エルゴメータ時の非観血連続血圧モニター1
This study investigated the neural regions involved in blood pressure reactions to negative stimuli and their possible modulation by attention.Twenty-fourhealthyhumansubjects(11females;age24.752.49years)participatedinanaffectiveperceptualloadtask thatmanipulatedattentiontonegative/neutraldistractorpictures.fMRIdatawerecollectedsimultaneouslywithcontinuousrecordingof peripheral arterial blood pressure. A parametric modulation analysis examined the impact of attention and emotion on the relation between neural activation and blood pressure reactivity during the task. When attention was available for processing the distractor pictures,negativepicturesresultedinbehavioralinterference,neuralactivationinbrainregionspreviouslyrelatedtoemotion,atransient decrease of blood pressure, and a positive correlation between blood pressure response and activation in a network including prefrontalandparietalregions,theamygdala,caudate,andmid-brain.Theseeffectsweremodulatedbyattention;behavioralandneural responsestohighlynegativedistractorpictures(comparedwithneutralpictures)weresmallerordiminished,aswasthenegativeblood pressureresponsewhenthecentraltaskinvolvedhighperceptualload.Furthermore,comparinghighandlowloadrevealedenhanced activationinfrontoparietalregionsimplicatedinattentioncontrol.Ourresultsfittheoriesemphasizingtheroleofattentioninthecontrol of behavioral and neural reactions to irrelevant emotional distracting information. Our findings furthermore extend the function of attention to the control of autonomous reactions associated with negative emotions by showing altered blood pressure reactions to emotionalstimuli,thelatterbeingofpotentialclinicalrelevance.
Introduction Threatening stimuli prototypically facilitate adaptive motor behavior and activate the autonomic nervous system, affecting heart rate and blood pressure (Lang et al., 2000). These vascular responsescanaggravatewhenthethreateningsituationdevelops into stress for the organism. It has been shown that, among healthy subjects, those with higher blood pressure responses are morelikelytosubsequentlydevelophypertension(Matthewsetal., 2004). It is therefore highly relevant to identify neural mechanisms forthevascularresponseandpotentialwaystomodulateit. Studies on the neural underpinnings of vascular response to stressidentifiedbrainareasknowntobeassociatedwithemotion processing, including the amygdala, insula, and cingulate (Gian
aros and Sheu, 2009). These pioneer studies used intermittent bloodpressuremeasurementsbetweenfunctionalneuroimaging andwerethereforelimitedtolonger-lasting“stressperiods.”Recent technical developments (Gray et al., 2009), however, on which we build here, allow for simultaneous recording of blood pressure during fMRI to match neural activity associated with brief (threatening) events closely to blood pressure changes. Regarding potential ways to modulate emotion-related autonomicresponses,acrucialquestionconcernsthedegreetowhich reactions to emotional stimuli are affected by cognitive mechanisms. A debate exists on whether processing of emotional items depends on allocation of sufficient attention to them (see Pessoa et al., 2002 and Evans et al., 2011 for similar effects on attention bias to drug-related cues in drug-addicts). Recent models propose that projections from frontoparietal regions to amygdala modulatereactionstoemotionalstimuli(cf.Pessoa,2009,Pourtois et al., 2013). Conversely, it has been suggested that although attentioninfluencesemotionprocessing,itmaynotaffectneural activation related to defensive motor responses (Pichon et al., 2012). If the latter were coupled to autonomic responses, this would mean that (action-related) vascular responses to emotional stimuli could occur independently of attention to them. Motivatedbytheseconsiderations,theaimsofthisstudywereto identifyneuralregionsinvolvedinbloodpressureresponsestoemo
ReceivedFeb
Introduction Threatening stimuli prototypically facilitate adaptive motor behavior and activate the autonomic nervous system, affecting heart rate and blood pressure (Lang et al., 2000). These vascular responsescanaggravatewhenthethreateningsituationdevelops into stress for the organism. It has been shown that, among healthy subjects, those with higher blood pressure responses are morelikelytosubsequentlydevelophypertension(Matthewsetal., 2004). It is therefore highly relevant to identify neural mechanisms forthevascularresponseandpotentialwaystomodulateit. Studies on the neural underpinnings of vascular response to stressidentifiedbrainareasknowntobeassociatedwithemotion processing, including the amygdala, insula, and cingulate (Gian
aros and Sheu, 2009). These pioneer studies used intermittent bloodpressuremeasurementsbetweenfunctionalneuroimaging andwerethereforelimitedtolonger-lasting“stressperiods.”Recent technical developments (Gray et al., 2009), however, on which we build here, allow for simultaneous recording of blood pressure during fMRI to match neural activity associated with brief (threatening) events closely to blood pressure changes. Regarding potential ways to modulate emotion-related autonomicresponses,acrucialquestionconcernsthedegreetowhich reactions to emotional stimuli are affected by cognitive mechanisms. A debate exists on whether processing of emotional items depends on allocation of sufficient attention to them (see Pessoa et al., 2002 and Evans et al., 2011 for similar effects on attention bias to drug-related cues in drug-addicts). Recent models propose that projections from frontoparietal regions to amygdala modulatereactionstoemotionalstimuli(cf.Pessoa,2009,Pourtois et al., 2013). Conversely, it has been suggested that although attentioninfluencesemotionprocessing,itmaynotaffectneural activation related to defensive motor responses (Pichon et al., 2012). If the latter were coupled to autonomic responses, this would mean that (action-related) vascular responses to emotional stimuli could occur independently of attention to them. Motivatedbytheseconsiderations,theaimsofthisstudywereto identifyneuralregionsinvolvedinbloodpressureresponsestoemo
ReceivedFeb
httpswww.ncbi.nlm.nih.govpmcarticlesPMC5361833
BMC Anesthesiol. 2017; 17: 48.
Published online 2017 Mar 21. doi: 10.1186/s12871-017-0337-z
PMCID: PMC5361833
PMID: 28327093
Continuous Non-invasive finger cuff CareTaker® comparable to invasive intra-arterial pressure in patients undergoing major intra-abdominal surgery
Irwin Gratz,1 Edward Deal,1 Francis Spitz,1 Martin Baruch,2 I. Elaine Allen,3 Julia E. Seaman,4 Erin Pukenas,1 and Smith Jean1
Author information Article notes Copyright and License information Disclaimer
This article has been cited by other articles in PMC.
Associated Data
Data Availability Statement
The datasets generated during and analysed for the current study are available from the corresponding author on reasonable request.
Abstract
Background
Despite increased interest in non-invasive arterial pressure monitoring, the majority of commercially available technologies have failed to satisfy the limits established for the validation of automatic arterial pressure monitoring by the Association for the Advancement of Medical Instrumentation (AAMI). According to the ANSI/AAMI/ISO 81060–2:2013 standards, the group-average accuracy and precision are defined as acceptable if bias is not greater than 5 mmHg and standard deviation is not greater than 8 mmHg. In this study, these standards are used to evaluate the CareTaker® (CT) device, a device measuring continuous non-invasive blood pressure via a pulse contour algorithm called Pulse Decomposition Analysis.
Methods
A convenience sample of 24 patients scheduled for major abdominal surgery were consented to participate in this IRB approved pilot study. Each patient was monitored with a radial arterial catheter and CT using a finger cuff applied to the contralateral thumb. Hemodynamic variables were measured and analyzed from both devices for the first thirty minutes of the surgical procedure including the induction of anesthesia. The mean arterial pressure (MAP), systolic and diastolic blood pressures continuously collected from the arterial catheter and CT were compared. Pearson correlation coefficients were calculated between arterial catheter and CT blood pressure measurements, a Bland-Altman analysis, and polar and 4Q plots were created.
Results
The correlation of systolic, diastolic, and mean arterial pressures were 0.92, 0.86, 0.91, respectively (p < 0.0001 for all the comparisons). The Bland-Altman comparison yielded a bias (as measured by overall mean difference) of −0.57, −2.52, 1.01 mmHg for systolic, diastolic, and mean arterial pressures, respectively with a standard deviation of 7.34, 6.47, 5.33 mmHg for systolic, diastolic, and mean arterial pressures, respectively (p < 0.001 for all comparisons). The polar plot indicates little bias between the two methods (90%/95% CI at 31.5°/52°, respectively, overall bias = 1.5°) with only a small percentage of points outside these lines. The 4Q plot indicates good concordance and no bias between the methods.
Conclusions
In this study, blood pressure measured using the non-invasive CT device was shown to correlate well with the arterial catheter measurements. Larger studies are needed to confirm these results in more varied settings. Most patients exhibited very good agreement between methods. Results were well within the limits established for the validation of automatic arterial pressure monitoring by the AAMI.
Keywords: Non-Invasive, CareTaker, Central blood pressure, Finger cuff, Intra-Arterial pressure
BMC Anesthesiol. 2017; 17: 48.
Published online 2017 Mar 21. doi: 10.1186/s12871-017-0337-z
PMCID: PMC5361833
PMID: 28327093
Continuous Non-invasive finger cuff CareTaker® comparable to invasive intra-arterial pressure in patients undergoing major intra-abdominal surgery
Irwin Gratz,1 Edward Deal,1 Francis Spitz,1 Martin Baruch,2 I. Elaine Allen,3 Julia E. Seaman,4 Erin Pukenas,1 and Smith Jean1
Author information Article notes Copyright and License information Disclaimer
This article has been cited by other articles in PMC.
Associated Data
Data Availability Statement
The datasets generated during and analysed for the current study are available from the corresponding author on reasonable request.
Abstract
Background
Despite increased interest in non-invasive arterial pressure monitoring, the majority of commercially available technologies have failed to satisfy the limits established for the validation of automatic arterial pressure monitoring by the Association for the Advancement of Medical Instrumentation (AAMI). According to the ANSI/AAMI/ISO 81060–2:2013 standards, the group-average accuracy and precision are defined as acceptable if bias is not greater than 5 mmHg and standard deviation is not greater than 8 mmHg. In this study, these standards are used to evaluate the CareTaker® (CT) device, a device measuring continuous non-invasive blood pressure via a pulse contour algorithm called Pulse Decomposition Analysis.
Methods
A convenience sample of 24 patients scheduled for major abdominal surgery were consented to participate in this IRB approved pilot study. Each patient was monitored with a radial arterial catheter and CT using a finger cuff applied to the contralateral thumb. Hemodynamic variables were measured and analyzed from both devices for the first thirty minutes of the surgical procedure including the induction of anesthesia. The mean arterial pressure (MAP), systolic and diastolic blood pressures continuously collected from the arterial catheter and CT were compared. Pearson correlation coefficients were calculated between arterial catheter and CT blood pressure measurements, a Bland-Altman analysis, and polar and 4Q plots were created.
Results
The correlation of systolic, diastolic, and mean arterial pressures were 0.92, 0.86, 0.91, respectively (p < 0.0001 for all the comparisons). The Bland-Altman comparison yielded a bias (as measured by overall mean difference) of −0.57, −2.52, 1.01 mmHg for systolic, diastolic, and mean arterial pressures, respectively with a standard deviation of 7.34, 6.47, 5.33 mmHg for systolic, diastolic, and mean arterial pressures, respectively (p < 0.001 for all comparisons). The polar plot indicates little bias between the two methods (90%/95% CI at 31.5°/52°, respectively, overall bias = 1.5°) with only a small percentage of points outside these lines. The 4Q plot indicates good concordance and no bias between the methods.
Conclusions
In this study, blood pressure measured using the non-invasive CT device was shown to correlate well with the arterial catheter measurements. Larger studies are needed to confirm these results in more varied settings. Most patients exhibited very good agreement between methods. Results were well within the limits established for the validation of automatic arterial pressure monitoring by the AAMI.
Keywords: Non-Invasive, CareTaker, Central blood pressure, Finger cuff, Intra-Arterial pressure
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.
Keywords Central pressure † Blood pressure † Anti-hypertensive treatment † Cardiovascular risk
Introduction
The brachial cuff sphygmomanometer was introduced into medical
practice well over 100 years ago, enabling the routine, non-invasive,
measurement of arterial blood pressure. Life insurance companies
were among the first to capitalize on the information provided by
cuff sphygmomanometry, by observing that blood pressure in
largely asymptomatic individuals relates to future cardiovascular
risk—observations that are nowsupported by a wealth of epidemiological
data.1 The most recent Global Burden of Disease report2
identified hypertension as the leading cause of death and disability
worldwide. 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 pressure
has become embedded in routine clinical assessment throughout the
developed world, and is one of the most widely accepted ‘surrogate
measures’ for regulatory bodies.
The major driving force for the continued use of brachial blood
pressure has been its ease of measurement, and the wide variety of
devices available for clinical use. However, we have known for over
half a century that brachial pressure is a poor surrogate for aortic
pressure, which is invariably lower than corresponding brachial
values. Recent evidence suggests that central pressure is also more
strongly related to future cardiovascular events4 – 7 than brachial
pressure, and responds differently to certain drugs.8,9 Appreciating
this provides an ideal framework for understanding the much publicized
inferiority of atenolol and some other beta-blockers,10 compared
with other drug classes, in the management of essential
hypertension. Although central pressure can now be assessed noninvasively
with the same ease as brachial pressure, clinicians are unlikely
to discard the brachial cuff sphygmomanometer without
robust evidence that cardiovascular risk stratification, and monitoring
response to therapy, are better when based on central rather
than peripheral pressure. Central pressure assessment and accuracy
will also have to be standardized, as it has been for brachial pressure
assessment with oscillometric devices. This review will discuss our
current understanding about central pressure and the evidence
required to bring blood pressure measurement, and cardiovascular
risk assessment into the modern era.
Physiological concepts
Arterial pressure varies continuously over the cardiac cycle, but in
clinical practice only systolic and diastolic pressures are routinely
reported. These are invariably measured in the brachial artery
using 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
Pressure measured with a cuff and sphygmomanometer in the brachial artery is accepted as an important predictor of future cardiovascular risk.However, systolic pressure varies throughout the arterial tree, such that aortic (central) systolic pressure is actually lower than corresponding brachial values, although this difference is highly variable between individuals. Emerging evidence now suggests that central pressure is better related to future cardiovascular events than is brachial pressure. Moreover, anti-hypertensive drugs can exert differential effects on brachial 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.As discussed earlier, a full synthesis of the available evidence concerning
central pressure and the risk of future cardiovascular events is now required. However, it will also be necessary to determine the clinical relevance of differences between brachial and central pressure
for the individual patient, especially given the relatively high correlation between the two. Emerging data support the prognostic superiority of both 24-h ambulatory blood pressure monitoring
(ABPM)79 – 81 andhomemonitoring81 in comparison with office measurements. Interestingly, a recent study82 demonstrated that 24-h ambulatory cuff pressures were comparable with office central pressure
measurements in the prediction of risk, although the significance of this study awaits confirmation.83 As yet, there are no data comparing the predictive value ofhomemonitoring vs. central pressure in the
prediction of risk. Ultimately, it will be necessary to evaluate the prognostic value of 24-h ambulatory central pressure.With the recent development of ambulatory central pressure systems,84,85 this is now
possible and it may be reasonable to hypothesize that 24-h central, rather than brachial ABPM would be superior in terms of risk prediction.
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.
Keywords Central pressure † Blood pressure † Anti-hypertensive treatment † Cardiovascular risk
Introduction
The brachial cuff sphygmomanometer was introduced into medical
practice well over 100 years ago, enabling the routine, non-invasive,
measurement of arterial blood pressure. Life insurance companies
were among the first to capitalize on the information provided by
cuff sphygmomanometry, by observing that blood pressure in
largely asymptomatic individuals relates to future cardiovascular
risk—observations that are nowsupported by a wealth of epidemiological
data.1 The most recent Global Burden of Disease report2
identified hypertension as the leading cause of death and disability
worldwide. 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 pressure
has become embedded in routine clinical assessment throughout the
developed world, and is one of the most widely accepted ‘surrogate
measures’ for regulatory bodies.
The major driving force for the continued use of brachial blood
pressure has been its ease of measurement, and the wide variety of
devices available for clinical use. However, we have known for over
half a century that brachial pressure is a poor surrogate for aortic
pressure, which is invariably lower than corresponding brachial
values. Recent evidence suggests that central pressure is also more
strongly related to future cardiovascular events4 – 7 than brachial
pressure, and responds differently to certain drugs.8,9 Appreciating
this provides an ideal framework for understanding the much publicized
inferiority of atenolol and some other beta-blockers,10 compared
with other drug classes, in the management of essential
hypertension. Although central pressure can now be assessed noninvasively
with the same ease as brachial pressure, clinicians are unlikely
to discard the brachial cuff sphygmomanometer without
robust evidence that cardiovascular risk stratification, and monitoring
response to therapy, are better when based on central rather
than peripheral pressure. Central pressure assessment and accuracy
will also have to be standardized, as it has been for brachial pressure
assessment with oscillometric devices. This review will discuss our
current understanding about central pressure and the evidence
required to bring blood pressure measurement, and cardiovascular
risk assessment into the modern era.
Physiological concepts
Arterial pressure varies continuously over the cardiac cycle, but in
clinical practice only systolic and diastolic pressures are routinely
reported. These are invariably measured in the brachial artery
using 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
Pressure measured with a cuff and sphygmomanometer in the brachial artery is accepted as an important predictor of future cardiovascular risk.However, systolic pressure varies throughout the arterial tree, such that aortic (central) systolic pressure is actually lower than corresponding brachial values, although this difference is highly variable between individuals. Emerging evidence now suggests that central pressure is better related to future cardiovascular events than is brachial pressure. Moreover, anti-hypertensive drugs can exert differential effects on brachial 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.As discussed earlier, a full synthesis of the available evidence concerning
central pressure and the risk of future cardiovascular events is now required. However, it will also be necessary to determine the clinical relevance of differences between brachial and central pressure
for the individual patient, especially given the relatively high correlation between the two. Emerging data support the prognostic superiority of both 24-h ambulatory blood pressure monitoring
(ABPM)79 – 81 andhomemonitoring81 in comparison with office measurements. Interestingly, a recent study82 demonstrated that 24-h ambulatory cuff pressures were comparable with office central pressure
measurements in the prediction of risk, although the significance of this study awaits confirmation.83 As yet, there are no data comparing the predictive value ofhomemonitoring vs. central pressure in the
prediction of risk. Ultimately, it will be necessary to evaluate the prognostic value of 24-h ambulatory central pressure.With the recent development of ambulatory central pressure systems,84,85 this is now
possible and it may be reasonable to hypothesize that 24-h central, rather than brachial ABPM would be superior in terms of risk prediction.
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Reference Intervals of Central Aortic Blood Pressure and Augmentation Index2018
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