Invasive Assessment of the Human Arterial Palmar Arch and Forearm Collateral Function During Transradial Access.

BACKGROUND: The present study aimed to quantitatively measure the pressure-derived function of the palmar arch and forearm arterial collateral circulation during transradial access. METHODS AND RESULTS: Palmar arch and forearm collateral function was determined using radial artery pressure signals in the nonobstructed vessel and during brief manual occlusions of the more proximal radial artery and of the radial plus ulnar arteries. Collateral flow index (CFI), the ratio of mean occlusive divided by mean nonocclusive arterial blood pressure, both subtracted by central venous pressure, was determined for CFI during radial artery occlusion (CFIrad) and CFI during radial plus ulnar artery occlusion. Before invasive CFI measurements, arterial palmar arch and forearm function was tested noninvasively by the modified Allen test (MAT). Two hundred fifty patients undergoing transradial access coronary angiography were included in the study. CFIrad was equal to 0.802±0.150 (95% CI, 0.783-0.820). CFI during radial plus ulnar artery occlusion was equal to 0.424±0.188 (95% CI, 0.400-0.447). There was an inverse linear relation between CFIrad and MAT in seconds (s): MAT=64-63×CFIrad ( r2=0.229; P<0.0001). Two hundred eleven patients had a normal and 39 patients an abnormal (>15 seconds) MAT. The group with normal MAT had a CFIrad of 0.830±0.111, and patients with abnormal MAT had a CFIrad of 0.648±0.224 ( P<0.0001). CONCLUSIONS: Direct invasive hemodynamic assessment of the palmar arch and forearm arterial function reveals collateral supply to the briefly occluded in comparison to the patent radial artery of 0.802. During external occlusion of both radial and ulnar artery, CFI amounts to an unexpectedly high value of 0.424.

The ACRA Anatomy Study (Assessment of Disability After Coronary Procedures Using Radial Access): A Comprehensive Anatomic and Functional Assessment of the Vasculature of the Hand and Relation to Outcome After Transradial Catheterization.

BACKGROUND: The palmar arches serve as the most important conduits for digital blood supply, and incompleteness may lead to digital ischemia when the radial artery becomes obstructed after cardiac catheterization. The rate of palmar arch incompleteness and the clinical consequences after transradial access are currently unknown. METHODS AND RESULTS: The vascular anatomy of the hand was documented by angiography in 234 patients undergoing transradial cardiac catheterization. In all patients, a preprocedural modified Allen test and Barbeau test were performed. Upper-extremity function was assessed at baseline and 2-year follow-up by the QuickDASH. Incompleteness of the superficial palmar arch (SPA) was present in 46%, the deep palmar arch was complete in all patients. Modified Allen test and Barbeau test results were associated with incompleteness of the SPA (P=0.001 and P=0.001). The modified Allen test had a 33% sensitivity and 86% specificity for SPA incompleteness with a cutoff value of >10 seconds and a 59% sensitivity and 60% specificity with a cutoff value of >5 seconds. The Barbeau test had a 7% sensitivity and 98% specificity for type D and a 21% sensitivity and 93% specificity for types C and D combined. Upper-extremity dysfunction was not associated with SPA incompleteness (P=0.77). CONCLUSIONS: Although incompleteness of the SPA is common, digital blood supply is always preserved by a complete deep palmar arch. Preprocedural patency tests have thus no added benefit to prevent ischemic complications of the hand. Finally, incompleteness of the SPA is not associated with a loss of upper-extremity function after transradial catheterization.

Non-invasive assessment of the collateral circulation in the hand: validation of the Nexfin system and relation to clinical outcome after transradial catheterisation.

AIMS: This study aims primarily to assess the extent of the collateral circulation of the hand in a combined population of healthy individuals and patients who underwent transradial catheterisation, using both the Nexfin system and laser Doppler perfusion imaging. METHODS AND RESULTS: In total, 85 adults were included in the study (18 healthy volunteers; 67 patients who underwent transradial catheterisation). The perfusion of the thumb was assessed prior to and during complete radial artery compression using laser Doppler perfusion imaging (LDPI) and the Nexfin system. The palmar collateral flow index (PCFI) was compared between both devices and PCFINEXFIN was related to hand angiography and the upper limb function, using the QuickDASH questionnaire. Mean PCFILDPI was 0.77±0.15 and mean PCFINEXFIN was 0.88±0.08. Both were significantly related (Pearson correlation=0.49, 95% CI: 0.31-0.64, p<0.001, agreement -0.11±0.13). PCFINEXFIN correlated with the maximal diameter of the superficial palmar arch (R=0.49, p=0.04) and total minimal arch diameter (R=0.51, p<0.02). High PCFINEXFIN, measured at baseline, was correlated with a lower QuickDASH score for pain, activity and total at one month post transradial catheterisation (p=0.02, p<0.01, p<0.01), but not with discomfort or disability. CONCLUSIONS: The Nexfin monitoring system is comparable with laser Doppler perfusion imaging in the quantification of the collateral perfusion in the hand. In patients, the Nexfin-derived collateral flow index measured at baseline is associated with clinical outcome at 30 days post transradial catheterisation.

Assessment of Radial Artery Graft Patency in Symptomatic Patients.

BACKGROUND: The purpose of this study is to evaluate the patency of radial artery (RA) grafts consistent with the target vessel characteristics. METHODS: Between October 2001 and January 2012, 83 symptomatic patients or patients with positive ischemic test results underwent coronary angiography following coronary artery bypass grafting. Of these, 68 patients with 81 RA grafts at a mean 49.2 ± 31.9 months (range, 1-137 months) were evaluated. According to the location and degree of proximal stenosis, 5-year graft patency was determined by Kaplan-Meier analysis. The relationships between RA graft patency and degree of proximal stenosis, target vessel location, and inflow characteristics of grafts were assessed by means of Cox proportional hazard models. RESULTS: Mean age of the patients was 56.4 ± 10.2 years. The period between the operation and postoperative coronary angiography was 49.2 ± 31.9 months (range, 1-137 months; median, 48.8 months). There was no impact on RA patency with regard to preoperative characteristics of the patients. RA patency was higher for left coronary system compared with right system (p = 0.038; 85.5 vs. 65.4%). In addition, patency rate was statistically higher for the proximal stenosis ≥ 90% (odds ratio, 3.65; 95% confidence interval, 1.20-11.07; p = 0.018). Kaplan-Meier patency analysis showed a patency of RA as 79.2% at 5 years. CONCLUSION: RA graft patency differs with degree of preoperative native coronary artery stenosis and location of target vessel. RA grafts to not severely stenosed (< 90%) coronary system and to the right coronary territory carry a remarkably high risk of graft failure.

Optimal conduit for diabetic patients: propensity analysis of radial and right internal thoracic arteries.

BACKGROUND: Multiple arterial grafts, in addition to the left internal thoracic artery, improve long-term survival after coronary artery bypass grafting (CABG); yet, the use of this procedure remains low for both the right internal thoracic artery (RITA) and the radial artery (RA). To identify the optimal arterial conduit to deploy for revascularization of diabetic patients, we compared the outcomes for RA and RITA grafts to the circumflex coronary. METHODS: From January 1, 1995, to December 31, 2011, 908 consecutive diabetic patients underwent first-time, isolated CABG (99% on-pump), 659 with the RA and 502 with the RITA, respectively, in two affiliated hospitals. Data were prospectively collected, and late mortality was determined from the Social Security Death Index. Propensity matching, based on preoperative and operative variables, identified 202 matched pairs from each group. RESULTS: Long-term survival was similar for matched patients. Mortality, myocardial infarction, reoperation for bleeding, stroke, sepsis, and renal failure were not significantly different between groups. However, deep sternal wound infection (p<0.035) and respiratory failure (p<0.048) favored the RA group, in which the total major adverse events were significantly fewer (p=0.002). CONCLUSIONS: In diabetic patients undergoing multivessel revascularization with either RA or RITA grafts to the circumflex coronary, long-term survival is similar. However, RA patients experienced significantly fewer respiratory or sternal wound adverse events. The RA is the preferred conduit to extend to more diabetic patients the recognized survival benefit of a multiple arterial graft strategy.

[Noninvasive assessment of functional competence of the radial artery as a possible vascular graft for coronary artery bypass grafting].

Described herein is a variant of surgical treatment of a patient presenting with type A aortic dissection extending to the brachiocephalic branches accompanied by thrombosis of the false channel of the latter. In the rare cases in dissection and thrombosis of the brachiocephalic branches for adequate protection of the body (systemic protection) it is necessary to use bidirectional arterial perfusion under the conditions of moderate hyperthermia: through a preliminarily sewn into the carotid artery prosthesis - perfusion of the brain, through cannulated aortic arch or femoral artery - body perfusion.

Assessment of collateral circulation to the hand prior to radial artery harvest.

Assessment of collateral circulation to the hand is required prior to invasive procedures or harvesting of the radial artery (RA). A modified Allen's test (MAT) is commonly used to assess palmar arch collaterals. A variety of non-invasive methods including digital pressures, plethysmography, pulse oximetry and duplex ultrasonography are available to supplement physical examination. However, no consensus exists about the proper role of the MAT and the most appropriate non-invasive test (NIT) in this situation. Interpretation of the MAT and NIT findings are also controversial. This paper reviews the anatomy and the physiologic basis for the MAT and various NITs, the pros and cons of various NITs and recommendations for the assessment of collateral circulation to the hand prior to interventions directed at the RA.

[Assessment of arterial damage by noninvasive peripheral arterial tonometry in non-diabetic hemodialysis patients]. / Daño arterial asociado a la enfermedad renal crónica: evaluación mediante técnicas de laboratorio no invasivo en pacientes hemodializados.

BACKGROUND: Hemodialysis patients (HD) display high rates of cardiac disease and mortality. The cardiovascular morbidity and mortality of HD patients is attributable in a significant proportion to endothelial dysfunction, arterial stiffness, and vascular calcifications. AIM: To measure vascular reactivity in HD subjects and compare them with healthy volunteers. MATERIAL AND METHODS: Forty eight non diabetic patients aged 58 ± 4.6 years (29 males) on hemodialysis for a mean lapse of 4.8 years were studied. Arterial stiffness was measured in the radial artery. Pulse wave velocity was measured by noninvasive peripheral arterial tonometry in carotid and femoral arteries. Endothelial function was assessed, measuring reactive hyperemia response after a 5 min period of ischemia. As a control, all values were also measured in age and gender-matched healthy volunteers. RESULTS: Arterial stiffness was significantly higher in HD patients than controls (23.9 ± 3.3 and 18.4 ± 3.4% respectively, p < 0.05). HD subjects had an increased pulse wave velocity (10.0 ± 0.8 and 7.6 ± 0.9 m/s respectively, p < 0.05). A reduction in the change in pulse amplitude pressure, as a measure of arterial dysfunction, was only observed in male patients (1.7 ± 0.4 and 2.7 ± 0.4 respectively p < 0.01). CONCLUSIONS: Noninvasive assessment of peripheral vascular function may be useful for the identification of patients at risk for late cardiac events.

Assessment of long-term vasoplegia induced by brachial plexus block: a favorable effect for hemodialysis angioaccess surgery?

PURPOSE: Loco-regional anesthesia, along with the neurosensitive inhibition causes arterial and venous vasodilatation, that could be of interest for vascular access surgery. We evaluated the long term vasoplegia persistence after brachial plexic block. METHODS: Five patients submitted to brachial plexus block for an orthopedic procedure have been observed. Both radial arteries, that of the blocked arm and the opposite as a control, were analyzed by ultrasound examination, at time 0 and 360 minutes after anesthesia induction. All patients were treated with the same anesthesiologic protocol: axillary approach, use of an electroneurostimulator, injection 10 ml of ropivacain 7.5% + 10 ml of mepivacain 2%. The parameters evaluated from the arterial ultrasound flowmetry were: peak systolic velocity (PSV), end diastolic velocity (EDV) and resistance index (RI). RESULTS: No modification of the arterial flow were observed in the control arm at 0 and 360'after block induction. The blocked arm instead showed a significant decrease of the resistive index, stable at 360 minutes. CONCLUSIONS: The vasoplegia accompaning plexic block lasted 6 hours after anesthesia induction. Whereas this longstanding haemodynamic effect is beneficial for early patency of vascular access for hemodialysis, needs to be ascertained by further investigations.

Noninvasive assessment of left ventricular contractility in pediatric patients using the maximum rate of pressure rise in peripheral arteries.

The maximum rate of left ventricular pressure rise (LV dp/dt(max)) is a good indicator of ventricular contractility. However, its measurement requires invasive cardiac catheterization. By applying the relationship between the ratio of aorta (Ao) dp/dt(max) to LV dp/dt(max) and the mean artery pressure (MAP), we tested the possible noninvasive estimation of LV dp/dt(max) by the maximum rate of pressure rise in peripheral arteries, as measured by tonometry. The study subjects were 31 children with cardiovascular disease. The LV and Ao pressures were measured during cardiac catheterization, with simultaneous recording of the brachial (BrA) or radial (RaA) artery pressure. The relationships between BrA dp/dt(max) and Ao dp/dt(max) and between RaA dp/dt(max) and Ao dp/dt(max) were determined (Ao dp/dt(max) = 0.299 × BrA dp/dt(max) + 210.6, n = 17, r = 0.78, SEE = 74.0, P = 0.0002, and Ao dp/dt(max) = 1.442 × RaA dp/dt(max) + 165.9, n = 14, r = 0.87, SEE = 66.1, P = 0.0001). Using these relationships and the equation Ao dp/dt(max)/LV dp/dt(max) = 0.694 - 4.00 × 10(-3) × MAP, LV dp/dt(max) was estimated from BrA dp/dt(max) or RaA dp/dt(max). The estimated LV dp/dt(max) correlated well with the measured LV dp/dt(max) independent of the site of measurement (y = 0.912 × x + 112.9, r = 0.91, P < 0.0001). Furthermore, there was excellent correlation between the measured and estimated LV dp/dt(max) after changes in contractility with dobutamine in 10 randomly selected patients (y = 0.86 × x + 34.2, r = 0.77, P = 0.01). It is possible to estimate LV dp/dt(max) noninvasively in children using tonometry. This procedure can be useful for bedside assessment of LV contractility and the clinical management of patients with cardiovascular disease.

A single center study of clinical success in radiocephalic fistula creation.

PURPOSE: To compare standard methods (control) with a new protocol for radiocephalic fistula (RCF) creation involving ultrasound vein mapping by the surgeon in the operating room, ligation of cephalic vein branches in the lower forearm, and use of a tourniquet for the arteriovenous anastomosis. METHODS: This is a retrospective cohort study of patients who underwent radiocephalic fistula creation between April 2008 and March 2010 in a regional vascular center. Patients were identified retrospectively by reviewing hospital operating room and office billing records. The electronic charts of all patients were reviewed. The primary endpoint was functional RCF patency at last follow-up. RESULTS: A total of 118 patients underwent arteriovenous (AV) fistula creation by 3 surgeons during the two-year study period. Of these, 59 patients underwent RCF creation, 33 of whom were managed using the new protocol. The two groups were comparable, except for age (66 in the study group vs. 60 in the control group, P=.04). Tourniquet use shortened operative time from 48 to 36 minutes (P=.04). Functional patency was 82% vs 77% (P=.64). CONCLUSION: The new protocol for RCF creation results in shorter operative times and high functional patency rates.

Asynchronous arterial systolic expansion as a marker of vascular aging: assessment of the carotid artery with velocity vector imaging.

OBJECTIVE: Arterial elastic properties change with aging. Measurements of pulse wave velocity and augmentation index are useful for the evaluation of arterial stiffness. However, they likely represent only global characteristics of the arterial tree rather than local vascular alterations. The aim of this study was to evaluate whether local vascular properties assessed by velocity vector imaging differed with aging. METHODS: Vascular properties of carotid arteries with ages were assessed in 100 healthy volunteers (52 men) ranging from 20 to 68 years using velocity vector imaging. The peak circumferential strain and strain rate of the six segments in left common carotid arteries were analyzed and the standard deviation of the time to peak circumferential strain and strain rate of the six segments, representing the synchronicity of the arterial expansion, were calculated. Central blood pressure, augmentation index and pulse wave velocity were assessed by commercially available radial artery tonometry, the SphygmoCor system (AtCor Medical, West Ryde, Australia). A validated generalized transfer function was used to acquire the central aortic pressures and pressure waveforms. RESULTS: Pulse wave velocity, augmentation index and velocity vector imaging parameters showed significant changes with age. However, the age-related changes in pulse wave velocity, augmentation index and velocity vector imaging parameters were different. The increase in pulse wave velocity was more prominent in older individuals, whereas the changes in augmentation index and carotid strain and strain rate were evident earlier, at the age of 30 years. Unlike augmentation index, which showed little change in older individuals, the standard deviation of time to peak strain and strain rate showed a steady increase from younger to older individuals. CONCLUSION: Asynchronous arterial expansion could be a useful discriminative marker of vascular aging independent of individual's age.

Morphology variability analysis of wrist pulse waveform for assessment of arteriosclerosis status.

In this paper, approximate entropy (ApEn) is applied to study the variability of pulse waveform for assessing coronary arteriosclerosis status. Having analyzed the wrist pulse waveforms taken from both normal subjects and the patients suffering from coronary arteriosclerosis (CA) disorders, we find that pulse morphology variability (PMV) is more efficient than pulse interval variability (PIV) in assessing the conditions of human coronary artery. Usually, the PMVs of the healthy are higher than those of the patients with CA diseases, and the PMVs of patients with CA diseases have more high frequency components than those of the healthy subjects. That is to say, the CA disease also has influence on vascular tone. The effect of changes in cardiac performance due to CA disease can be reflected through the PMV. The experiment demonstrates that the specificity and sensitivity of the PMV's spectral energy ratio for clinical diagnosis of cardiovascular system is 80% and 97%, respectively.

Non-invasive radial pulse wave assessment for the evaluation of left ventricular systolic performance in heart failure.

INTRODUCTION: Left ventricular (LV) developed pressure (dP/dt) is a classical index of myocardial contractility related to prognosis during heart failure. We sought to assess the reproducibility and feasibility of use of the maximal first derivative of the radial pulse, Rad dP/dt, as a peripheral criterion of ventricular contractility in patients with heart failure. METHODS: We assessed 50 consecutive, patients with heart failure using aplanation tonometry to record the radial pulse wave and calculate Rad dP/dt. Echocardiography, Doppler flow and tissue Doppler imaging were used to record classical parameters of LV function: LV ejection fraction (LVEF), Tei index, dP/dt on mitral regurgitation (MR dP/dt) and peak systolic velocity (S'). Total systemic vascular resistance (TSVR) was calculated by use of the Doppler calculated cardiac output. Preload was assessed by the E/Ea ratio. Feasibility was tested in an ongoing prospective mortality study (n=310). RESULTS: The Bland and Altman representation of repeated measurements of the Rad dP/dt showed good agreement. Feasibility was greater than 99% for a successful assessment on the right arm during the first attempt. The Rad dP/dt correlated with the LVEF, S' or Tei index as usual parameters of impaired contractility but not preload (E/Ea) or afterload (TSVR) parameters. MR dP/dt and Rad dP/dt were closely related (r=0.75, p<0.001). The ability of the arterial dP/dt to characterize LVEF was not modified by adjustment for arterial viscoelastic properties. CONCLUSION: The maximal dP/dt of the radial pulse appears to be a valuable and reproducible peripheral criterion of LV systolic performance.

Assessment of the efficacy of phentolamine to prevent radial artery spasm during cardiac catheterization procedures: a randomized study comparing phentolamine vs. verapamil.

The objective of this study was to evaluate phentolamine as radial artery spasmolytic in transradial catheterization procedures. Radial artery spasm is a relatively frequent complication during transradial approach, causing patient discomfort or even making it impossible to continue the procedure. As radial artery spasm is mediated by the stimulation of alpha-adrenoreceptors, the use of the alpha-blocker phentolamine could make sense as spasmolytic. We designed a randomized double-blind study to compare phentolamine vs. verapamil, the standard spasmolytic agent. Five hundred patients (250 in each arm) submitted to a transradial cardiac catheterization were consecutively included and randomly assigned to receive 2.5 mg of verapamil or 2.5 mg of phentolamine after sheath insertion. Both vasodilator agents induced a significant radial artery diameter increase (from 2.22 +/- 0.53 to 2.48 +/- 0.57 mm, P < 0.001 for verapamil, and from 2.20 +/- 0.53 to 2.45 +/- 0.53 mm, P < 0.001 for phentolamine). However, verapamil was more efficacious to prevent radial artery spasm (13.2% compared with 23.2% in phentolamine-treated patients; P = 0.004). Follow-up (20 +/- 18 days) evaluation of the radial artery patency by plestismography and pulse oximetry showed no differences between the two groups in the rate of radial occlusion (3.0% vs. 3.2% in verapamil and phentolamine treated patients, respectively). Phentolamine was an effective radial vasodilator agent, although it showed less ability to prevent radial artery spasm than verapamil. Radial artery occlusion rate was almost identical for both vasodilators. Thus, phentolamine could be a valid alternative to verapamil as a radial artery spasmolytic agent.

Randomized comparison of rapid ambulation using radial, 4 French femoral access, or femoral access with AngioSeal closure.

Radial access and closure devices are associated with improved quality of life (QOL) after cardiac catheterization. Whether this is related to the access site or time to ambulation is unknown. Seventy-five patients undergoing cardiac catheterization were randomized to femoral 6 Fr with AngioSeal closure (F+C), femoral 4 Fr without closure, and radial (R) access. All patients were ambulated at 1 hr. QOL was measured utilizing visual analogue scales and Short Form-36 at baseline, 1 day, and 1 week. Time to ambulation and discharge were equivalent, as was postprocedure QOL. However, angiographic quality was lower in the 4 Fr group (P < 0.0001) and catheterization costs were higher in the F+C group (P < 0.0001). Ambulation 1 hr after catheterization can be accomplished utilizing radial, femoral 6 Fr with closure device, or femoral 4 Fr access with equivalent outcomes and QOL. However, this is achieved at a higher cost with a closure device, or lesser angiographic quality with 4 Fr catheters.

Thermographic assessment of stellate ganglion block effectiveness during cardiosurgical procedures.

UNLABELLED: The study present thermographic assessment of the effectiveness of temporary stellate blockade performed during cardiosurgical procedures. The assumption behind this method was the increase in the temperature of upper extremity on the side of blockade, due to the broadening of arterial bed. MATERIAL AND METHOD: The study was conducted on a group of 30 patients (21 men and 9 women) operated due to coronary disease involving three vessels. Mean age of the patients was 53 years. After introduction of anaesthesia blockade were performed with 2 ml 2% lignocainum and 8 ml 0.5% bupivacaine solution using peratracheal approach. Blockade effectiveness was assessed on the basis of images obtained in thermovisual camera, comparing the temperatures of upper extremity before and within 15 minutes after performing the blockade. Free blood outflow from radial artery, its diameter and length were also evaluated. The results obtained were subject to statistical analysis. RESULTS: Twenty-three patients (76.6%) displayed the increase in the temperature of upper extremity by 1-3 degrees C. Free blood outflow from radial artery was greater in this group than in the remaining patients. CONCLUSIONS: Thermography is a useful method for the assessment of stellate blockade effectiveness. Effective blockade results in the increased blood flow in radial artery.

Preoperative assessment of the efficacy of distal radial artery ligation in treatment of steal syndrome complicating access for hemodialysis.

Hand ischemic steal syndrome due to a forearm arteriovenous fistula is a rare occurrence. We report here a case in which we applied a new diagnostic method to assess the efficacy of distal radial ligation to treat this syndrome. A favorable comparison of distal radial artery pressure measurements before and after temporary occlusion of the artery with a balloon catheter indicated that perfusion of the hand would be dramatically improved after surgical artery ligation.

Non-invasive assessment of systemic elastic behaviour in hypertensive patients: analysis of possible determinants.

Knowledge about the viscoelastic behaviour of the arterial wall has been proved to have physiological importance and clinical usage. Our purpose was to study the changes of the systemic arterial wall's elastic properties non-invasively, in patients with established essential and with borderline hypertension, and to evaluate its possible determinants. Three groups of normotensive, borderline and established essential hypertensive patients were evaluated. Arterial pulse wave velocity (PWV) was measured and arterial compliance (Cm) was derived in all patients. Pulse wave velocity was obtained from the pressure values of digitized carotid and radial arteries. Arterial compliance (Cm = dD/dP with P pressure and D diameter) was calculated using a formula derived from the Bramwell and Hill equation: Cm = (1,334 x D)/(2 rho x PWV2), where for D humeral diameter was used as measured by high resolution echograph, and rho is the blood density (rho = 1.06). Pulse wave velocity was significantly higher in established essential hypertensive patients with respect to normotensive patients (p < 0.05). Arterial compliance was significantly diminished in established and in borderline hypertensive patients with respect to normotensive patients (p < 0.05), which implies early alterations in hypertensive cardiovascular disease. Multiple regression analysis of the cofactors showed that age and diastolic pressure are independent determinants of Cm. Impairment of the arterial wall's intrinsic elastic properties was demonstrated in established essential hypertension, independent of age and diastolic pressure.