Arterial stiffness in Hypertension - 대한심장학회혈관연구회
Arterial stiffness in Hypertension - 대한심장학회혈관연구회
Arterial stiffness in Hypertension - 대한심장학회혈관연구회
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
혈관연구회 연수강좌<br />
27 Aug, 2005<br />
<strong>Arterial</strong> Stiffness <strong>in</strong> <strong>Hypertension</strong><br />
- Ag<strong>in</strong>g, <strong>Hypertension</strong>, and <strong>Arterial</strong> Stiffness -<br />
Weon Kim, MD, PhD<br />
The Heart Center of Chonnam National University Hospital
Endothelial dysfunction<br />
Bonetti et al. ATVB 2003; 23:168
<strong>Arterial</strong> Stiffness<br />
▶ Pulse wave velocity (PWV)<br />
: the speed of blood pressure wave to travel a given distance<br />
between 2 sites of the artery.<br />
: correlates well with arterial distensibility and <strong>stiffness</strong><br />
: strongly associated with the presence and extent of atherosclerosis<br />
and a forceful marker and predictor of CV risk <strong>in</strong> HT patients<br />
: correlates with the severity of DM complications<br />
▶ Ankle-Brachial Index (ABI)<br />
Balcher et al. <strong>Hypertension</strong> 1999<br />
Mahmud A et al. Expert Rev Cardiovasc Ther 2003
<strong>Arterial</strong> Stiffness: Pulse wave velocity<br />
맥압은 두 개의 압파 즉 심장에서 말초로 향하는 투사파와 말초에서 심장으로 되돌아오<br />
는 반사파의 중첩에 의해 생기는데 투사파는 좌심실 구출과 동맥의 경직도에 의해 좌우,<br />
반사파는 동맥의 경직도와 맥파의 반사지점과 연관이 있다.
Pathogenesis of Wide Pulse Pressure<br />
Izzo JL et al. J AM Geriatr Soc
Difference <strong>in</strong> coronary heart disease prediction<br />
between SBP and DBP as a function of age<br />
• Fram<strong>in</strong>gham연구; Frankl<strong>in</strong>등은 나이에 따라 관동맥 위험의 예측인자는 확장기 혈<br />
압에서 수축기 혈압을 거쳐 맥압으로 이동<br />
• 50세 이하는 확장기 혈압, 50대에는 이행기로서 혈압의 세 요소가 엇비슷하게 중<br />
요, 60세 이후에는 확장기 혈압은 관동맥 위험과 음의 상관관계—맥압이 수축기<br />
혈압보다 강력한 위험 예측인자
Case: 78/M<br />
Essential <strong>Hypertension</strong><br />
stage I<br />
PWV Results<br />
2003. 01. 30 진단<br />
Cl<strong>in</strong>ical Impact of <strong>Arterial</strong> Stiffness<br />
---- Telmisartan 40/DCZ 12.5mg<br />
- old age hypertensive patient -
Cl<strong>in</strong>ical Impact of <strong>Arterial</strong> Stiffness<br />
- old age hypertensive patient -<br />
PWV Results<br />
2004. 08. 05 (7 months later)<br />
---- Telmisartan 40/DCZ 12.5mg
Cl<strong>in</strong>ical Impact of <strong>Arterial</strong> Stiffness<br />
PWV Results<br />
2005. 06. 10 (16 months later)<br />
---- Telmisartan 40/DCZ 12.5mg
Cl<strong>in</strong>ical Impact of <strong>Arterial</strong> Stiffness
Composition of <strong>Arterial</strong> Wall<br />
• 대동맥 근위부의 혈관벽은 elast<strong>in</strong>이 풍<br />
부하여 혈관의 신전성이 좋으나 말초동<br />
맥으로 갈수록 혈관벽에는 collagen과 평<br />
활근 세포가 많아져 혈관이 경직되어 압<br />
파의 전파 속도가 빨라진다<br />
• 고령이 됨에 따라 혈관벽은 동맥경화로<br />
두께가 증가하여 경직되는데 이 변화는<br />
중심성 탄력동맥에서 두드러지게 나타<br />
나 수축기압은 상승하고 맥압은 켜져 점<br />
차 말초동맥과의 차이가 사라지게 된다
Pressure wave recorded along arterial tree from ascend<strong>in</strong>g<br />
aorta to femoral atery
Factor Contribut<strong>in</strong>g to Increase <strong>Arterial</strong> Stiffness<br />
Dyslipidemia<br />
Hyper<strong>in</strong>sul<strong>in</strong>emia<br />
Hyperglycemia<br />
<strong>Hypertension</strong><br />
Endothelial<br />
Dysfunction<br />
Oxidative Stress<br />
Ag<strong>in</strong>g<br />
Elast<strong>in</strong><br />
fracture<br />
<strong>Arterial</strong><br />
Stiffness<br />
Collagen<br />
deposition<br />
Ag<strong>in</strong>g<br />
Left ventricular<br />
Dysfunction/<br />
Hypertrophy<br />
Pulse pressure/<br />
<strong>Hypertension</strong><br />
Myocardial ischemia/<br />
Metabolicdemand
<strong>Hypertension</strong> and <strong>Arterial</strong> Stiffness<br />
▶ Heterogenecity of changes<br />
: Not all arteries become stiff with age.<br />
-- thoracic aorta and its branches : <strong>in</strong>creased <strong>stiffness</strong><br />
-- more peripheral muscular branch (such as brachial artery)<br />
: reta<strong>in</strong> their normal <strong>in</strong>creased elasticity <strong>in</strong> hypertension.<br />
▶ Loss of elast<strong>in</strong><br />
: arterial elasticity dependent on matrtix prote<strong>in</strong> elast<strong>in</strong>.<br />
: fatigue of elast<strong>in</strong> fiber and lamella occur <strong>in</strong> ag<strong>in</strong>g process.<br />
---- hypertension accelerates development of conduit artery <strong>stiffness</strong>.
Improvement of <strong>Arterial</strong> Stiffness by Drug<br />
Case: 66/F<br />
Essential <strong>Hypertension</strong><br />
with LVH, Gout<br />
PWV Results<br />
2003. 12. 11 진단<br />
---- Cilnidip<strong>in</strong>e 10mg<br />
2004. 04. 08 F/U
<strong>Arterial</strong> Stiffness <strong>in</strong> HTN : Complior Study<br />
Object :To evaluate the ability of an antihypertensive therapy to improve arterial <strong>stiffness</strong> as<br />
assessed by aortic pulse wave velocity (PWV) <strong>in</strong> a large population of hypertensive patients.<br />
Conclusions: The Complior Study is the first study to show the feasibility of a large-scale<br />
<strong>in</strong>tervention trial us<strong>in</strong>g PWV as the endpo<strong>in</strong>t <strong>in</strong> hypertensive patients.<br />
Asmar R. et al, J of <strong>Hypertension</strong> 2001
어떤 혈압약이 혈관경직도에 좋은가
Antihypertensive Drug and <strong>Arterial</strong> Stiffness<br />
Case: 47/F<br />
Essential <strong>Hypertension</strong><br />
PWV Results<br />
2003. 10. 04 진단<br />
---- Telmisartan 40mg<br />
2005. 01. 19 F/U
Case: 49/M<br />
Ess. <strong>Hypertension</strong> with LVH<br />
PWV Results<br />
2004. 01. 08 진단<br />
---- Amodip<strong>in</strong>e 5mg<br />
Losartan 50mg/DCZ 12.5mg<br />
2005. 06. 30 F/U
Anti-hypertensive Drug and <strong>Arterial</strong> Stiffness<br />
▶ 항고혈압 약제마다 혈관 구조 및 세포기질에 관한 효과가 약간 상이<br />
: ACEI , ARB, Ca blocker 등 – 혈관경직도 완화 효과가 비슷<br />
beta blocker – 약하다. 그러나, p<strong>in</strong>dolol, celiprolol등은 경직도 감소 효과 유의<br />
: meta-analysis에서는 약제들간의 큰 차이가 없었음.<br />
: 대규모 임상연구가 필요<br />
▶ 유전적인 요소도 일부 혈관경직도에 관여<br />
: angiotens<strong>in</strong> II AT1 receptor의 유전자 다형성
Effects of Antihypertensive Drugs on <strong>Arterial</strong> Stiffness<br />
PWV<br />
Wave<br />
reflexion<br />
Carotid dist.<br />
Mahmud A et al. Expert Rev Cardiovasc Ther 2003
Effects of Antihypertensive Drugs on <strong>Arterial</strong> Stiffness<br />
PWV<br />
Wave<br />
reflexion<br />
Carotid dist.<br />
Mahmud A et al. Expert Rev Cardiovasc Ther 2003
Effects of Antihypertensive Drugs on <strong>Arterial</strong> Stiffness<br />
PWV<br />
Wave<br />
reflexion<br />
Carotid dist.<br />
Mahmud A et al. Expert Rev Cardiovasc Ther 2003
Case : 23/F<br />
C/C: Mild headache (onset: 2-3years)<br />
P/H: No DM, Pul. Tbc<br />
S/H: Alcohol – social, smok<strong>in</strong>g-none<br />
P/I: 평소 심한 운동시 하지의 간헐적 파행이 있었던 이외에 특이한 증상 없이<br />
지내던 환자로서 개인 산부인과 병원 치료 중 혈압이 200mmHg 이상이어<br />
정밀검사 위해 전원 됨.<br />
P/E: pansystolic murmur <strong>in</strong> both upper chest and back area<br />
No bruit <strong>in</strong> carotid and abdomen<br />
BP: 180/100mmHg<br />
Lab: VMA 3.2, Metanephr<strong>in</strong>e 0.1,<br />
PRA: 4.1, Aldosterone: 3.2<br />
Thyroid function test: Normal
Electrocardiogram
<strong>Arterial</strong> Stiffness (2005. 4. 25)
2-D Echocardiogram
Coronary Angiogram : Normal
Aortogram and CT angiogram<br />
Pressure gradient = 80mmHg
Collateral Circulation
Stent<strong>in</strong>g for Coarctation<br />
Balloon<strong>in</strong>g 그림 2개
Post-Stent<strong>in</strong>g Aortogram and CTA<br />
Pressure gradient = 23mmHg
F/U 2-D Echocardiogram
<strong>Arterial</strong> Stiffness (3 days after stent<strong>in</strong>g)
<strong>Arterial</strong> Stiffness<br />
(1 month after stent<strong>in</strong>g)<br />
Cured hypertension<br />
-- No medication
경청해 주셔서 감사합니다.
Change language