Visit-to-Visit Variability of Blood Pressure and Coronary Heart Disease, Stroke, Heart Failure, and Mortality: A Cohort Study

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.

Sustained blood pressure control and coronary heart disease, stroke, heart failure, and mortality: An observational analysis of ALLHAT

Achieving blood pressure (BP) control is associated with lower cardiovascular disease (CVD) risk, but less is known about CVD risk associated with sustained BP control over time. This observational analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was restricted to participants with four to seven visits with systolic BP (SBP) measurements during a 22-month period (n = 24 309). The authors categorized participants as having sustained BP control (SBP < 140 mm Hg) at 100%, 75% to <100%, 50% to <75%, and <50% of visits during this period. Outcomes included fatal coronary heart disease (CHD)/nonfatal myocardial infarction (MI), stroke, heart failure (HF), a composite CVD outcome (fatal CHD/nonfatal MI, stroke, or HF), and mortality. Hazard ratios (HRs) for the association of category of sustained BP control for each outcome were obtained using proportional hazards models. SBP control was present among 20.0% of participants at 100%, 16.4% at 75% to less than 100%, 27.0% at 50% to less than 75%, and 36.6% at less than 50% of visits. Compared to those with SBP control at 100% visits, adjusted HR (95% CI) among those with SBP control at <50% of visits was 1.16 (0.93-1.44) for fatal CHD/nonfatal MI, 1.71 (1.26-2.32) for stroke, 1.63 (1.30-2.06) for HF, 1.39 (1.20-1.62) for the composite CVD outcome, and 1.14 (0.99-1.30) for mortality. Sustained SBP control may be beneficial for preventing stroke, HF, and CVD outcomes in adults taking antihypertensive medication.

Visit-to-Visit Glycemic Variability and Risks of Cardiovascular Events and All-Cause Mortality: The ALLHAT Study

OBJECTIVE

The prognostic value of long-term glycemic variability is incompletely understood. We evaluated the influence of visit-to-visit variability (VVV) of fasting blood glucose (FBG) on incident cardiovascular disease (CVD) and mortality.

RESEARCH DESIGN AND METHODS

We conducted a prospective cohort analysis including 4,982 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) who attended the baseline, 24-month, and 48-month visits. VVV of FBG was defined as the SD or variability independent of the mean (VIM) across FBG measurements obtained at the three visits. Participants free of CVD during the first 48 months of the study were followed for incident CVD (coronary heart disease [CHD], stroke, and heart failure [HF]) and all-cause mortality.

RESULTS

Over a median follow-up of 5 years, there were 305 CVD events (189 CHD, 45 stroke, and 81 HF) and 154 deaths. The adjusted hazard ratio (HR) comparing participants in the highest versus lowest quartile of SD of FBG (≥26.4 vs. <5.5 mg/dL) was 1.43 (95% CI 0.93-2.19) for CVD and 2.22 (95% CI 1.22-4.04) for all-cause mortality. HR for VIM was 1.17 (95% CI 0.84-1.62) for CVD and 1.89 (95% CI 1.21-2.93) for all-cause mortality. Among individuals without diabetes, the highest quartile of SD of FBG (HR 2.67 [95% CI 0.14-6.25]) or VIM (HR 2.50 [95% CI 1.40-4.46]) conferred a higher risk of death.

CONCLUSIONS

Greater VVV of FBG is associated with increased mortality risk. Our data highlight the importance of achieving normal and consistent glycemic levels for improving clinical outcomes.

Visit-to-visit systolic blood pressure variability in patients with ST-elevation myocardial infarction predicts long-term cardiovascular outcomes

Elevated visit-to-visit blood pressure variability (BPV), independent of mean BP, has been associated with cardiovascular events. However, its impact after ST-elevation myocardial infarction (STEMI) has not been established. This study aimed to investigate the prognostic impact of BPV on patients after STEMI. We analyzed the data and clinical outcomes of STEMI survivors who underwent successful primary coronary intervention from 2003 to 2009. BP was measured at discharge and at 1, 3, 6, 12, 24, and 36 months, and we calculated BPV as the intra-individual standard deviations (SDs) of systolic BP (SBP) across these measurements. We classified the patients as high and low-BPV group, and evaluated the outcomes: occurrence of major adverse cardiovascular events (MACEs), death, recurrent myocardial infarction, and target vessel revascularization within 60 months. We enrolled 343 patients, and mean follow-up duration was 68 ± 34 months (median: 76 months). Mean and median SBP SDs were 13.2 and 12.3 mmHg, and patients were divided into one of the two groups based on the median (high-BPV group = SD ≥ 12.3 mmHg; low-BPV group = SD < 12.3 mmHg). The MACE-free survival in the high-BPV group was significantly worse than that in low-BPV group (log-rank p = 0.035). For the high-BPV group, the risk of a MACE significantly increased by 57% (95% confidence interval: 1.03–2.39; p = 0.038). Visit-to-visit systolic BPV was associated with increased rates of adverse clinical outcomes in patients after STEMI. Careful assessment of BP and attempts to reduce BPV might be also important in STEMI survivors.

Visit-To-Visit Blood Pressure Variability and the Risk of Dementia in Older People

BACKGROUND

High visit-to-visit variability (VVV) in blood pressure (BP) is associated with cerebrovascular lesions on neuroimaging.

OBJECTIVE

Our primary objective was to investigate whether VVV is associated with incident all-cause dementia. As a secondary objective, we studied the association of VVV with cognitive decline and cardiovascular disease (CVD).

METHODS

We included community-dwelling people (age 70-78 year) from the 'Prevention of Dementia by Intensive Vascular Care' (preDIVA) trial with three to five 2-yearly BP measurements during 6-8 years follow-up. VVV was defined using coefficient of variation (CV; SD/mean×100). Cognitive decline was assessed using the Mini-Mental State Examination (MMSE). Incident CVD was defined as myocardial infarction or stroke. We used a Cox proportional hazard regression and mixed-effects model adjusted for sociodemographic factors and cardiovascular risk factors.

RESULTS

In 2,305 participants (aged 74.2±2.5), mean systolic BP over all available visits was 150.1 mmHg (SD 13.6), yielding a CV of 9.0. After 6.4 years (SD 0.8) follow-up, 110 (4.8%) participants developed dementia and 140 (6.1%) CVD. Higher VVV was not associated with increased risk of dementia (hazard ratio [HR] 1.00 per point CV increase; 95% confidence interval [CI] 0.96-1.05), although the highest quartile of VVV was associated with stronger decline in MMSE (β -0.09, 95% CI -0.17 to -0.01). Higher VVV was associated with incident CVD (HR 1.07; 95% CI 1.04-1.11).

CONCLUSION

In our study among older people, high VVV is not associated with incident all-cause dementia. It is associated with decline in MMSE and incident CVD.

Blood pressure, glycemic control, and white matter hyperintensity progression in type 2 diabetics

OBJECTIVE

To determine whether higher blood pressure mean (BPM) or hemoglobin A1c is associated with progression of white matter hyperintensity (WMH) on MRI in patients with type 2 diabetes, and whether intensive blood pressure or glycemic control can reduce that progression.

METHODS

We performed a secondary analysis of the Action to Control Cardiovascular Risk in Diabetes Memory in Diabetes (ACCORD MIND) research materials. The primary outcome is change in WMH volume (ΔWMH) between a baseline and month-40 MRI, and the primary predictor is BPM and A1c between the MRIs. Additional analyses compared ΔWMH in the intensive vs standard glycemic control randomization arms (n = 502) and intensive vs standard blood pressure control randomization arms (n = 314).

RESULTS

Higher systolic BPM, but not diastolic BPM or A1c, was associated with WMH progression. The ΔWMH in tertiles of increasing systolic BPM (115 ± 4, 127 ± 3, and 139 ± 6 mm Hg) was 0.7, 0.9, and 1.2 cm³ (p < 0.001). ΔWMH was lower in the intensive vs standard blood pressure control randomization arm (ΔWMH = 0.67 ± 0.95 vs 1.16 ± 1.13 cm³, p < 0.001), but there was no difference in the glycemic control arms (p = 0.917).

CONCLUSION

In ACCORD MIND, higher systolic blood pressure was associated with WMH progression. The intensive blood pressure control intervention reduced this progression. Comorbid diabetes and hypertension has synergistic deleterious properties that increase the risk of micro- and macrovascular complications. These results provide further support for an aggressive approach to blood pressure control in type 2 diabetics.

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.

Relationship of Inter-Individual Blood Pressure Variability and the Risk for Recurrent Stroke

Background Evidence suggests that patients with higher blood pressure variability ( BPV ) have a higher risk for stroke, but any link between BPV and stroke recurrence is unknown among those who had a stroke or transient ischemic attack ( TIA ). Methods and Results Data for patients with a history of stroke or TIA at enrollment were extracted from the ASCOT (Anglo Scandinavian Cardiac Outcomes Trial) and the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). BPV was defined as the within-subject standard deviation or coefficient of variation of systolic blood pressure across visits from 12 weeks poststroke or TIA onward. BPV was significantly higher in patients with a history of stroke or TIA than those without. BPV was a predictor of recurrent stroke in the pooled analysis. In the ASCOT study, 252 patients (12.3%) had a recurrent stroke among 2046 with a history of stroke. Incidence of recurrent stroke was significantly higher in the highest BPV quartile (17.8%) compared with the lowest quartile (10.5%); by treatment arm, this reached significance for the amlodipine-arm only (high- BPV : 18.7% versus low- BPV : 12.9%; P=0.029). Of the 2173 patients from the ALLHAT with a history of stroke or TIA , patients with the highest quartile of BPV had a higher incidence of recurrent stroke (9.6%) compared with the lowest quartile BPV (5.5%); by treatment arm, this reached significance for the chlorthalidone-arm only (high- BPV : 12.1% versus low- BPV : 5.4%; P=0.007). Conclusions Visit-to-visit BPV is a predictor of recurrent stroke in patients with a history of stroke or TIA on antihypertensive treatment. Considering BPV following a stroke may be important to reduce the risk for a recurrent stroke.

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.

Clinical implication of visit-to-visit blood pressure variability

In clinical practice, out-of-office blood pressure (BP) measurements, i.e., ambulatory BP monitoring and home BP measurement, provide superior results, reproducibility, and evaluation of the effect of antihypertensive drugs compared with office BP measurement. However, following a report on the clinical impact of visit-to-visit BP variability, in addition to the results of a clinical trial, office BP measurement has regained prominence in clinical and research settings. Many reports have been published on the association between visit-to-visit BP variability and cardiovascular outcomes. However, other indexes of BP variability besides visit-to-visit BP variability can be evaluated in the office. In addition, methodology has been developed for calculation of visit-to-visit BP variability. Although most studies have shown a positive association between visit-to-visit BP variability and cardiovascular outcomes, this association was not observed in some studies. Further research is still needed for clarification.

Peak lung function during young adulthood and future long-term blood pressure variability: The Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND AND AIMS

Long-term blood pressure variability (BPV) is associated with cardiovascular events independent of mean blood pressure (BP); however, little is known about its predictors.

METHODS

Using data from the CARDIA study, we investigated the association between peak lung-function and long-term BPV in 2917 individuals (mean age 24.8 years, 45.3% males, 58.6% whites) who were not taking antihypertensive medications. Lung-function was measured using forced vital capacity (FVC) and forced expiratory volume in 1-s (FEV1) at years 0, 2, 5, 10 and 20 and the maximum score attained was considered as peak lung-function. Variability independent of the mean (VIM) and coefficient of variation (CV) of BP were calculated to quantify BPV since achieving peak lung-function across 9 visits over 30 years.

RESULTS

In a multivariate linear regression models, individuals in the 2nd (-0.64 mmHg; 95% CI: -1.06, -0.19), 3rd (-0.96; -1.47, -0.45), and 4th (-0.85: -1.53, -0.17) quartiles of FVC had lower VIM of systolic BP than the those in quartile 1 (p-trend = 0.005). CV of systolic BP was also lower by -0.58 (-0.98, -0.19), -0.92 (-1.42, -0.43), and -0.74 (-1.40, -0.08) percentage points, in the three progressively higher quartiles of FVC compared to quartile 1 (p-trend = 0.008). Similar findings were observed when the outcome was diastolic BPV. There was no association of FEV1 and FEV1-to-FVC ratio with BPV.

CONCLUSIONS

These findings suggest that smaller lung volume or restrictive lung disease during young adulthood, which result in lower peak FVC, may independently increase the risk of higher long-term BPV during middle adulthood.

Incremental Value of Repeated Risk Factor Measurements for Cardiovascular Disease Prediction in Middle-Aged Korean Adults: Results From the NHIS-HEALS (National Health Insurance System-National Health Screening Cohort)

BACKGROUND

Increasing evidence suggests that repeatedly measured cardiovascular disease (CVD) risk factors may have an additive predictive value compared with single measured levels. Thus, we evaluated the incremental predictive value of incorporating periodic health screening data for CVD prediction in a large nationwide cohort with periodic health screening tests.

METHODS AND RESULTS

A total of 467 708 persons aged 40 to 79 years and free from CVD were randomly divided into development (70%) and validation subcohorts (30%). We developed 3 different CVD prediction models: a single measure model using single time point screening data; a longitudinal average model using average risk factor values from periodic screening data; and a longitudinal summary model using average values and the variability of risk factors. The development subcohort included 327 396 persons who had 3.2 health screenings on average and 25 765 cases of CVD over 12 years. The C statistics (95% confidence interval [CI]) for the single measure, longitudinal average, and longitudinal summary models were 0.690 (95% CI, 0.682-0.698), 0.695 (95% CI, 0.687-0.703), and 0.752 (95% CI, 0.744-0.760) in men and 0.732 (95% CI, 0.722-0.742), 0.735 (95% CI, 0.725-0.745), and 0.790 (95% CI, 0.780-0.800) in women, respectively. The net reclassification index from the single measure model to the longitudinal average model was 1.78% in men and 1.33% in women, and the index from the longitudinal average model to the longitudinal summary model was 32.71% in men and 34.98% in women.

CONCLUSIONS

Using averages of repeatedly measured risk factor values modestly improves CVD predictability compared with single measurement values. Incorporating the average and variability information of repeated measurements can lead to great improvements in disease prediction.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02931500.

Blood pressure variability predicts adverse events and cardiovascular outcomes in SPRINT

SPRINT (Systolic Blood Pressure Intervention Trial) highlighted the benefits of intensive targeted antihypertensive therapy but resulted in higher rates of treatment-related adverse events. Blood pressure (BP) variability has emerged as a significant predictor of outcomes over and above levels of BP. Using the SPRINT data set, we aimed to determine the relationship of BP variability with cardiovascular outcomes and side effects of antihypertensive therapy. The analyses included all participants randomized in SPRINT who reached the target systolic BP (SBP) for their respective groups (intensive < 120 mm Hg; standard < 140 mm Hg). Coefficients of variation (CV) for SBP, diastolic BP (DBP), and PP for each patient characterized variability. Student t test was used to compare treatment arms for each CV metric. Cox proportional hazards regression was used to identify independent predictors of the SPRINT primary outcome and adverse events. P < .15 on univariate analysis was required to enter the model and P < .05 to remain in it. A total of 8884 patients (4561 standard group; 4323 intensive group) met inclusion criteria. DBP CV differed between the groups (9.12 ± 3.20 standard group; 9.47 ± 3.49 intensive group [P < .0001]). DBP CV predicted a greater hazard for the primary outcome (hazard ratio [HR], 1.14) in the overall model as well as separate analyses by treatment arms (standard group HR, 1.15; intensive group HR, 1.19), each P < .0001. DBP CV also independently predicted a greater hazard for acute kidney injury (HR, 1.12) and hypotensive events (HR, 1.12). Visit-to-visit DBP variability independently predicted worse cardiovascular outcomes and hypoperfusion-related adverse events in SPRINT.

Visit-to-visit variability of blood pressure and cardiovascular outcomes in patients with stable coronary heart disease. Insights from the STABILITY trial

Aims

To study the relation between visit-to-visit variability of blood pressure (BP) and cardiovascular risk in patients with stable coronary heart disease.

Methods and results

In 15 828 patients from the STABILITY trial (darapladib vs. placebo in patients with established coronary heart disease), BP variability was assessed by the standard deviation (SD) of systolic BP, the SD of diastolic BP, maximum BP, and minimum BP, from 5 measurements (baseline and months 1, 3, 6, and 12) during the first year after randomisation. Mean (SD) average BP during the first year of study was 131.0 (13.7) mmHg over 78.3 (8.3) mmHg. Mean (SD) of the visit-to-visit SD was 9.8 (4.8) mmHg for systolic and 6.3 (3.0) mmHg for diastolic BP. During the subsequent median follow-up of 2.6 years, 1010 patients met the primary endpoint, a composite of time to cardiovascular death, myocardial infarction, or stroke. In Cox regression models adjusted for average BP during first year of study, baseline vascular disease, treatment, renal function and cardiovascular risk factors, the primary endpoint was associated with SD of systolic BP (hazard ratio for highest vs. lowest tertile, 1.30, 95% CI 1.10-1.53, P = 0.007), and with SD of diastolic BP (hazard ratio for highest vs. lowest tertile, 1.38, 95% CI 1.18-1.62, P < 0.001). Peaks and troughs in BP were also independently associated with adverse events.

Conclusion

In patients with stable coronary heart disease, higher visit-to-visit variabilities of both systolic and diastolic BP are strong predictors of increased risk of cardiovascular events, independently of mean BP.

Twenty-four-hour blood pressure variability plays a detrimental role in the neurological outcome of hemorrhagic stroke

Background

Blood pressure variability (BPV) is a modifiable risk factor for stroke. This study was performed to determine the prognostic role of BPV in patients with acute hemorrhagic stroke.

Methods

The data of 131 hospitalized hypertensive patients with spontaneous intracerebral hemorrhage (sICH) were collected. All patients underwent examinations using several neurological scales (Glasgow Coma Scale, National Institutes of Health Stroke Scale, and modified Rankin scale [mRS]) and BP measurements at different time points.

Results

Sex, age, hematoma volume, and neurological scores were not significantly different between patients with a favorable and unfavorable prognosis for sICH. However, significant differences were found in hypertension, diabetes, metabolic syndrome, atrial fibrillation, smoking, and stroke history. The standard deviation (SD), coefficient of variation (CV), and maximum–minimum range (Max–Min) of diastolic BP and the mean, SD, CV, and Max–Min of systolic BP significantly differed between the groups. Statistical analysis also demonstrated correlations between the 90-day mRS score and BPV and between systolic BPV and the 90-day mRS score.

Conclusion

High systolic or diastolic BPV within 24 hours of hemorrhagic stroke onset is associated with the 90-day neurological prognosis. The 24-hour BPV plays a critical role in the neurological outcome of hemorrhagic stroke.

The role of clinic blood pressure for the diagnosis of hypertension

PURPOSE OF REVIEW

Recent data from randomized clinical trials and updates to hypertension guidelines warrant a review of the literature for the diagnosis and management of hypertension in the clinic setting. Although there have been significant advances in ambulatory blood pressure (BP) monitoring and home BP monitoring, office BP (OBP) measurements remains the primary means of diagnosis and treatment.

RECENT FINDINGS

The current review focuses on updated guidelines, proper technique, device selection, and the recent controversy regarding unattended BP measurements. We review the data on cardiovascular outcomes, the comparison of OBP with ambulatory BP monitoring and home BP monitoring and some of the pitfalls of OBP measurements.

SUMMARY

The current review highlights the need for constant review of BP goals to minimize cardiovascular risk and some of the ongoing controversies regarding OBP measurements.

Intradialytic blood pressure pattern recognition based on density peak clustering

End-stage renal disease (ESRD) is the final stage of chronic kidney disease (CKD) and requires hemodialysis (HD) for survival. Intradialytic blood pressure (IBP) measurements are necessary to ensure patient safety during HD treatments and have critical clinical and prognostic significance. Studies on IBP measurements, especially IBP patterns, are limited. All related studies have been based on a priori knowledge and artificially classified IBP patterns. Therefore, the results were influenced by subjective concepts. In this study, we proposed a new approach to identify IBP patterns to classify ESRD patients. We used the dynamic time warping (DTW) algorithm to measure the similarity between two series of IBP data. Five blood pressure (BP) patterns were identified by applying the density peak clustering algorithm (DPCA) to the IBP data. To illustrate the association between BP patterns and prognosis, we constructed three random survival forest (RSF) models with different covariates. Model accuracy was improved 3.7-6.3% by the inclusion of BP patterns. The results suggest that BP patterns have critical clinical and prognostic significance regarding the risk of cerebrovascular events. We can also apply this clustering approach to other time series data from electronic health records (EHRs). This work is generalizable to analyses of dense EHR data.

Real World Home Blood Pressure Variability in Over 56,000 Individuals With Nearly 17 Million Measurements

BACKGROUND

Using the data from 56,365 individuals, from 185 countries, and a Nokia Health Wireless blood pressure (BP) monitor, we investigated real-world characteristics of BP variability (BPV).

METHODS

All included individuals self-measured and uploaded their BP using Bluetooth at least 20 times over a period of ≥1 month at a frequency and duration of their choosing. In total, 16,904,844 BP measurements were analyzed, with a median of 146 measurements per person (interquartile range [IQR] 73-321) over a median of 14 months (IQR 7-31). SD, coefficient of variation, maximum BP, and maximum minus minimum BP difference were all calculated as measures of BPV.

RESULTS

BPV showed a distinct pattern, influenced by season of year, day of week, and time of day. BPV index was higher in females compared with males (P < 0.001) and increased with age (P < 0.001). Compared to the weekend, the weekday BPV index was significantly higher, and this finding was more prominent in females (P = 0.001). In multivariate analysis, BPV index were significantly associated with age, gender, geographic location, and mean BP values.

CONCLUSION

Using the largest BP data set we are aware of, with the benefits and limitations of real-world measurement, we could show the pattern of BPV and provide reference values that may be helpful in understanding the nature of BPV as self-measurement at home becomes more common, and help guide individualized management.

Pre-end-stage renal disease visit-to-visit systolic blood pressure variability and post-end-stage renal disease mortality in incident dialysis patients

OBJECTIVES

Higher SBP visit-to-visit variability (SBPV) has been associated with increased risk of adverse events in patients with chronic kidney disease, but the association of SBPV in advanced nondialysis-dependent chronic kidney disease with mortality after the transition to end-stage renal disease (ESRD) remains unknown.

METHODS

Among 17 729 US veterans transitioning to dialysis between October 2007 and September 2011, we assessed SBPV calculated from the SD of at least three intraindividual outpatient SBP values during the last year prior to dialysis transition (prelude period). Outcomes included factors associated with higher prelude SBPV and post-transition all-cause, cardiovascular, and infection-related mortality, assessed using multivariable linear regression and Cox and competing risk regressions, respectively, adjusted for demographics, comorbidities, medications, cardiovascular medication adherence, SBP, BMI, estimated glomerular filtration rate, and type of vascular access.

RESULTS

Modifiable clinical factors associated with higher prelude SBPV included higher SBP, use of antihypertensive medications and erythropoiesis-stimulating agents, inadequate cardiovascular medication adherence, and catheter use. After multivariable adjustment, higher prelude SBPV was significantly associated with higher post-ESRD all-cause and infection-related mortality, but not cardiovascular mortality [hazard/subhazard ratios (95% confidence interval) for the highest (vs. lowest) quartile of SBPV, 1.08 (1.01-1.16), 1.02 (0.89-1.15), and 1.41 (1.10-1.80) for all-cause, cardiovascular, and infection-related mortality, respectively].

CONCLUSION

High pre-ESRD SBPV is potentially modifiable and associated with higher all-cause and infection-related mortality following dialysis initiation. Further studies are needed to test whether modification of pre-ESRD SBPV can improve clinical outcomes in incident ESRD patients. VIDEO ABSTRACT:.

Association of visit-to-visit blood pressure variability with the risk of all-cause mortality and cardiovascular events in general population

The association between blood pressure variability (BPV) and the risk of all-cause mortality and cardiovascular diseases (CVD) is not well understood. The Kailuan study is a prospective longitudinal cohort study on cerebrovascular events and cardiovascular factors. In this study, resting blood pressure was measured at baseline and every 2 years from 2006 to 2007. BPV is mainly defined as the coefficient of variation (CV). Hazard ratio (HR), with 95% confidence intervals (CI) was calculated using Cox regression model. Among 52 387 participants, we identified 1817 who ended up with all-cause death and 1198 with CVD. Each 4.68% increase in BPV was associated with a 13% increase in the risk of mortality (HR = 1.13, 95% CI = 1.09-1.18) and a 7% increase in CVD (HR = 1.07, 95% CI = 1.02-1.13), respectively. After adjustment of confounding factors, the HR of comparing participants in the highest versus lowest quartile of CV of systolic blood pressure (SBP) was 1.37 (1.19, 1.57) for all-cause death, 1.18 (1.01, 1.39) for CVD. Similar results were also observed when BPV was measured by different parameters. We concluded that visit-to-visit BPV was associated with all-cause death and cardiovascular and cerebrovascular events in Chinese general population.

Association of 24 h-systolic blood pressure variability and cardiovascular disease in patients with obstructive sleep apnea

Background

To evaluate association of 24 h–systolic blood pressure (SBP) variability and obstructive sleep apnea (OSA) as defined by the apnea-hypopnea index ≥5/h; and association of 24 h–SBP variability and prevalent cardiovascular disease (CVD) in OSA patients.

Methods

Participants underwent polysomongraphy to evaluate the presence of OSA, and 24 h–ambulatory blood pressure monitoring was applied to evaluate 24 h–SBP variability as indexed by weighted 24 h–standard deviation (SD) of SBP. Between-group differences were evaluated in participants with and without OSA. Participants with OSA were divided into high and low 24 h–SBP variability groups and between-group differences were evaluated.

Results

Mean age of 384 participants was 50 years old and 42.2% had OSA. Mean 24 h–systolic/diastolic BP were 130/78 mmHg, with mean weighted 24 h–SD of systolic/diastolic BP were 12.9/7.3 mmHg. Compared to those without OSA, OSA participants had higher clinic-, 24 h-, daytime- and nighttime-SBP, and weighted 24 h, daytime- and nighttime-SD of SBP. Age, prevalent CVD and OSA, usage of angiotensin converting enzyme inhibitor/angiotensin receptor blocker, calcium channel blocker and diuretic were significantly associated with 24 h–SBP variability. In OSA patients, compared to those with low variability, participants with high variability had higher weighted 24 h, daytime- and nighttime-SD of SBP. After adjusted for covariates including clinic-SBP and 24 h–SBP, per 1-SD increment weighted 24 h–SD of SBP was associated with 21% increased prevalent CVD.

Conclusions

Patients with newly-diagnosed OSA have higher 24 h–SBP variability compared to those without OSA; in OSA patients, increased 24 h–SBP variability is associated with increased prevalence of CVD.

Visit-to-Visit Blood Pressure Variability in Young Adulthood and Hippocampal Volume and Integrity at Middle Age: The CARDIA Study (Coronary Artery Risk Development in Young Adults)

The aims of this study are to assess the relationships of visit-to-visit blood pressure (BP) variability in young adulthood to hippocampal volume and integrity at middle age. We used data over 8 examinations spanning 25 years collected in the CARDIA study (Coronary Artery Risk Development in Young Adults) of black and white adults (age, 18-30 years) started in 1985 to 1986. Visit-to-visit BP variability was defined as by SDBP and average real variability (ARVBP, defined as the absolute differences of BP between successive BP measurements). Hippocampal tissue volume standardized by intracranial volume (%) and integrity assessed by fractional anisotropy were measured by 3-Tesla magnetic resonance imaging at the year-25 examination (n=545; mean age, 51 years; 54% women and 34% African Americans). Mean systolic BP (SBP)/diastolic BP levels were 110/69 mm Hg at year 0 (baseline), 117/73 mm Hg at year 25, and ARVSBP and SDSBP were 7.7 and 7.9 mm Hg, respectively. In multivariable-adjusted linear models, higher ARVSBP was associated with lower hippocampal volume (unstandardized regression coefficient [standard error] with 1-SD higher ARVSBP: -0.006 [0.003]), and higher SDSBP with lower hippocampal fractional anisotropy (-0.02 [0.01]; all P<0.05), independent of cumulative exposure to SBP during follow-up. Conversely, cumulative exposure to SBP and diastolic BP was not associated with hippocampal volume. There was no interaction by sex or race between ARVSBP or SDSBP with hippocampal volume or integrity. In conclusion, visit-to-visit BP variability during young adulthood may be useful in assessing the potential risk for reductions in hippocampal volume and integrity in midlife.

Systolic Blood Pressure Response in SPRINT (Systolic Blood Pressure Intervention Trial) and ACCORD (Action to Control Cardiovascular Risk in Diabetes): A Possible Explanation for Discordant Trial Results

Background

SPRINT (Systolic Blood Pressure Intervention Trial) and the ACCORD (Action to Control Cardiovascular Risk in Diabetes) blood pressure trial used similar interventions but produced discordant results. We investigated whether differences in systolic blood pressure (SBP) response contributed to the discordant trial results.

Methods and Results

We evaluated the distributions of SBP response during the first year for the intensive and standard treatment groups of SPRINT and ACCORD using growth mixture models. We assessed whether significant differences existed between trials in the distributions of SBP achieved at 1 year and the treatment‐independent relationships of achieved SBP with risks of primary outcomes defined in each trial, heart failure, stroke, and all‐cause death. We examined whether visit‐to‐visit variability was associated with heterogeneous treatment effects. Among the included 9027 SPRINT and 4575 ACCORD participants, the difference in mean SBP achieved between treatment groups was 15.7 mm Hg in SPRINT and 14.2 mm Hg in ACCORD, but SPRINT had significantly less between‐group overlap in the achieved SBP (standard deviations of intensive and standard groups, respectively: 6.7 and 5.9 mm Hg in SPRINT versus 8.8 and 8.2 mm Hg in ACCORD; P<0.001). The relationship between achieved SBP and outcomes was consistent across trials except for stroke and all‐cause death. Higher visit‐to‐visit variability was more common in SPRINT but without treatment‐effect heterogeneity.

Conclusions

SPRINT and ACCORD had different degrees of separation in achieved SBP between treatment groups, even as they had similar mean differences. The greater between‐group overlap of achieved SBP may have contributed to the discordant trial results.

Time in Therapeutic Range, as a Determinant of All-Cause Mortality in Patients With Hypertension

Background

Accumulating evidence indicates that reducing systolic blood pressure (BP) to <140 mm Hg improves health outcomes; however, an optimal level has not yet been determined. Many population studies or post hoc analyses suggest a target systolic BP between 120 and 140 mm Hg with increased risk above and below that range. We tested the hypothesis that consistent control of systolic BP between 120 and 140 mm Hg—time in therapeutic range—is a strong determinant of all‐cause mortality among US veterans.

Methods and Results

A total of 689 051 individuals from 15 Veterans Administration Medical Centers were followed over a 10‐year period. Participants were classified as hypertensive, intermediate hypertensive, and normotensive according to the number of elevated BP recordings (>3, 1 or 2, and none, respectively). Time within, above, or below therapeutic range (120–140 mm Hg) was considered in quartiles and related to all‐cause mortality. The study population consisted of 54% hypertensive, 19.9% intermediate, and 26.1% normotensive participants; the corresponding mortality rates for the 3 groups were 11.5%, 8%, and 1.9%, respectively (P<0.0001 for all comparisons). Mortality rates for hypertensive participants with BP consistently within, above, or below the therapeutic range were 6.5%, 21.9%, and 33.1%, respectively (P<0.0001 for all comparisons). Mortality rates in hypertensive participants increased from 6.5% in the most consistently controlled quartile (>75%) to 8.9%, 15.6%, and 23.5% towards the less consistently controlled quartiles (50–75%, 25–50%, and <25%, respectively; P<0.0001 for all comparisons).

Conclusions

An inverse and gradual association between time in therapeutic range and all‐cause mortality was observed in this large veteran cohort. Consistency of BP control over time is a strong determinant of all‐cause mortality, and consistency of BP control should be monitored in everyday clinical practice.

The years of life lost on cardiovascular disease attributable to ambient temperature in China

Few studies have examined the association between ambient temperature and years of life lost (YLL). We aim to explore the burden of cardiovascular disease attributed to non-optimum temperature in China. YLL provides a complementary measure for examining the burden of disease due to ambient temperature. Non-optimal temperature leads to the increase of YLL. The mortality of fourteen cities in China during 2008–2013 was included in this study. We used the Distributed Lag Non-linear Model (DLNM) to estimate the association between daily mean temperature and YLL, controlling for long term trends, day of the week, seasonality and relative humidity. The daily YLL varied from 807 in Changchun to 2751 in Chengdu, with males higher than females. Extreme high and low temperatures were associated with higher YLL. The attributable fraction (AF) to cold effect is from 2.67 (95%CI: −1.63, 6.70) to 8.55 (95%CI: 5.05, 11.90), while the AF to heat effect is from 0.16 (95%CI: 0.06, 0.26) to 2.29 (95%CI: 1.29, 3.19). Cold effect was significantly higher than heat effect on cardiovascular disease in both men and women and for different age groups.

Visit-to-Visit Office Blood Pressure Variability and Cardiovascular Outcomes in SPRINT (Systolic Blood Pressure Intervention Trial)

Studies of visit-to-visit office blood pressure (BP) variability (OBPV) as a predictor of cardiovascular events and death in high-risk patients treated to lower BP targets are lacking. We conducted a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial), a well-characterized cohort of participants randomized to intensive (<120 mm Hg) or standard (<140 mm Hg) systolic BP targets. We defined OBPV as the coefficient of variation of the systolic BP using measurements taken during the 3-,6-, 9-, and 12-month study visits. In our cohort of 7879 participants, older age, female sex, black race, current smoking, chronic kidney disease, and coronary disease were independent determinants of higher OBPV. Use of thiazide-type diuretics or dihydropyridine calcium channel blockers was associated with lower OBPV whereas angiotensin-converting enzyme inhibitors or angiotensin receptor blocker use was associated with higher OBPV. There was no difference in OBPV in participants randomized to standard or intensive treatment groups. We found that OBPV had no significant associations with the composite end point of fatal and nonfatal cardiovascular events (n=324 primary end points; adjusted hazard ratio, 1.20; 95% confidence interval, 0.85-1.69, highest versus lowest quintile) nor with heart failure or stroke. The highest quintile of OBPV (versus lowest) was associated with all-cause mortality (adjusted hazard ratio, 1.92; confidence interval, 1.22-3.03) although the association of OBPV overall with all-cause mortality was marginal (P=0.07). Our results suggest that clinicians should continue to focus on office BP control rather than on OBPV unless definitive benefits of reducing OBPV are shown in prospective trials.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Patterns of blood pressure response during intensive BP lowering and clinical events: results from the secondary prevention of small subcortical strokes trial

PURPOSE

We applied cluster analysis to identify discrete patterns of concomitant responses of systolic (SBP), diastolic (DBP) and pulse pressure (PP) during intensive BP lowering; and to evaluate their clinical relevance and association with risk of mortality, major vascular events (MVEs), and stroke.

MATERIAL AND METHODS

We used an unsupervised cluster procedure to identify distinct patterns of BP change during the first 9 months of anti-hypertensive therapy intensification among 1,331 participants in the Secondary Prevention of Small Subcortical Strokes Trial who were previously randomized to lower BP target (SBP < 130 mm Hg) after lacunar stroke.

RESULTS

The cluster procedure partitioned participants into three groups in the lower SBP target arm, persons with: 1) mildly elevated baseline SBP and minimal visit-to-visit BP variability (mild reducers); 2) moderately elevated baseline SBP and moderate visit-to-visit BP variability (moderate reducers); and 3) very elevated baseline SBP with very large visit-to-visit BP variability during intensification (large reducers). In the lower SBP target group, moderate reducers had a higher risk of death (adjusted HR 1.6 [95% CI 1.0-2.7]), MVE (adjusted HR 2.1 [95% CI 1.4-3.2]), and stroke (adjusted HR 2.6[95% CI 1.7-4.1]) compared to mild reducers. Large reducers had the highest risk of death (adjusted HR 2.3 [95% CI 1.2-4.4]), but risk of MVE (HR = 1.7 [95%CI 0.9-3.1]) and stroke (HR = 1.6 [95%CI: 0.8-3.5]) were not statistically significantly different compared to mild reducers.

CONCLUSIONS

Among persons with prior lacunar stroke, baseline BP levels, and BP variability in the setting of intensive BP lowering can identify discrete groups of persons at higher risk of adverse outcomes.

[Effect of a fixed-dose combination of perindopril arginine/amlodipine on the level and variability of blood pressure according to its office visit-to-visit measurements and self-measurements at home: A subanalysis of the PREVOSHODSTVO (SUPERIORITY) program]

AIM

To study the effect of a fixed-dose combination of perindopril arginine/amlodipine (prestans) on the goal levels and variability of blood pressure (BP) according to its office visit-to-visit measurements and self-measurement (OVVM and SM) in a subgroup of 483 people from the population of the Russian observational SUPERIORITY program, most cases of whom are given the combination replacing the previously ineffective mono- and combination antihypertensive therapy (AHT).

SUBJECTS AND METHODS

The subanalysis included data on 483 patients (34% men) aged 57.9±10.8 years with uncontrolled hypertension, who were both untreated and treated with antihypertensive mono- or combination therapy using a free or fixed-dose combination of 2-3 antihypertensive drugs and in whom the physicians decided to use prestans to correct AHT. The follow-up period was 24 weeks.

RESULTS

At the end of the investigation, the patients received prestans in the following doses: 5/5 mg (34% of the patients), 10/5 mg (39.5%), 5/10 mg (3.9%), and 10/10 mg (22%). In the analyzed patient group, the baseline BP was 160.8±8.8/92.6±7.4 mm Hg and dropped to 125.9±7.9/77.8±5.0 mm Hg at 24 weeks (p<0.001). According to SM, the morning BP significantly decreased from 147.0±13.3/85.6±7.2 to 127.5±8.3/78,9±5.6 mm Hg at 24 weeks (p<0.001). The evening BP readings showed the similar trends. Target BP was achieved in 93 and 78% of the patients, as shown by OVVM and SM, respectively. According to SCM, the day-to-day variability of BP significantly decreased from 5.1±3.2/3.4±2.3 Hg mm at Visit 2 to 2.7±2/0/2,3±1/5 mm Hg at Visit 5 (p<0.001).

CONCLUSION

The use of the fixed-dose combination of perindopril arginine/amlodipine in hypertensive patients just at the beginning of treatment, by switching from insufficiently effective mono- or combination AHT to the fixed-dose combination of perindopril arginine/amlodipine, is an effective way to optimize AHT in clinical practice, which lowers the BP level and variability, as evidenced by both OVVM and SM.

Blood Pressure and Heart Rate Measures Associated With Increased Risk of Covert Brain Infarction and Worsening Leukoaraiosis in Older Adults

OBJECTIVE

In people without previous stroke, covert findings on serial magnetic resonance imaging (MRI) of incident brain infarcts and worsening leukoaraiosis are associated with increased risk for ischemic stroke and dementia. We evaluated whether various measures of blood pressure (BP) and heart rate are associated with these MRI findings.

APPROACH AND RESULTS

In the CHS (Cardiovascular Health Study), a longitudinal cohort study of older adults, we used relative risk regression to assess the associations of mean, variability, and trend in systolic BP, diastolic BP, and heart rate measured at 4 annual clinic visits between 2 brain MRIs with incident covert brain infarction and worsening white matter grade (using a 10-point scale to characterize leukoaraiosis). We included participants who had both brain MRIs, no stroke before the follow-up MRI, and no change in antihypertensive medication status during follow-up. Among 878 eligible participants, incident covert brain infarction occurred in 15% and worsening white matter grade in 27%. Mean systolic BP was associated with increased risk for incident covert brain infarction (relative risk per 10 mm Hg, 1.28; 95% confidence interval, 1.12-1.47), and mean diastolic BP was associated with increased risk for worsening white matter grade (relative risk per 10 mm Hg, 1.45; 95% confidence interval, 1.24-1.69). These findings persisted in secondary and sensitivity analyses.

CONCLUSIONS

Elevated mean systolic BP is associated with increased risk for covert brain infarction, and elevated mean diastolic BP is associated with increased risk for worsening leukoaraiosis. These findings reinforce the importance of hypertension in the development of silent cerebrovascular diseases, but the pathophysiologic relationships to BP for each may differ.

Using Predicted Cardiovascular Disease Risk in Conjunction With Blood Pressure to Guide Antihypertensive Medication Treatment

Using cardiovascular disease (CVD) risk instead of or in addition to blood pressure (BP) to guide antihypertensive treatment is an active area of research. The purpose of this review is to provide an overview of studies that could inform this treatment paradigm. We review data from randomized trials on relative and absolute CVD risk reduction that can occur when antihypertensive treatment is guided by CVD risk. We also review population-level data on using CVD risk in conjunction with BP to guide antihypertensive treatment, the broad distribution in CVD risk for people with similar BP levels, and the use of CVD risk for guiding antihypertensive treatment among subgroups including older adults, young adults, and those with diabetes mellitus or chronic kidney disease. In addition, we review potential challenges in implementing antihypertensive treatment recommendations that incorporate CVD risk. In closing, we provide recommendations for using CVD risk in combination with BP to guide antihypertensive treatment.

Healthy Lifestyle and Blood Pressure Variability in Young Adults

BACKGROUND

The aim of this study was to assess the relationships between healthy lifestyle metrics and blood pressure variability (BPV) in young and healthy adults.

METHODS

A population-based sample of 1,999 individuals aged 25-41 years was investigated. A lifestyle-score from 0 (most unhealthy) to 7 (most healthy) was calculated by giving one point for each of the following components: never smoking cigarettes, adhering to a healthy diet, performing moderate or intense physical activity, having a body mass index <25 kg/m2, a total cholesterol <200 mg/dl, a glycated hemoglobin <5.7%, or a conventional BP <120/80 mm Hg. Standardized ambulatory 24-hour BP measurements were obtained in all individuals. BPV was defined as the SD of all individual ambulatory BP recordings. We constructed multivariable linear regression models to assess the relationships between the lifestyle-score and BPV. None of the results were adjusted for multiple testing.

RESULTS

Median age was 37 years and 46.8% were men. With increasing lifestyle-score, systolic and diastolic BPV is decreasing linearly (P for trend <0.0001), even after multivariable adjustment. Per 1-point increase in lifestyle-score, the β-coefficient (95% confidence interval) for systolic and diastolic 24-hour BPV was -0.03 (-0.03; -0.02) and -0.04 (-0.05; -0.03), respectively, both P for trend <0.0001. These relationships were attenuated but remained statistically significant after additional adjustment for mean individual BP.

CONCLUSION

In this study of young and healthy adults, adopting a healthy lifestyle was associated with a lower BPV. These associations were independent of mean BP levels.

Prognostic Value of Variability in Systolic Blood Pressure Related to Vascular Events and Premature Death in Type 2 Diabetes Mellitus: The ADVANCE-ON Study

Visit-to-visit variability in systolic blood pressure (SBP) is a risk factor for cardiovascular events. However, whether it provides additional predictive information beyond traditional risk factors, including mean SBP, in the long term is unclear. The ADVANCE trial (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation) was a randomized controlled trial in patients with type 2 diabetes mellitus; ADVANCE-ON (ADVANCE-Observational) followed-up patients subsequently. In these analyses, 9114 patients without major macrovascular or renal events or death during the first 24 months were included. Data on SBP from 6 visits during the first 24 months after randomization were used to estimate visit-to-visit variability in several ways: the primary measure was the standard deviation. Events accrued during the following 7.6 years. The primary outcome was a composite of major macrovascular and renal events and all-cause mortality. Standard deviation of SBP was log-linearly associated with an increased risk of the primary outcome (P<0.001) after adjustment for mean SBP and other cardiovascular risk factors. The hazard ratio (HR; 95% confidence interval [CI]) in the highest, compared with the lowest, tenth of the standard deviation was 1.39 (1.15-1.69). Results were similar for major macrovascular events alone and all-cause mortality alone (both P<0.01). Addition of standard deviation of SBP significantly improved 8-year risk classification (continuous net reclassification improvement, 5.3%). Results were similar for other measures of visit-to-visit variability, except maximum SBP. Visit-to-visit variability in SBP is an independent predictor of vascular complications and death, which improves risk prediction beyond that provided by traditional risk factors, including mean SBP.

Impact of Visit-to-Visit Variability in Systolic Blood Pressure on Cardiovascular Outcomes in Korean National Health Insurance Service-National Sample Cohort

BACKGROUND

Despite an association between visit-to-visit blood pressure (BP) variability (VV-BPV) and cardiovascular (CV) outcomes, many studies performed during the past 4 years have shown conflicting results. This study investigated the impact of VV-BPV on CV outcomes in the Korean National Health Insurance Service (NHIS) database-National Sample Cohort.

METHODS

From the 2002 Korean NHIS database (n = 47,851,928), sample subjects with 3 or more BP measurements (n = 51,811) were divided into 2 groups according to a 10 mm Hg cutoff in the SD of systolic BP (SD-SBP). The CV outcomes of these groups were compared by sensitivity analyses using various sampling methods.

RESULTS

Irrespective of sampling method, subjects with SD-SBPs ≥10 mm Hg had higher rates of CV events or death, nonfatal myocardial infarction (MI) or stroke, and total mortality, but were not associated with CV mortality. The hazard ratios for CV events or death, nonfatal MI or stroke, CV mortality, and total mortality were 1.43 (95% confidence interval [CI], 1.25-1.63, P < 0.01), 1.45 (95% CI, 1.27-1.65, P < 0.01), 1.32 (95% CI, 0.89-1.94, P = 0.17), and 1.18 (95% CI, 1.01-1.38, P = 0.04), respectively.

CONCLUSIONS

Increased VV-BPV was an independent risk factor for future CV outcomes, independent of mean BP status, even in normotensive subjects and in all subgroups, except females. Similar VV-BPV values in the sensitivity analyses suggest VV-BPV is a reproducible phenomenon, reflecting the various types of intrinsic physiologic properties.

Association of Blood Pressure Trajectory With Mortality, Incident Cardiovascular Disease, and Heart Failure in the Cardiovascular Health Study

BACKGROUND

Common blood pressure (BP) trajectories are not well established in elderly persons, and their association with clinical outcomes is uncertain.

METHODS

We used hierarchical cluster analysis to identify discrete BP trajectories among 4,067 participants in the Cardiovascular Health Study using repeated BP measures from years 0 to 7. We then evaluated associations of each BP trajectory cluster with all-cause mortality, incident cardiovascular disease (CVD, defined as stroke or myocardial infarction) (N = 2,837), and incident congestive heart failure (HF) (N = 3,633) using Cox proportional hazard models.

RESULTS

Median age was 77 years at year 7. Over a median 9.3 years of follow-up, there were 2,475 deaths, 659 CVD events, and 1,049 HF events. The cluster analysis identified 3 distinct trajectory groups. Participants in cluster 1 (N = 1,838) had increases in both systolic (SBP) and diastolic (DBP) BPs, whereas persons in cluster 2 (N = 1,109) had little change in SBP but declines in DBP. Persons in cluster 3 (N = 1,120) experienced declines in both SBP and DBP. After multivariable adjustment, clusters 2 and 3 were associated with increased mortality risk relative to cluster 1 (hazard ratio = 1.21, 95% confidence interval: 1.06-1.37 and hazard ratio = 1.20, 95% confidence interval: 1.05-1.36, respectively). Compared to cluster 1, cluster 3 had higher rates of incident CVD but associations were not statistically significant in demographic-adjusted models (hazard ratio = 1.16, 95% confidence interval: 0.96-1.39). Findings were similar when stratified by use of antihypertensive therapy.

CONCLUSIONS

Among community-dwelling elders, distinct BP trajectories were identified by integrating both SBP and DBP. These clusters were found to have differential associations with outcomes.

Effect of Azilsartan on Day-to-Day Variability in Home Blood Pressure: A Prospective Multicenter Clinical Trial

Background

The blood pressure variability (BPV) such as visit-to-visit, day-by-day, and ambulatory BPV has been also shown to be a risk of future cardiovascular events. However, the effects of antihypertensive therapy on BPV remain unclear. The purpose of this study was to evaluate the effect of azilsartan after switching from another angiotensin II receptor blocker (ARB) on day-to-day BPV in home BP monitoring.

Methods

This prospective, multicenter, open-labeled, single-arm study included 28 patients undergoing treatment with an ARB, which was switched to azilsartan after enrollment. The primary outcome was the change in the mean of the standard deviation and the coefficient of variation of morning home BP for 5 consecutive days from baseline to the 24-week follow-up. The secondary outcome was the change in arterial stiffness measured by the cardio-ankle vascular index.

Results

The mean BPs in the morning and evening for 5 days did not statistically differ between baseline and 24 weeks. For the morning BP, the means of the standard deviations and coefficient of variation of the systolic BP were significantly decreased from 7.4 ± 3.6 mm Hg to 6.1 ± 3.2 mm Hg and from 5.4±2.7% to 4.6±2.3% (mean ± standard deviation, P = 0.04 and P = 0.04, respectively). For the evening BP, no significant change was observed in the systolic or diastolic BPV. The cardio-ankle vascular index significantly decreased from 8.3 ± 0.8 to 8.1 ± 0.8 (P = 0.03).

Conclusions

Switching from another ARB to azilsartan reduced day-to-day BPV in the morning and improved arterial stiffness.

Decreased systolic blood pressure is associated with increased risk of all-cause mortality in patients with type 2 diabetes and renal impairment: A nationwide longitudinal observational study of 27,732 patients based on the Swedish National Diabetes Register

BACKGROUND

Previous studies have shown a U-shaped relationship between systolic blood pressure and risk of all-cause of mortality in patients with type 2 diabetes and renal impairment.

AIMS

To evaluate the associations between time-updated systolic blood pressure and time-updated change in systolic blood pressure during the follow-up period and risk of all-cause mortality in patients with type 2 diabetes and renal impairment.

PATIENTS AND METHODS

A total of 27,732 patients with type 2 diabetes and renal impairment in the Swedish National Diabetes Register were followed for 4.7 years. Time-dependent Cox models were used to estimate risk of all-cause mortality. Time-updated mean systolic blood pressure is the average of the baseline and the reported post-baseline systolic blood pressures.

RESULTS

A time-updated systolic blood pressure < 130 mmHg was associated with a higher risk of all-cause mortality in patients both with and without a history of chronic heart failure (hazard ratio: 1.25, 95% confidence interval: 1.13-1.40 and hazard ratio: 1.26, 1.17-1.36, respectively). A time-updated decrease in systolic blood pressure > 10 mmHg between the last two observations was associated with higher risk of all-cause mortality (-10 to -25 mmHg; hazard ratio: 1.24, 95% confidence interval: 1.17-1.32).

CONCLUSION

Both low systolic blood pressure and a decrease in systolic blood pressure during the follow-up are associated with a higher risk of all-cause mortality in patients with type 2 diabetes and renal impairment.

Associations between body fat variability and later onset of cardiovascular disease risk factors

OBJECTIVE

There is current debate regarding whether body weight variability is associated with cardiovascular events. Recently, high body fat percentage (BF%) has been shown to be a cardiovascular risk factor. We therefore hypothesized that BF% variability would present a stronger cardiovascular risk than body weight variability.

METHODS

A single-center retrospective cohort study of medical check-up examinees aged 20 years or older at baseline (2005) was performed. Examinees were followed in 2007, 2009, and 2013-2014. BF% variability in 2005, 2007 and 2009 was calculated as the root-mean square error (RMSE) using a simple linear regression model. Multiple logistic regression models estimated the association between BF%-RMSE and new diagnoses of cardiovascular risk factors occurring between the 2009 and 2013-2014 visits.

RESULTS

In total, 11,281 participants (mean age: 51.3 years old, 48.8% were male) were included in this study. The average BF%-RMSE of our subjects was 0.63, and the average BMI-RMSE was 0.24. The high BF%-RMSE group (76-100th percentile) had a higher incidence of hypertension and a lower incidence of diabetes mellitus than the low BF%-RMSE group (1-25th percentile). This tendency was particularly evident in male participants. BMI-RMSE was not associated with any cardiovascular risks in our study.

CONCLUSIONS

This study indicates that body fat variability has contrasting effects on cardiovascular risk factors, while body weight variability has no significant effects.

Prognostic value of long-term blood pressure changes in patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is the final stage of many heart diseases. To improve outcomes, important risk factors for adverse clinical events in the CHF population need to be identified. The aim of the present study was to delineate the influence of long-term blood pressure (BP) changes on prognosis and mortality in a real-world cohort of CHF patients.

METHODS AND RESULTS

This is a retrospective longitudinal analysis. Repeated office BP measurements were scheduled during follow-up visits every 3-6 months. The primary endpoint was time to death or heart transplantation (HTx). A Cox regression with time-dependent strata was used to analyse the effect of systolic BP (SBP) values and its change during follow-up on the primary endpoint. A total of 927 patients presented with a median survival of 7.7 [95% confidence interval (CI) 6.6-9.8] years. During follow-up, 220 patients died and 70 patients underwent HTx. The BP stratum with the most stable values showed the best survival. Blood pressure changes with an increase or decrease greater than ±10 mmHg per year led to a significantly worse outcome [hazard ratio (HR) 1.8 and 2.0, respectively]. The stratum with the lowest SBP levels (<90 mmHg) had the highest mortality. Multiple regression analysis showed a HR factor of 17 (95% CI 9.7-29) in comparison with the stratum with SBP ≥130 mmHg.

CONCLUSION

Low SBP (<90 mmHg) and pronounced long-term changes in SBP were associated with poor survival in patients with CHF. Additional prospective studies are warranted to further specify optimal BP targets in patients with CHF.

Visit-to-visit Variability of Blood Pressure and Risk of Stroke: Results of the Kailuan Cohort Study

Uncertainty persists regarding the need to address blood pressure (BP) variability in the general population to reduce the heavy burden of stroke. In this cohort study, we prospectively recruited 57,927 participants from southeast of Beijing, who have completed all 3 health examinations between 2006 and 2010. BP variability was defined as the coefficient of variation (CV) across these 3 visits. Over a median follow-up of 3.0 years, we identified 582 first stroke cases. Of these, 489 (84.0%) were ischemic strokes and 94 (16.2%) were hemorrhagic strokes. After multivariable adjustment, the hazard ratios (HR) (95% Confidence Intervals, CI) of comparing participants in the highest versus lowest quartile of CV of systolic blood pressure (SBP) was 1.44 (1.11, 1.87) for any stroke, 1.33 (1.00, 1.77) for ischemic stroke, and 2.17 (1.09, 4.35) for hemorrhagic stroke. Similar results were also observed when the CV of SBP was considered as a continuous exposure variable (per SD increase). Moreover, higher variability of diastolic blood pressure (DBP) was also significantly associated with the risk of any stroke and specifically with hemorrhagic stroke, but not with ischemic stroke. In conclusion, higher visit-to-visit BP variability might be an important target to reduce stroke risk, particularly for hemorrhagic stroke.

Association of Visit-to-Visit Variability of Systolic Blood Pressure With Cardiovascular Disease and Mortality in Primary Care Chinese Patients With Type 2 Diabetes-A Retrospective Population-Based Cohort Study

OBJECTIVE

This study aimed to evaluate the impact of visit-to-visit variability (VVV) of systolic blood pressure (SBP) on cardiovascular disease (CVD) and mortality among primary care Chinese patients with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

A retrospective cohort study was conducted in 124,105 Chinese adult primary care patients with T2DM and without prior diagnosed CVD from August 2008 to December 2009. The VVV of SBP was evaluated using SDs of SBP over 24 months. The risks of CVD and all-cause mortality associated with variability in SBP were evaluated using Cox proportional hazards regression. Subgroup analysis was conducted by the stratification of age, sex, duration of diabetes, the presence of chronic kidney disease, baseline SBP and trend, and the number and class of antihypertensive drugs.

RESULTS

A positive linear relationship between the VVV of SBP and the first incidence of CVD and all-cause mortality was identified over a median follow-up time of 39.5 months. Patients with a low SD of SBP of <5 mmHg had the lowest risks of CVD and all-cause mortality, and patients with an SD of SBP of ≥10 mmHg had significantly higher risks. For every 1 SD increase in the SD of SBP, the risks of CVD, all-cause mortality, and the composite of both events increased by 2.9% (95% CI 2.4-3.4%), 4.0% (95% CI 3.5-4.6%), and 3.4% (95% CI 3.0-3.8%), respectively. A direct linear relationship was also observed in all selected subgroups.

CONCLUSIONS

SBP variability, irrespective of the mean SBP level, is a potential predictor for the development of CVD and all-cause mortality in patients with diabetes. In addition to monitoring BP targets for their patients with diabetes, clinicians should also remain vigilant about the visit-to-visit fluctuation of BP.