To the Editor:

Many thanks to Balta and colleagues for the appreciation of our work “Increased Aortic Stiffness and Related Factors in Patients With Peripheral Arterial Disease” recently published in The Journal of Clinical Hypertension. However, we disagree on some remarks made by the same authors.

We did not mention the effects of heart failure and inflammatory disease such as psoriasis on aortic stiffness. Neither of these conditions were included in our analysis because the patients did not present these symptoms at the time of enrollment in the study. In addition, it would be more interesting to conduct a study in patients without atherosclerosis disease, diabetes, or hypertension to clarify the relationship between alcohol intake and aortic stiffness. In the discussion, we mention the lack of relationship between the common risk factors (smoking and diabetes) and aortic pulse wave velocity (aPWV) illustrating the results (in Table 2) on the main determinants of aPWV (age, heart rate, blood pressure) leaving out, however, the lack of relationship between smoking (β=0.56, P=.31), dyslipidemia (β=0.82, P=.08), low-density lipoprotein (β=0.008, P=.19), cerebrovascular disease (β=2.87, P=.12), and aortic stiffness.

These results are in agreement with the findings of a recent systematic review of the literature concerning aPWV and cardiovascular risk factors.[1] In particular, Cecelja and Chowienczyk identified several studies with data relating aPWV to age, blood pressure, and a variable number of other cardiovascular risk factors, in which regression models were available. The results from this review demonstrate that only age and blood pressure are consistently related to aPWV. Other risk factors were no longer significant after adjusting for age and blood pressure, suggesting that the impact of traditional risk factors, other than BP, on aPWV is small or insignificant. Furthermore, atherosclerosis risk factors, per se, appear to play a minor role in aortic stiffening as highlighted by McEniery and colleagues.[2] Finally, we report that the regression model could only predict a part of the variability of aPWV (R=11; 8%, P=.01) indicating that markers of inflammation and/or vascular calcification associated with PAD, not currently studied in our paper, may play an important role in aortic stiffness.[3, 4] Arteriosclerosis and atherosclerosis are two processes pathologically distinct and largely driven by different mechanisms.[5]


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  2. References
  • 1
    Cecelja M, Chowienczyk PJ. Dissociation of aortic pulse wave velocity with risk factors for cardiovascular disease other than hypertension: a systematic review. Hypertension. 2009;54:13281336.
  • 2
    McEniery CM, Spratt M, Munnery M, et al. An analysis of prospective risk factors for aortic stiffness in men: 20-year follow-up from the Caerphilly prospective study. Hypertension. 2010;56:3643.
  • 3
    Kals J, Zagura M, Serg M, et al. β-2-microglobulin, a novel biomarker of peripheral arterial disease, independently predicts aortic stiffness in these patients. Scand J Clin Lab Invest. 2011;71:257263.
  • 4
    Zagura M, Serg M, Kampus P, et al. Association of osteoprotegerin with aortic stiffness in patients with symptomatic peripheral arterial disease and in healthy subjects. Am J Hypertens. 2010;23:586591.
  • 5
    Wilkinson IB, McEniery CM. Arteriosclerosis: inevitable or self-inflicted? Hypertension. 2012;60:35.