Central blood pressure: current evidence

and clinical importance

Carmel M. McEniery1*, John R. Cockcroft2, Mary J. Roman3,

Stanley S. Franklin4, and Ian B.Wilkinson1

1Clinical Pharmacology Unit, University of Cambridge, Addenbrooke’s Hospital, Box 110, Cambridge CB22QQ, UK; 2Department of Cardiology,Wales Heart Research Institute, Cardiff

CF14 4XN, UK; 3Division of Cardiology,Weill Cornell Medical College, New York, NY 10021, USA; and 4University of California, UCI School of Medicine, Irvine, CA 92697-4101, USA

Received 29 April 2013; revised 27 November 2013; accepted 17 December 2013; online publish-ahead-of-print 23 January 2014

and central pressure. Therefore, basing treatment decisions on central, rather than brachial pressure, is likely to have important implications

for the future diagnosis and management of hypertension. Such a paradigm shift will, however, require further, direct evidence that selectively

targeting central pressure, brings added benefit, over and above that already provided by brachial artery pressure.

Central pressure † Blood pressure † Anti-hypertensive treatment † Cardiovascular risk

Introduction

The brachial cuff sphygmomanometer was introduced into medicalpractice well over 100 years ago, enabling the routine, non-invasive,

measurement of arterial blood pressure. Life insurance companieswere among the first to capitalize on the information provided by

cuff sphygmomanometry, by observing that blood pressure inlargely asymptomatic individuals relates to future cardiovascular

risk—observations that are nowsupported by a wealth of epidemiologicaldata.1 The most recent Global Burden of Disease report2

identified hypertension as the leading cause of death and disabilityworldwide. Moreover, data from over 50 years of randomized controlled

trials clearly demonstrate that lowering brachial pressure,in hypertensive individuals, substantially reduces cardiovascular

events.1,3 For these reasons, measurement of brachial blood pressurehas become embedded in routine clinical assessment throughout the

developed world, and is one of the most widely accepted ‘surrogatemeasures’ for regulatory bodies.

The major driving force for the continued use of brachial bloodpressure has been its ease of measurement, and the wide variety of

devices available for clinical use. However, we have known for overhalf a century that brachial pressure is a poor surrogate for aortic

pressure, which is invariably lower than corresponding brachialvalues. Recent evidence suggests that central pressure is also more

strongly related to future cardiovascular events4 – 7 than brachialpressure, and responds differently to certain drugs.8,9 Appreciating

this provides an ideal framework for understanding the much publicizedinferiority of atenolol and some other beta-blockers,10 compared

with other drug classes, in the management of essentialhypertension. Although central pressure can now be assessed noninvasively

with the same ease as brachial pressure, clinicians are unlikelyto discard the brachial cuff sphygmomanometer without

robust evidence that cardiovascular risk stratification, and monitoringresponse to therapy, are better when based on central rather

than peripheral pressure. Central pressure assessment and accuracywill also have to be standardized, as it has been for brachial pressure

assessment with oscillometric devices. This review will discuss ourcurrent understanding about central pressure and the evidence

required to bring blood pressure measurement, and cardiovascularrisk assessment into the modern era.

Physiological concepts

Arterial pressure varies continuously over the cardiac cycle, but inclinical practice only systolic and diastolic pressures are routinely

reported. These are invariably measured in the brachial arteryusing cuff sphygmomanometry—a practice that has changed little

over the last century. However, the shape of the pressure waveform* Corresponding author. Tel: +44 1223 336806, Fax: +44 1223 216893, Email: cmm41@cam.ac.uk

Published on behalf of the European Society of Cardiology. All rights reserved. &The Author 2014. For permissions please email: journals.permissions@oup.com

European Heart Journal (2014) 35, 1719–1725　doi:10.1093/eurheartj/eht565