H igh blood pressure (BP) is an established modifiable risk factor for cardiovascular disease and mortality. However, the association between BP and cardiovascular risk weakens in the elderly.1 A major confounding factor is atherosclerotic peripheral arterial disease (PAD). 2,3 When PAD is present in subclavian and brachial arteries, arm BP cannot be accurately measured, and hypertension therefore cannot be timely diagnosed and properly managed in clinical practice. 4,5 Current technology allows simultaneous BP measurement in 4 limbs, 6,7 which may provide a comprehensive evaluation of BP and generate accurate BP differences between 4 limbs, such as ankle-brachial BP index (ABI) and the interarm and interankle BP differences. ABI is a well-documented diagnostic tool for PAD in lower extremities. 8 The interarm BP difference is also being recognized as an indicator of PAD in the subclavian or brachial arteries. [2][3][4][5][9][10][11] To the best of our knowledge, the diagnostic and prognostic significances of the interankle BP difference have not been investigated in prospective studies.We performed simultaneous BP measurement in 4 limbs in an elderly Chinese population, which was prospectively followed up for mortality. In the present study, we investigated total and cardiovascular mortality in relation to the level of arm BP, ABI, and the interarm and interankle BP differences. Methods Study PopulationOur study was conducted in the framework of the Chronic Disease Detection and Management in the Elderly (≥60 years) Program supported by the municipal government of Shanghai. In a newly urbanized suburban town, 30 kilometers from the city center, we invited all residents of 60 years or older to take part in comprehensive examinations of cardiovascular disease and risk. The Ethics Committee of Ruijin Hospital, Shanghai Jiaotong University School of Medicine approved the study protocol. All subjects gave written informed consent.A total of 3263 subjects (participation rate 90%) were enrolled in the period from 2006 to 2008, and followed up for vital status and cause of death till June 30, 2011. We excluded 130 subjects from the present analysis, because 4-limb BP measurement was not performed (n=45) or because of missing other information (n=85). Thus, the number of participants included in the present analysis was 3133. See Editorial Commentary, pp 1146-1147Abstract-The predictive value of blood pressure (BP) for cardiovascular morbidity and mortality diminishes in the elderly, which may be confounded and compensated by the BP differences across the 4 limbs, markers of peripheral arterial disease. In a prospective elderly (≥60 years) Chinese study, we performed simultaneous 4-limb BP measurement using an oscillometric device in the supine position, and calculated BP differences between the 4 limbs. At baseline, the mean age of the 3133 participants (1383 men) was 69 years. During 4 years (median) of follow-up, all-cause and cardiovascular deaths occurred in 203 and 93 subjects, respectively. In multiple regression...

P ulse wave velocity (PWV) is a measure of arterial stiffness and can be measured by recording pulse waves on 2 superficial arterial sites and measuring the distance between the 2 arterial sites.1 PWV is usually measured using the applanatation technique between carotid and femoral arteries, 2 between carotid and brachial arteries, 3 or between femoral and tibial or dorsalis arteries. 4 Carotid-femoral PWV is considered as a measure of aortic arterial stiffness and mostly studied for cardiovascular prediction.1 Several studies have demonstrated that carotid-femoral PWV predicts cardiovascular events and mortality in the general population 5,6 and in various patient cohorts. 7,8 Carotid-femoral PWV is, therefore, recommended by several recent hypertension guidelines as a measure of target-organ damage. 9,10 Current technology allows automatic detection of pulse waves using cuffs on the limb arterial sites, such as the brachial and posterior tibial arteries. With the time difference between the pulse waves of these arterial sites and an estimated travel path of the pulse waves according to body height, brachialankle PWV can then be calculated.11 Previous studies have shown that brachial-ankle PWV is closely correlated with carotid-femoral PWV 12 and is also predictive of cardiovascular events and mortality in the general population [13][14][15][16] and in various patient cohorts. [17][18][19][20][21][22][23][24][25] Nonetheless, brachial-ankle PWV measures stiffness of mixed elastic with muscular arteries, 26 instead of the elastic aorta alone, and hence quantitatively differs from carotid-femoral PWV and may have distinct values of cardiovascular prediction. In the present study, we investigated the predictive value of brachial-ankle PWV for mortality in an elderly Chinese population. Methods Study PopulationOur study was conducted in the framework of the Chronic Disease Detection and Management in the Elderly (≥60 years) Program supported by the municipal government of Shanghai. 27,28 In a newly urbanized suburban town, 30 km from the city center, we invited all residents ≥60 years to take part in comprehensive examinations of cardiovascular disease and risk. The Ethics Committee of Ruijin Hospital, Shanghai Jiaotong University School of Medicine, approved the study protocol. All subjects gave written informed consent.A total of 4140 subjects (participation rate 90%) were enrolled in the period from 2006 to 2011 and followed up for vital status and cause of death till June 30, 2013. We excluded 101 subjects from the present analysis, because brachial-ankle PWV was not measured (n=63) or because of missing other information (n=38). We further excluded 163 subjects with an ankle-brachial index <0.90 (n=107) or Abstract-Pulse wave velocity (PWV) is a measure of arterial stiffness and predicts cardiovascular events and mortality in the general population and various patient populations. In the present study, we investigated the predictive value of brachial-ankle PWV for mortality in an elderly Chinese population. Ou...

Background: Whether cardiovascular risk is more tightly associated with central (cSBP) than brachial (bSBP) systolic pressure remains debated, because of their close correlation and uncertain thresholds to differentiate cSBP into normotension versus hypertension. Methods: In a person-level meta-analysis of the International Database of Central Arterial Properties for Risk Stratification (n=5576; 54.1% women; mean age 54.2 years), outcome-driven thresholds for cSBP were determined and whether the cross-classification of cSBP and bSBP improved risk stratification was explored. cSBP was tonometrically estimated from the radial pulse wave using SphygmoCor software. Results: Over 4.1 years (median), 255 composite cardiovascular end points occurred. In multivariable bootstrapped analyses, cSBP thresholds (in mm Hg) of 110.5 (95% CI, 109.1–111.8), 120.2 (119.4–121.0), 130.0 (129.6–130.3), and 149.5 (148.4–150.5) generated 5-year cardiovascular risks equivalent to the American College of Cardiology/American Heart Association bSBP thresholds of 120, 130, 140, and 160. Applying 120/130 mm Hg as cSBP/bSBP thresholds delineated concordant central and brachial normotension (43.1%) and hypertension (48.2%) versus isolated brachial hypertension (5.0%) and isolated central hypertension (3.7%). With concordant normotension as reference, the multivariable hazard ratios for the cardiovascular end point were 1.30 (95% CI, 0.58–2.94) for isolated brachial hypertension, 2.28 (1.21–4.30) for isolated central hypertension, and 2.02 (1.41–2.91) for concordant hypertension. The increased cardiovascular risk associated with isolated central and concordant hypertension was paralleled by cerebrovascular end points with hazard ratios of 3.71 (1.37–10.06) and 2.60 (1.35–5.00), respectively. Conclusions: Irrespective of the brachial blood pressure status, central hypertension increased cardiovascular and cerebrovascular risk indicating the importance of controlling central hypertension.