Elsevier

Progress in Cardiovascular Diseases

Volume 63, Issue 1, January–February 2020, Pages 22-32
Progress in Cardiovascular Diseases

Systemic hemodynamic atherothrombotic syndrome (SHATS) – Coupling vascular disease and blood pressure variability: Proposed concept from pulse of Asia

https://doi.org/10.1016/j.pcad.2019.11.002Get rights and content

Abstract

Hypertension (HTN) is an important risk factor for cardiovascular disease (CVD) but the association between HTN and CVD cannot be explained by average blood pressure (BP) alone. BP variability (BPV) is another important factor, along with the effects of HTN on the vasculature. The concept of systemic hemodynamic atherothrombotic syndrome (SHATS) has been proposed, describing an age-related and synergistic vicious cycle of hemodynamic stress and vascular disease. The importance of SHATS is based on the assumption that the assessment of BPV and arterial disease is likely to provide an effective opportunity to intervene early to reduce progression to HTN in younger patients or to CVD events and organ damage in older patients. In addition to providing an overview of current evidence for the mechanisms and clinical data related to SHATS, this article proposes a new SHATS score for use to diagnose and assess the severity of SHATS. The score includes two components – a BP score and a vascular score – which are multiplied to generate the SHATS score. This reflects the synergistic, rather than additive, effects of BP and vascular disease on target organ damage and CVD events. Although it requires refinement and validation in future studies, early detection of SHATS using tools such as the proposed score, combined with population-based stratification and technology-based anticipation medicine incorporating real-time individual data, has the potential to contribute to meaningful reductions in rates of CVD events and target organ damage.

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,

References (119)

  • PM Rothwell et al.

    Prognostic significance of visit-to-visit variability, maximum systolic blood pressure

    and episodic hypertension Lancet

    (2010)
  • N Di Daniele et al.

    Circadian blood pressure patterns and blood pressure control in patients with chronic kidney disease

    Atherosclerosis

    (2017)
  • MR Weir et al.

    Nocturnal reduction of blood pressure and the antihypertensive response to a diuretic or angiotensin converting enzyme inhibitor in obese hypertensive patients

    TROPHY Study Group Am J Hypertens

    (1998)
  • T Ohkuma et al.

    Ankle-brachial index measured by oscillometry is predictive for cardiovascular disease and premature death in the Japanese population: an individual participant data meta-analysis

    Atherosclerosis

    (2018)
  • MH Stewart et al.

    Prognostic implications of left ventricular hypertrophy

    Prog Cardiovasc Dis

    (2018)
  • RR Townsend

    Arterial stiffness in CKD: a review

    Am J Kidney Dis

    (2019)
  • C Vlachopoulos et al.

    The role of vascular biomarkers for primary and secondary prevention. A position paper from the European Society of Cardiology Working Group on peripheral circulation: endorsed by the Association for Research into arterial structure and physiology (ARTERY) society

    Atherosclerosis

    (2015)
  • K Kario et al.

    Blood pressure measurement and treatment decisions

    Circ Res

    (2019)
  • K Kario

    Essential manual on perfect 24-hour blood pressure management from morning to nocturnal hypertension: up-to-date for anticipation medicine

    Wiley Publishing Japan

    (2018)
  • Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the...
  • K Kario

    Global impact of 2017 American Heart Association/American College of Cardiology Hypertension Guidelines: a perspective from Japan

    Circulation

    (2018)
  • K Kario et al.

    Could 130/80 mm hg be adopted as the diagnostic threshold and management goal of hypertension in consideration of the characteristics of Asian populations?

    Hypertension

    (2018)
  • K Kario

    Orthostatic hypertension-a new haemodynamic cardiovascular risk factor

    Nat Rev Nephrol

    (2013)
  • K Kario

    Systemic hemodynamic atherothrombotic syndrome: a blind spot in the current management of hypertension

    J Clin Hypertens (Greenwich)

    (2015)
  • K Kario

    Hemodynamic arteriosclerotic syndrome - a vicious cycle of hemodynamic stress and vascular disease

    J Clin Hypertens (Greenwich)

    (2018)
  • K Kario

    Systemic hemodynamic atherothrombotic syndrome (SHATS): diagnosis and severity assessment score

    J Clin Hypertens (Greenwich)

    (2019)
  • G Pucci et al.

    Morning pressor surge, blood pressure variability, and arterial stiffness in essential hypertension

    J Hypertens

    (2017)
  • K Kario

    Prognosis in relation to blood pressure variability: pro side of the argument

    Hypertension

    (2015)
  • G Parati et al.

    Assessment and management of blood-pressure variability

    Nat Rev Cardiol

    (2013)
  • Webb AJS, Mazzucco S, Li L, Rothwell PM. Prognostic significance of blood pressure variability on beat-to-beat...
  • FF Wei et al.

    Beat-to-beat, reading-to-reading, and day-to-day blood pressure variability in relation to organ damage in untreated Chinese

    Hypertension

    (2014)
  • K Kario

    Hemodynamic biomarker-initiated anticipation medicine in the future management of hypertension

    Am J Hypertens

    (2017)
  • K Kario

    New insight of morning blood pressure surge into the triggers of cardiovascular disease-synergistic resonance of blood pressure variability

    Am J Hypertens

    (2016)
  • S Ito et al.

    Strain vessel hypothesis: a viewpoint for linkage of albuminuria and cerebro-cardiovascular risk

    Hypertens Res

    (2009)
  • K Kario et al.

    Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study

    Circulation

    (2003)
  • V Srikanth et al.

    Cerebral white matter lesions, gait, and the risk of incident falls: a prospective population-based study

    Stroke

    (2009)
  • AR Pries et al.

    Coronary microcirculatory pathophysiology: can we afford it to remain a black box?

    Eur Heart J

    (2017)
  • J Hashimoto et al.

    Different role of wave reflection magnitude and timing on left ventricular mass reduction during antihypertensive treatment

    J Hypertens

    (2008)
  • P Zamani et al.

    Resistive and pulsatile arterial load as predictors of left ventricular mass and geometry: the multi-ethnic study of atherosclerosis

    Hypertension

    (2015)
  • T Weber et al.

    Pulsatile arterial haemodynamics in heart failure

    Eur Heart J

    (2018)
  • JA Chirinos et al.

    Early and late systolic wall stress differentially relate to myocardial contraction and relaxation in middle-aged adults: the Asklepios study

    Hypertension

    (2013)
  • JA Chirinos et al.

    Arterial pulsatile hemodynamic load induced by isometric exercise strongly predicts left ventricular mass in hypertension

    Am J Physiol Heart Circ Physiol

    (2010)
  • JA Chirinos et al.

    Late systolic myocardial loading is associated with left atrial dysfunction in hypertension

    Circ Cardiovasc Imaging

    (2017)
  • JA Chirinos et al.

    Late systolic central hypertension as a predictor of incident heart failure: the multi-ethnic study of atherosclerosis

    J Am Heart Assoc

    (2015)
  • Y Matsui et al.

    Impact of arterial stiffness reduction on urinary albumin excretion during antihypertensive treatment: the Japan morning Surge-1 study

    J Hypertens

    (2010)
  • Kario K. Systemic hemodynamic atherothrombotic syndrome (SHATS): diagnosis and severity assessment score. J Clin...
  • National Institute for Health and Care Excellence. Hypertension: clinical management of primary hypertension in adults...
  • G Parati et al.

    European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring

    J Hypertens

    (2014)
  • JE Sharman et al.

    Home blood pressure monitoring: Australian expert consensus statement

    J Hypertens

    (2015)
  • K Shimamoto et al.

    The Japanese Society of Hypertension guidelines for the management of hypertension (JSH 2014)

    Hypertens Res

    (2014)
  • Cited by (0)

    View full text