Arterial stiffness as a risk factor for clinical hypertension

Key Points

  • In uncomplicated essential hypertension, cardiac output remains normal, whereas mean circulatory pressure is increased; vascular resistance is thus augmented, and the viscoelastic properties of the cardiovascular system are markedly impaired

  • Carotid–femoral arterial stiffness, wave reflections, and the ensuing structural vascular changes and endothelial dysfunction are fundamental aspects of the vessel damage observed in chronic hypertension

  • Pulse pressure (PP; the difference between systolic and diastolic blood-pressure (BP) levels) is influenced by arterial stiffness, which also negatively influences wave reflections, kidney function, and cardiovascular risk

  • The stiffness-induced increase in PP is an independent predictor of cardiovascular risk

  • Drug therapies should not only reduce elevated BP levels, but also target arterial stiffness, wave reflections, and PP

  • Effective drug strategies to reduce cardiovascular risk should take individual patient profiles into consideration, including age, sex, and ethnic factors


In patients with uncomplicated essential hypertension, cardiac output remains within normal ranges and intravascular volume is normal or low, assuming the presence of a sufficient Windkessel effect and usual resistance and compliance calculations. However, mean circulatory pressure is elevated in these patients. In addition, vascular resistance is augmented, and most importantly, the viscoelasticity of the cardiovascular system is substantially impaired. Such considerations are essential to understanding the mechanisms behind carotid–femoral arterial stiffness, a major risk factor in individuals with hypertension. Arterial stiffness, measured from pulse wave velocity, is substantially increased in hypertension even independently of blood pressure levels. Structural vascular changes and endothelial dysfunction are consistently associated with vessel impairments in animal models of hypertension. Increased arterial stiffness has a major effect on pulse pressure (the difference between systolic and diastolic blood pressure), wave reflections, kidney function, and above all, cardiovascular risk. This increased cardiovascular risk is particularly deleterious in patients with hypertension and/or type 2 diabetes mellitus, who are at risk of both renal and cardiovascular events. In this Review, we discuss the importance of arterial stiffness in the diagnosis and management of hypertension and the need for new approaches for the treatment of hypertension in patients with or without diabetes and/or renal impairment.

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Figure 1: Schematic measurements of arterial stiffness and distensibility in hypertensive and normotensive settings.
Figure 2: Mean pulse wave velocity (PWV) values according to age.
Figure 3: Representation of the transition between pulsatile and steady pressure.


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This Review was written in collaboration with the GPH-CV (Groupe de Pharmacologie et d'Hémodynamique Cardiovasculaire), Paris, France. The author thanks M. Barbier for stimulating discussions and editorial assistance. I dedicate this manuscript to my wife, Anne Safar, and my children, Marie-Claude, Hélène, and Pierre.

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Correspondence to Michel E. Safar.

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Safar, M. Arterial stiffness as a risk factor for clinical hypertension. Nat Rev Cardiol 15, 97–105 (2018).

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