Systemic hemodynamic atherothrombotic syndrome (SHATS) – Coupling vascular disease and blood pressure variability: Proposed concept from pulse of Asia
Section snippets
Background
Cardiovascular (CV) disease (CVD) events often occur suddenly, perhaps in response to an acute trigger, but underlying predisposing conditions are present long before the index event (Fig. 1). Hypertension (HTN) is a critically important risk factor for CVD, particularly when it accompanies comorbidities such as diabetes, dyslipidemia and inflammatory conditions. The diagnosis of HTN is based on the average of blood pressure (BP) measurements obtained several times at rest in the sitting
Definition of SHATS
“A man is as old as his arteries”.
–Thomas Sydenham (physician, 1624–1689)
Both systolic BP (SBP) and vascular disease increase with advancing age. We have recently proposed the concept of systemic hemodynamic atherothrombotic syndrome (SHATS), an age-related and synergistic vicious cycle of hemodynamic stress and vascular disease (Fig. 2),6., 7., 8. and a SHATS score for the diagnosis and evaluation of SHATS severity.9 The synergistic consideration of various types of BPV and hemodynamic stress
Concept
In SHATS, increased hemodynamic stress caused by dysregulation of BP and blood flow promotes vascular disease, from the large arteries to smaller arterioles (Fig. 2). The development of SHATS is closely related to the aging process. Clinical phenotypes of SHATS include stroke, coronary artery disease (CAD), heart failure (HF), renal disease, and other arterial diseases such as aortic dissection, aortic aneurysm and peripheral artery disease. In addition, small artery disease and microvascular
Mechanisms
Most recently we have focused on the pathogenic mechanism of arterial stiffness as SHATS, separately from atherosclerosis (Fig. 5).8 Aging, sympathetic activation, and CVD risk factors accelerate SHATS. Fig. 5 shows mechanistic trigger pathways for the clinical CV phenotypes of SHATS1: BP surge to atherosclerotic plaque2; strain to strain vessel3; afterload to left ventricle (LV).
One of the important vascular components in SHATS is large arterial atherosclerosis with arterial stiffness. The
SHATS score – diagnosis and assessment of severity of SHATS
There is currently no consensus on how to diagnose or define the severity of SHATS. We have developed a proposed preliminary SHATS score for this purpose (Table 1),37 based on the concept that both BP and vascular disease form part of a vicious cycle to accelerate organ damage and trigger CVD events in SHATS. The score includes two different components: the BP score and the vascular score. The novelty of this concept is the synergistic rather than additive effects of BP and vascular disease on
Treatment
SHATS can contribute to CVD risk throughout life, although the clinical implications and importance of SHATS might vary in younger versus older populations. The key goal is to detect and reduce the risk of SHATS in the early phase.
In younger adults, SHATS precedes hypertension, but BPV is increased even before HTN develops. Increased BPV (e.g. isolated morning HTN and orthostatic HTN) is associated with future sustained HTN and CVD events. Thus, earlier detection of SHATS and lifestyle
Perspectives
Precision medicine is a key term in CV medicine and prevention for healthy living.112., 113., 114., 115., 116., 117. In theory, it may be possible to achieve a marked reduction in the risk of CVD events, based on individualized treatment strategies that combine precision medicine (based on deep phenotyping of the CV system and population-based big data), and anticipation medicine (based on remote sensoring and individual time-series big data) for healthy living (Fig. 6).15 Healthy arterial aging
Disclosures
K Kario has received research grants from A&D Co., Omron Helthcare Co., Roche Diagnostics K.K., MSD K.K., Astellas Pharma, Otsuka Holdings Co., Otsuka Pharmaceutical Co., Ltd., Sanofi K.K., Shionogi & Co. Ltd., Sanwa Kagaku Kenkyusho Co., Daiichi Sankyo Co., Dainippon Sumitomo Pharma Co., Ltd., Takeda Pharmaceutical Company, Mitsubishi Tanabe Pharma Corporation, Teijin Pharma, Boehringer Ingelheim Japan Inc., Pfizer Japan, and Fukuda Denshi Co. JA Chirinos has consulted for Sanifit, Bayer,
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