Impact of Antihypertensive Agents on Central Systolic Blood Pressure and Augmentation Index: A Meta-Analysis

Abstract

Elevated blood pressure (BP) is a leading modifiable risk factor for cardiovascular disease and continues to affect approximately 1 in 3 adults, or 66.9 million people, in the United States. 1 Traditionally, hypertension is diagnosed and treated by assessing the pressure at the brachial artery (peripheral BP), 2 but recent evidence suggests that central hemodynamics are better predictors of cardiovascular outcomes and mortality. 3,4 Central BP is indicative of the pressure directly exerted on target organs and often varies from peripheral BP. 2 Aortic and carotid arteries are more elastic than fibrous peripheral vasculature and the difference in peripheral and central pressures is thought to be a result of amplification due to wave reflections caused by the variance in arterial stiffness. 2,5 As a result of arterial stiffness increasing with distance from the heart, peripheral systolic BP (pSBP) tends to be greater than central systolic BP (cSBP). 6 Additionally, augmentation index (AI), which measures the degree of enhancement in the central pressure waveform due to reflected waves, has been shown to be an independent predictor of cardiovascular events. 4 Recent technology has increased the availability of several noninvasive techniques to estimate central BP allowing for incorporation of these parameters in a multitude of patient populations and disease states. [7][8][9][10] Differences between the various classes of antihypertensive agents regarding their effects on central hemodynamics have been identified. 11,12 The Conduit Artery Function Evaluation (CAFE) study 13 was one of the first trials to show differing clinical outcomes despite similar reductions in peripheral BP. In a previous meta-analysis, differing responses of β-blockers (BBs) and diuretics on central hemodynamics were implied but extrapolation of their finding was limited due to a modest number of included studies. 12 As a result of a greater number of new publications in the last few years assessing the effects of antihypertensives on central BP, we performed a meta-analysis analyzing the differential effects of antihypertensive agents on cSBP and AI. An assessment as such will help better determine the incorporation and place in therapy of the various antihypertensives in clinical practice. Impact of Antihypertensive Agents on BACKGROUNDNew evidence suggests that central systolic blood pressure (cSBP) and augmentation index (AI) are superior predictors of adverse cardiovascular outcomes compared to peripheral systolic BP (pSBP). We performed a meta-analysis assessing the impact of antihypertensives on cSBP and AI.

Reappraisal of the diuretic effect of empagliflozin in the EMPA-REG OUTCOME trial: Comparison with classic diuretics

“…New evidence suggests that central SBP is a better predictor of adverse CV outcomes than peripheral SBP [36]. It has also been shown that thiazide diuretics reduce central SBP and peripheral SBP in a similar manner [36], and with results comparable to what is observed with other antihypertensive agents [37].…”

Clinical relevance of central blood pressure - a critical review

“…Overall, it appears that beta-blockers reduce central blood pressure signifi cantly less than brachial blood pressure [59]. In contrast, the other drug classes signifi cantly decrease central blood pressure, although the extent to which this is independent of their brachial blood pressurelowering eff ect is still debated.…”

“…In contrast, the other drug classes signifi cantly decrease central blood pressure, although the extent to which this is independent of their brachial blood pressurelowering eff ect is still debated. A recent meta-analysis showed that most antihypertensive drug classes, including alpha-blockers, angiotensin-converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), renin inhibitors and thiazides, may reduce peripheral and central pressure to the same extent and confi rmed the lack of effi cacy of beta-blockers in lowering central compared with brachial blood pressure [59]. A further meta-analysis of 24 randomised clinical trials [60] suggested that beta-blockers and diuretics reduce central pressure less than brachial pressure, whereas monotherapy with ACEis, ARBs, CCBs, alpha-blockers or spironolactone reduced both parameters to a similar extent [60].…”

“…A further meta-analysis of 24 randomised clinical trials [60] suggested that beta-blockers and diuretics reduce central pressure less than brachial pressure, whereas monotherapy with ACEis, ARBs, CCBs, alpha-blockers or spironolactone reduced both parameters to a similar extent [60]. Interestingly, it was suggested that antihypertensive drug combinations that include beta-blockers, such as beta-blockers + ARBs or diuretics, have a greater eff ect on brachial pressure than on central pressure [59]. In contrast, other combinations, such as ACEis or ARBs + CCBs as well as ARBs + diuretics, had similar eff ects on both brachial and central pressure [59].…”

“…Interestingly, it was suggested that antihypertensive drug combinations that include beta-blockers, such as beta-blockers + ARBs or diuretics, have a greater eff ect on brachial pressure than on central pressure [59]. In contrast, other combinations, such as ACEis or ARBs + CCBs as well as ARBs + diuretics, had similar eff ects on both brachial and central pressure [59].…”