Artificial intelligence measuring the aortic diameter assist in identifying adverse blood pressure status including masked hypertension

Figures & data

Figure 1. Schematic diagram of segmentation of 9 consecutive levels of the aorta.

Male, 39 years old, without hypertension a. sagittal plane; b. horizontal plane; c. coronal plane; d. 9 measured AD locations; e. three-dimensional cross

Figure 2. The distribution of ADs at nine positions among groups.

Figure 2.a The ADs distribution difference between each adjacent anatomical positions. The t-test was used to compare the difference of ADs between adjacent anatomical levels

Figure 2.b The ADs distribution difference between HTN grades in all participants at nine positions. The ANOVA test was used to compare the difference of ADs between HTN classification.

0, Non-HTN;1, grade I; 2, grade II; 3, grade III

Figure 2.c The ADs distribution difference between Bp controlled status in participants with HTN at 9 positions. The t-test was used to test the difference between the groups of good BP control and poor BP control.

0, BP well-controlled; 1, BP poor-controlled

Figure 2.d The ADs distribution difference between MH and Non-HTN at nine positions. The t-test is used to test the difference between the groups of MH and those without HTN.

0, Non-HTN; 1, MH

value, AD (mm); ns, P > 0.05; *, P < 0.05; ****, P < 0.01

AD, aortic diameter; Other abbreviations are the same as in Table 1

Table 1. The distribution of basic population materials in the graded diagnosis of HTN

	HTN grading
	Non-HTN	Grade I	Grade II	Grade III	p
n	356	68	144	233
age	52.00 [45.00, 60.00]	57.00 [51.00, 67.50]	58.00 [52.00, 70.25]	61.00 [51.00, 73.00]	<0.001
sex = Male (%)	215 (60.4)	49 (72.1)	115 (79.9)	179 (76.8)	<0.001
BMI	23.44 (3.03)	25.44 (3.29)	25.01 (3.17)	25.69 (3.29)	<0.001
BMI_group = low weight(%)	12 (3.4)	1 (1.5)	4 (2.8)	2 (0.9)	<0.001
normal (%)	197 (55.3)	22 (32.4)	53 (36.8)	74 (31.8)
overweight(%)	120 (33.7)	33 (48.5)	66 (45.8)	112 (48.1)
obesity(%)	27 (7.6)	12 (17.6)	21 (14.6)	45 (19.3)
SBP	137.00 [126.00, 148.00]	157.50 [142.75, 165.50]	154.00 [139.00, 168.25]	159.00 [145.00, 172.00]	<0.001
DBP	75.00 [69.00, 81.00]	83.50 [77.75, 88.00]	80.50 [73.00, 87.00]	83.00 [75.00, 91.00]	<0.001
SV	34.20 (4.28)	36.08 (4.32)	35.66 (3.62)	36.28 (4.21)	<0.001
STJ	31.91 (3.99)	33.61 (4.47)	33.73 (3.84)	33.97 (3.75)	<0.001
MAs	35.37 (4.58)	37.94 (3.83)	38.19 (4.30)	38.94 (4.55)	<0.001
PAr	31.70 (3.57)	33.92 (2.95)	33.91 (3.33)	34.68 (3.53)	<0.001
MAr	29.19 (2.98)	30.75 (2.64)	30.94 (2.86)	31.50 (2.92)	<0.001
PD	27.38 (3.16)	28.97 (2.66)	29.23 (3.12)	30.00 (3.02)	<0.001
MD	24.13 (2.95)	26.17 (2.42)	26.47 (2.87)	27.28 (2.90)	<0.001
DP	24.32 (2.63)	25.43 (2.15)	25.82 (2.26)	26.27 (2.35)	<0.001
Ab	22.99 (2.63)	24.17 (2.31)	24.32 (2.23)	24.78 (2.30)	<0.001
ALT	20.00 [12.00, 32.00]	23.00 [16.50, 35.50]	23.00 [13.00, 32.50]	23.00 [15.00, 32.00]	0.201
AST	20.50 [17.00, 25.25]	21.00 [18.00, 27.00]	21.00 [18.00, 25.25]	21.00 [18.00, 26.00]	0.666
Ca	2.23 [2.16, 2.30]	2.22 [2.16, 2.30]	2.22 [2.16, 2.32]	2.22 [2.15, 2.31]	0.942
P	1.02 [0.93, 1.12]	1.02 [0.90, 1.10]	0.99 [0.89, 1.08]	1.01 [0.92, 1.12]	0.297
CREA	68.65 [58.68, 77.25]	71.00 [65.47, 80.15]	75.25 [66.20, 83.17]	78.40 [66.60, 91.60]	<0.001
CHOL	4.51 [3.88, 5.20]	4.56 [3.60, 5.29]	4.22 [3.61, 5.03]	4.20 [3.36, 5.02]	0.003
TG	1.11 [0.85, 1.59]	1.48 [1.01, 2.17]	1.49 [1.01, 2.18]	1.65 [1.19, 2.85]	<0.001
DM = Yes(%)	32 (9.0)	9 (13.2)	27 (18.8)	47 (20.2)	0.404
CHD = Yes (%)	39 (11.0)	8 (11.8)	36 (25.0)	72 (30.9)	0.310
OP = Yes (%)	54 (15.2)	11 (16.2)	30 (20.8)	41 (17.6)	0.080
Smoking = Yes (%)	101 (28.4)	27 (39.7)	49 (34.0)	88 (37.8)	0.063
Drinking = Yes (%)	81 (22.8)	20 (29.4)	53 (36.8)	72 (30.9)	0.010

Population characteristics are compared between HTN grades. Values are represented as medians [InterQuartile Range, IQR],mean ± SD or n (%).Differences among groups were respectively analyzed by Kruskal–Wallis test and ANOVA test for continuous variables in line with non-normal and normal distribution. Chi-square test was used to compare the difference of categorical data between groups.

HTN, hypertension; SBP Systolic blood pressure;DBP Diastolic blood pressure; SV: Aortic sinuses of Valsalva; STJ: Sinotubular junction; MAs: Mid ascending aorta (midpoint in length between STJ and PAr); PAr: Proximal aortic arch (aorta at the origin of the innominateartery); MAr: Mid aortic arch (between left common carotid and subclavian arteries); PD: Proximal descending thoracic aorta (begins at the isthmus, approximately 2 cm distal to left subclavian artery); MD: Mid descending aorta (midpoint in length between PD and DP); DP: Aorta at diaphragm (2 cm above the celiac axis origin); Ab: Abdominal aorta at the celiac axis origin; ALT:alanine aminotransferase; AST:aspartate aminotransferase; Ca, calcium; P, phosphorus; CREA: Creatinine; CHOL: cholesterol; TG: Triglycerides; DM, diabetes mellitus; CHD, Coronary heart disease; OP, Osteoporosis.

Table 2. The distribution of basic materials between groups of BP well-controlled and BP poor-controlled in HTN and the distribution of basic materials between groups of MH and non-HTN in people with normal clinic BP

	HTN		p	Normal clinic BP		p
	Well-controlled	Poor-controlled		Non_HTN	MH
n	92	353		195	92
age	57.50 [51.75, 68.00]	61.00 [51.00, 72.00]	0.567	50.00 [45.00, 56.00]	57.50 [51.75, 68.00]	<0.001
sex = Male (%)	76 (82.6)	267 (75.6)	0.201	98 (50.3)	76 (82.6)	<0.001
BMI	25.76 (3.02)	25.35 (3.31)	0.282	22.64 (2.66)	25.76 (3.02)	<0.001
BMI_group = low weight(%)	1 (1.1)	6 (1.7)	0.47	6 (3.1)	1 (1.1)	<0.001
normal (%)	25 (27.2)	124 (35.1)		131 (67.2)	25 (27.2)
overweight(%)	47 (51.1)	164 (46.5)		51 (26.2)	47 (51.1)
obesity(%)	19 (20.7)	59 (16.7)		7 (3.6)	19 (20.7)
SBP	131.50 [128.00, 135.25]	162.00 [151.00, 173.00]	<0.001	127.00 [121.50, 132.50]	131.50 [128.00, 135.25]	<0.001
DBP	74.00 [69.75, 79.00]	85.00 [78.00, 91.00]	<0.001	71.00 [66.00, 75.00]	74.00 [69.75, 79.00]	<0.001
SV	35.78 (3.96)	36.12 (4.07)	0.465	33.04 (4.07)	35.78 (3.96)	<0.001
STJ	33.84 (4.39)	33.83 (3.75)	0.982	31.00 (3.85)	33.84 (4.39)	<0.001
MAs	37.75 (4.55)	38.75 (4.31)	0.052	33.89 (4.02)	37.75 (4.55)	<0.001
PAr	33.86 (3.66)	34.44 (3.32)	0.147	30.65 (3.18)	33.86 (3.66)	<0.001
MAr	30.84 (3.10)	31.30 (2.80)	0.173	28.29 (2.74)	30.84 (3.10)	<0.001
PD	29.24 (3.34)	29.69 (2.93)	0.21	26.36 (2.85)	29.24 (3.34)	<0.001
MD	26.24 (2.97)	27.00 (2.80)	0.023	23.11 (2.79)	26.24 (2.97)	<0.001
DP	25.55 (2.35)	26.11 (2.29)	0.037	23.56 (2.62)	25.55 (2.35)	<0.001
Ab	24.11 (2.07)	24.65 (2.33)	0.044	22.32 (2.65)	24.11 (2.07)	<0.001
ALT	23.00 [13.00, 32.00]	23.00 [15.00, 34.00]	0.728	20.00 [12.00, 31.00]	23.00 [13.00, 32.00]	0.15
AST	20.50 [18.00, 24.00]	22.00 [18.00, 27.00]	0.199	20.00 [17.00, 24.00]	20.50 [18.00, 24.00]	0.516
Ca	2.22 [2.17, 2.32]	2.22 [2.15, 2.30]	0.593	2.21 [2.15, 2.28]	2.22 [2.17, 2.32]	0.267
P	1.02 [0.91, 1.14]	1.00 [0.91, 1.09]	0.201	1.02 [0.94, 1.12]	1.02 [0.91, 1.14]	0.964
CREA	76.40 [67.65, 90.38]	75.70 [65.50, 85.40]	0.221	66.50 [56.85, 76.60]	76.40 [67.65, 90.38]	<0.001
CHOL	3.90 [3.35, 4.65]	4.38 [3.51, 5.17]	0.007	4.47 [3.83, 5.11]	3.90 [3.35, 4.65]	<0.001
TG	1.98 [1.15, 2.83]	1.57 [1.07, 2.40]	0.105	1.08 [0.85, 1.48]	1.98 [1.15, 2.83]	<0.001
DM = Yes(%)	25 (27.2)	58 (16.4)	0.017	15 (7.7)	25 (27.2)	<0.001
CHD = Yes (%)	32 (34.8)	84 (23.8)	0.045	16 (8.2)	32 (34.8)	<0.001
OP = Yes (%)	17 (18.5)	65 (18.4)	1	27 (13.8)	17 (18.5)	0.4
Smoking = Yes (%)	40 (43.5)	124 (35.1)	0.175	55 (28.2)	40 (43.5)	0.015
Drinking = Yes (%)	26 (28.3)	119 (33.7)	0.385	36 (18.5)	26 (28.3)	0.084

Divide two populations with different blood pressure status characteristics from the total population, and conduct subgroup analysis, separately. Values are represented as medians [InterQuartile Range, IQR],mean ± SD or n (%). Differences among groups were respectively analyzed by Kruskal–Wallis test and ANOVA test for continuous variables in line with non-normal and normal distribution. Chi-square test was used to compare the difference of categorical data between groups.

MH, maked hypertension; BP, blood pressure; Other abbreviations could be seen in Table 1.

Figure 3. The Correlation matrix of age, BMI, SBP, DBP and ADs at 9 positions.

The diagonal shows the distribution of variables, the bottom left shows the bivariate scatter diagram with the fitting line, and the top right shows the correlation coefficient and significance location.

value, AD (mm); ***, P < 0.01

AD, aortic diameter. Other abbreviations are the same as in Table 1

Figure 4. Scatter plot and fitting curve/plane between BP, age and ADs.

a. The SBP is the independent variable and the ADs at nine positions is the dependent variable, fitted with LOSSES

b The SBP is the independent variable and the ADs at nine positions is the dependent variable, fitted with a linear function

c The DBP is the independent variable and the ADs at nine positions is the dependent variable, fitted with LOSSES

d The DBP is the independent variable and the ADs at nine positions is the dependent variable, fitted with a linear function

e The age is the independent variable and the ADs at nine positions is the dependent variable, fitted with LOSSES

f The age is the independent variable and the ADs at nine positions is the dependent variable, fitted with a linear function

g Three-dimensional scatter plot, the x-axis is age, the y-axis is SBP, the z-axis is AD at the position of MD, and a linear function is used to fit the plane

h Three-dimensional scatter plot, the x-axis is age, the y-axis is DBP, and the z-axis is AD at the position of SV, and a linear function is used to fit the plane

value, AD (mm); LOSSES, The locally weighted regression scatter smoothing method; Other abbreviations are the same as in Table 1

Table 3. Univariate linear regression analysis between BP (SBP, DBP) and AD, age and AD

	Regression coefficients	95% CI	Adjusted R-squared	P
SV ^a	0.040	0.026 ~ 0.054	0.036	<0.001
STJ ^a	0.032	0.019 ~ 0.046	0.026	<0.001
MAs ^a	0.068	0.052 ~ 0.083	0.085	<0.001
PAr ^a	0.052	0.040 ~ 0.064	0.081	<0.001
MAr ^a	0.042	0.032 ~ 0.052	0.076	<0.001
PD ^a	0.048	0.038 ~ 0.059	0.091	<0.001
MD ^a	0.056	0.046 ~ 0.066	0.130	<0.001
DP ^a	0.042	0.033 ~ 0.050	0.107	<0.001
Ab ^a	0.037	0.029 ~ 0.046	0.089	<0.001
SV ^b	0.094	0.066 ~ 0.121	0.050	<0.001
STJ ^b	0.079	0.052 ~ 0.105	0.039	<0.001
MAs ^b	0.080	0.048 ~ 0.111	0.029	<0.001
PAr ^b	0.071	0.047 ~ 0.100	0.038	<0.001
MAr ^b	0.061	0.041 ~ 0.082	0.041	<0.001
PD ^b	0.070	0.049 ~ 0.092	0.048	<0.001
MD ^b	0.076	0.055 ~ 0.097	0.059	<0.001
DP ^b	0.053	0.036 ~ 0.070	0.043	<0.001
Ab ^b	0.042	0.025 ~ 0.059	0.028	<0.001
SV ^c	0.067	0.047 ~ 0.088	0.049	<0.001
STJ ^c	0.080	0.061 ~ 0.099	0.077	<0.001
MAs ^c	0.187	0.168 ~ 0.206	0.311	<0.001
PAr ^c	0.138	0.122 ~ 0.153	0.274	<0.001
MAr ^c	0.109	0.096 ~ 0.122	0.248	<0.001
PD ^c	0.113	0.099 ~ 0.127	0.235	<0.001
MD ^c	0.136	0.123 ~ 0.148	0.360	<0.001
DP ^c	0.091	0.080 ~ 0.102	0.246	<0.001
Ab ^c	0.087	0.076 ~ 0.098	0.230	<0.001

a Univariate linear regression analysis with the SBP as an independent variable and the AD at each position as a dependent variable; b Univariate linear regression analysis with the DBP as an independent variable and the AD at each position as a dependent variable; c Univariate linear regression analysis with the age as an independent variable and the AD at each position as a dependent variable.

Abbreviations could be seen in Table 1.

Table 4. The OR value and 95% CI of the ADs in the population with different characteristics to the adverse BP states obtained by logistic regression analysis

		Model1			Model2
	OR	95%CI	P	OR	95%CI	P
SV ^a	1.115	1.076 ~ 1.156	<0.001	1.022	0.976 ~ 1.070	0.357
STJ ^a	1.137	1.095 ~ 1.183	<0.001	1.037	0.988 ~ 1.088	0.142
MAs ^a	1.177	1.136 ~ 1.220	<0.001	1.084	1.035 ~ 1.137	<0.001
PAr ^a	1.247	1.192 ~ 1.308	<0.001	1.125	1.060 ~ 1.195	<0.001
MAr ^a	1.270	1.205 ~ 1.342	<0.001	1.115	1.041 ~ 1.196	0.002
PD ^a	1.268	1.205 ~ 1.337	<0.001	1.110	1.040 ~ 1.185	0.002
MD ^a	1.387	1.310 ~ 1.474	<0.001	1.240	1.144 ~ 1.349	<0.001
DP ^a	1.324	1.243 ~ 1.413	<0.001	1.108	1.021 ~ 1.205	0.015
Ab ^a	1.299	1.221 ~ 1.386	<0.001	1.081	0.996 ~ 1.175	0.064
SV ^b	1.022	0.965 ~ 1.083	0.464	1.050	0.984 ~ 1.123	0.145
STJ ^b	0.999	0.943 ~ 1.061	0.982	1.024	0.961 ~ 1.094	0.472
MAs ^b	1.056	1.000 ~ 1.117	0.053	1.090	1.022 ~ 1.166	0.001
PAr ^b	1.052	0.983 ~ 1.129	0.148	1.093	1.009 ~ 1.186	0.031
MAr ^b	1.058	0.976 ~ 1.148	0.173	1.102	1.005 ~ 1.212	0.040
PD ^b	1.051	0.973 ~ 1.137	0.210	1.097	1.001 ~ 1.205	0.049
MD ^b	1.101	1.014 ~ 1.199	0.024	1.244	1.114 ~ 1.397	<0.001
DP ^b	1.114	1.007 ~ 1.236	0.038	1.196	1.062 ~ 1.354	0.004
Ab ^b	1.110	1.003 ~ 1.231	0.045	1.182	1.051 ~ 1.336	0.006
SV ^c	1.183	1.108 ~ 1.269	<0.001	1.073	0.976 ~ 1.184	0.147
STJ ^c	1.185	1.111 ~ 1.270	<0.001	1.092	0.994 ~ 1.206	0.071
MAs ^c	1.236	1.158 ~ 1.327	<0.001	1.179	1.056 ~ 1.326	0.004
PAr ^c	1.320	1.216 ~ 1.443	<0.001	1.205	1.057 ~ 1.383	0.006
MAr ^c	1.362	1.237 ~ 1.513	<0.001	1.247	1.071 ~ 1.465	0.005
PD ^c	1.351	1.235 ~ 1.491	<0.001	1.186	1.026 ~ 1.383	0.024
MD ^c	1.468	1.322 ~ 1.650	<0.001	1.258	1.036 ~ 1.539	0.023
DP ^c	1.377	1.233 ~ 1.551	<0.001	1.072	0.890 ~ 1.295	0.463
Ab ^c	1.365	1.217 ~ 1.547	<0.001	1.047	0.863 ~ 1.270	0.640

Model 1: No adjustment for any covariates;

Model 2: Adjusted for age,sex,BMI_group,Ca,P,CREA,CHOL,TG,ALT,AST,DM,CHD,OP,history of smoking and drinking

a. In the general population, the risk effect of ADs on patients with HTN

b. In people with HTN, the risk effect of ADs on patients with poor BP controlled

c. In people with normal clinic BP, the risk effect of ADs on the MH

OR Odds Ratios; CI Confidence Intervals; Other abbreviations could be seen in Table 1.

Figure 5. The ROCs of ADs at nine positions to identify poor BP status.

a Utilize ADs to identify patients with HTN in the general population

b Utilize ADs to identify poor BP controlled patients in the HTN

c Utilize ADs to identify MH in people with normal Clinic BP

ROC, receiver operating characteristic curves; AD, aortic diameter; Other abbreviations are the same as in Table 1

Table 5. The ROCs of ADs to identify poor BP states among people with different BP characteristics

	AUC (95%CI)	Specificity	Sensitivity	Cutoff	Youden’s index
SV ^a	0.624(0.585 ~ 0.663)	0.652	0.544	35.45	0.20
STJ ^a	0.638(0.600 ~ 0.677)	0.315	0.879	29.75	0.19
MAs ^a	0.698(0.661 ~ 0.735)	0.640	0.683	36.35	0.32
PAr ^a	0.711(0.675 ~ 0.748)	0.497	0.845	31.15	0.34
MAr ^a	0.691(0.654 ~ 0.727)	0.674	0.613	30.35	0.28
PD ^a	0.699(0.663 ~ 0.736)	0.469	0.840	26.95	0.31
MD ^a	0.743(0.709 ~ 0.778)	0.545	0.818	24.35	0.36
DP ^a	0.682(0.645 ~ 0.720)	0.719	0.562	24.65	0.28
Ab ^a	0.671(0.633 ~ 0.708)	0.685	0.573	24.15	0.26
SV ^b	0.485(0.417 ~ 0.553)	0.315	0.725	37.59	0.04
STJ ^b	0.507(0.440 ~ 0.524)	0.547	0.499	33.55	0.05
MAs ^b	0.562(0.495 ~ 0.629)	0.413	0.708	36.35	0.12
PAr ^b	0.546(0.477 ~ 0.616)	0.435	0.703	32.65	0.14
MAr ^b	0.534(0.467 ~ 0.602)	0.359	0.734	29.55	0.09
PD ^b	0.544(0.474 ~ 0.614)	0.315	0.844	27.55	0.16
MD ^b	0.578(0.512 ~ 0.644)	0.533	0.632	26.05	0.17
DP ^b	0.569(0.504 ~ 0.634)	0.663	0.467	26.35	0.13
Ab ^b	0.558(0.496 ~ 0.621)	0.728	0.408	25.15	0.14
SV ^c	0.688(0.623 ~ 0.754)	0.759	0.554	35.50	0.31
STJ ^c	0.695(0.631 ~ 0.759)	0.421	0.880	29.85	0.30
MAs ^c	0.747(0.688 ~ 0.807)	0.728	0.652	35.95	0.38
PAr ^c	0.753(0.694 ~ 0.812)	0.610	0.772	31.10	0.38
MAr ^c	0.744(0.683 ~ 0.805)	0.626	0.761	29.05	0.39
PD ^c	0.752(0.692 ~ 0.811)	0.610	0.772	26.95	0.38
MD ^c	0.784(0.729 ~ 0.839)	0.687	0.750	24.35	0.44
DP ^c	0.716(0.655 ~ 0.777)	0.662	0.685	24.65	0.35
Ab ^c	0.707(0.644 ~ 0.769)	0.615	0.717	23.25	0.33

a The ROCs of AD to identify HTN in the total population

b The ROCs of AD to identify patients with poor BP controlled among HTN

c The ROCs of AD to identify MH among people with normal clinic BP

ROC the receiver operating characteristic curve; Other abbreviations could be seen in Table 1.

Data availability statement

Data is openly available in a public repository that issues datasets with DOIs