Supplement One
Non-Invasive Techniques - Descriptions
SphygmoCor™ (AtCor Medical, Sydney, Australia)
The SphygmoCor device utilizes the radial pressure waveform as acquired with a pencil type applanation tonometer. Waveform quality is assessed in real-time by proprietary software. The final ensemble averaged radial pressure waveform is then transformed with a proprietary generalized transfer function as previously reported [1, 2]. The transfer function was obtained in 14 patients undergoing diagnostic catheterization via the brachial artery. Radial applanation and invasive aortic pressure waveform acquisition was performed simultaneously with a 5F Millar catheter. The majority of studies utilising the SphygmoCor™ technique utilize non-invasively acquired oscillometric brachial SBP and DBP applied to the radial pressure waveform. An alternative calibration is to bMAP and bDBP. The relative accuracy of the alternative calibration method against the invasive standard is unknown
Carotid applanation with calibration to MBP and DBP
Pressure waveforms are acquired from the right common carotid artery by applanation tonometry. The waveform is usually calibrated to non-invasively acquired brachial MBP and DBP, based on the assumption that these parameters are constant throughout the arterial tree [3, 4]. Alternatively, the acquired carotid pressure waveform may be transformed utilising a generalized transfer function (eg. SphygmoCor™) to derive an ascending
aortic pressure waveform. The estimated cSBP is typically 2-3 mmHg higher than “true” ascending aortic pressure.
Novacor Diasys Integra II (Novacor, France)
This technique [5] utilizes a Diasys Integra II semi-automated oscillometric cuff based brachial BP monitor that also measures QKD (Timing of Korotkoff sound appearance, relative to the Q wave on ECG). The QKD provides a measure of arterial stiffness, whilst the non-invasively acquired brachial mean blood pressure is used for calibration. A regression equation allows estimation of cSBP from bMBP, HR, height and the Q wave to Korotkoff delay (QKD).
BPro device with A-Pulse (HealthSTATS, Singapore)
This wristwatch-like device comprises a piezoelectric tonometric device which constantly acquires the radial pressure waveform. An N-point moving average (NPMA) filter is then applied to this radial artery waveform to estimate cBP [6].
The NPMA filter does not generate an aortic waveform and so cannot be used to derive the augmentation index. The device requires calibration to non- invasive brachial oscillometric pressures prior to use. Two studies have compared BPro to Sphygmocor™ and invasive measurement [7, 8].
Arteriograph (TensioMed, Budapest, Hungary)
This device utilizes an automated bBP cuff, which is inflated to 35mmHg above measured bSBP. At this occlusion pressure, the early systolic wave
(P1), late systolic wave (P2) and diastolic waves (P3) cause small volume and pressure changes that are recorded by a high fidelity pressure sensor within the device [9]. This device has primarily been used to measure PWV, AIx, SBPao and peripheral BP but can also report central blood pressure [9-11].
Mobil-O-Graph (IEM, Stolberg, Germany)
The Mobil-O-Graph device applies the ARCSolver method (Austrian Institute of Technology) to transform brachial pulse waves recorded with a standard brachial oscillometric blood pressure cuff[12]. Following inflation to brachial pressure, the device acquires the pulse waveform (detected using a pressure sensor) over 10 seconds. This data is subsequently digitized, and transformed with a proprietary generalized transfer function to obtain an aortic pressure waveform. This device has been validated against SphygmocorTM but not against invasive measurement [12-14].
Gaon (Hanbyul Meditech, Jeonju, South Korea)
The Gaon device uses an automated radial tonometry cradle to facilitate acquisition of the radial pressure waveform. A proprietary generalized transfer function is then applied to derive the central aortic pressure waveform. The device is calibrated to non-invasively acquired oscillometric brachial blood pressure [15]
HEM 9000AI (Omron Healthcare, Kyoto, Japan)
This device incorporates semi-automated multi-sensor array that detects the late systolic shoulder of the radial pulse waveform (pSBP2). The device then applies a commercial algorithm to estimate the central systolic pressure (cSBP). Non-invasive blood pressure measurements taken with the integrated oscillometric brachial cuff are then used to calibrate the device. The device incorporates an algorithm to “correct” the non-invasively obtained brachial blood pressure. As a result of this correction factor, estimated central systolic blood pressure with this device is often equivalent to or higher than the reported brachial systolic pressure. The initial description and validation of the pSBP2 technique was provided by Takazawa and colleagues [16, 17].
Subsequently multiple studies have compared this device to existing techniques [11, 18-20].
Vicorder (Skidmore Medical, Bristol, UK)
The Vicorder system is a commercially available cuff based, operator independent device that determines brachial oscillometric BP in the upper arm[21]. Brachial pressure waveforms are recorded using the same cuff inflated to 70 mmHg (applying a volume displacement technique conceptually similar to the Mobil-O-graphTM system). Central blood pressure parameters are then derived from the brachial pressure waveforms (calibrated to bSBP and bDBP) by applying a previously reported brachial to aortic transfer function [22]
Radial P2 equivalence technique
With this technique, radial applanation is employed to acquire a waveform, which is calibrated using brachial oscillometric mean / diastolic blood pressure. The second peak of the radial pressure waveform is assumed to approximate cSBP [23]
Centron CBP 301 (Centron Diagnostics Ltd, London, UK)
A brachial cuff is used to estimate the bSBP, bDBP and mean brachial BP (bMBP). The cuff is then re-inflated to an intermediate pressure (between bMBP and bSBP) and oscillations in cuff pressure are recorded over several seconds. These oscillations are calibrated against bSBP and bDBP and a brachial to central GTF used to estimate the cSBP[24, 25].
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617-623.
8. Ott, C., et al., Comparison of two noninvasive devices for measurement of central systolic blood pressure with invasive measurement during cardiac catheterization. J Clin Hypertens (Greenwich), 2012. 14(9): p. 575-9.
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2068-2075.
10. Jatoi, N.A., et al., Assessment of arterial stiffness in hypertension:
comparison of oscillometric (Arteriograph), piezoelectronic (Complior) and tonometric (SphygmoCor) techniques. J Hypertens, 2009. 27(11): p. 2186- 91.
11. Rezai, M.R., et al., Calibration mode influences central blood pressure differences between SphygmoCor and two newer devices, the Arteriograph and Omron HEM-9000. Hypertension Research, 2011. 34(9): p. 1046- 1051.
12. Wassertheurer, S., et al., A new oscillometric method for pulse wave analysis: Comparison with a common tonometric method. Journal of Human Hypertension, 2010. 24(8): p. 498-504.
13. Weber, T., et al., Validation of a brachial cuff-based method for estimating central systolic blood pressure. Hypertension, 2011. 58(5): p. 825-32.
14. Weiss, W., et al., Oscillometric estimation of central blood pressure:
Validation of the Mobil-O-Graph in comparison with the SphygmoCor device. Blood Pressure Monitoring, 2012. 17(3): p. 128-131.
15. Kang, J.H., et al., A comparison between central blood pressure values obtained by the Gaon system and the SphygmoCor system. Hypertension Research, 2012. 35(3): p. 329-333.
16. Takazawa, K., et al., Estimation of central aortic systolic pressure using late systolic inflection of radial artery pulse and its application to vasodilator therapy. Journal of Hypertension, 2012. 30(5): p. 908-916.
17. Takazawa, K., et al., Relationship between radial and central aeterial pulse wave and evaluation of central aortic pressure using the radial arterial pulse wave. Hypertension Research, 2007. 30(3): p. 219-228.
18. Ding, F.H., et al., Comparison of the SphygmoCor and Omron devices in the estimation of pressure amplification against the invasive catheter
measurement. J Hypertens, 2013. 31(1): p. 86-93.
19. Kips, J.G., et al., Comparison of central pressure estimates obtained from SphygmoCor, Omron HEM-9000AI and carotid applanation tonometry.
Journal of Hypertension, 2011. 29(6): p. 1115-1120.
20. Richardson, C.J., et al., Comparison of estimates of central systolic blood pressure and peripheral augmentation index obtained from the Omron HEM-9000AI and SphygmoCor systems. Artery Research, 2009. 3(1): p. 24- 31.
21. Pucci, G., et al., Evaluation of the Vicorder, a novel cuff-based device for the noninvasive estimation of central blood pressure. J Hypertens, 2013. 31(1):
p. 77-85.
22. Shahin, Y., et al., The Vicorder device compared with SphygmoCor in the assessment of carotid-femoral pulse wave velocity in patients with peripheral arterial disease. Hypertens Res, 2012.
23. Pauca, A.L., N.D. Kon, and M.F. O'Rourke, The second peak of the radial artery pressure wave represents aortic systolic pressure in hypertensive and elderly patients. Br J Anaesth, 2004. 92(5): p. 651-7.
24. Brett, S.E., et al., Estimating central systolic blood pressure during oscillometric determination of blood pressure: Proof of concept and
validation by comparison with intra-aortic pressure recording and arterial tonometry. Blood Pressure Monitoring, 2012. 17(3): p. 132-136.
25. Mekhail, A.M., et al., Non-invasive estimates of central systolic blood pressure: Comparison of the Centron cBP301 and SphygmoCor devices.
Artery Research, 2012. 6(3): p. 109-113.
1 Supplement Three.
Bibliography of Included Studies
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29. Ding, F.H., et al., Comparison of the SphygmoCor and Omron devices in the estimation of pressure amplification against the invasive catheter measurement. J Hypertens, 2013. 31(1): p. 86-93.
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8 39. Garcia-Ortiz, L., et al., Comparison of two measuring instruments, B- pro and SphygmoCor system as reference, to evaluate central systolic blood pressure and radial augmentation index. Hypertension Research, 2012. 35(6):
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48. Horv√°th, I.G., et al., Invasive validation of a new oscillometric device (Arteriograph) for measuring augmentation index, central blood pressure and aortic pulse wave velocity. Journal of Hypertension, 2010. 28(10): p. 2068- 2075.
10 49. Hu, J., et al., Effects of salt substitute on pulse wave analysis among individuals at high cardiovascular risk in rural China: A randomized controlled trial. Hypertension Research, 2009. 32(4): p. 282-288.
50. Hulsen, H.T., et al., Spurious systolic hypertension in young adults;
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51. Jankowski, P., et al., Pulsatile but not steady component of blood pressure predicts cardiovascular events in coronary patients. Hypertension, 2008. 51(4): p. 848-855.
52. Janner, J.H., et al., High aortic augmentation index predicts mortality and cardiovascular events in men from a general population, but not in women. Eur J PrevCardiol, 2012.
53. Jiang, X.J., et al., Superior effect of an angiotensin-converting enzyme inhibitor over a diuretic for reducing aortic systolic pressure. Journal of Hypertension, 2007. 25(5): p. 1095-1099.
54. Kampus, P., et al., Differential effects of nebivolol and metoprolol on central aortic pressure and left ventricular wall thickness. Hypertension, 2011.
57(6): p. 1122-1128.
11 55. Kang, J.H., et al., A comparison between central blood pressure values obtained by the Gaon system and the SphygmoCor system. Hypertension Research, 2012. 35[46]: p. 329-333.
56. Karalliedde, J., et al., Valsartan improves arterial stiffness in type 2 diabetes independently of blood pressure lowering. Hypertension, 2008.
51(6): p. 1617-1623.
57. Kips, J.G., et al., Comparison of central pressure estimates obtained from SphygmoCor, Omron HEM-9000AI and carotid applanation tonometry.
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58. Knez, W.L., et al., Central hemodynamics in ultra-endurance athletes.
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59. Koh, K.P., et al., Effect of Intradialytic Versus Home-Based Aerobic Exercise Training on Physical Function and Vascular Parameters in Hemodialysis Patients: A Randomized Pilot Study. American Journal of Kidney Diseases, 2010. 55(1): p. 88-99.
12 60. Kohara, K., et al., Clinical usefulness of the second peak of radial systolic blood pressure for estimation of aortic systolic blood pressure. Journal of Human Hypertension, 2009. 23(8): p. 538-545.
61. Kolade, O.O., et al., Arterial stiffness, central blood pressure and body size in health and disease. International Journal of Obesity, 2012. 36(1): p.
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62. Laurent, P., et al., Heart rate and pulse pressure amplification in hypertensive subjects. American Journal of Hypertension, 2003. 16(5 I): p.
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63. Laurent, P., et al., Differences in central systolic blood pressure and aortic stiffness between aerobically trained and sedentary individuals. Journal of the American Society of Hypertension, 2011. 5(2): p. 85-93.
64. Lazdam, M., et al., Elevated blood pressure in offspring born premature to hypertensive pregnancy: Is endothelial dysfunction the underlying vascular mechanism? Hypertension, 2010. 56(1): p. 159-165.
65. Leboeuf, A., et al., Impact of dialysate calcium concentration on the progression of aortic stiffness in patients on haemodialysis. Nephrology Dialysis Transplantation, 2011. 26(11): p. 3695-3701.
13 66. Lekakis, J.P., et al., Arterial wave reflection is associated with severity of extracoronary atherosclerosis in patients with coronary artery disease.
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67. Liao, C.F., et al., Determinants of pressure wave reflection:
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68. Lieber, A., et al., Cardiovascular prevention: Relationships between arterial aging and chronic drug treatment. Journal of Human Hypertension, 2011. 25(9): p. 524-531.
69. Lind, L., Endothelium-dependent vasodilation in relation to different measurements of blood pressure in the elderly: The prospective investigation of the Vasculature in Uppsala Seniors study. Blood Pressure Monitoring, 2008. 13(5): p. 245-250.
70. London, G.M., et al., Mechanism(s) of Selective Systolic Blood Pressure Reduction after a Low-Dose Combination of Perindopril/Indapamide in Hypertensive Subjects: Comparison with Atenolol. Journal of the American College of Cardiology, 2004. 43(1): p. 92-99.
14 71. Luzardo, L., et al., 24-h ambulatory recording of aortic pulse wave velocity and central systolic augmentation: A feasibility study. Hypertension Research, 2012. 35(10): p. 980-987.
72. Mahieu, D., et al., Noninvasive assessment of central and peripheral arterial pressure (waveforms): Implications of calibration methods. Journal of Hypertension, 2010. 28(2): p. 300-305.
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74. Majane, O.H.I., et al., Impact of age on the independent association of adiposity with pulse-wave velocity in a population sample of African ancestry.
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75. Manisty, C.H., et al., Differences in the magnitude of wave reflection account for differential effects of amlodipine- versus atenolol-based regimens on central blood pressure: An anglo-scandinavian cardiac outcome trial substudy. Hypertension, 2009. 54(4): p. 724-730.
15 76. Masugata, H., et al., Comparison of central blood pressure and cardio- ankle vascular index for association with cardiac function in treated hypertensive patients. Hypertension Research, 2009. 32(12): p. 1136-1142.
77. Matsui, Y., et al., Differential effects between a calcium channel blocker and a diuretic when used in combination with angiotensin II receptor blocker on central aortic pressure in hypertensive patients. Hypertension, 2009. 54(4):
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78. Matsui, Y., et al., Monitoring of the central pulse pressure is useful for detecting cardiac overload during antiadrenergic treatment: The Japan Morning Surge 1 study. Journal of Hypertension, 2008. 26(10): p. 1928-1934.
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83. Milan, A., et al., Aortic size index enlargement is associated with central hemodynamics in essential hypertension. Hypertension Research, 2011. 34(1): p. 126-132.
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88. Mullan, B.A., et al., Ascorbic acid reduces blood pressure and arterial stiffness in type 2 diabetes. Hypertension, 2002. 40(6): p. 804-809.
89. Nakamura, T., et al., Casein hydrolysate containing Val-Pro-Pro and Ile-Pro-Pro improves central blood pressure and arterial stiffness in hypertensive subjects: A randomized, double-blind, placebo-controlled trial.
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18 92. Nijdam, M.E., et al., Pulse pressure amplification and risk of cardiovascular disease. American Journal of Hypertension, 2008. 21(4): p.
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93. Norton, G.R., et al., Brachial blood pressure-independent relations between radial late systolic shoulder-derived aortic pressures and target organ changes. Hypertension, 2012. 59(4): p. 885-892.
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Supplement Two
Figure S1a: Individual study differences between cSBP and bSBP
measured with SphygmoCor™
Figure S1b: Individual study differences between cSBP and bSBP measured
with SphygmoCor™
Figure S1c: Individual study differences between cSBP and bSBP measured with SphygmoCor™
The mean weighted difference between cSBP and bSBP across all included studies
reporting the use of the SphygmoCor™ device calibrated to noninvasive brachial
SBP and DBP was 12.77 mmHg (95% CI 11.93, 13.60).
Figure S2: Individual study differences between cSBP and bSBP with Carotid applanation (calibration to brachial MBP and DBP)
In studies performed with carotid applanation and calibration to bMBP / bDBP,
the mean weighted difference between cSBP and bSBP was 8.83 mmHg
(95% CI 7.86, 9.79)
Figure S3: Individual study differences between cSBP and bSBP with Arteriograph
The mean weighed difference was -2.57 mmHg (95% CI -8.29, 3.14) for the
Arteriograph device
Figure S4: Individual study differences between cSBP and bSBP with Omron HEM 9000AI
The mean weighted difference between cSBP and bSBP was -1.14 mmHg
(95% CI -7.50, 5.21) across all included studies (non-invasive bSBP was typically
lower than estimated cSBP)
Figure S5: Individual study differences between cSBP and bSBP with Mobil-O-graph
In studies with the Mobil-O-graph device, the mean weighted difference
between cSBP and bSBP was 9.61 mmHg (95% CI -2.18, 21.41)
Figure S6: Individual study differences between cSBP and bSBP with radial applanation and transformation with a “non- SphygmoCor™” GTF
In studies reporting the use of radial applanation with a non- SphygmoCor™
GTF the mean weighted difference between cSBP and bSBP was 9.12 mmHg
(95% CI -4.24, 22.49)
Figure S7: Differences between cSBP and bSBP with carotid applanation and SphygmoCor™ transfer function
The mean weighted difference between cSBP and bSBP was 10.96 mmHg (95% CI
8.08, 13.85) where the SphygmoCor™ algorithm was used to transform the carotid
pressure waveform,
Figure S8: Individual study differences between cSBP and bSBP with the Novacor Diasys Integra II device
The mean weighted difference between cSBP and bSBP was -6.39 mmHg
(95% CI -58.59, 45.80) with the Novacor Diasys Integra™ device.
Figure S9: Individual study differences between cSBP and bSBP with the BPro device
The mean weighted difference between cSBP and bSBP was 9.73 mmHg (95% CI
0.81, 18.65) with the BPro™ algorithm.
Figure S10: Individual study differences between cSBP and bSBP with radial tonometry P2 equivalence technique
The mean weighted difference between cSBP and bSBP was 8.98 mmHg (95% CI - 11.92, 29.89) with radial P2 analysis.
Figure S11: Individual study differences between cSBP and bSBP with brachial oscillometric estimation of P2
The mean difference between brachial and cSBP with non-invasive brachial
estimation of cSBP2, was 10.34 mmHg (95% CI -29.45, 50.13).
Figure S12: Individual study differences between cSBP and bSBP with the Gaon system
The mean weighted difference between cSBP and bSBP was 13 mmHg (95% CI 8.68, 17.32) with the Gaon™ device / algorithm.
Figure S13: Individual study differences between cSBP and bSBP with the Centron CBP301 system
The mean weighted difference between cSBP and bSBP was 13.30 mmHg (95% CI
7.71, 18.89) with the Centron CBP 301™ device.
Figure S14: Differences between cSBP and bSBP with various devices in patients with Renal impairment
The mean weighted difference for the SphygmoCor™ technique was 11.93 mmHg
(95% CI -3.61, 27.46). Only two studies reported the use of the carotid applanation
technique with calibration to MBP and DBP. The pooled mean weighted difference
for these studies was 4.37 mmHg (95% CI -48.88, 57.61).
Figure S15: Differences between cSBP and bSBP with various devices in patients with Diabetes
The mean weighted difference for the SphygmoCor™ technique in cohorts with diabetes was 13.23 mmHg (95% CI -6.59, 19.87). The mean difference for the single study reporting results with the carotid applanation technique with calibration to MBP and DBP was -1.0 mmHg (95% CI -10.62, 8.62). The mean weighted difference for the single Arteriograph study was -2.9 mmHg (95% CI -4.82, -0.96).
Figure S16: Differences between cSBP and bSBP with various devices in
patients with other includable conditions
Three studies reporting invasive central pressures were available in this category, with a pooled mean difference of 0.13 mmHg (95% CI -32.48, 32.75). The mean weighted difference for the SphygmoCor™ technique was 10.72 mmHg (95% CI 1.36, 20.07) and 9.09 mmHg (95% CI -13.95, 32.13) for the carotid applanation technique with calibration to MBP and DBP. A negative mean weighted difference of -7.05 mmHg (95% CI -43.75, 29.64) was noted for the Omron HEM 9000AI technique.
Figure S17: Differences between cSBP and bSBP with various devices in
patients with mixed coronary risk factors
The mean weighted difference for the SphygmoCor™ technique in cohorts with a
high prevalence of coronary risk factors was 9.59 mmHg (95% CI -5.02, 24.19). The
mean weighted difference for the carotid applanation technique with calibration to
MBP and DBP was 9.47 mmHg (95% CI 6.74, 12.21)
