ISH PRE-1 REDUCTION OF CARDIOVASCULAR MORTALITY IN HYPERTENSIVES WITH COMORBIDITIES: BEYOND BLOOD PRESSURE LOWERING - THE ROLE OF ARTERIAL AGING.

Mid-life elevated BP is classically associated with a raised systemic vascular resistance. A classical interpretation of the association between aortic stiffness and blood pressure (BP) invokes hypertension as a simple form of premature aging that increases stress on the arterial wall and accelerates age-related stiffening of the aorta. Recent clinical and experimental data have called into question the directionality of this sequence of events associating stiffness and hypertension.Therefore an initial abnormality in stiffness may antedate and contribute initially to the pathogenesis of hypertension, namely isolated systolic hypertension. This possibility is important to consider since it might affect the individual estimation of cardiovascular risk even in low risk prehypertensive subjects. Therefore, it might be essential to direct therapy of hypertension toward the reduction of both BP and aortic stiffness.Cardiovascular (CV) complications are dominant causes of death in severe hypertensive patients with comorbidities, especially diabetic hypertensive patients (DHS) and patients with end-stage renal disease (ESRD). Vascular calcifi cation and arterial stiffness are highly prevalent in such subjects, particularly in those with co-morbidities. Carotid-femoral pulse wave velocity (CFPWV) is the gold standard and simple, non-invasive and reproducible measure of large artery stiffness.This measurement have been frequently used as predictors for CV events and CV mortality in the general population, in specifi c populations such as in patients with DHS and ESRD. These fi ndings have been widely observed using conventional cross-sectional investigations. However, in such studies, it has been observed that the association between single measurements of CFPWV and CV events is frequently driven by the high incidence of late events, i.e. after 12 months of follow-up.New data from our prospective studies in DHS and ESRD evaluated the association between longitudinal changes in delta (Δ) CFPWV over time and the subsequent development of CV events through a given follow-up period. Two different problems are also of interest. First, in ESRD subjects, it is important to determine the possible links between aortic stiffness and CV risk, while taking into account the corresponding BP level, with or without the presence of drug treatment. Second, in DHS type 2, aortic stiffness may remain signifi cantly elevated despite a substantial BP reduction obtained by drug treatment. A multifactorial risk management is therefore required for effective CV disease prevention in such populations.Such an approach should take into consideration the increase of arterial stiffness as well as its consequences, which is increased pressure wave refl ections, lower pulse pressure amplifi cation and increased aortic systolic BP.BP elevation and aortic rigidity are independent but largely interrelated variables, each of them affecting CV risk in their own way. If this assessment is correct, then measurement of aortic stiffness is an important addition in the assessment of hypertension and could become a new additional therapeutic target.