk factors and carotid IMT in young adults with enhanced, intermediate, and reduced FMD in the Cardiovascular Risk in Young Finns Study.
Lloyd-Jones et al. 2006; Juonala et al. 2004
Evaluation of Brachial Artery reactivity (%FMD)
US• B-mode (high-frequency)
• CD-US• PWD-US
Endothelial function, defined as flow mediated dilatation (FMD), is estimated as the percentage increase in vessel diameter from baseline conditions to maximum vessel diameter during hyperemia.
Celermajer et al 1994
Probe position in relation to cuffProbe position in relation to cuff
Schematic drawing of ultrasound imaging of the brachial artery with upper versus lower cuff placement and transducer position above the antecubital fossa. BP = blood pressure; FMD = flow-mediated vasodilation.
Assessment of flow-mediated vasodilatation (FMD) of the brachial artery: effects of technical aspects of
the FMD measurement on the FMD response Michiel L. Bots, J. Westerink, TJ Rabelink, E.J.P. de Koning
Assessment of flow-mediated vasodilatation (FMD) of the brachial artery: effects of technical aspects of
the FMD measurement on the FMD response Michiel L. Bots, J. Westerink, TJ Rabelink, E.J.P. de Koning
• The lower arm occlusion compared with upper arm occlusion was related to a significantly decreased FMD (mean difference in FMD –2.47%; 95% CI 0.55–4.39).
• An occlusion duration of 4.5 min was related to a significantly increased FMD compared with an occlusion time of 4 min (mean difference 1.30%; 95% CI 0.35–2.46).
Bots ML et al. Eur Heart J 2004
The unsolved issue is the broad spectrum of %FMD reference value
-1.9 – 19.2!?!
Bots ML et al. Eur Heart J 2004
4 min
Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated
vasodilation of the brachial artery
A report of the International Brachial Artery Reactivity Task Force Mary C. CorrettiMary C. Corretti, Todd J. Anderson, Emelia J. Benjamin, David Celermajer, Francois Charbonneau, Mark A. Creager, John Deanfield, Helmut Drexler,
Marie Gerhard-Herman, David Herrington, Patrick Vallance, Joseph Vita, and Robert Vogel
JACC 2002; 39:257-265
Representative flow-mediated response of brachial artery
(forearm occlusion)
1) baseline diameter (DBL), 2) maximum diameter after cuff release (Dmax) 3) diameter 3 minutes after cuff release, 4) time of maximum diameter after cuff release.
. The FMD was determined with the occlusion cuff on the upper arm . Images of the brachial artery were digitized (one image/cardiac cycle on the R-wave) at baseline (Pre) and continuously for 2 min beginning 20 s after cuff release using a commercially available image acquisition system (CVI Acquisition, Information Integrity, Stow, Massachusetts). Brachial artery diameters were measured using an automated edge-detection system (Brachial Tools, Medical Imaging Applications, Iowa City, Iowa).
Time course of brachial artery flow-mediated Time course of brachial artery flow-mediated vasodilation (FMD) in a healthy individualvasodilation (FMD) in a healthy individual
Peak percentage change in brachial artery diameter post-reactive hyperemia
Vasoactive substances
• Ach• NTG
Mechanical stress• Forearm ischemia
induced 4 min. by an occluding cuff
Peak vs Total hyperemia ?
Pyke KE et al. Appl Physiol 2007
30 sec 60 sec 180 sec
Flow-Mediated VasodilationA Diagnostic Instrument, or
an Experimental Tool?
Disfunctia endoteliala in HTADisfunctia endoteliala in HTA
• %FMD nu se coreleaza cu TA –cab
• %FMD se coreleaza cu TAM-24 ore (ABPM)
• %FMD nu se coreleaza cu profilul circadian (dipper/non-dipper)
• Nu se coreleaza cu IxMVS sau cu pattern-ul HVS
Rizzoni D 1998, Gomez C 2002, Andritoiu A 2004, Muiesan L 2004
Relatia %FMD –TOD in HTARelatia %FMD –TOD in HTA
11.88
10
7.376.85
NonTOD 1TOD 2TOD 3TOD
Xu J et al. J Hum Hypertens 2009
FMD%
• The most significant determinant of FMD was basal brachial artery diameter. • Greater basal diameter is associated with worse FMD.
HTA – fenotipuri hemodinamice HTA – fenotipuri hemodinamice diferitediferite
• HTA la tanarHTA la tanar• HTA primaraHTA primara• HTA sistolica izolataHTA sistolica izolata• Preeclampsie Preeclampsie • WC-HTWC-HT
%FMD in WCH vs SEH
SEH – HT sustinuta WCH – HT de halat alb
Gómez-Cerezo J et al. Hypertension. 2002;40:304
HTA la varstniciHTA la varstnici
%FMD%FMD• Scade la varstnici• Scade in HTA• Relatie cu rigidizarea peretelui arterial
Saka B et al. Arch Gerontol Geriatr 2005
Parker PA et al. Am J Physiol Heart Circ Physiol, 2006
Variatia circadiana a %FMD in HTAVariatia circadiana a %FMD in HTA
2.22
4.284.37
7 12 21
%FMD
Orele
Kollias GE J Hum Hypertens 2009
Relationship Between Carotid Artery Intima-Media Thickness and Brachial
Artery Flow-Mediated Dilation in Middle-Aged Healthy Men
R.T. Yan, T.J. Anderson, F. Charbonneau, L. Title, S. Verma, E. Lonn, on behalf of the FATE Investigators
Yan RT et al- JACC 2005
• Carotid IMTCarotid IMT and brachial artery FMD are frequently used as surrogate measures of subclinical atherosclerosis. • Whereas carotid IMT identifies early structural abnormalities, brachial artery FMD, considered a bioassay of endothelial function, measures functional vascular integrity. • The relationship between carotid IMT and brachial artery FMD has not been well studied.
Correlation between Flow-Mediated Vasodilatation of the Brachial Artery and
Inima-Media Thickness in the Carotid Artery in Men
• 34 M with ATS vs controls• 61+/- 2 yr• B-mode US
%FMD
CIMT
5.1+/-0.6%
2.8+/-0.4%
ATS Control
Hashimoto M et al. Arteriosclerosis, Thrombosis and Vascular Biology 1999
P<0.01
%FMD showed a significant negative correlation with IMT of CCA
%FMD
Relatia CIM ACC-%FMDRelatia CIM ACC-%FMD
Yan RT et al. J Am Coll Cardiol, 2005; 45:1980-1986
%FMD – CIMT - PWV%FMD – CIMT - PWV
135 pts• 110 pts - CVRFs• 33 pts. -CAD,
stroke, PADMETHODo USo CIMT/plaqueso BA-FMD%o PWV (brachial-ankle)
• All measurements are related each other !
• All measurements had a markedly higher prevalence of ATS disease and carotid plaques !
• The combination of these The combination of these measurements will be of measurements will be of stronger clinical stronger clinical relevance !relevance !
Kobayashi K et al. Atherosclerosis 2004
Caz clinicCaz clinic
• MV, 51y, F• HTA• LDL-Col 167 mg/dl• Non - Carotid ATS • FMD = 9%
Caz clinicCaz clinic
• NE, 56y, F• Hiper-CT• HTA• Car ATS 2/6• FMD =12%
AB-largirea anvelopei spectrale
Caz clinicCaz clinic
• AI, 52y, M• Fumator• Hiper-CT• HTA• Car-ATS 3/6• FMD = 6.6%
Relatia AB cu CIMT
• Mean CIMT - CA ATS stage r = 0.74; p<0.001• Max CIMT - CA ATS stage r = 0.51; p<0.01• Mean CIMT - BA area r = 0.40; p<0.05• Max CIMT - BA area r = 0.32; p<0.05• BA area - CA ATS stage r = 0.47; p<0.01• BA TAMx - BA spectral-broad. score r = 0.73; p<0.001• BA TAV - BA spectral-broad. score r = 0.66; p<0.001
Andritoiu A, 2008
%FMD in predictia HTA%FMD in predictia HTA
• Studiu de cohorta• 3.500 subiecti• 4.8 yr• 31.3% au dezvoltat
HTA
• Relatia dintre %FMD si aparitia HTA nu a fost semnificativa !
• Alterarea functiei endoteliale nu joaca un rol crucial in aparitia HTA !
Hiperemia reactiva (%FMD)Hiperemia reactiva (%FMD) este predictor de PE ! este predictor de PE !
1.6+/-1
11+/-4.5
0
2
4
6
8
10
12
PE Norm
Takase B et al. J Hum Hypertens 2003
• Sb 88%• Sp 93%• VPP 84%• VPN 94.8%
• %FMD sapt 18-24 • predictor precoce
HTA si MenopauzaHTA si Menopauza
• Studiu de cohorta• N = 952 • Follow-up 3.6+/0.7 yr• 112 pts dezv HTA
%FMD <3.5
RR = 5.77 (4.38-8.10)
Alterarea functiei vasomotorii endoteliale are valoare predictiva in aparitia HTA la femeile in post-menopauza
Rossi R et al. JACC 2004
%FMD-relatia cu varsta
Average brachial and popliteal responses to nitroglycerin (NTG) in young and older subjects.
Dilation was calculated as percent change from pre-NTG diameter to maximum diameter measured during the 10 min following NTG administration. Values are means
± SE. *Significantly different from young (P < 0.05).
Parker PA et al. Am J Physiol Heart Circ Physiol 291: H3043-H3049, 2006
AB - tinta terapeutica?AB - tinta terapeutica?
• Remodelarea arteriala
• Imbunatatirea functiei endoteliale
• Imbunatatirea proprietatilor peretelui arterial
ObiectiveObiective
AntihipertensiveEfecte terapeutice
• IECA• Sartani• Ca-antag.• Diuretice• Beta-bloc
End (++), Remod (++)
End (+/-), Remod (+/-)
End(+), Remod (++)
End (-), Remod (-)
End(+/-), Remod (-)
Gokce, N. et al. J Am Coll Cardiol 2002;40:761-765
The acute effect of a single oral dose of vasoactive medication on systolic blood pressure (SBP) (mm Hg) and absolute percent change in brachial artery flow-mediated (FMD) and
nitroglycerin-mediated dilation (NMD) in normal subjects (3 hrs)in normal subjects (3 hrs)
TAS (mmHg)
FMD%
Modificarile Modificarile FMDFMD--AAB dupa 6-12 luni de B dupa 6-12 luni de terapie antihipertensivaterapie antihipertensiva
(nifedipina) – 58 pacienti
Muiesan ML et col. Hypertension 1999;33:575-580
%FMD - Carvedilol
Matsuda Y et al. Am Heart J 140(5):753-759, 2000
5.1% ± 0.5% at baseline to 7.8% ± 0.5%; p < .05
Flow mediated post-ischemic endothelium-dependent vasodilatation expressed as percent increase in arterial diameter (mean ± SD) with respect to baseline values in
hypercholesterolemic coronary artery disease patients under the effects of the statin Simvastatin and the ECA inhibitor Enalapril, either separately or combined.
E: Enalapril, GI: Group I, GII: Group II, S: Simvastatin. * p < 0.001 vs baseline, ‡ p < 0.01 vs Baseline, † p < 0.05 vs 8 weeks, § p < 0.001 vs 8 weeks.
Esper et al. Cardiovascular Diabetology 2006 5:4
Studii personaleStudii personale
• Comportamentul vasoactiv al arterei brahiale pa pacientii hipertensivi-studiu comparativ Eco-Doppler. Al 39-Lea Cong. Nat Cardiol, Sinaia (Premiul Soc. Rom. Cardiologie), 2000
• Vasoactive behaviour of brachyal artery in hypertensive patients. The 5th Cong BMMC, Ankara, 2000
• Ateroscleroza carotidiana si relatia cu profilul spectral al arterei brahiale. Al 40-lea Cong Nat Craiologie, Sinaia, 2001
• Brachial artery. Ultrasound evaluation and Brachial artery. Ultrasound evaluation and clinical utilityclinical utility.. Conf SRUMB, Timisoara 2009
MESAJEMESAJE
• La un pacient hipertensiv, nu limita examinarea doar la masurarea TA (AB) !
• Aplicarea transductorului la nivelul AB poate sa ofere informatii noi, nebanuite, ce pot modifica esential managementul pacientului (incadrarea intr-un grad superior de RCV) !
• Modificarile anvelopei spectrale AB pot fi asociate ATS arterelor mari – marker surogat de ATS !
• Examinarea US a AB va fi asociata examinarii arterelor mari (Car, Fem) !