Visit-to-visit variability of blood pressure and cardiovascular disease and all-cause mortality: a systematic review and meta-analysis

The HARVEST. Looking for optimal management of young people with stage 1 hypertension

In the last few decades there has been much debate about the management of low-risk stage 1 hypertension in youth. In this article, we review the main findings of the HARVEST cohort accrued over 30 years, highlighting the contribution of this study to the existing literature. Tachycardia and sympathetic overdrive were closely intertwined in our HARVEST participants, promoting the development of sustained hypertension, metabolic abnormalities, and increased susceptibility to vascular complications. Short-term blood pressure variability in this age group had a prognostic power even greater than that of average 24h blood pressure. In the HARVEST participants, changes in left ventricular anatomy and contractility were the earliest signs of hypertensive cardiac involvement, whereas left ventricular filling was only marginally affected. Our results highlighted the role of glomerular hyperfiltration in determining microalbuminuria and renal damage in the early stage of hypertension. The genetic approach provided an important contribution to risk stratification and patient management. The HARVEST confirmed the importance of maintaining a good lifestyle for preventing the onset of hypertension, diabetes and cardiovascular events. Isolated systolic hypertension in the first decades of life appeared as a heterogeneous condition. To establish whether antihypertensive drug treatment should be started in this condition the clinician should consider the individual cardiovascular risk profile, the level of office mean BP and central BP. Despite recent progress in our knowledge, systolic hypertension still represents a challenging issue for the clinician. Hopefully, the HARVEST will continue to contribute data that help to fill the present gaps in evidence.

24-Hour Ambulatory Blood Pressure Variability in Children with Obstructive Sleep Apnea

OBJECTIVE

To evaluate blood pressure (BP) variability in 24-hour ambulatory BP monitoring in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Case series study.

METHODS

Children aged 4 to 16 years with clinical symptoms were recruited in a tertiary medical center. Overnight polysomnography and 24-hour recordings of ambulatory BP were performed for each child. The severity of OSA was classified as primary snoring (apnea-hypopnea index [AHI] < 1), mild OSA (1 ≤ AHI < 5), moderate OSA (10 > AHI ≥ 5), and severe OSA (AHI ≥ 10). The standard deviation of mean BP was used as an indicator of BP variability.

RESULTS

A total of 550 children were included (mean age: 7.6 years; 70% were boys; 20% were obese). Compared with the children with primary snoring, children with severe OSA exhibited significantly higher nighttime systolic BP (108.0 vs. 100.5 mmHg, P < .001), nighttime diastolic BP (58.9 vs 55.6 mmHg, P = .002), nighttime mean arterial pressure (75.3 vs. 70.5 mmHg, P < .001), nighttime systolic BP load (40.5% vs. 25.0%, P < .001), nighttime diastolic BP load (25.3% vs. 12.9%, P < .001), and nighttime systolic BP variability (11.4 vs. 9.6, P = .001). Multiple linear regression analyses revealed an independent association between AHI and nighttime systolic BP variability (regression coefficient = 0.31, 95% CI = 0.06-0.56, P = .015) after adjustment for age, gender, adiposity, and hypertensive status.

CONCLUSIONS

OSA in children is associated with increased BP and BP variability.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2126-2132, 2021.

Building clinical risk score systems for predicting the all-cause and expanded cardiovascular-specific mortality of patients with type 2 diabetes

AIM

To develop and validate risk score systems by examining the effects of glycaemic and blood pressure variabilities on the all-cause and expanded cardiovascular-specific mortality of people with type 2 diabetes.

MATERIALS AND METHODS

This retrospective cohort study consisted of 9692 patients aged 30-85 years, diagnosed with type 2 diabetes and enrolled in a managed care programme of a medical centre from 2002 to 2016. All the patients were randomly allocated into two groups, namely, training and validation sets (2:1 ratio), and followed up until death or August 2019. Cox's proportional hazard regression was performed to develop all-cause and expanded cardiovascular-specific mortality prediction models. The performance of the prediction model was assessed by using the area under the receiver operating characteristic curve (AUROC).

RESULTS

Overall, 2036 deaths were identified after a mean of 8.6 years of follow-up. The AUROC-measured prediction accuracies of 3-, 5-, 10- and 15-year all-cause mortalities based on a model containing the identified traditional risk factors, biomarkers and variabilities in fasting plasma glucose, HbA1c and blood pressure in the validation set were 0.79 (0.76-0.83), 0.78 (0.76-0.81), 0.80 (0.78-0.82) and 0.80 (0.78-0.82), respectively. The corresponding values of the expanded cardiovascular-specific mortalities were 0.85 (0.80-0.90), 0.83 (0.79-0.86), 0.80 (0.77-0.83) and 0.79 (0.77-0.82), respectively.

CONCLUSIONS

Our prediction models considering glycaemic and blood pressure variabilities had good prediction accuracy for the expanded cardiovascular-specific and all-cause mortalities of patients with type 2 diabetes.

Smartphone / smartwatch-based cuffless blood pressure measurement : a position paper from the Korean Society of Hypertension

Smartphone technology has spread rapidly around the globe. According to a report released by the Korea Information Society Development Institute, about 95% of Koreans aged more than 30 years old owned smartphones. Recently, blood pressure (BP) measurement using a photoplethysmography-based smartphone algorithm paired with the smartwatch is continuously evolving. In this document, the Korean Society of Hypertension intends to remark the current results of smartphone / smartwatch-based BP measurement and recommend optimal BP measurement methods using a smartphone device. We aim to increase the likelihood of success in implementing these new technologies into improved hypertension awareness, diagnosis, and control.

Assessment of visit-to-visit variability in systolic blood pressure over 5 years and phasic left atrial function by two-dimensional speckle-tracking echocardiography

Visit-to-visit variability in systolic blood pressure (VVV-SBP) has been associated with increased cardiac events. Hence, volume analysis by two-dimensional speckle-tracking echocardiography (2-DSTE) allows physicians to easily measure phasic left atrial (LA) function. However, the relationship of VVV-SBP and functional deformation of the left atrium with patients' clinical outcome is unclear. The aim of the study was to investigate the relationship between phasic LA function and VVV-SBP. The subjects were 70 male participants in whom 2-DSTE was performed to measure blood pressure at health check-ups every year for 5 years. The standard deviation of systolic blood pressure (SBP) was calculated to assess VVV-SBP. The average SBP (Ave-SBP) was also assessed. Total emptying function (EF) (reservoir function), passive EF (conduit function), and active EF (booster pump function) of the left atrium were calculated to evaluate phasic LA function by 2-DSTE. The Pearson correlation, simple regression analysis, and multivariate logistic regression analysis were used in data analysis. Participants' mean age was 50 ± 10 years, and 16 participants had hypertension. VVV-SBP correlated with total EF (r =  - 0.30, p = 0.014) and active EF (r =  - 0.35, p = 0.003). There was no correlation between the standard deviation of SBP and passive EF (r =  - 0.10, p = 0.39). Ave-SBP had no significant relationship with total EF (r =  - 0.06, p = 0.62), passive EF (r =  - 0.08, p = 0.50), or active EF (r =  - 0.03, p = 0.78). Active EF was also associated with VVV-SBP in multiple regression analysis. The active EF was significantly decreased in the highest quartile of VVV-SBP. Despite the small sample size of our study, the VVV-SBP showed a relationship with the phasic LA function. Our findings suggest that high VVV-SBP is noted to be associated with cardiovascular risk including a deterioration of LA function in clinical practice.

Visit-to-visit variability in blood pressure and the development of chronic kidney disease in treated general hypertensive patients

BACKGROUND

Data on the association between visit-to-visit variability (VVV) in blood pressure (BP) and the risk of chronic kidney disease (CKD) in general treated hypertensive patients were limited. We aimed to evaluate the relation of VVV in BP with the development of CKD, and examine any possible effect modifiers in hypertensive patients without prior cardiovascular diseases (CVDs) or CKD.

METHODS

This is a post hoc analysis of the Renal Sub-study of the China Stroke Primary Prevention Trial (CSPPT). A total of 10 051 hypertensives without CVD and CKD and with at least six visits of BP measurements from randomization to the 24-month visit were included. The main VVV in BP was expressed as standard deviation (SD). The primary outcome was the development of CKD, defined as a decrease in estimated glomerular filtration rate ≥30% and to a level of <60 mL/min/1.73 m2, or end-stage renal disease.

RESULTS

The median treatment duration was 4.4 years. After multivariable adjustment, including baseline systolic blood pressure (SBP) and mean SBP during the first 2-year treatment period, there was a significantly positive relationship of SD of SBP with the risk of CKD development (per SD increment; odds ratio, 1.27; 95% confidence interval: 1.10-1.46). The results were similar for coefficient of variation (CV) of SBP. Results across various subgroups, including age, sex, SBP at baseline, treatment compliance, concomitant antihypertensive medications and mean SBP during the first 24-month treatment period, were consistent.

CONCLUSIONS

SBP variability, irrespective of mean BP level, was significantly associated with the development of CKD in general treated hypertensive patients.

Association of Blood Pressure Variability and Diuretics With Cardiovascular Events in Patients With Chronic Kidney Disease Stages 1-5

Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events in the general population. Data are scarce in chronic kidney disease. We hypothesized that BPV would be associated with cardiovascular outcomes, death, and end-stage kidney disease (ESKD) and that diuretics would modify these associations in patients with chronic kidney disease. We studied US Veterans with nondialysis chronic kidney disease stages 1-5 and hypertension on nondiuretic antihypertensive monotherapy. At the time of second antihypertensive agent prescription, we propensity-matched for exposure to a loop or thiazide diuretic versus any other antihypertensive. BPV was defined as the coefficient of variation of systolic blood pressure over 6 months after second agent prescription. Cox proportional hazards regression measured associations of BPV with a primary cardiovascular event composite (fatal or nonfatal myocardial infarction or ischemic stroke; heart failure hospitalization). Secondary outcomes included all-cause death, each primary outcome component, end-stage kidney disease, and cardiovascular death. There were 31 394 participants in each group. BPV was associated with composite cardiovascular events, hazard ratio (95% CI) at second, third, fourth, and fifth versus first quintile: 1.79 (1.53-2.11), 2.32 (1.99-2.71), 2.60 (2.24-3.02), and 3.12 (2.68-3.62). Diuretics attenuated associations between the fourth and fifth BPV quintiles with composite events (P_interaction=0.03 and 0.04, respectively). BPV was associated with all secondary outcomes except end-stage kidney disease, with no diuretic interactions. BPV was associated with cardiovascular events and death but not end-stage kidney disease in patients with chronic kidney disease, with attenuated associations with cardiovascular events in the diuretic-treated group at high BPV quintiles. Future studies should investigate whether other antihypertensive classes modify these risks.

Blood Pressure Variability and Dementia: A State-of-the-Art Review

Accumulating evidence demonstrates that blood pressure variability (BPV) may contribute to target organ damage, causing coronary heart disease, stroke, and renal disease independent of the level of blood pressure (BP). Several lines of evidence have also linked increased BPV to a higher risk of cognitive decline and incident dementia. The estimated number of dementia cases worldwide is nearly 50 million, and this number continues to grow with increasing life expectancy. Because there is no effective treatment to modify the course of dementia, targeting modifiable vascular factors continues as a top priority for dementia prevention. A clear understanding of the role of BPV in dementia may shed light on the etiology, early prevention, and novel therapeutic targets of dementia, and has therefore gained substantial attention from researchers and clinicians. This review summarizes state-of-art evidence on the relationship between BPV and dementia, with a specific focus on the epidemiological evidence, the underlying mechanisms, and potential intervention strategies. We also discuss challenges and opportunities for future research to facilitate optimal BP management and the clinical translation of BPV for the risk assessment and prevention of dementia.

Impact of Blood Pressure Visit-to-Visit Variability on Adverse Events in Patients With Nonvalvular Atrial Fibrillation: Subanalysis of the J-RHYTHM Registry

Background

Blood pressure (BP) variability has reportedly been a risk factor for various clinical events. To clarify the influence of BP visit‐to‐visit variability on adverse events in patients with nonvalvular atrial fibrillation, a post hoc analysis of the J‐RHYTHM Registry was performed.

Methods and Results

Of 7406 outpatients with nonvalvular atrial fibrillation from 158 institutions, 7226 (age, 69.7±9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6±5.0 times) during the 2‐year follow‐up period or until occurrence of an event, constituted the study group. SD and coefficient of variation of BP values were calculated as BP variability. Thromboembolism, major hemorrhage, and all‐cause death occurred in 110 (1.5%), 121 (1.7%), and 168 (2.3%) patients, respectively. When patients were divided into quartiles of systolic BP‐SD (<8.20, 8.20–10.49, 10.50–13.19, and ≥13.20 mm Hg), hazard ratios (HRs) for all adverse events were significantly high in the highest quartile compared with the lowest quartile (HR, 2.00, 95% CI, 1.15–3.49, P=0.015 for thromboembolism; HR, 2.60, 95% CI, 1.36–4.97, P=0.004 for major hemorrhage; and HR, 1.85, 95% CI, 1.11–3.07, P=0.018 for all‐cause death) after adjusting for components of the CHA₂DS₂‐VASc score, warfarin and antiplatelet use, atrial fibrillation type, BP measurement times, and others. These findings were consistent when BP‐coefficient of variation was used instead of BP‐SD.

Conclusions

Systolic BP visit‐to‐visit variability was significantly associated with all adverse events in patients with nonvalvular atrial fibrillation. Further studies are needed to clarify the causality between BP variability and adverse outcomes in patients with nonvalvular atrial fibrillation.

Registration

URL: https://www.umin.ac.jp/ctr/; Unique Identifier: UMIN000001569.

Higher visit-to-visit blood pressure variability and N-terminal pro-brain natriuretic peptide elevation: influence of left ventricular hypertrophy and left ventricular diastolic function

OBJECTIVE

The issue of whether visit-to-visit blood pressure variability (VVV) is associated with higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) has been controversial, and the underlying mechanism is not well understood. We hypothesized that (1) VVV is associated with the NT-proBNP level, and (2) this association is mediated by left ventricular (LV) hypertrophy and LV diastolic dysfunction.

PATIENTS AND METHODS

A total of 72 hypertensive patients were examined. Clinic blood pressure was measured at each visit for 12 months (1×/month or every 2 months), and echocardiography was performed during this period. VVV is expressed as the SD, coefficient of variation (CV), and delta (Δ; the difference between the maximum and the minimum) in SBP and in DBP. We investigated the association between VVV and NT-proBNP and whether the LV mass index (LVMI) and the mitral early diastolic inflow velocity (E) to mitral annular early-diastolic peak velocity (e') ratio (E/e') influence this association.

RESULTS

The loge NT-proBNP values were significantly correlated with the CV of SBP (r = 0.42), ΔSBP (r = 0.41), the CV of DBP (r = 0.32), and ΔDBP (r = 0.28). The CV and Δ in SBP or those in DBP were not significantly correlated with LVMI or E/e'. A multiple linear regression analysis revealed that higher CV of SBP and ΔSBP were significantly associated with loge NT-proBNP.

CONCLUSION

Higher VVV was significantly associated with higher NT-proBNP independently of LV hypertrophy and diastolic function.

The Association Between Obesity and Visit-to-Visit Variability in Systolic Blood Pressure: A Prospective Study

With the prevalence of obesity and all accompanying health risks, both prevention and health education, as well as identifying predictors for the development of obesity-related diseases are primary. The pathophysiological relationship between obesity and visit-to-visit variability in systolic blood pressure (SBPV) has not been completely resolved. To investigate the association between obesity and SBPV in hypertensive patients. The prospective study comprised three visits was performed at the hypertension outpatient clinic during the follow up period of 22-months between March 2014 and January 2016. This study included 300 randomly selected hypertensive patients (average 67.76±9.84 years), who were divided in groups of obese/non-obese examinees. SBPV was defined as the standard deviation (SD) from three values of SBP. The values of SBP and SBP-SD were significantly higher in the group of obese hypertensive patients than in the group of non-obese patients (127.06±8.30 vs. 120.37±7.75; 11.29±5.67 vs. 7.37±3.94 mmHg; p<0.01). The highest SBPV was recorded in the 4th quartile in obese patients (43.13±7.50 mmHg). SBPV was strongly correlated with BMI and Waist cirumferences (WC) (ρo=0.425, ρo=0.356, p<0.01). During 22-months follow up there was a significant decrease of SBPV for 8.2 mmHg, BP for 31/5 mmHg, BMI for 3.8 kg/m2, WC for 10 cm and body weight for 8.24 kg. During 22-months follow-up, reduction of body weight was associated with reduction of blood pressure variability in hypertensive patients. Persistently decrease both body weight and long term visit-to-visit variability may explain lower cardiovascular risk in obese-related disease.

Association Between Pain, Blood Pressure, and Medication Intensification in Primary Care: an Observational Study

BACKGROUND

Treating hypertension is important but physicians often do not intensify blood pressure (BP) treatment in the setting of pain.

OBJECTIVE

To identify whether reporting pain is associated with (1) elevated BP at the same visit, (2) medication intensification, and (3) elevated BP at the subsequent visit.

DESIGN

Retrospective cohort SETTING: Integrated health system PARTICIPANTS: Adults seen in primary care EXPOSURE: Pain status based on numerical scale: mild (1-3), moderate (4-6), or severe (≥ 7).

MAIN MEASURES

We defined elevated BP as ≥ 140/80 mmHg and medication intensification as increasing the dose or adding a new antihypertensive medication. Multilevel regression models were used to find the association between pain and (1) elevated BP at the index visit; (2) medication intensification at the index visit; and (3) elevated BP at the subsequent visit. Models adjusted for demographics, chronic conditions, and clustering within physician. In the third model, we adjusted for initial systolic BP as well.

KEY RESULTS

Our population included 56,322 patients; 3155 (6%) reported mild pain, 5050 (9%) reported moderate pain, and 4647 (8%) reported severe pain at the index visit. Compared with no pain, the adjusted odds ratios of elevated BP were 1.38 (95% CI: 1.28-1.48) for severe pain, 1.06 (95% CI: 0.99-1.14) for moderate pain, and 1.02 (95% CI: 0.93-1.12) for mild pain. Adjusted odds ratios of medication intensification at the index visit were 0.65 (95% CI: 0.54-0.80) for mild pain, 0.61 (95% CI: 0.52-0.72) for moderate pain, and 0.55 (95% CI: 0.47-0.64) for severe pain. Among patients with elevated BP at the index visit, reporting pain at the index visit was not associated with elevated BP at the subsequent visit.

CONCLUSIONS

When patients reported pain, physicians were less likely to intensify antihypertensive treatment; nevertheless, patients reporting pain were not more likely to have elevated BP at the subsequent visit.

Prognostic impact of short-term ambulatory blood pressure variability for microvascular and macrovascular outcomes in patients with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

OBJECTIVE

To evaluate the prognostic importance of short-term blood pressure variability (BPV) for the occurrence of macrovascular and microvascular complications in individuals with type 2 diabetes.

METHODS

Six hundred and forty patients had 24-h ambulatory BP monitoring performed at baseline and were followed-up over a median of 11.2 years. Daytime, night-time and 24-h SBP and DBPV parameters (standard deviations and variation coefficients) were calculated. Multivariate Cox analysis, adjusted for risk factors and mean BPs, examined the associations between BPV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications [total cardiovascular events (CVEs), major adverse CVEs [MACEs]), and cardiovascular and all-cause mortalities. Improvements in risk discrimination were assessed by the C-statistic and Integrated Discrimination Improvement (IDI) index.

RESULTS

During follow-up, 186 patients had a CVE (150 MACEs), and 237 patients died (107 from cardiovascular diseases); 155 newly developed or worsened diabetic retinopathy, 200 achieved the renal composite outcome (124 newly developed microalbuminuria and 102 deteriorated renal function), and 170 newly developed or worsened peripheral neuropathy. Daytime DBPV was the best predictor for all cardiovascular outcomes and mortality, with hazard ratios (for increments of 1SD) ranging from 1.27 (95% CI 1.09-1.48) for all-cause mortality to 1.55 (1.29-1.85) for MACEs, and it improved cardiovascular risk discrimination (with increases in C-statistic of up to 0.026, and IDIs of up to 22.8%). No BPV parameter predicted any microvascular outcome.

CONCLUSION

Short-term BPV, particularly daytime DBPV, predicts future development of macrovascular complications and mortality and improves cardiovascular risk discrimination in patients with diabetes.

Short-Term but not Long-Term Blood Pressure Variability Is a Predictor of Adverse Cardiovascular Outcomes in Young Untreated Hypertensives

BACKGROUND

Whether blood pressure variability (BPV) measured with ambulatory monitoring (short-term BPV) or computed from office visits (long-term BPV) are related to each other and carry similar prognostic information is not well known. We investigated the independent determinants of short-term and long-term BPVs and their predictive capacity for the development of major adverse cardiovascular and renal events (MACEs) in a cohort of young hypertensive participants.

METHODS

Long-term BPV was calculated as visit-to-visit SD and average real variability from office blood pressure (BP) measured during 7 visits, within 1 year. Short-term BPV was calculated as weighted 24-hour SD and coefficient of variation. Hazard ratios (HRs) for risk of MACE were computed from multivariable Cox regressions.

RESULTS

1,167 participants were examined; mean age was 33.1 ± 8.5 years. Variables independently associated with 24-hour systolic SD were 24-hour systolic BP, low physical activity, smoking, baseline office pulse pressure, systolic BP dipping, and diastolic white coat effect, while those associated with long-term BPV were mean systolic BP, age, female gender, and baseline office heart rate. During a median follow-up of 17.4 years 75 MACEs occurred. In Cox analysis only short-term BPV resulted a significant predictor of MACE (HR, 1.31 (1.07-1.59); P = 0.0086), while no index of long-term BPV was independently associated with outcome.

CONCLUSIONS

In young hypertensive subjects only short-term BPV resulted a significant predictor of MACE on top of traditional ambulatory BP monitoring parameters. Whether reduction of short-term BPV with therapy may reduce the cardiovascular risk independently from the effects on 24-hour BP is a matter for future research.

Prognostic importance of long-term SBP variability in high-risk hypertension

OBJECTIVE

In addition to high blood pressure variability (BPV), low BPV was associated with adverse cardiovascular prognosis in selected high-risk patients. We explored this issue in the Systolic Blood Pressure Intervention Trial (SPRINT) using a nonlinear approach with BPV as a continuous variable.

METHODS

Long-term systolic BPV (SBPV) (coefficient of variation, CoV %) was calculated on quarterly visits until a fatal/nonfatal cardiovascular event or all-cause mortality, excluding titration period and patients with missing visits. We used Cox proportional hazard models with penalized smoothing splines to shape the risk of outcomes against the continuum of SBPV (independent variable). Adjusted hazard ratios (aHR, 95% CI) were calculated using the reference range derived from the nonlinear model. Sensitivity analysis based on propensity score matching (PSM) was performed.

RESULTS

The association of SBPV with fatal/nonfatal cardiovascular events was J-shaped, whereas that with all-cause mortality was linear. After multivariate adjustment, however, the only significant associations remained that of low SBPV (CoV <5%) with cardiovascular events (hazard ratio 1.85, 95% CI 1.24-2.75, P = 0.003), and of high SBPV (CoV >10%) with the composite of cardiovascular events and all-cause mortality (hazard ratio 1.35, 95% CI 1.02-1.80; P = 0.037). Low SBPV was associated with ischemic heart disease (hazard ratio 2.76, 95% CI 1.55-4.91; P < 0.001). There was a significant U-shaped association of SBPV with cardiovascular events in the PSM cohort.

CONCLUSION

Nonlinear modeling indicates that low and high long-term SBPV have prognostic relevance in high-risk hypertensive individuals from SPRINT. Randomized trials are needed to test these findings and their potential therapeutic implications.

Impact of visit-to-visit variability in blood pressure on coronary plaque as assessed by integrated backscatter intravascular ultrasound

INTRODUCTION

Visit-to-visit variability (VVV) in blood pressure (BP) has been reported to be a strong predictor of cardiovascular disease. However, the association between VVV in BP and coronary plaque composition has not been fully elucidated.

METHODS

One hundred-two consecutive patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI) using integrated backscatter (IB) intravascular ultrasound (IVUS), and who had at least six clinic visits a year before PCI were included. We measured systolic and diastolic BP (SBP and DBP) at each visit and determined VVV in BP expressed as the standard deviation of the average BP. Grayscale and IB IVUS examinations were performed for the culprit lesion of a coronary artery just before PCI.

RESULTS

There were no significant associations between the average SBP or DBP and various IVUS parameters. However, VVV in SBP was positively correlated with both the percentage (%) of atheroma volume (β = 0.23, p = .02) and % lipid volume (β = 0.53, p < .0001). VVV in DBP was positively correlated with % lipid volume (β = 0.24, p = .01), while there was no significant correlation between VVV in DBP and % atheroma volume. A  multivariable linear regression analysis showed that VVV in SBP was independently associated with % atheroma volume (p = .04) and % lipid volume (p < .001).

CONCLUSIONS

Larger VVV in SBP was significantly associated with an increased plaque burden and lipid composition at the culprit lesion of a coronary artery in CAD patients. The improvement of VVV in SBP may contribute to the regression and stabilization of coronary plaques.

Visit-to-visit blood pressure variability and renal outcomes: results from ONTARGET and TRANSCEND trials

AIMS

There is conflicting evidence on whether in treated hypertensive patients the risk of renal outcomes is associated with visit-to-visit SBP variability. Furthermore, limited evidence is available on how important is SBP variability for prediction of renal outcomes compared with on-treatment mean SBP. We addressed these issues in 28 790 participants of the Ongoing Treatment Alone and in combination with Ramipril Global End point Trial and Telmisartan Randomized AssessmeNt Study in ACE iNtolerant Subjects with Cardiovascular Disease trials.

METHODS AND RESULTS

SBP variability was expressed as the coefficient of variation of the mean with which it showed no relationship. SBP variability and mean values were obtained from five visits during the first 2 years of treatment after the end of the titration phase. Incidence of several renal outcomes (end-stage renal disease, doubling of serum creatinine, new microalbuminuria, new macroalbuminuria and their composite) was calculated from the third year of treatment onward. Patients were divided in quintiles of SBP-coefficient of variation (SBP-CV) or mean SBP, which exhibited superimposable mean blood pressure and SBP-CV values, respectively. A progressive increase of SBP-CV was not accompanied by a parallel increase in a widely adjusted (baseline and on-treatment confounders) risk of most renal outcomes (end-stage renal disease, new macroalbuminuria, new microalbuminuria and their composite) in the subsequent on-treatment years. In contrast, the adjusted risk of most renal outcomes increased progressively from the lowest to the highest quintile of on-treatment mean SBP. Progression from lowest to highest mean on-treatment SBP, but not SBP-CV, was also associated with a less frequent return to normoalbuminuria in patients with initial micro or macroalbuminuria. Renal outcome prediction was slightly improved by the combined use of SBP-CV and mean SBP quintiles.

CONCLUSION

Visit-to-visit SBP variability had no major predictive value for the risk of renal outcomes, which, in contrast, was sensitively predicted by mean on-treatment SBP. A further slight increase in prediction of renal outcomes was seen by combining on-treatment mean SBP and variability.

Blood Pressure Changes in a Chinese Population Have a Greater Impact on Short-Term Outcomes Rather Than Long-Term Outcomes of Major Adverse Cardiovascular Events

The purpose of our study was to explore the association of blood pressure (BP) changes on short-and long-term outcomes of major adverse cardiovascular events (MACEs) in rural China. This study was designed to learn the effects of BP changes (2004-2008) on short-term (2008-2010, within 2 years of the initial examination) and long-term (2008-2017) outcomes of MACE, including 24 285 and 27 290 participants, respectively. In this study, 423 (short-term) and 1952 (long-term) MACEs were identified. For prehypertension to hypertension, the risk of long-term stroke was increased (hazard ratio [HR] = 1.18 [1.00-1.39]). For hypertension to prehypertension, the short-term MACE risk (0.65 [0.47-0.90]), short-term stroke risk (0.45 [0.26-0.76]), and long-term stroke risk (0.83 [0.70-0.99]) all decreased. Short-term outcomes conferred a stronger impact than long-term outcomes (Fisher Z test, measured as the difference of β coefficients, all P < .05).

Establishment of a novel nomogram for the clinically diagnostic prediction of minimal change disease, -a common cause of nephrotic syndrome

Background

Minimal change disease (MCD) is one of the major causes of nephrotic syndrome (NS). A confirmed MCD diagnosis mainly depends on renal biopsy at present, which is an invasive procedure with many potential risks. The overall incidence of complications caused by renal biopsy procedures has been reported as approximately 11 and 6.6% outside and within China, respectively. Unfortunately, there is currently no noninvasive procedure or practical classification method for distinguishing MCD from other primary glomerular diseases available.

Method

A total of 1009 adult patients who underwent renal biopsy between January 2017 and November 2019 were enrolled in this study. Twenty-five parameters extracted from patient demographics, clinical manifestations, and laboratory test results were statistically analysed. LASSO regression analysis was further performed on these parameters. The parameters with the highest area under the curve (AUC) were selected and used to establish a logistic diagnostic prediction model.

Results

Of the 25 parameters, 14 parameters were significantly different (P < 0.05). MCD patients were mostly younger (36 (22, 55) vs. 41 (28.75, 53)) and male (59% vs. 52%) and had lower levels of diastolic blood pressure (DBP) (79 (71, 85.5) vs. 80 (74, 89)) and IgG (5.42 (3.17, 6.36) vs. 9.38 (6.79, 12.02)) and higher levels of IgM (1.44 (0.96, 1.88) vs. 1.03 (0.71, 1.45)) and IgE (160 (46.7, 982) vs. 47.3 (19, 126)) than those in the non-MCD group. Using the LASSO model, we established a classifier for adults based on four parameters: DBP and the serum levels of IgG, IgM, IgE. We were able to clinically classify adult patients with NS into MCD and non-MCD using this model. The validation accuracy of the logistic regression model was 0.88. A nomogram based on these four classifiers was developed for clinical use that could predict the probability of MCD in adult patients with NS.

Conclusions

A LASSO model can be used to distinguish MCD from other primary glomerular diseases in adult patients with NS. Combining the model and the nomogram potentially provides a novel and valuable approach for nephrologists to diagnose MCD, avoiding the complications caused by renal biopsy.

Cardiovascular Risk Factors: It's Time to Focus on Variability!

Atherosclerotic heart disease remains a leading cause of morbidity and mortality worldwide. While extensive research supports cardiovascular risk factor reduction in the form of achieving evidence-based blood pressure, lipid, glucose, and body weight targets as a means to improve cardiovascular outcomes, residual risk remains. Emerging data have demonstrated that the intraindividual variability of these risk factor targets potentially contribute to this residual risk. It may therefore be time to define risk factor by not only its magnitude and duration as done traditionally, but perhaps also by the variability of that particular risk factor over time.

Effect of Visit-to-Visit Blood Pressure Variability on Cognitive and Functional Decline in Mild to Moderate Alzheimer's Disease

BACKGROUND

Visit-to-visit blood pressure (BP) variability (VVV) is increasingly recognized as a marker of cardiovascular risk. Although implicated in cognitive decline, few studies are currently available assessing its effects on established dementia.

OBJECTIVE

To investigate if VVV is associated with one-year rate of decline in measures of cognition and function in patients with mild to moderate Alzheimer's disease (AD) in the Doxycycline And Rifampicin for Alzheimer's Disease study.

METHODS

Patients were included if ≥3 BP readings were available (n = 392). VVV was defined using different approaches including the coefficient of variation (CV) in BP readings between visits. Outcomes included rates of decline in the Standardized Alzheimer's Disease Assessment Scale-Cognitive Subscale (SADAS-cog), Standardized MMSE, Clinical Dementia Rating Scale, the Quick Mild Cognitive Impairment screen and the Lawton-Brody activities of daily living (ADL) scale.

RESULTS

Half of the patients (196/392) had a ≥4-point decline in the SADAS-cog over one-year. Using this cut-off, there were no statistically significant associations between any measures of VVV, for systolic or diastolic BP, with and without adjustment for potential confounders including treatment allocation, history of hypertension and use of anti-hypertensive and cognitive enhancing medications. Multiple regression models examining the association between systolic BP CV by quartile and decline over one-year likewise showed no clinically significant effects, apart from a U-shaped pattern of ADL decline of borderline clinical significance.∥Conclusions: This observational study does not support recent research showing that VVV predicts cognitive decline in AD. Further studies are needed to clarify its effects on ADL in AD.

Digital Management of Hypertension Improves Systolic Blood Pressure Variability

BACKGROUND

Higher systolic blood pressure variability has been shown to be a better predictor of all-cause and cardiovascular disease mortality, stroke, and cardiac disease compared with average systolic blood pressure.

METHODS

We evaluated the impact of a digital hypertension program on systolic blood pressure variability in 803 consecutive patients with long-standing hypertension who had been under the care of a primary care physician for a minimum of 12 months prior to enrollment (mean 4.7 years). Blood pressure readings were transmitted directly from home using a digitally connected blood pressure unit. Medication adjustments and lifestyle coaching was performed virtually via a dedicated team of pharmacists and health coaches. Systolic blood pressure variability was grouped by quartile and measured using the standard deviation (SD) of all systolic blood pressure values per individual.

RESULTS

The mean age was 67 ± 12 years, 41% were male, submitting 3.3 ± 3.7 blood pressures per week. Under usual care, only 30% of patients were in the lowest-risk quartile, and 21% of patients were in the highest risk. After 24 months, the mean systolic blood pressure variability progressively fell from 12.8 ± 4.3 mm Hg to 9.9 ± 5.1 mm Hg (P <0.0001) with 57% of patients achieving the lowest-risk quartile.

CONCLUSIONS

The majority of patients with hypertension under usual care have elevated systolic blood pressure variability exposing them to higher risk of cardiovascular disease events. Digital management of hypertension that includes weekly submission of home readings leads to improvement in average systolic blood pressure as well as systolic blood pressure variability over time, which should improve cardiovascular prognosis.

Risk Factor Variability and Cardiovascular Outcome: JACC Review Topic of the Week

Until recently, intraindividual visit-to-visit variability of cardiovascular risk factors has been dismissed as random fluctuation. This simplistic concept was challenged by demonstrating that visit-to-visit blood pressure variability, independent of average blood pressure, was a powerful risk factor for stroke. Subsequently, variability of other cardiovascular risk factors such as cholesterol, glycemia, and body weight was documented to increase risk independent of their absolute values. Variability of these risk factors has been demonstrated to be a powerful predictor for all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia. With the notable exception of heart rate, cardiovascular risk factors must now be defined by 2 components: the magnitude and duration of sustained risk factor elevation and, equally important, the variability of the same risk factor over time.

The effect of blood pressure variability on the prognosis of hypertensive patients

Objective:

Our study aims to compare the effects of blood pressure variability (BPV) during ambulatory blood pressure measurement (ABPM) and visit-to-visit measurements to predict future cardiovascular complications among hypertensive patients.

Methods:

This is a retrospective case-control study of patients with hypertension over 10 years. All adult patients with at least one recorded ABPM, and at least three recorded visit measurements were included. Patients with incomplete ABPM readings, a history of a tested outcome, or the occurrence of any of the tested outcomes within the measurement period were excluded. The outcome was the development of any of the following: acute coronary syndrome (ACS), chronic ischemic heart disease (IHD), heart failure (HF), or stroke.

Results:

Of the 305 cases reviewed, 152 were included. The mean follow-up was 6.6±2.3 years. The mean age was 53.5±14.3 years. Eighty-two (53.9%) patients were male, while 70 (46.1%) were female. Risk factors included diabetes mellitus (53.9%), dyslipidemia (39.5%), obesity (16.4%), and smoking (8.6%). Comorbidities included stroke (2%), ACS (8.6%), IHD (20.4%), HF (2.6%), and renal failure (1.3%). One or more complications were seen in 22.4 % of the included patients. The variation of the daytime systolic ABP had been found to predict the future risk of developing IHD (OR=1.94; 95% CI=1.09–3.45; p=0.025). Moreover, IHD was associated with night-time systolic standard deviation (SD) in ABPM (OR=1.23; 95% CI=1.00–1.51; p=0.048). On the other side, ACS was found to be associated with systolic SD in visit-to-visit measurement (OR=1.10; 95% CI=1.01–1.21; p=0.04).

Conclusion:

Hypertensive patients with high variability of daytime and night-time SD in ABPM are more likely to have IHD. Whereas, having high variability in systolic SD in visit-to-visit measurements is associated with developing ACS.

Association Between Blood Pressure Variability and Cerebral Small-Vessel Disease: A Systematic Review and Meta-Analysis

Background

Research links blood pressure variability (BPV) with stroke; however, the association with cerebral small‐vessel disease (CSVD) remains unclear. As BPV and mean blood pressure are interrelated, it remains uncertain whether BPV adds additional information to understanding cerebrovascular morphological characteristics.

Methods and Results

A systematic review was performed from inception until March 3, 2019. Eligibility criteria included population, adults without stroke (<4 weeks); exposure, BPV quantified by any metric over any duration; comparison, (1) low versus high or mean BPV and (2) people with versus without CSVD; and outcomes, (1) CSVD as subcortical infarct, lacunae, white matter hyperintensities, cerebral microbleeds, or enlarged perivascular spaces; and (2) standardized mean difference in BPV. A total of 27 articles were meta‐analyzed, comprising 12 309 unique brain scans. A total of 31 odds ratios (ORs) were pooled, indicating that higher systolic BPV was associated with higher odds for CSVD (OR, 1.27; 95% CI, 1.14–1.42; I²=85%) independent of mean systolic pressure. Likewise, higher diastolic BPV was associated with higher odds for CSVD (OR, 1.30; 95% CI, 1.14–1.48; I²=53%) independent of mean diastolic pressure. There was no evidence of a pairwise interaction between systolic/diastolic and BPV/mean ORs (P=0.47), nor a difference between BPV versus mean pressure ORs (P=0.58). Fifty‐four standardized mean differences were pooled and provided similar results for pairwise interaction (P=0.38) and difference between standardized mean differences (P=0.70).

Conclusions

On the basis of the available studies, BPV was associated with CSVD independent of mean blood pressure. However, more high‐quality longitudinal data are required to elucidate whether BPV contributes unique variance to CSVD morphological characteristics.

Factors Associated with Visit-to-Visit Variability of Blood Pressure Measured as Part of Routine Clinical Care among Patients Attending Cardiology Outpatient Department of a Tertiary Care Centre in Northern Sri Lanka

Visit-to-visit variability (VVV) is a relatively new concept in the hypertensive arena. Data regarding VVV are lacking in our region, and factors associated with VVV are rarely examined in previous studies. This study was conducted among 406 patients attended to the cardiology outpatient department of Teaching Hospital, Jaffna, Sri Lanka, in 2018 to assess the long-term variability of blood pressure (BP) by reviewing last six consecutive BP readings from the records retrospectively. Data regarding sociodemographic variables and behavioural factors such as medication adherence, physical activity, smoking, alcohol consumption, and relevant comorbidities were taken through an interviewer-administered questionnaire. Data were analysed by using SPSS version 25 and VVV of systolic blood pressure (SBP) matrix expressed as mean of SD and association were examined with various factors and VVV of SBP. SBP showed high VVV among the participants as expressed by mean of SD which was 13.06 ± 5.64. When comparing mean SD among the categories of different variables, female sex (P=0.023) and comorbidities such as diabetes mellitus (DM) (P=0.013), chronic kidney disease (CKD) (P=0.007), and risk of developing obstructive sleep apnoea (OSA) (P=0.04) showed significant variation. Medication adherence to prescribed hypertensive medication was a major issue even though significant association was not found with high VVV (P=0.536). The SD of SBP was then classified into high and low VVV groups by means of a cutoff point at the 50th percentile. Bivariate analysis by using Chi-squared test revealed comorbidities such as DM, CKD, and physical activity (P=0.044) were significantly associated with high VVV. Further multivariate regression analysis revealed that comorbidities such as DM and CKD have 1.561 times and 5.999 times more risk to show high variability, respectively. In conclusion, we recommend simple practical measures to achieve sustainable BP control among hypertensive patients with DM and CKD to minimize the VVV and improve their cardiovascular outcome.

Change in Blood Pressure Variability Among Treated Elderly Hypertensive Patients and Its Association With Mortality

Background

Information is scarce regarding effects of antihypertensive medication on blood pressure variability (BPV) and associated clinical outcomes. We examined whether antihypertensive treatment changes BPV over time and whether such change (decline or increase) has any association with long‐term mortality in an elderly hypertensive population.

Methods and Results

We used data from a subset of participants in the Second Australian National Blood Pressure study (n=496) aged ≥65 years who had 24‐hour ambulatory blood pressure recordings at study entry (baseline) and then after a median of 2 years while on treatment (follow‐up). Weighted day‐night systolic BPV was calculated for both baseline and follow‐up as a weighted mean of daytime and nighttime blood pressure standard deviations. The annual rate of change in BPV over time was calculated from these BPV estimates. Furthermore, we classified both BPV estimates as high and low based on the baseline median BPV value and then classified BPV changes into stable: low BPV, stable: high BPV, decline: high to low, and increase: low to high. We observed an annual decline (mean±SD: −0.37±1.95; 95% CI, −0.54 to −0.19; P<0.001) in weighted day‐night systolic BPV between baseline and follow‐up. Having constant stable: high BPV was associated with an increase in all‐cause mortality (hazard ratio: 3.03; 95% CI, 1.67–5.52) and cardiovascular mortality (hazard ratio: 3.70; 95% CI, 1.62–8.47) in relation to the stable: low BPV group over a median 8.6 years after the follow‐up ambulatory blood pressure monitoring. Similarly, higher risk was observed in the decline: high to low group.

Conclusions

Our results demonstrate that in elderly hypertensive patients, average BPV declined over 2 years of follow‐up after initiation of antihypertensive therapy, and having higher BPV (regardless of any change) was associated with increased long‐term mortality.

Impact of a system-wide quality improvement initiative on blood pressure control: a cohort analysis

OBJECTIVE

To assess the impact of a quality improvement programme on blood pressure (BP) control and determine whether medication intensification or repeated measurement improved control.

DESIGN

Retrospective cohort comparing visits in 2015 to visits in 2016 (when the programme started).

SUBJECTS

Adults with ≥1 primary care visit between January and June in 2015 and 2016 and a diagnosis of hypertension in a large integrated health system.

MEASURES

Elevated BP was defined as a BP ≥140/90 mm Hg. Physician response was defined as: nothing; BP recheck within 30 days; or medication intensification within 30 days. Our outcome was BP control (<140/90 mm Hg) at the last visit of the year. We used a multilevel logistic regression model (adjusted for demographic and clinical variables) to identify the effect of the programme on the odds of BP control.

RESULTS

Our cohort included 111 867 adults. Control increased from 72% in 2015 to 79% in 2016 (p<0.01). The average percentage of visits with elevated blood pressure was 31% in 2015 and 25% in 2016 (p<0.01). During visits with an elevated BP, physicians were more likely to intensify medication in 2016 than in 2015 (43% vs 40%, p<0.01) and slightly more likely to obtain a BP recheck (15% vs 14%, p<0.01). Among patients with ≥1 elevated BP who attained control by the last visit in the year, there was 6% increase from 2015 to 2016 in the percentage of patients who received at least one medication intensification during the year and a 1% increase in BP rechecks. The adjusted odds of the last BP reading being categorised as controlled was 59% higher in 2016 than in 2015 (95% CI 1.54 to 1.64).

CONCLUSION

A system-wide initiative can improve BP control, primarily through medication intensification.

Visit-to-Visit Variability in Total Cholesterol Correlates with the Progression of Renal Function Decline in a Chinese Community-Based Hypertensive Population

BACKGROUND

Studies have demonstrated that cholesterol variability is an independent predictor of cerebrovascular and cardiovascular events.

OBJECTIVE

This study aimed to investigate the association of visit-to-visit variability in total cholesterol (TC) with kidney decline in a Chinese community-based population.

METHODS

We assessed intraindividual variability in TC among 6,465 hypertensive participants and correlated the results with endpoints. TC variability was measured using standard deviation (SD), average successive variability (ASV), coefficient of variation (CV), and variability independent of the mean (VIM). The endpoint of this study was progression of renal function decline defined as a decrease in estimated glomerular filtration rate (eGFR) ≥30% and to a level <60 mL/min/1.73 m2 during follow-up if the baseline eGFR was ≥60 mL/min/1.73 m2, or a decrease in eGFR ≥50% during follow up if the baseline eGFR was <60 mL/min/1.73 m2.

RESULTS

After a median follow-up of 27 months, 13.5% (n = 877) of the participants experienced progression of renal function decline. In the multivariable-adjusted Cox model, each 1-SD increase in TC variability (by SD) increased the risk of renal function decline by 11% (HR = 1.11; 95% CI 1.034-1.197; p = 0.004); this was independent of the baseline eGFR, mean follow-up TC levels, and the lipid-lowering therapy. Similar results were found for the 3 other measures of variability, i.e., ASV, CV, and VIM.

CONCLUSION

In subjects with hypertension, visit-to-visit variability in TC is an independent predictor of renal function decline.

Blood Pressure Change from Normal to 2017 ACC/AHA Defined Stage 1 Hypertension and Cardiovascular Risk

The purpose of this study was to investigate the clinical significance of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) defined stage 1 hypertension (systolic blood pressure (SBP) 130–139 mmHg or diastolic blood pressure (DBP) 80–89 mmHg), and increase in BP from previously normal BP in Korean adults. We conducted a retrospective analysis of 60,866 participants from a nationally representative claims database. Study subjects had normal BP (SBP < 120 mmHg and DBP < 80 mmHg), no history of anti-hypertensive medication, and cardiovascular disease (CVD) in the first period (2002–2003). The BP change was defined according to the BP difference between the first and second period (2004–2005). We used time-dependent Cox proportional hazards models in order to evaluate the effect of BP elevation on mortality and CVD with a mean follow-up of 7.8 years. Compared to those who maintained normal BP during the second period, participants with BP elevation from normal BP to stage 1 hypertension had a higher risk for CVD (adjusted hazard ratio (aHR) 1.23; 95% confidence interval (CI), 1.08–1.40), and ischemic stroke (aHR 1.32; 95% CI, 1.06–1.64). BP elevation to 2017 ACC/AHA defined elevated BP (SBP 120–129 mmHg and DBP < 80 mmHg) was associated with an increased risk of CVD (aHR 1.26; 95% CI, 1.06–1.50), but stage 1 isolated diastolic hypertension (SBP < 130 and DBP 80–89 mmHg) was not significantly related with CVD risk (aHR 1.12; 95% CI, 0.95–1.31).

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

The accurate measurement of blood pressure (BP) is essential for the diagnosis and management of hypertension. This article provides an updated American Heart Association scientific statement on BP measurement in humans. In the office setting, many oscillometric devices have been validated that allow accurate BP measurement while reducing human errors associated with the auscultatory approach. Fully automated oscillometric devices capable of taking multiple readings even without an observer being present may provide a more accurate measurement of BP than auscultation. Studies have shown substantial differences in BP when measured outside versus in the office setting. Ambulatory BP monitoring is considered the reference standard for out-of-office BP assessment, with home BP monitoring being an alternative when ambulatory BP monitoring is not available or tolerated. Compared with their counterparts with sustained normotension (ie, nonhypertensive BP levels in and outside the office setting), it is unclear whether adults with white-coat hypertension (ie, hypertensive BP levels in the office but not outside the office) have increased cardiovascular disease risk, whereas those with masked hypertension (ie, hypertensive BP levels outside the office but not in the office) are at substantially increased risk. In addition, high nighttime BP on ambulatory BP monitoring is associated with increased cardiovascular disease risk. Both oscillometric and auscultatory methods are considered acceptable for measuring BP in children and adolescents. Regardless of the method used to measure BP, initial and ongoing training of technicians and healthcare providers and the use of validated and calibrated devices are critical for obtaining accurate BP measurements.

Number of blood pressure measurements needed to estimate long-term visit-to-visit systolic blood pressure variability for predicting cardiovascular risk: a 10-year retrospective cohort study in a primary care clinic in Malaysia

OBJECTIVE

To determine the reproducibility of visit-to-visit blood pressure variability (BPV) in clinical practice. We also determined the minimum number of blood pressure (BP) measurements needed to estimate long-term visit-to-visit BPV for predicting 10-year cardiovascular (CV) risk.

DESIGN

Retrospective study SETTING: A primary care clinic in a university hospital in Malaysia.

PARTICIPANTS

Random sampling of 1403 patients aged 30 years and above without any CV event at baseline.

OUTCOMES MEASURES

The effect of the number of BP measurement for calculation of long-term visit-to-visit BPV in predicting 10-year CV risk. CV events were defined as fatal and non-fatal coronary heart disease, fatal and non-fatal stroke, heart failure and peripheral vascular disease.

RESULTS

The mean 10-year SD of systolic blood pressure (SBP) for this cohort was 13.8±3.5 mm Hg. The intraclass correlation coefficient (ICC) for the SD of SBP based on the first eight and second eight measurements was 0.38 (p<0.001). In a primary care setting, visit-to-visit BPV (SD of SBP calculated from 20 BP measurements) was significantly associated with CV events (adjusted OR 1.07, 95% CI 1.02 to 1.13, p=0.009). Using SD of SBP from 20 measurement as reference, SD of SBP from 6 measurements (median time 1.75 years) has high reliability (ICC 0.74, p<0.001), with a mean difference of 0.6 mm Hg. Hence, a minimum of six BP measurements is needed for reliably estimating intraindividual BPV for CV outcome prediction.

CONCLUSION

Long-term visit-to-visit BPV is reproducible in clinical practice. We suggest a minimum of six BP measurements for calculation of intraindividual visit-to-visit BPV. The number and duration of BP readings to derive BPV should be taken into consideration in predicting long-term CV risk.

Blood pressure variability in individuals with and without (pre)diabetes: The Maastricht Study

OBJECTIVE

The mechanisms associating (pre)diabetes and cardiovascular disease (CVD) are incompletely understood. We hypothesize that greater blood pressure variability (BPV) may underlie this association, due to its association with (incident) CVD. Therefore, we investigated the association between (pre)diabetes and very short-term to mid-term BPV, that is within-visit, 24-h and 7-day BPV.

METHODS

Cross-sectional data from The Maastricht Study [normal glucose metabolism (NGM), n = 1924; prediabetes, n = 511; type 2 diabetes mellitus (T2DM), n = 975; 51% men, aged 60 ± 8 years]. We determined SD for within-visit BPV (n = 3244), average real variability for 24-h BPV (n = 2699) day (0900-2100 h) and night (0100-0600 h) separately, and SD for 7-day BPV (n = 2259). Differences in BPV as compared with NGM were assessed by multiple linear regressions with adjustment for potential confounders.

RESULTS

In T2DM, the average systolic/diastolic values of within-visit, 24-h and 7-day BPV were 4.8/2.6, 10.5/7.3 and 10.4/6.5 mmHg, respectively, and in prediabetes 4.9/2.6, 10.3/7.0 and 9.4/5.9 mmHg, respectively. T2DM was associated with greater nocturnal systolic BPV [0.42 mmHg (95% confidence interval: 0.05-0.80)], and greater 7-day systolic [0.76 mmHg (0.32-1.19)] and diastolic BPV [0.65 mmHg (0.29-1.01)], whereas prediabetes was associated with greater within-visit systolic BPV only [0.35 mmHg (0.06-0.65)], as compared with NGM.

CONCLUSION

Both T2DM and prediabetes are associated with slightly greater very short-term to mid-term BPV, which may, according to previous literature, explain a small part of the increased CVD risk seen in (pre)diabetes. Nevertheless, these findings do not detract from the fact that very short-term to mid-term BPV is substantial and important in individuals with and without (pre)diabetes.

Blood Pressure Circadian Variation, Cognition and Brain Imaging in 90+ Year-Olds

Purpose: To analyze the relationship between blood pressure (BP) variables, including circadian pattern, and cognition in 90+ year-olds.

Methods: Twenty-four hour ambulatory BP monitoring was completed on 121 participants drawn from a longitudinal study of aging and dementia in the oldest-old. Various measures of BP and its variability, including nocturnal dipping, were calculated. Each person was given both a neuropsychological test battery covering different cognitive domains and a neurological examination to determine cognitive status. Seventy-one participants had a brain magnetic resonance imaging (MRI) scan.

Results: Participants ranged in age from 90 to 102 years (mean = 93), about two-thirds were female, and nearly 80% had at least some college education. Mean nocturnal dips differed significantly between cognitively normal (n = 97) and impaired individuals (n = 24), with cognitively normal participants having on average greater nocturnal dips [6.6% vs. 1.3%, p = 0.006 for systolic BP (SBP); 11% vs. 4.4%, p = 0.002 for diastolic BP (DBP)]. Nocturnal dips were also related to performance on select cognitive test scores (especially those related to language, recent memory and visual-spatial ability), with individuals who performed below previously established median norms having significantly smaller nocturnal dips (both SBP and DBP) than those above the median. DBP reverse dippers had larger mean white matter hyperintensities (WMH as percent of total brain volume; 1.7% vs. 1.2%, 1.1% and 1.0% in extreme dippers, dippers, non-dippers) and a greater proportion had lobar cerebral microbleeds (CMBs; 44% vs. 0%, 7%, 16%, p < 0.05). Impaired participants had higher mean WMH than those with normal cognition (1.6% vs. 1.0% p = 0.03) and more tended to have CMB (31% vs. 20%, p = n.s.).

Conclusion: These findings suggest that cognitive dysfunction is associated with dysregulation in the normal circadian BP pattern. Further study is warranted of the potential role of WHM and CMB as mediators of this association.

Patient Judgments About Hypertension Control: The Role of Variability, Trends, and Outliers in Visualized Blood Pressure Data

BACKGROUND

Uncontrolled hypertension is a significant health problem in the United States, even though multiple drugs exist to effectively treat this chronic disease.

OBJECTIVE

As part of a larger project developing data visualizations to support shared decision making about hypertension treatment, we conducted a series of studies to understand how perceptions of hypertension control were impacted by data variations inherent in the visualization of blood pressure (BP) data.

METHODS

In 3 Web studies, participants (internet sample of patients with hypertension) reviewed a series of vignettes depicting patients with hypertension; each vignette included a graph of a patient's BP. We examined how data visualizations that varied by BP mean and SD (Study 1), the pattern of change over time (Study 2), and the presence of extreme values (Study 3) affected patients' judgments about hypertension control and the need for a medication change.

RESULTS

Participants' judgments about hypertension control were significantly influenced by BP mean and SD (Study 1), data trends (whether BP was increasing or decreasing over time-Study 2), and extreme values (ie, outliers-Study 3).

CONCLUSIONS

Patients' judgment about hypertension control is influenced both by factors that are important predictors of hypertension related-health outcomes (eg, BP mean) and factors that are not (eg, variability and outliers). This study highlights the importance of developing data visualizations that direct attention toward clinically meaningful information.

Relationship between Within-Visit Blood Pressure Variability and Skeletal Muscle Mass

Sarcopenia, defined as loss of skeletal muscle mass and function with age, is an important health issue in aging society. We tried to investigate the relationship between blood pressure variability and skeletal muscle mass in nation-wide large population cohort. This cross-sectional study was based on data acquired in the Korea National Health and Nutrition Examination Survey (KNHANES), conducted from 2009 to 2011 by the Korean Centers for Disease Control and Prevention. We included 14,481 participants (age ≥ 20 years, male 6,302) for the analysis who had both blood pressure and whole-body dual energy X-ray absorptiometry (DXA) scan data. As an intra-individual within-visit blood pressure variability index, we calculated standard deviation (SD), coefficient of variation (CV), and maximum minus minimum BP difference (MMD) of systolic and diastolic blood pressure, which was measured 3 times. Appendicular skeletal muscle mass (ASM) was the sum of lean masses of both arms and legs. We adjusted ASM by body mass index. Significant inverse relationship was observed between blood pressure variability index (SD, CV, and MMD) and adjusted ASM. Blood pressure variability index were significantly higher in the lowest ASM quintile group both in male and female participants (p<0.001). In multivariate analysis, blood pressure variability index were significantly associated with ASM, even after adjusting confounding factors (p<0.001). In conclusion, hemodynamic influence may play an important role in the development of sarcopenia.

The frequency of remission and low disease activity in patients with rheumatoid arthritis, and their ability to identify people with low disability and normal quality of life

OBJECTIVE

Treat-to-target in rheumatoid arthritis (RA) recommends targeting remission, with low disease activity (LDA) being an alternative goal. When deciding to target remission or LDA, important considerations are the likelihood of attaining them, and their impacts on function and health-related quality of life (HRQoL). We have addressed this by studying: (a) the frequency of remission and LDA/remission; (b) DAS28-ESR trends after remission; (c) ability of remission vs. LDA to identify patients with normal function (HAQ ≤ 0.5) and HRQoL (EQ-5D ≥ the normal population).

METHODS

We studied 571 patients in two clinical trials, and 1693 patients in a 10-year routine care cohort. We assessed the frequency and sustainability of remission and LDA/remission, variability in DAS28-ESR after remission, and sensitivity/specificity of remission and LDA/remission at identifying patients with low disability levels and normal HRQoL using Receiver Operator Characteristic (ROC) curves.

RESULTS

Point remission and remission/LDA were common (achieved by 35-58% and 49-74% of patients, respectively), but were rarely sustained (sustained remission and remission/LDA achieved by 5-9% and 9-16% of patients, respectively). Following attaining remission, DAS28-ESR levels varied substantially. Despite this, of those patients attaining point remission, the majority (53-61%) were in remission at study end-points. Whilst remission was highly specific at identifying patients with low disability (85-91%) it lacked sensitivity (51-57%); similar findings were seen for normal HRQoL (specificity 78-86%; sensitivity 52-59%). The optimal DAS28-cut-off to identify individuals with low disability and normal HRQoL was around the LDA threshold.

CONCLUSIONS

Our findings support both the treat-to-target goals. Attaining remission is highly specific for attaining low disability and normal HRQoL, although many patients with more active disease also have good function and HRQoL. Attaining a DAS28-ESR ≤ 3.2 has a better balance of specificity and sensitivity for attaining these outcomes, with the benefit of being more readily achievable. Although sustaining these targets over time is rare, even attaining them on a one-off basis leads to better function and HRQoL outcomes for patients.

Factors associated with intra-individual visit-to-visit variability of blood pressure in four countries: the INTERMAP study

Several studies demonstrated that visit-to-visit variability of blood pressure (BP) predicted future events of total death, stroke and cardiovascular disease. Little is known about factors associated with visit-to-visit BP variability in different countries. We recruited participants aged 40-59 years from four countries (Japan, the People's Republic of China [PRC], the United Kingdom [UK] and the United States [US]). At each study visit, BP was measured twice by trained observers using random zero sphygmomanometers after five minutes resting. We defined visit-to-visit BP variability as variation independent of mean (VIM) by using average systolic BP of 1st and 2nd measurement across four study visits. Data on 4680 men and women were analyzed. Mean ± standard deviation of VIM values among participants in Japan, the PRC, the UK and the US were 5.44 ± 2.88, 6.85 ± 3.49, 5.65 ± 2.81 and 5.84 ± 3.01, respectively; VIM value in the PRC participants was significantly higher. Sensitivity analyses among participants without antihypertensive treatment or past history of cardiovascular disease yielded similar results. Higher VIM value was associated with older age, female gender, lower pulse rate and urinary sodium excretion and use of antihypertensive agents such as angiotensin converting enzyme inhibitors, beta blockers and calcium channel blockers. The difference of visit-to-visit BP variability between PRC and other countries remained significant after adjustment for possible confounding factors. In this large international study across four countries, visit-to-visit BP variability in the PRC was higher than in the other three countries. Reproducibility and mechanisms of these findings remain to be elucidated.

Extent of, and variables associated with, blood pressure variability among older subjects

BACKGROUND

Blood pressure variability (BPV) may have prognostic implications for cardiovascular risk and cognitive decline; however, BPV has yet to be studied in old and very old people.

AIMS

Aim of the present study was to evaluate the extent of BPV and to identify variables associated with BPV among older subjects.

METHODS

A retrospective study of patients aged ≥ 65 years who underwent 24-h ambulatory blood pressure monitoring (ABPM) was carried out. Three different BPV indexes were calculated for systolic and diastolic blood pressure (SBP and DBP): standard deviation (SD), coefficient of variation (CV), and average real variability (ARV). Demographic variables and use of antihypertensive medications were considered.

RESULTS

The study included 738 patients. Mean age was 74.8 ± 6.8 years. Mean SBP and DBP SD were 20.5 ± 4.4 and 14.6 ± 3.4 mmHg. Mean SBP and DBP CV were 16 ± 3 and 20 ± 5%. Mean SBP and DBP ARV were 15.7 ± 3.9 and 11.8 ± 3.6 mmHg. At multivariate analysis older age, female sex and uncontrolled mean blood pressure were associated with both systolic and diastolic BPV indexes. The use of calcium channel blockers and alpha-adrenergic antagonists was associated with lower systolic and diastolic BPV indexes, respectively.

CONCLUSIONS

Among elderly subjects undergoing 24-h ABPM, we observed remarkably high indexes of BPV, which were associated with older age, female sex, and uncontrolled blood pressure values.

Effect of inter-individual blood pressure variability on the progression of atherosclerosis in carotid and coronary arteries: a post hoc analysis of the NORMALISE and PREVENT studies

Aims

To investigate the relationship between visit-to-visit blood pressure variability (BPV) and the progression of both carotid and coronary artery disease (CAD).

Methods and results

Data from two cardiovascular endpoint studies [Norvasc for Regression of Manifest Atherosclerotic Lesions by Intravascular Sonographic Evaluation (NORMALISE) and Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial (PREVENT)] were analysed separately. Systolic BPV was assessed as within-subject standard deviation of systolic BP across visits from 12-weeks onwards. Follow-up was 24 months (NORMALISE) or 36 months (PREVENT). Any association between BPV and progression of atherosclerosis was assessed using quantitative coronary angiography (QCA), intravascular ultrasound (IVUS), or B-mode ultrasound (depending on study). Patients from NORMALISE (n = 261) and PREVENT (n = 688 for QCA; n = 364 for ultrasound) were stratified within study according to median systolic BPV. No significant difference in change of minimal luminal diameter (by QCA in PREVENT) or change in percent atheroma volume or normalized total atheroma volume (by IVUS in NORMALISE) was detected for subjects with low BPV (BPV < median) compared with high BPV (BPV ≥ median), regardless of treatment. In PREVENT, a significantly greater reduction in maximum carotid intima-media thickness (IMT) (left and right common carotid artery far wall) was observed for patients with BPV < median compared with those with BPV ≥ median [least squares mean difference 0.06 (95% confidence interval 0.01, 0.11); P = 0.0271], after adjusting for treatment, carotid artery segment (left or right), baseline maximum carotid IMT, and other baseline and cardiovascular risk factors/covariates.

Conclusions

In patients with existing CAD and well-controlled BP, visit-to-visit BPV was not associated with progression of coronary atherosclerosis; however, a significantly greater reduction in maximum carotid IMT was observed for patients with low BPV.

Effect of visit-to-visit LDL-, HDL-, and non-HDL-cholesterol variability on mortality and cardiovascular outcomes after percutaneous coronary intervention

BACKGROUND AND AIMS

Visit-to-visit variability in biological measures has been suggested as an independent predictor of cardiovascular disease (CVD). Although low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) are important risk factors of CVD, there are few studies investigating the effect of variability in LDL-C and HDL-C on cardiovascular outcomes. We investigated the association between visit-to-visit variability in LDL-C, HDL-C, and non-HDL-C and major adverse cardiovascular and cerebrovascular events (MACCE) in patients who underwent percutaneous coronary intervention (PCI).

METHODS

Data from 1792 subjects who underwent PCI from January 2004 to December 2009 were analyzed. Visit-to-visit variability was calculated using various indices: standard deviation (SD), coefficient of variation, and corrected variability independent of mean (cVIM). MACCE comprised all-cause death, non-fatal myocardial infarction, and stroke.

RESULTS

During a median follow-up period of 65 months, 114 subjects (6.4%) experienced MACCE: 68 (3.8%) all-cause death; 43 (2.4%) stroke, and 15 (0.8%) non-fatal myocardial infarction. Visit-to-visit variability in LDL-C, HDL-C, and non-HDL-C was significantly higher in the MACCE group compared to the non-MACCE group. In multiple regression analysis, all LDL-C, HDL-C, and non-HDL-C variability parameters were independent predictors for MACCE after adjusting for potential confounding factors. Each 1-SD increase of cVIM in LDL-C, HDL-C, and non-HDL-C increased the risk of MACCE by 34% (HR 1.34 [95% CI, 1.18-1.52]), 50% (HR 1.50 [95% CI 1.32-1.71]), and 37% (HR 1.37 [95% CI, 1.20-1.57]), respectively. These relationships were observed in various subgroups according to age, sex, and diabetes status.

CONCLUSIONS

Visit-to-visit variability in LDL-C, HDL-C, and non-HDL-C is associated with MACCE in subjects with previous PCI.

The association between blood pressure variability (BPV) with dementia and cognitive function: a systematic review and meta-analysis protocol

BACKGROUND

A body of empirical work demonstrates that wide fluctuations in a person's blood pressure across consecutive measures, known as blood pressure variability (BPV), hold prognostic value to predict stroke and transient ischemic attack. However, the magnitude of association between BPV and other neurological outcomes remains less clear. This systematic review aims to pool together data regarding BPV with respect to incident dementia, cognitive impairment, and cognitive function.

METHODS

Electronic databases (MEDLINE, EMBASE, and SCOPUS) will be searched for the key words blood pressure variability and outcomes of dementia, cognitive impairment, and cognitive function. Authors and reference lists of included studies will also be contacted to identify additional published and unpublished studies. Eligibility criteria are as follows: population-adult humans (over 18 years but with no upper age limit) without dementia at baseline, with or without elevated blood pressure, or from hypertensive populations (systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg or use of antihypertensive drug for hypertension) and from primary care, community cohort, electronic database registry, or randomized controlled trial (RCT); exposure-any metric of BPV (systolic, diastolic or both) over any duration; comparison-persons without dementia who do not have elevated BPV; and outcome-dementia, cognitive impairment, cognitive function at follow-up from standardized neurological assessment, or cognitive testing. Article screening will be undertaken by two independent reviewers with disagreements resolved through discussion. Data extraction will include original data specified as hazard ratios, odds ratios, correlations, regression coefficients, and original cell data if available. Risk of bias assessment will be undertaken by two independent reviewers. Meta-analytic methods will be used to synthesize the data collected relating to the neurological outcomes with Comprehensive Meta-Analysis Version 2.0 (Biostat Inc., Engelwood, NJ).

DISCUSSION

This systematic review aims to clarify whether BPV is associated with elevated risk for dementia, cognitive impairment, and cognitive function. An evaluation of the etiological links between BPV with incident dementia might inform evidence-based clinical practice and policy concerning blood pressure measurement and hypertension management. The review will identify sources of heterogeneity and may inform decisions on whether it is feasible and desirable to proceed with an individual participant data meta-analysis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017081977.

[Follow-up of patients with Ixodes tick-borne borrelioses caused by Borrelia miyamotoi or Borrelia burgdorferi sensu lato]

Ixodes tick-borne borrelioses (ITBB) are caused by two different spirochetes: Borrelia from the group of Borrelia burgdorferi sensu lato, the agents of the classic Lyme borreliosis (LB), and Borrelia miyamotoi that belongs to the group of Borrelia causing tick-borne relapsing fevers. ITBB caused by B. miyamotoi (BM-ITBB) is a previously unknown infectious disease discovered in Russia. It is known that the LB sequelae may reduce the long-term life guality of convalescents.

AIM

To study the follow-up of those who have recovered from new BM-ITBB infection in comparison with persons who have had LB.

SUBJECTS AND METHODS

The investigation enrolled 41 patients with BM-ITBB and 41 patients with LB who were treated at the Republican Infectious Diseases Hospital of Udmurtia. Within a year after the disease, they were followed up through clinical and instrumental examination of cardiac performance, expanded biochemical analysis of blood and urine, which could; estimate kidney and liver functions, and psychological questioning.

RESULTS

Asthenic syndrome and complaints about and objective signs of cardiac dysfunctions persisted supraventricular extrasystoles, left ventricular diastolic dysfunction, and elevated and/or unstable systolic blood pressure were detected in 20-30% of the convalescents for a long time. Kidney dysfunctions were manifested in albuminuria and the decrease of glomerular filtration rate. A year following the disease, 10-20% patients had persistently elevated concentrations of alanine aminotransferase, aspartate aminotransferase, and C-reactive protein and had higher levels of total cholesterol and low-density lipoproteins. The pathological consequences of ITBB were polymorphic and varied in different patients; in general, only 68% of them showed health improvement.

CONCLUSION

We assume that a significant role in the pathogenesis of BM-ITBB and LB is played by vascular endothelial damage possibly associated with the inflammatory and autoimmune aspects of an immune response in Borrelia infection. The consequences of this damage may persist and even intensify during a year, which provokes chronic dysfunction of the heart, kidney, or liver in a number of convalescents.

Ten-second central SBP variability predicts first and recurrent cardiovascular events

OBJECTIVE

Long-term (day-to-day or visit-to-visit) blood pressure variability (BPV) predicts elevated risk of cardiovascular events but represents just one BPV type. We examined whether 10-s BPV predicts cardiovascular events.

METHODS

In 4999 adults (58% men; aged 50-84 years; 670 with a prior cardiovascular event), we performed suprasystolic brachial pressure measurements over ∼10 s, yielding aortic pressure waveforms. BPV was calculated by average real variability (ARV), root mean square of successive differences, standard deviation (SD), coefficient of variation and relative range. Participants were followed up for 4.6 years (median), accruing 310 first and 187 recurrent cardiovascular events, respectively.

RESULTS

In multivariable-adjusted analyses, all central SBPV parameters were associated with first cardiovascular events: the standardized hazard ratio for each ranged from 1.25 to 1.29. The hazard ratio between the lowest and highest sextile ranged from 1.92 [95% confidence interval (CI) 1.31-2.80] for coefficient of variation to 2.19 (95% CI 1.38-3.46) for ARV. All central SBPV parameters also were associated with higher risk of recurrent cardiovascular events: adjusted standardized hazard ratio ranged from 1.16 to 1.21. Because of fewer recurrent events, these low-versus-high comparisons were based on tertiles; hazard ratios between the lowest and highest tertiles ranged from 1.50 (95% CI 1.02-2.23) for ARV to 1.76 (95% CI 1.20-2.60) for SD. The highest categorical net reclassification improvement for 5-year risk of first cardiovascular events was 13% (95% CI 7-18%) and substantially higher among those with intermediate (10-20%) risk: 39% (95% CI 26-52%).

CONCLUSION

Ten-second central SBPV parameters predict first and recurrent cardiovascular events.