Arterial Stiffness From Monitoring of Timing

of Korotkoff Sounds Predicts the Occurrence

of Cardiovascular Events Independently of Left
Ventricular Mass in Hypertensive Patients
Philippe Gosse, Antoine Cremer, Georgios Papaioannou, Sunthareth Yeim
See Editorial Commentary, pp 1012
AbstractSeveral studies have established that the increase in arterial stiffness (AS) is a cardiovascular risk factor but
to date no studies have evaluated in hypertensive patients its prognostic value in comparison with another powerful
risk factor, left ventricular mass (LVM) as measured by echocardiography. We prospectively evaluated the prognostic
value of AS and LVM in patients with essential hypertension. The population studied comprised 793 patients (56%
men) aged 5414 years. For 519 patients, baseline measurements were made before any antihypertensive treatment,
for 274 patients, the measurement were obtained during the follow-up period under antihypertensive treatment. AS was
assessed from ambulatory monitoring of blood pressure and timing of Korottkoff sounds. Left ventricular mass was
measured in 523 patients. After a mean follow-up of 97 months, 122 cardiovascular events were recorded in the
whole population and 74 in the group with LVM determination. AS as continuous or discontinuous variable was
independently related to cardiovascular events. The existence or not of antihypertensive treatment at the time of its
measurement did not affect its prognostic value. When LVM was forced in the model, AS remained significantly
related to cardiovascular events. Thus, AS has an independent prognostic value in the hypertensive, whether measured
before or after the administration of antihypertensive treatment. This prognostic value persists after taking LVM into
account.(Hypertension. 2013;62:161-167.)
Key Words: arterial stiffness

ambulatory BP monitoring

arkers of subclinical target organ damage increase

cardiovascular risk prediction beyond traditional risk
factors. Arterial stiffness (AS) is one of these markers.1 The
predictive value for future cardiovascular events (CVEs) has
been demonstrated for the carotido-femoral pulse wave velocity (PWV) in patients with renal failure,2 in hypertensives,3
and in the general population,4 as well as from ambulatory
measurement of the timing of Korotkoff sounds (QKD) in
hypertensives.5 The predictive value of AS is independent of
traditional risk factors: sex, age, diabetes mellitus, smoking,
cholesterol, and blood pressure (BP), even when monitored
during 24 hours with the QKD method. However, very few
studies6 have compared the respective predictive values of different markers of target organ damage. This is a major issue
because the question whether all parameters should be measured, or only some of them, in routine condition is opened.
To date there are no studies that have evaluated the prognostic
value of AS in comparison with another powerful risk factor,
left ventricular mass (LVM) as measured by echocardiography in hypertensive patients We evaluated the prognostic

cardiovascular events

left ventricular mass

QKD

value of these 2 parameters in the same population of patients

with essential hypertension using the QKD method, which
offers the advantages to combine 24-hour BP monitoring and
an estimation of AS independent of BP.

Methods
Population
The patients included in this study belong to the Bordeaux cohort
of hypertensive. This registry was started in 1984 and includes all
patients consecutively referred to our center before administration of
antihypertensive treatment and fulfilling the following criteria:
Office BP>140/90 on 2 occasions; Essential hypertension.
Absence of cardiovascular complications or pathology likely to
affect the prognosis, absence of type 1 diabetes mellitus.
For the validity of the ambulatory measurement of AS, 2 other
selection criteria were used.
Absence of bundle-branch block on ECG (QRS duration <120 ms).
Absence of known thyroid pathology.
All the patients gave their consent to participation in this registry,
which was approved by our local committee of ethics and protection

Received January 10, 2013; first decision April 22, 2013; revision accepted April 22, 2013.
From the Department of Cardiology and Hypertension, University Hospital of Bordeaux, Bordeaux, France.
Correspondence to Philippe Gosse, Department of Cardiology and Hypertension, University Hospital of Bordeaux, Hopital Saint Andre, 1 Rue Jean
Burguet, 33075 Bordeaux, France. E-mail philippe.gosse@chu-bordeaux.fr
2013 American Heart Association, Inc.
Hypertension is available at http://hyper.ahajournals.org

DOI: 10.1161/HYPERTENSIONAHA.113.01039

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161

162HypertensionJuly 2013
of the individual (Committee for Protection of Persons in the SouthWest and overseas III).
After the initial evaluation, the patients were given
antihypertensive treatment and followed up by their family
physicians who were not informed of AS results. These patients
were not systematically convened, but could be sent again by their
doctors during the follow-up period. We included in this study
the patients of the cohort who had benefited from a good quality
ambulatory measurement of BP and QKD either on inclusion in the
cohort before treatment or during the follow-up under treatment for
the patients for whom this measurement was not initially available,
as this monitoring became available only in late 1992. Baseline
for this study was defined as the time of the first QKD monitoring,
at entry in the cohort (untreated patients) or later on treatment for
patients for whom QKD could not be monitored before treatment,
at entry in the cohort.

influence of the pre-ejection time. The QKD100-60 is no longer correlated with mean 24 hours HR >24 hours or with systolic function
evaluated by echocardiography.11 Second, it provides an isobaric
index of AS, making it possible to compare patients at equal BP,
a clear advantage over PWV, which is highly dependent on BP and
HR at the time of the measurement. The QKD100-60 also depends on
the length of the arterial segment considered. We defined its correlation to height in a population of adult young subjects (<30) without
risk factors12 and proposed an equation for calculating QKD100-60
referred to height: theoretical QKD100-60=0.73height (cm)+91. The
measured value of the QKD100-60 is thus presented with reference to
the value predicted by height in normal subjects. We only included
patients who had 80 valid measurements during 24 hours. Results
of 24-hour BP recordings were sent to the family physician but the
results of QKD were not.

Measurement of LVM

Ambulatory Measurement of BP and QKD Interval

LVM was measured at the same time as QKD, the day ABPM (ambulatory blood pressure monitoring) was fitted in most cases and within
a 3-month interval in few cases. LVM was measured from M mode
tracings of the left ventricle obtained from the left parasternal view.
The tracings were read blind to clinical and QKD data, according to
the PENN convention. LVM was calculated from Devereux formula13
and indexed to height to the power 2.7 (LVM index [LVMI]). Other
modes of indexation (height and body surface area) and relative wall
thickness were also tested.

All the patients benefited from an ambulatory measurement of BP

coupled with the measurement of QKD interval.7 The equipment
(Diasys 200RK then Diasys integra, Novacor, France) is a device
based on the auscultatory measurement of BP, which also determined for each measurement the duration of the QKD interval as
the time between the QRS wave on the ECG and the detection of the
last Korotkoff sound on deflation of the cuff. So Q is for the ECG
QRS, K for Korotkoff sound, and D for diastolic BP. This interval is
measured every 15 min along with BP and heart rate (HR) during 24
hours (Figure1). This time has 2 components: the pre-ejection time
and the time of transmission of the pulse wave from the aortic valves
to the brachial artery, which for a cuff usually placed on the left arm,
includes the aortic arch, the left subclavian artery, and part of the
brachial artery. This time is related to the PWV810 and the length of
the arterial route. The ambulatory measurement of BP, QKD, and HR
enables evaluation of the variations in QKD with the spontaneous
variations in BP and HR. The variations with HR depend primarily
on variations in the pre-ejection time, and the variations with systolic
BP (SBP) in those of PWV. From the 96 measurements obtained,
the software automatically calculates the bivariate linear regression
equation of QKD according to SBP and HR and the theoretical value
of QKD for a 100 mmHg SBP and a 60 bpm HR. The interest of
this index, the QKD100-60 is 2-fold. First, it effectively reduces the

Estimation of Risk SCORE

An estimation of 10-year risk of fatal CVE was calculated from the
SCORE (Systematic COronary Risk Evaluation) project14 charts for
low-risk populations using office SBP and total cholesterol levels. For
patients with diabetes mellitus, results were multiplied by 2 in men
and 4 in women.

Follow-Up
Information from these patients is obtained regularly (every 2
years on average) either directly from the patients or from their
physicians. A detailed report was requested in the event of CVE. The
CVEs retained for analysis were myocardial infarction, coronary
revascularization, stroke documented by computed tomography

mmHg min-1ms
200
180

160
140
120
100
80
60
40

13

ms

14

15 16

17

18

19

20

21

22

23

10

11

12 13

14 h

180

160

160

140

140

120
100

120

140

160

180

120
mmHg 50

70

90

110

130

min-1

Figure 1. Twenty fourhour ambulatory recording of blood pressure (BP), heart rate (HR), and timing of Korotkoff sound (QKD)
in a 64-year-old hypertensive patient. A, Results of monitoring. B, Univariate linear regression of QKD vs systolic BP (SBP).
C, Univariate linear regression of QKD vs HR. QKD100-60, value of QKD for 100 mmHg SBP and 60 bpm HR; QKDh, measured
QKD100-60/height predicted value in normal subjects. Results in this patient: bivariate regression analysis:
QKD=2150.369SBP0.146HR; QKD100-60=169 ms; height predicted QKD100-60=162 cm0.73+91=209 ms; QKDh=0.81.

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Gosse et al Arterial Stiffness, Left Ventricular Mass, and Risk 163

Table 1. Main Characteristics of Population Studied at Baseline
Variables
Men/women

Min

Max

Mean

SD

442/351

Smokers (Y/N)

153/640

Hypercholesterolemia (Y/N)

154/639

Type 2 diabetes mellitus (Y/N)

67/726

Previous treatment (Y/N)

274/519

14

Age, y

793

18

80

54

BMI, kg/m2

793

17

39

26

Office SBP, mmHg

793

110

240

154

18

Office DBP, mmHg

793

60

140

93

11

24-h SBP, mmHg

793

95

198

131

16

24-h DBP, mmHg

793

54

135

84

11

24-h HR, bpm

793

41

105

74

11

24-h PP, mmHg

793

20

102

46

13

24-h MBP, mmHg

793

72

154

100

11

QKD100-60, ms

793

142

256

206

19

QKDh, %

793

66

123

97

SOKOLOFF, mm

605

58

23

Plasma fasting blood glucose, mmol/L

601

3.4

15.1

5.5

1.2

Plasma creatinin, mol/L

560

40

221

86

23

Total cholesterol, mmol/L

497

10.0

5.6

1.2

LVMI, g/m2.7

523

18

149

51

16

LVMI, g/m2

523

49

319

115

37

BMI indicates body mass index; BP, blood pressure; DBP, diastolic blood pressure; HR, hazard ratio; LVMI, left ventricular mass indexed for height to the power
2.7 (g/m2.7) or for body surface area (g/m2); MBP, mean blood pressure; PP, pulse pressure; QKD, timing of Korotkoff sound; QKDh, measured QKD100-60/height predicted
value in normal subjects; and SBP, systolic blood pressure.

scan or NMRI (nuclear magnetic resonance imaging), sudden death,

terminal renal failure, cardiac failure, arteriopathy of the lower
limbs requiring revascularization, aneurism of the abdominal aorta
operated or ruptured, carotid stenosis requiring angioplasty. We
regarded as major events coronary events (infarction or coronary
revascularization), stroke, and deaths from all causes.

Statistics
The data were analyzed with SPSS 18 IBM software. Survival
was analyzed according to the Cox model for the whole study
population and then in the group whose LVM was measured. The
analysis was carried out for all the CVE, then for the major events
and deaths. QKDh was used as both continuous and discontinuous variable (normal or abnormal values). Abnormal QKDh was
defined as value <100% of the normal height predicted value. The
risk factors included for analyses were discontinuous variables:

sex, diabetes mellitus, smoking, hypercholesterolemia, recording

performed on treatment; continuous variables: average 24-hour
pulse pressure (PP) and mean BP (MBP), mean 24-hour HR, body
mass index, LVMI. In another model, 24-hour MBP and PP were
replaced by 24-hour SBP and diastolic BP. The adjusted hazard
ratio was calculated as the antilogarithm of the coefficient of the
Cox model.

Results
The population studied comprised 793 patients whose main
characteristics are summarized in Table1. For 519 patients,
baseline measurements were made before any antihypertensive treatment; for 274 patients, the measurement of the QKD
could only be obtained during the follow-up period under

Table 2. Cardiovascular Complications Observed as a Function of Normal or Reduced QKDh at Baseline

Events

Normal QKDh
100%, n=303

Reduced QKDh
<100%, n=475

P Value

All events

16

106

<0.0001

Cardiac events

52

<0.001

Stroke

30

<0.001

Other

24

<0.001

Deaths

42

<0.001

Cardiovascular deaths

20

<0.01

Major events

16

95

<0.001

QKD indicates timing of Korotkoff sound; and QKDh, measured QKD100-60/height predicted value in normal subjects.

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164HypertensionJuly 2013
Table 3. Main Results of Multivariate Cox Analysis in the Whole Population
All CV Events
(n=122)
Variables

HaRa

Major Events
(n=111)

CI

P
Value

HaRa

CI

P
Value

HaRa

CI

P
Value

1.054

1.0341.073

<0.001

1.046

1.0151.072

0.003

Age (1 y)

1.047

1.0221.066

<0.001

24-h PP (1 mmHg)

1.023

1.0091.038

0.001

24-h MBP (1 mmHg)

NS

1.026

1.0081.044

0.004

Smoking (Y/N)

1.6

1.12.4

0.02

On treatment (Y/N)

1.99

1.293.1

0.002

1.93

QKDh (1%)

1.037

1.0111.064

0.004

2.8

1.64.8

<0.001

Reduced QKDh (Y/N)

Deaths
(n=45)

1.043

1.0261.061

<0.001

NS
1.035

1.0081.063

0.01

NS

NS

1.32.9

0.01

NS

1.048

1.0231.073

<0.001

1.07

1.031.11

<0.001

2.8

1.64.9

<0.001

5.6

1.718

0.005

CI indicates confidence interval; CV, cardiovascular; HaRa, hazard ratio; MBP, mean blood pressure; NS, not significant; PP, pulse pressure; QKD, timing of Korotkoff
sound; and QKDh, measured QKD100-60/height predicted value in normal subjects.

antihypertensive treatment. Only 15 patients were lost to follow-up. For the patients followed up, a measurement of LVM
was obtained in 523 patients. The group for which LVM was
available was on average younger (5113 versus 5814 years;
P<0.01), had a lower mean 24-hour PP (4612 versus 4814
mmHg; P<0.05) and longer QKDh (988 versus 959%;
P<0.01). The average follow-up period for the population was
9761 months.
In this population, 122 CVE were recorded (Table2),
111 major events including 45 deaths (22 of proved cardiovascular origin). QKDh was significantly correlated with
24-hour PP (r=0.50; P<0.0001) and with age (r=0.38;
P<0.001).
In this population (Table3), 6 variables remained
significantly and independently linked to the occurrence of
CVE in multivariate Cox model: age, QKDh as a continuous
or discontinuous variable (Figure2A), smoking, recording
performed on treatment, 24-hour PP, and 24-hour MBP.
The QKDh as continuous or discontinuous variable was
also independently related to the major events together
with age, smoking, recording on treatment, and 24-hour
MBP but in this case 24-hour PP was no more significant
independent predictor. It was also independently related
to all-cause deaths with age and 24-hour MBP. Figure3
presents the receiver operating characteristic curve plots of
the relations of QKDh with the occurrence of CVE (left) or
major events (right). The 100% threshold had a sensitivity
of 86% and a specificity of 43% for the prediction of CVE

and a sensitivity of 95% with a specificity of 40% for the

prediction of major events. The best total sensitivity (83%)
plus specificity (47%) for prediction of CVE was obtained
for a QKDh of 99%. When the analysis was performed
with 24-hour SBP and diastolic BP instead of 24-hour PP
and MBP, only SBP was significantly related to event-free
survival. The results for the other variables and specially
QKD are almost the same. In our cohort, 24-hour SBP was
the best predictor of events as compared with daytime or
nightime BP. However, the differences among the 3 are
small and whatever BP level is entered in the COX model
the results for QKD stay unchanged. The population was
split into 3 groups according to the risk SCORE: low (1%),
moderate (>1% to <5%), and high (5%). Table4 shows the
number of patients with reduced QKDh and the number of
events recorded in each subgroup. In all SCORE groups,
reduced QKDh was associated with a significant increase
in CVE and all-cause deaths. QKDh was reduced in 42%
of patients in the low-risk score with a 10-fold increased
incidence of all-cause deaths. In the Cox analysis, QKDh
remained a significant predictor of all CVEs, major events,
and all-cause deaths when the risk SCORE was entered in
the model.
In the subgroup, where LVM was measured, 74 CVEs
were recorded, 65 major events, and 23 deaths. LVMI was
correlated significantly with QKDh (r=0.18; P<0.001).
LVMI was related to the risk of CVE (n=74) or major
events (n=65) in the monovariate analysis (P<0.001). The

Figure 2. Event-free survival

curves (all events) according to
baseline values of QKDh adjusted
for all significant risk factors (A)
plus left ventricular mass (LVM)
index in the population with
baseline LVM assessment (B).
QKDh, measured QKD100-60/height
predicted value in normal subjects.

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Gosse et al Arterial Stiffness, Left Ventricular Mass, and Risk 165

Figure 3. Receiver operating

characteristic curve plots for
QKD100-60 and the occurrence of
cardiovascular complications (A)
or major events (B). Area under the
curve (95% confidence interval):
A, 0.72 (0.680.77); B, 0.69
(0.640.74).

between 2 examinations ranging from 9 to 12 ms for a normal

value 200 to 210 ms.
We have already shown in our cohort5,23 that QKDh is
significantly related to the occurrence of the CVE independently of age, mean 24-hour BP, and other traditional risk
factors. This index also has a prognostic value for worsening
of systemic sclerosis.16
This new analysis of our cohort is based on a larger number of CVE (122 versus 6223). It confirms our previous results
showing a relation between QKDh and CVE independently of
age, mean 24-hour BP (SBP, PP, or MBP), sex, diabetes mellitus, smoking, and hypercholesterolemia. The present analysis
affords new data. The QKDh is an independent predictor of allcause deaths. The predictive value of QKDh does not seem to be
influenced by the existence or not of antihypertensive treatment
at the time of measurement. Above all, it remains significantly
correlated with the prognosis when LVMI is also introduced
into the model. An increasing number of intermediate markers
of cardiovascular risk are now proposed: LVM, intima-media
thickness, and AS. LVM is the intermediate marker that seems
to be the best documented2426 and it may be proposed as a surrogate end point in hypertension. Its reduction with antihypertensive treatment is related to an improved prognosis.27,28 LVM
and AS are linked.2931 We noted a significant but weak correlation between the 2 parameters in our population. It was thus
important to check whether the link between AS and cardiovascular risk was independent of LVM. This seemed to be the case.
The lack of predictive value of LVMI in multivariate analysis
when both 24-hour BP and QKD are entered in the model is
probably linked to the fact that these 2 parameters are important
determinants of increased LVM. Our study raises the question
of whether LVM remains an independent risk factor when AS
is known. Unfortunately, our study was not powerful enough

results of multivariate Cox analysis are shown in Table5.

QKDh (continuous or discontinuous) remained significantly
predictive of outcome independently of LVMI which was
significant only in the study of major events. Figure2B shows
the adjusted event-free survival curves according to normal
or reduced QKDh. The use of other modes of indexation of
LVM (height, body surface area, or relative wall thickness)
did not change the results.

Discussion
The ambulatory measurement of QKD interval enables
determination of an index of AS coupled with a measurement
of BP. The index obtained, measured QKD100-60/heightpredicted theoretical value, QKDh, is inversely related to
AS. It is significantly reduced in the hypertensive and in
other populations where AS is increased (renal failure15
and systemic sclerosis16). A criticism of this technique
is the evaluation of the transmission of the pulse wave
over a territory, including muscular arteries (subclavian
and brachial). In fact, the stiffness of these arteries is little
influenced by age or hypertension,17 and so has little influence
on the overall QKD. One of the interests of this method is that
it mainly depends on the transmission of the pulse wave along
the aortic arch whose physiological role is paramount and
which is more subjected to the consequences of physiological
or premature aging than is the rest of the aorta.18 This portion
of the aorta is not taken into account by the carotid-femoral
PWV considered as the gold standard.19 We have also shown
with an invasive study that the QKD interval was significantly
correlated to aortic SBP and could be used for a assessment of
central BP by a noninvasive method.20 Finally, the QKD100-60
is a reproducible technique21,22 with a SD of the differences

Table 4. Risk Classification According to Risk SCORE and Value of QKD

Low-Risk Score, 1%
Variables
n
Average FU, y

High-Risk Score, 5%

Medium Risk, >1%, <5%

Normal QKDh

Reduced QKDh

Normal QKDh

Reduced QKDh

Normal QKDh

Reduced QKDh

191

138

73

171

39

166

8.75

9.65

7.45

85

85

75

All CVE

7 (3.7%)

15 (10.9%)

4 (5%)

33 (19%)

5 (13%)

58 (35%)

Major events

7 (3.7%)

15 (10.9%)

4 (5%)

33 (19%)

5 (13%)

47 (28%)

Deaths

1 (0.5%)

7 (5%)

1 (1%)

10 (6%)

1 (2%)

25 (15%)

CVE indicates cardiovascular event; FU, follow-up; QKD, timing of Korotkoff sound; and QKDh, measured QKD100-60/height predicted value in normal subjects.

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166HypertensionJuly 2013
Table 5. Main Results of Multivariate Cox Analysis in the Population with LVM Measurements
All CV Events
(n=74)
Variables

HaRa

CI

Major Events
(n=65)
P Value

HaRa

Deaths
(n=23)

CI

P Value

HaRa

CI

P Value

Age (1 y)

1.034

1.0131.056

0.002

1.042

1.0211.067

<0.001

NS

24-h PP (1 mmHg)

1.032

1.0141.050

<0.001

1.023

1.0031.042

0.02

1.046

1.0211.072

<0.001

24-h MBP (1 mmHg)

NS

NS

NS

Smoking (Y/N)

NS

NS

NS

On treatment (Y/N)

2.5

1.54.1

<0.001

NS

NS

LVMI (1 g/m2.7)

NS

1.012

11.82

0.04

NS

1.035

1.0031.068

0.03

1.038

1.0041.074

0.03

1.67

1.0041.068

0.03

2.7

1.45.2

0.004

2.7

1.45.5

0.005

10.5

1.480

0.02

QKDh (1%)
Reduced QKDh (Y/N)

CI indicates confidence interval; CV, cardiovascular; HaRa, hazard ratio; LVM, left ventricular mass; MBP, mean blood pressure; NS, not significant; PP, pulse
pressure; QKD, Korotkoff sound; and QKDh, measured QKD100-60/height predicted value in normal subjects.

to demonstrate this. As far as we know, only 1 other study6

tested the predictive value of PWV as compared with LVMI
in a population of 1968 healthy patients. In a Cox multivariate
model, LVMI was not significantly associated with cardiovascular deaths when PWV and SCORE were entered in the model
but remained significantly associated with a composite of fatal
and nonfatal CVEs.
Some important limitations stem from the structure of this
study. It is a prospective registry. Only 67% of patients benefited from an echocardiographic examination at the time of
QKD measurement. Initially, the antihypertensive treatments
were proposed by our team, but later choices and modifications were carried out by the family doctors and were based
only on the office BP. It was impossible to study the influence of the different classes of antihypertensive agent in this
cohort. The number of recorded CVE is still modest. Finally,
this population was mostly composed of white individuals, although it should be noted that race information is not
recorded in France. Our results cannot thus be extrapolated to
other populations.

Perspectives
AS evaluated by the ambulatory measurement of QKD interval has an independent prognostic value in the hypertensive,
whether measured before or after the administration of antihypertensive treatment. The prognostic value of QKD-assessed
AS persists after taking 24-hour BP and LVM into account, 2
important risk factors. This emphasizes the idea that AS may
allow a better assessment of risk in hypertensive patients and
could be a target for future intervention studies.

Disclosures
None.

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Novelty and Significance

What Is New?

Arterial stiffness measured with the QKD method is a strong predictor

of cardiovascular event and all-cause deaths in hypertensive patients.
It remains significantly correlated with future events when left ventricular
mass, another powerful and independent risk factor, is taken into account.
Current antihypertensive treatment does not interfere with the prognostic
value of the QKD method.

This method may help to better assess cardiovascular risk in hypertensive patients.

Summary
Measurement of arterial stiffness with QKD method is predictive of
future cardiovascular event and all-cause deaths independently of
24-hour blood pressure and left ventricular mass in hypertensive
patients.

What Is Relevant?

The QKD method allows to measure 24-hour blood pressure and arterial
stiffness in a single examination.

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Arterial Stiffness From Monitoring of Timing of Korotkoff Sounds Predicts the

Occurrence of Cardiovascular Events Independently of Left Ventricular Mass in
Hypertensive Patients
Philippe Gosse, Antoine Cremer, Georgios Papaioannou and Sunthareth Yeim
Hypertension. 2013;62:161-167; originally published online May 20, 2013;
doi: 10.1161/HYPERTENSIONAHA.113.01039
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2013 American Heart Association, Inc. All rights reserved.
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