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JACC VOL. 66, NO. 3, 2015
Letters
JULY 21, 2015:328–33
(3) if based solely on the brachial cuff measurement of systolic pressure without taking into account the shape of the pressure waveform in
central and peripheral (i.e., brachial and/ or radial)
arteries. We have pressed this view (4) on the
European Society of Hypertension/European Society
of Cardiology committee (Yano et al. [1] reference
6) on the basis that elevated brachial and radial
systolic pressure in young persons (especially tall
male subjects) is caused by an exaggerated narrow
4. O’Rourke MF, Adji A. Guidelines on guidelines: focus on isolated systolic
hypertension in youth. J Hypertens 2013;31:649–54.
5. Gosain P. Navigating patient preference and guidelines as a fellow. J Am
Coll Cardiol 2015;65:398–9.
REPLY: Interpreting Blood Pressure in
Young Adults
We thank Dr. O’Rourke and colleagues for their interest in our findings. Their comments are primarily
focused on how our findings can be translated into
systolic pressure peak of the radial and brachial
practice or policy. We urge caution when extrapo-
pressure waves but a normal aortic pulse. This
lating epidemiological findings to clinical recom-
contrasts with elevated systolic pressure (i.e., ISH)
in persons over age 60 years who almost invariably
have a much broader systolic peak, which is similar
in the aorta and upper limb arteries (Yano et al. [1]
reference 41).
On the basis of outcomes in the Chicago study,
one would find it hard to justify a randomized study
of therapy compared with placebo in ISH of adult
male subjects <50 years of age. Another important
factor in guidelines, addressed by a cardiology
fellow in the same issue of the journal (5) is “patient
preference.” For the trivial difference in outcome at
mendations. Research findings, especially those from
observational studies, need to be interpreted within
the context of global evidence. Unfortunately, evidence is sparse pertaining to long-term outcomes in
younger adults with isolated systolic hypertension
(ISH). Considering the limited prognostic data on ISH
at younger ages, which our data begin to address, we
agree with the comment that it would be premature
and difficult to conduct randomized intervention
trials in a population of younger individuals who
would be at low risk for events in the near term. We
suggest that the next major step is to replicate our
20 years, would not most male subjects wish to defer
results in other studies with long-term follow-up of
the stigma of disease, the expense, the inconve-
younger adults (1,2).
nience, and side effects of treatment for another
The letter also addresses precision (personalized)
year or 2 until issues are clarified? How are young
medicine. Execution of precision medicine in younger
fellows (5) expected to include opinions, guidelines,
adults with ISH will (partly) resolve concerns regarding
and patient preference in their discussions with
patients <50 years of age with ISH?
*Michael F. O’Rourke, MD DSc
Audrey Adji, Mb MBiomedE
Mayooran Namasivayam, MBBS(Hons), BSc(Med)Hons
*Suite 810, St. Vincent’s Clinic
438 Victoria Street
Darlinghurst, Sydney
NSW 2010
Australia
E-mail: [email protected]
http://dx.doi.org/10.1016/j.jacc.2015.04.070
Please note: Dr. O’Rourke is a founding director of both AtCor Medical P/L and
Aortic Wrap P/L. All other authors have reported that they have no relationships
relevant to the contents of this paper to disclose.
patient preference, unnecessary expense, and adverse
effects associated with treatments (3). ISH in younger
adults appears to be a heterogeneous condition; some
have higher stroke volume, whereas others have
higher aortic stiffness, or both (4). One size does not
seem to fit all in the clinical management of ISH at
younger ages. The optimal means to identify higherrisk groups among younger ISH patients merits
further research. Clinical characteristics (e.g., body
weight, diabetes), biomarkers (e.g., brain natriuretic
peptide), and out-of-office blood pressure measurement (e.g., home or ambulatory monitoring) may serve
to identify higher-risk individuals. Rather than treating ISH in younger adults as a monolithic disease
and continuing to debate whether it is “pseudo” or
“spurious” hypertension, detailed phenotyping of
REFERENCES
ISH patients based on (patho) physiology and global
1. Yano Y, Stamler J, Garside DB, et al. Isolated systolic hypertension in young
and middle-aged adults and 31-year risk for cardiovascular mortality: the
Chicago Heart Association Detection Project in Industry study. J Am Coll
Cardiol 2015;65:327–35.
context of risk for cardiovascular events would seem to
2. Peterson ED, Gaziano JM, Greenland P. Recommendations for treating
hypertension: what are the right goals and purposes? JAMA 2014;311:
474–6.
3. O’Rourke MF, Vlachopoulos C, Graham RM. Spurious systolic hypertension
in youth. Vasc Med 2000;5:141–5.
be most useful to assess an individual patient’s expected net benefit from therapy.
Yuichiro Yano, MD, PhD
Stanley S. Franklin, MD
Philip Greenland, MD
*Donald Lloyd-Jones, MD, ScM
JACC VOL. 66, NO. 3, 2015
Letters
JULY 21, 2015:328–33
Of
*Department of Preventive Medicine
the
patients
presenting
with
ST-segment
Northwestern University Feinberg School of Medicine
elevation myocardial infarction, 40% to 65% have
680 North Lake Shore Drive, Suite 1400
multivessel disease. The severity of nonculprit
Chicago, Illinois 60611
stenosis can be overestimated during infarct angio-
E-mail: [email protected]
graphy, potentially leading to inappropriate decision
http://dx.doi.org/10.1016/j.jacc.2015.05.019
making in a non-negligible number of patients (4).
Please note: The authors have reported that they have no relationships relevant
to the contents of this paper to disclose.
In CvLPRIT (Complete Versus Lesion-Only Primary
PCI Trial), the bystander lesion was considered significant if stenosis was >70% in 1 angiographic view
REFERENCES
or >50% in 2 views. If the latter cut-off was to be
1. McCarron P, Smith GD, Okasha M, McEwen J. Blood pressure in young
adulthood and mortality from cardiovascular disease. Lancet 2000;355:
1430–1.
2. Sundström J, Neovius M, Tynelius P, Rasmussen F. Association of blood
pressure in late adolescence with subsequent mortality: cohort study of
applied to define multivessel disease, this could
lead to a large number of procedures, if complete
revascularization strategy was adopted, with an
inevitable major impact on the PPCI service provi-
Swedish male conscripts. BMJ 2011;342:d643.
sion. Adenosine stress cardiac magnetic resonance 1
3. Collins FS, Varmus H. A new initiative on precision medicine. N Engl J Med
2015;372:793–5.
to 5 days after ST-segment elevation myocardial
4. McEniery CM, Yasmin, Wallace S, et al., for the ENIGMA Study Investigators. Increased stroke volume and aortic stiffness contribute to isolated
systolic hypertension in young adults. Hypertension 2005;46:221–6.
infarction is safe and can allow accurate detection of
significant nonculprit territory stenosis. A recent
study by our group (5) demonstrated that <40% of
patients undergoing PPCI with moderate to severe
bystander nonculprit coronary artery disease need
Complete
Revascularization in
Patients Undergoing
Primary Percutaneous
Coronary Intervention
for STEMI
further revascularization, when stress cardiac mag-
Is it Really What We Should Be Doing?
considering immediate complete revascularization
netic resonance was used as a gatekeeper to complete
revascularization.
We do not believe that the control group in
CvLPRIT reflects current practice. The question of
how and when best to deal with bystander lesions
detected during PPCI remains unanswered. We feel
that caution should be used in directly translating the
results of this trial in clinical practice, and in
merely on the presence of multivessel disease. Inhospital invasive or noninvasive ischemia assess-
We read with interest the work by Gershlick et al. (1),
ment should perhaps play a greater role in the
which reported that in patients with ST-segment
decision making process, especially in the bystander
elevation
multivessel
disease of moderate stenosis severity. A large ran-
coronary artery disease undergoing infarct-artery
domized study that is adequately powered for mor-
percutaneous coronary intervention (PCI), complete
tality is immediately warranted to answer this.
myocardial
infarction
and
revascularization in noninfarct coronary arteries
with major stenoses significantly reduces the risk of
adverse cardiovascular events, as compared with
PCI limited to the infarct-related artery. We feel the
management of the latter group (infarct-related artery
PCI only) was not per the current European Society of
Cardiology guideline (2), which recommends using
either
a
conservative
(symptom-/noninvasive
ischemia–guided) strategy or a staged revascularization approach (preferably fractional flow reserve–
guided) performed several days or weeks after primary
percutaneous coronary intervention (PPCI). The metaanalysis by Vlaar et al. (3) has clearly shown that when
significant nonculprit vessel lesions are suitable for
PCI, they should only be treated during staged
procedures.
Amardeep Ghosh Dastidar, MBBS(Hons)
Jonathan Rodrigues, MBChB(Hons)
Anna Baritussio, MD
Andreas Baumbach, MD
*Chiara Bucciarelli-Ducci, MD, PhD
*NIHR Bristol Cardiovascular Biomedical Research Unit
Bristol Heart Institute
Bristol, BS2 8HW
United Kingdom
E-mail: [email protected]
http://dx.doi.org/10.1016/j.jacc.2015.04.068
Please note: This work was supported by the Bristol National Institute of Health
Research (NIHR) Cardiovascular Biomedical Research Unit at the Bristol Heart
Institute. The views expressed are those of the authors and not necessarily
those of the National Health Service, National Institute of Health Research, or
Department of Health. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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