HomeHypertensionVol. 53, No. 4Arterial Stiffness, Fatness, and Physical Fitness Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBArterial Stiffness, Fatness, and Physical FitnessReady for Intervention in Childhood and Across the Life Course? J. Kennedy Cruickshank, Mohammadreza Rezailashkajani and Guillaume Goudot J. Kennedy CruickshankJ. Kennedy Cruickshank From the Cardiovascular Sciences (J.K.C., M.R.), University of Manchester, Manchester, United Kingdom; and U 684 INSERM-UHP (G.G.), Faculty of Medicine, Nancy Universite, France. Search for more papers by this author , Mohammadreza RezailashkajaniMohammadreza Rezailashkajani From the Cardiovascular Sciences (J.K.C., M.R.), University of Manchester, Manchester, United Kingdom; and U 684 INSERM-UHP (G.G.), Faculty of Medicine, Nancy Universite, France. Search for more papers by this author and Guillaume GoudotGuillaume Goudot From the Cardiovascular Sciences (J.K.C., M.R.), University of Manchester, Manchester, United Kingdom; and U 684 INSERM-UHP (G.G.), Faculty of Medicine, Nancy Universite, France. Search for more papers by this author Originally published9 Mar 2009https://doi.org/10.1161/HYPERTENSIONAHA.108.128033Hypertension. 2009;53:602–604Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 9, 2009: Previous Version 1 Arterial distensibility and its converse stiffness have come of age as physiological concepts1 and now as a target for intervention. The central hypothesis sustained so far is that an individual’s “arterial stiffness” measured as aortic pulse wave velocity (PWV) is a convenient, integrated index of vascular pathology over a person’s life course, more precise and reliable than other risk factors individually. For example, blood pressure (BP), whether casual or 24 hour, is more sensitive to stimuli and, therefore, more variable. Arterial distensibility is in part dependent on BP, yet its prognostic power is because of its “independence” from BP, including pulse pressure.2 It appears to indicate the general burden of atherosclerotic disease and subclinical damage from multiple risk factors over time: the “wear and tear” of constant distension and recoil (part of “aging”), effects of smoking, lipid metabolism, (hyper)glycemia, ethnicity, how family history expresses itself, etc.3 European hypertension guidelines now include PWV as a recommended but optional measure. The relationship of arterial distensibility with cardiac function and structure, known as aorto-ventricular coupling, is tantalizing because, as a bioengineering feedback loop, cause and effect are still unclear. Many other key questions remain, most critically related to the natural history of arterial stiffness but also fundamental ones of basic structural biology in the vessel wall.A clue to the natural history of arterial stiffness is published in this issue of Hypertension, an Australian study of 9- to 10-year-old, generally prepubescent schoolchildren.4 The study shows a clear relationship among degree of body fat, physical fitness, and arterial stiffness, measured by carotid-femoral PWV. The link of PWV with fitness was not independent of body fat. Why should this article be of interest, being only cross-sectional, whereby association may well not imply cause? The answer is its insight into primary prevention and underlying mechanisms. The study’s strengths include its community base, large number of healthy children properly sampled, gold-standard “DXA” assessment of body composition, and an accepted method for PWV measurement. Its weaknesses include PWV measured sequentially rather than simultaneously at carotid and femoral sites over only 8 cardiac cycles. Another is the use of a 20-m shuttle run to assess cardiorespiratory fitness, which can be characterized by a variety of methods that the authors understandably could not apply but do not discuss or compare. Similarly, the pedometer is insensitive for assessing physical activity, especially in children, who may remove it. Perhaps as a result, only 20% of the variance of the PWV measured was related to any of their variables. However, these weaknesses would tend to bias the results toward the null so that any association with PWV was remarkable.OpportunitiesIf the hypothesis(es) listed above are not refuted and they stand the test of time and of effective intervention, the interplay of fatness and physical fitness on regional and central arterial performances offers tremendous opportunities. First and most widely applicable is a role for arterial stiffness in public health education, rather more immediate than what BP can offer. Promoting to children and adolescents how their blood vessels and heart work and respond to exercise might just encourage practical uptake of physical activity but also scientific interest in their own human biology. Some relatively simple concepts can be grasped by teachers and potentially at least secondary or high school children: how blood vessel expansion after each heart beat becomes limited over time (“stiffening”) and that the vessels can then no longer act as effectively to “smooth” the circulation of blood while the heart rests, which can lead to disease. It may be no coincidence that the lay public use and perhaps intuitively appreciate “hardening of the arteries” as a term. Having such a focus on which to hang projects for intervention in early life might have a better chance of success than mere preaching.Second, the list of nonpharmacological interventions that favorably affect arterial stiffness is impressive and growing, as reviewed recently.5 Physical activity remains highly promising; 15 years ago, a month’s moderate exercise training was found to improve arterial compliance independent of BP change in sedentary people. However, muscular strength training appears to do the opposite.6 Salt restriction is effective.7 Other dietary factors, such as moderate alcohol intake and types of fat, including oddities such as α-linoleic acid, fish oil, garlic powder, and dark chocolate, all apparently lower arterial stiffness (see Reference2). Whether and how these alter arterial pathology, per se, are unclear.8Third, these data provide momentum for the definitive test of the use of arterial stiffness as a target: full-scale randomized trials of pharmacological interventions on the background of these lifestyle maneuvers. Such trials are long overdue, but their time surely has arrived.Why Stiffness Rather Than Other Vascular Measures (Intima-Medial Thickness, Flow-Mediated Dilatation, or Central Pressure)?Noninvasive vascular measures available in youth are the same as those in adults,9 including carotid intima-medial thickness, forearm flow-mediated dilatation (FMD), and central pressures. Intima-medial thickness and flow-mediated dilatation both demand highly trained observers and, more troublesome, the change in intima-medial thickness values from 7 to 18 years of age seems to be minimal. A disadvantage of flow-mediated dilatation is that forearm vessels are not subject to atheroma, and the ischemic time hurts many people. However, flow-mediated dilatation values are markedly reduced in obese, diabetic, and hypercholesterolemic children,9 and there is little doubt that improved endothelial function promptly improves vessel distensibility in arteries with little disease (probably via endothelial NO synthase). Finally, “central” BP, derived from the radial or carotid tonometric waveform, varies as brachial BP does, even if interventions may differentially affect these values.10 The use of central BP in children is not established yet, but the technique has its enthusiasts.11We would argue that for a brief, one-time estimate of general arterial health and as a more complete index of arterial integrity, measurement of arterial stiffness via PWV is the most useful. It has greater simplicity; less general variability and, hence, good repeatability; is a more complete index of arterial integrity; and is much less uncomfortable for the participant. One issue before its widespread acceptance is that several techniques for different arterial paths exist,2 confusing to those happy with BP measurement alone. Which technique should be used? Most devices measuring PWV over the carotid-femoral path use Doppler (flow wave) and tonometric (pressure wave) methods at each site, R-wave gated or not. Length measures are arbitrary and may be prone to error (eg, suprasternal notch to the probe site on the neck or groin). Tonometry requires a surface vessel, whereas Doppler ultrasound can penetrate short distances through adipose or other tissue. We prefer Doppler methods for insonating the central descending aorta (from the arch at the left subclavian junction to just proximal to the bifurcation around the umbilicus), which minimizes diameter tapering of vessels and reflection artifacts that result. However, these devices, although relatively simple, are not as quick to use as tonometry or commercially available, even if they are cheaper and among the oldest in use.12 Finally, there are more sophisticated techniques, eg, for aortic impedance, which require blood flow measures.13For children, carotid-femoral tonometry, despite its anatomic drawbacks, is probably the quickest, as used by Sakuragi et al4 via the well-known SphygmoCor. Other recent methods include the so-called ankle-brachial PWV by the Collin-Omron device (in fact cardiac-radial and cardiac-to-posterior tibial or dorsalis pedis, which the software can provide).14 A novel Hungarian-origin device, the Arteriograph, using just upper-arm oscillometry and the suprasternal notch-to-pubis distance, has been validated.15 Note that only the Doppler methods and the Collin-Omron device allow femoral-to-dorsalis pedis PWV measurement over a muscular artery pathway, which may be of particular interest in growing children.Pharmacological InterventionsMany antihypertensive, lipid-lowering, and anti–tumor necrosis factor drugs reduce PWV, as do discontinued “advanced glycation end-product” breakers in diabetes mellitus and hormone replacement therapy.16 Importantly, as studied to date, statins reduce PWV but not central pressure.10ConclusionChanges of arterial stiffness with physical fitness, perhaps mediated through body fat, start early in childhood. In principle, because of less variability, PWV has apparently greater precision than any BP measure. As an index of general arterial status, effective interventions on PWV offer greater power, and, thus, a much smaller sample size in which to test efficacy on cardiovascular outcomes. Trials should, therefore, cost much less. The key question is whether PWV reduction results in reduced cardiovascular events and mortality, a hypothesis that needs testing in randomized trials as soon as possible.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.DisclosuresThere are no conflicts of interest to disclose: J.K.C.’s unit continues to test out and use various devices, bought, loaned, or donated, for measuring pulse wave velocity, including those mentioned in the text.FootnotesCorrespondence to J. Kennedy Cruickshank, Cardiovascular Sciences, 3rd Floor CTF, University of Manchester, 46 Grafton St, Manchester M13 9NT, United Kingdom. E-mail [email protected] References 1 Nichols WW, O'Rourke MF, McDonald DA. McDonald’s Blood Flow in Arteries: Theoretic, Experimental, and Clinical Principles. London, United Kingdom: Hodder Arnold; distributed in the United States by Oxford University Press; 2005.Google Scholar2 Laurent S, Cockcroft J, Van Bortel L, Boutouyrie P, Giannattasio C, Hayoz D, Pannier B, Vlachopoulos C, Wilkinson I, Struijker-Boudier H. Expert consensus document on arterial stiffness: methodological issues and clinical applications. Eur Heart J. 2006; 27: 2588–2605.CrossrefMedlineGoogle Scholar3 Cruickshank K, Riste L, Anderson SG, Wright JS, Dunn G, Gosling RG. Aortic pulse-wave velocity and its relationship to mortality in diabetes and glucose intolerance: an integrated index of vascular function? Circulation. 2002; 106: 2085–2090.LinkGoogle Scholar4 Sakuragi S, Abhayaratna K, Gravenmaker KJ, O'Reilly C, Srikusalanukul W, Budge MM, Telford RD, Abhayaratna WP. Influence of adiposity and physical activity on arterial stiffness in healthy children: the Lifestyle of Our Kids Study. Hypertension. 2009; 53: 611–616.LinkGoogle Scholar5 Hamilton PK, Lockhart CJ, Quinn CE, McVeigh GE. Arterial stiffness: clinical relevance, measurement and treatment. Clin Sci (Lond). 2007; 113: 157–170.CrossrefMedlineGoogle Scholar6 Bertovic DA, Waddell TK, Gatzka CD, Cameron JD, Dart AM, Kingwell BA. Muscular strength training is associated with low arterial compliance and high pulse pressure. Hypertension. 1999; 33: 1385–1391.CrossrefMedlineGoogle Scholar7 Gates PE, Tanaka H, Hiatt WR, Seals DR. Dietary sodium restriction rapidly improves large elastic artery compliance in older adults with systolic hypertension. Hypertension. 2004; 44: 35–41.LinkGoogle Scholar8 Greenwald SE. Ageing of the conduit arteries. J Pathol. 2007; 211: 157–172.CrossrefMedlineGoogle Scholar9 Fernhall B, Agiovlasitis S. Arterial function in youth: window into cardiovascular risk. J Appl Physiol. 2008; 105: 325–333.CrossrefMedlineGoogle Scholar10 Williams B, Lacy PS, Cruickshank JK, Collier D, Hughes AD, Stanton A, Thom S, Thurston H. Impact of statin therapy on central aortic pressures and hemodynamics: principal results of the Conduit Artery Function Evaluation-Lipid-Lowering Arm (Cafe-LLA) Study. Circulation. 2009; 119: 53–61.LinkGoogle Scholar11 Agabiti-Rosei E, Mancia G, O'Rourke MF, Roman MJ, Safar ME, Smulyan H, Wang JG, Wilkinson IB, Williams B, Vlachopoulos C. Central blood pressure measurements and antihypertensive therapy: a consensus document. Hypertension. 2007; 50: 154–160.LinkGoogle Scholar12 Laogun AA, Gosling RG. In vivo arterial compliance in man. Clin Phys Physiol Meas. 1982; 3: 201–212.CrossrefMedlineGoogle Scholar13 Lieb W, Larson MG, Benjamin EJ, Yin X, Tofler GH, Selhub J, Jacques PF, Wang TJ, Vita JA, Levy D, Vasan RS, Mitchell GF. Multimarker approach to evaluate correlates of vascular stiffness: the Framingham Heart Study. Circulation. 2009; 119: 37–43.LinkGoogle Scholar14 Sugawara J, Hayashi K, Yokoi T, Cortez-Cooper MY, DeVan AE, Anton MA, Tanaka H. Brachial-ankle pulse wave velocity: an index of central arterial stiffness? J Hum Hypertens. 2005; 19: 401–406.CrossrefMedlineGoogle Scholar15 Rajzer MW, Wojciechowska W, Klocek M, Palka I, Brzozowska-Kiszka M, Kawecka-Jaszcz K. Comparison of aortic pulse wave velocity measured by three techniques: Complior, Sphygmocor and Arteriograph. J Hypertens. 2008; 26: 2001–2007.CrossrefMedlineGoogle Scholar16 Hope SA, Hughes AD. Drug effects on the mechanical properties of large arteries in humans. Clin Exp Pharmacol Physiol. 2007; 34: 688–693.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sun P, Chen X, Zeng Z, Li S, Wang J, Yu F, Liu S, Li H and Fernhall B (2020) Sex differences in lower-limb arterial stiffness following acute aerobic exercise, Science & Sports, 10.1016/j.scispo.2019.02.007, 35:2, (e39-e48), Online publication date: 1-Apr-2020. Yeboah K, Agyekum J, Owusu Mensah R, Affrim P, Adu-Gyamfi L, Doughan R and Adjei A (2018) Arterial Stiffness Is Associated with Peripheral Sensory Neuropathy in Diabetes Patients in Ghana, Journal of Diabetes Research, 10.1155/2018/2320737, 2018, (1-8), . Meyer J, Elmenhorst J, Giegerich T, Oberhoffer R and Müller J (2017) Controversies in the association of cardiorespiratory fitness and arterial stiffness in children and adolescents, Hypertension Research, 10.1038/hr.2017.19, 40:7, (675-678), Online publication date: 1-Jul-2017. Tan C, Low K, Kong T, Fletcher M, Zimmerman B, Maclin E, Chiarelli A, Gratton G, Fabiani M and Rypma B (2017) Mapping cerebral pulse pressure and arterial compliance over the adult lifespan with optical imaging, PLOS ONE, 10.1371/journal.pone.0171305, 12:2, (e0171305) Weberruß H, Pirzer R, Schulz T, Böhm B, Dalla Pozza R, Netz H and Oberhoffer R (2016) Reduced arterial stiffness in very fit boys and girls, Cardiology in the Young, 10.1017/S1047951116000226, 27:1, (117-124), Online publication date: 1-Jan-2017. Yeboah K, Antwi D, Gyan B, Govoni V, Mills C, Cruickshank J and Amoah A (2016) Arterial stiffness in hypertensive and type 2 diabetes patients in Ghana: comparison of the cardio-ankle vascular index and central aortic techniques, BMC Endocrine Disorders, 10.1186/s12902-016-0135-5, 16:1, Online publication date: 1-Dec-2016. Bal-Theoleyre L, Lalande A, Kober F, Giorgi R, Collart F, Piquet P, Habib G, Avierinos J, Bernard M, Guye M, Jacquier A and Pirro M (2016) Aortic Function’s Adaptation in Response to Exercise-Induced Stress Assessing by 1.5T MRI: A Pilot Study in Healthy Volunteers, PLOS ONE, 10.1371/journal.pone.0157704, 11:6, (e0157704) Cruickshank J, Silva M, Molaodi O, Enayat Z, Cassidy A, Karamanos A, Read U, Faconti L, Dall P, Stansfield B and Harding S (2016) Ethnic Differences in and Childhood Influences on Early Adult Pulse Wave Velocity, Hypertension, 67:6, (1133-1141), Online publication date: 1-Jun-2016. Zhu W, Hooker S, Sun Y, Xie M, Su H and Cao J (2014) Associations of cardiorespiratory fitness with cardiovascular disease risk factors in middle-aged Chinese women: a cross-sectional study, BMC Women's Health, 10.1186/1472-6874-14-62, 14:1, Online publication date: 1-Dec-2014. Alwan N, Cade J, Greenwood D, Deanfield J, Lawlor D and Blachier F (2014) Associations of Maternal Iron Intake and Hemoglobin in Pregnancy with Offspring Vascular Phenotypes and Adiposity at Age 10: Findings from the Avon Longitudinal Study of Parents and Children, PLoS ONE, 10.1371/journal.pone.0084684, 9:1, (e84684) Vlachantoni I, Dikaiakou E, Antonopoulos C, Stefanadis C, Daskalopoulou S and Petridou E (2013) Effects of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea in arterial stiffness: A meta-analysis, Sleep Medicine Reviews, 10.1016/j.smrv.2012.01.002, 17:1, (19-28), Online publication date: 1-Feb-2013. Doonan R, Scheffler P, Yu A, Egiziano G, Mutter A, Bacon S, Carli F, Daskalopoulos M, Daskalopoulou S and Abbate A (2011) Altered Arterial Stiffness and Subendocardial Viability Ratio in Young Healthy Light Smokers after Acute Exercise, PLoS ONE, 10.1371/journal.pone.0026151, 6:10, (e26151) Lawrence-Wright M, Boyne M, Osmond C, Fraser R, Soares-Wynter S, Thame M, Reid M, Taylor-Bryan C and Forrester T (2010) The effect of feto-maternal size and childhood growth on left ventricular mass and arterial stiffness in Afro-Caribbean children, Journal of Human Hypertension, 10.1038/jhh.2010.84, 25:7, (457-464), Online publication date: 1-Jul-2011. Barton M and Meyer M (2009) Postmenopausal Hypertension, Hypertension, 54:1, (11-18), Online publication date: 1-Jul-2009. April 2009Vol 53, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/HYPERTENSIONAHA.108.128033PMID: 19273738 Originally publishedMarch 9, 2009 PDF download Advertisement SubjectsEpidemiologyImagingPrimary PreventionTreatmentUltrasoundVascular Biology