Arterial Wave Reflections and Incident Cardiovascular Events and Heart Failure

Q: What are the key findings of this study?

Reflection magnitude strongly and independently predicted incident congestive heart failure (HR 2.69 per 10% increase; 95% CI 1.79-4.04; p<0.0001) and hard cardiovascular events (HR 1.46; p=0.006).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Adults free of clinically apparent cardiovascular disease (n=5960). Intervention: Reflection magnitude (RM) per 10% increase (assessed via radial arterial tonometry and wave separation analysis). Primary outcome: Incident congestive heart failure (CHF) (HR 2.69 per 10% increase, 95% CI 1.79-4.04, p=<0.0001).

Q: What does this research mean for the field?

Arterial reflection magnitude is a strong independent predictor of incident congestive heart failure and hard cardiovascular events in the general population. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.ESTABLISHES_NEW_DIRECTION.

Q: What question did this study set out to answer?

To assess the relationship between central arterial pressure profiles, specifically wave reflections, and incident cardiovascular events and congestive heart failure in a large community-based cohort.

Julio A. Chirinos; Jan G. Kips; David R. Jacobs; Lyndia C. Brumback; Daniel A. Duprez; Richard A. Kronmal; David A. Bluemke; Raymond R. Townsend; Sebastian J. Vermeersch; Patrick Segers

doi:10.1016/j.jacc.2012.07.054

October 24, 2012Journal of the American College of CardiologyOpen Access

Arterial Wave Reflections and Incident Cardiovascular Events and Heart Failure

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Key result

Higher reflection magnitude linked to increased risk of incident heart failure.

HR 2.69 per 10% increase
95% CI 1.79-4.04
P<0.0001
n=5,960

Why the study?

Experimental and physiologic data mechanistically implicate wave reflections in the pathogenesis of left ventricular failure and cardiovascular disease, but their association with these outcomes in the general population was unclear.

Do central pressure profiles and arterial wave reflections (specifically reflection magnitude, augmentation index, and pulse pressure amplification) independently predict incident cardiovascular events and congestive heart failure in multiethnic adults free of baseline cardiovascular disease?

Key Points

To assess the relationship between central arterial pressure profiles, specifically wave reflections, and incident cardiovascular events and congestive heart failure in a large community-based cohort.
Prospective cohort study analyzing noninvasive radial artery tonometry waveforms from 5,960 participants enrolled in the Multiethnic Study of Atherosclerosis.
Aortic pressure waveforms were separated into forward and reflected waves to derive reflection magnitude (RM), augmentation index (AIx), and pulse pressure amplification (PPA), with a median follow-up of 7.61 years.
RM was independently predictive of all cardiovascular events (HR per 10% increase: 1.34; 95% CI: 1.08 to 1.67; p = 0.009), hard cardiovascular events (HR per 10% increase: 1.46; 95% CI: 1.12 to 1.90; p = 0.006), and strongly predictive of new-onset congestive heart failure (HR per 10% increase: 2.69; 95% CI: 1.79 to 4.04; p < 0.0001).
Aortic AIx independently predicted hard cardiovascular events (HR per 10% increase: 1.08; 95% CI: 1.01 to 1.14; p = 0.016), whereas PPA independently predicted all cardiovascular events (HR per 10% increase: 0.82; 95% CI: 0.70 to 0.96; p = 0.012).
Compared to nonhypertensive participants with low RM, fully adjusted hazard ratios for heart failure were 1.81 (95% CI: 0.85 to 3.86) for hypertensive participants with low RM, 2.16 (95% CI: 1.07 to 5.01) for nonhypertensive participants with high RM, and 3.98 (95% CI: 1.96 to 8.05) for hypertensive participants with high RM.

Study Design

Type

Cohort (n=5,960)

Blinding

Blinded endpoint classification

Multicenter

Yes

Structured PICO

Do central pressure profiles and arterial wave reflections (specifically reflection magnitude, augmentation index, and pulse pressure amplification) independently predict incident cardiovascular events and congestive heart failure in multiethnic adults free of baseline cardiovascular disease?

P

Population

5,960 multiethnic adults aged 45-84 years free of clinically apparent cardiovascular disease from six US communities, followed for a median of 7.61 years.

E

Exposure

Central pressure profiles and arterial wave reflections assessed non-invasively via radial arterial tonometry and wave separation analysis: reflection magnitude (RM = [Reflected/Forward wave amplitude] x 100), augmentation index (AIx = [Second/First systolic peak] x 100), and pulse pressure amplification (PPA = [Radial/aortic pulse pressure] x 100).

O

Outcome

Incident congestive heart failure (CHF; requiring clinical symptoms/signs, physician diagnosis, medical treatment, and either pulmonary edema/congestion on chest X-ray or dilated ventricle/poor LV systolic or diastolic function on imaging) and incident hard cardiovascular events (myocardial infarction, resuscitated cardiac arrest, coronary heart disease death, stroke, or stroke death) over a median follow-up of 7.61 years, adjudicated by two blinded physicians.hard clinical

Main Result

Hazard Ratio: 2.69 (95% CI 1.79–4.04)

p-value: p=<0.0001

Arterial wave reflection magnitude assessed noninvasively by radial tonometry is a strong, independent predictor of incident heart failure and cardiovascular events in adults free of baseline cardiovascular disease, representing a potential target for primary heart failure prevention.

Limitations

Observational study design cannot prove a causal link between wave reflections and CHF or cardiovascular events.
Central flow was not measured directly; a physiologic flow waveform was assumed, which provides only an approximation of true reflection magnitude.
Cohort was free of baseline cardiovascular disease with a relatively low absolute risk of CHF and insufficient events for gender-specific sub-analyses.
Aortic pulse wave velocity (an index of aortic wall stiffness) was not measured.
Observational study design cannot prove a causal link between wave reflections and CHF/CVE
Did not measure central flow directly, instead assuming a physiologic flow waveform to approximate reflection magnitude
Healthy baseline cohort resulted in a relatively low absolute risk of CHF and insufficient events for gender-specific sub-analyses
Did not measure aortic pulse wave velocity (an index of aortic wall stiffness)

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Implication

Reflection magnitude may aid HF risk stratification; hypothesis-generating and should not yet change practice or prompt targeted interventions.

Abstract

Objectives This study sought to assess the relationship between central pressure profiles and cardiovascular events (CVEs) in a large community-based sample. Background Experimental and physiologic data mechanistically implicate wave reflections in the pathogenesis of left ventricular failure and cardiovascular disease, but their association with these outcomes in the general population is unclear. Methods Aortic pressure waveforms were derived from a generalized transfer function applied to the radial pressure waveform recorded noninvasively from 5,960 participants in the Multiethnic Study of Atherosclerosis. The central pressure waveform was separated into forward and reflected waves using a physiologic flow waveform. Reflection magnitude (RM = [Reflected/Forward wave amplitude] × 100), augmentation index ([Second/First systolic peak] × 100) and pulse pressure amplification ([Radial/aortic pulse pressure] × 100) were assessed as predictors of CVEs and congestive heart failure (CHF) during a median follow-up of 7.61 years. Results After adjustment for established risk factors, aortic AIx independently predicted hard CVEs (hazard ratio [HR] per 10% increase: 1.08; 95% confidence interval [CI]: 1.01 to 1.14; p = 0.016), whereas PPA independently predicted all CVEs (HR per 10% increase: 0.82; 95% CI: 0.70 to 0.96; p = 0.012). RM was independently predictive of all CVEs (HR per 10% increase: 1.34; 95% CI: 1.08 to 1.67; p = 0.009) and hard CVEs (HR per 10% increase: 1.46; 95% CI: 1.12 to 1.90; p = 0.006) and was strongly predictive of new-onset CHF (HR per 10% increase: 2.69; 95% CI: 1.79 to 4.04; p < 0.0001), comparing favorably to other risk factors for CHF as per various measures of model performance, reclassification, and discrimination. In a fully adjusted model, compared to nonhypertensive subjects with low RM, the HRs (95% CI) for hypertensive subjects with low RM, nonhypertensive subjects with high RM, and hypertensive subjects with high RM were 1.81 (0.85 to 3.86), 2.16 (1.07 to 5.01), and 3.98 (1.96 to 8.05), respectively. Conclusions Arterial wave reflections represent a novel strong risk factor for CHF in the general population.

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Cite This Study

Chirinos et al. (2012) conducted a cohort in Adults free of clinically apparent cardiovascular disease (n=5,960). Reflection magnitude (RM) per 10% increase (assessed via radial arterial tonometry and wave separation analysis) was evaluated on Incident congestive heart failure (CHF) (HR 2.69 per 10% increase, 95% CI 1.79-4.04, p=<0.0001). Reflection magnitude strongly and independently predicted incident congestive heart failure (HR 2.69 per 10% increase; 95% CI 1.79-4.04; p<0.0001) and hard cardiovascular events (HR 1.46; p=0.006).

synapsesocial.com/papers/6af2e0c661ec8bd28c38b3ee https://doi.org/10.1016/j.jacc.2012.07.054

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Arterial Wave Reflections and Incident Cardiovascular Events and Heart Failure

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Arterial Wave Reflections and Incident Cardiovascular Events and Heart Failure

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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