Relationships between the risk of cardiovascular disease in type 2 diabetes patients and both visit-to-visit variability and time-to-effect differences in blood pressure

Joint effect of blood pressure and glycemic variation on the risk of cardiovascular morbidity and mortality in persons with type 2 diabetes

OBJECTIVE

Few studies have explored the association of visit-to-visit variation in blood pressure (BP) and glycemic factors with cardiovascular disease (CVD) morbidity and mortality. This study aimed to examine the independent and joint effect of visit-to-visit BP and glycemic variation on CVD morbidity and mortality in persons with T2DM.

METHODS

The present study consisted of two retrospective cohort studies. The Taiwan Diabetes Study was based on a database of the National Diabetes Care Management Program (DCMP) and linked with cardiovascular morbidity incidence. The Taichung Diabetes Study was based on the DCMP database of a medical center, which can be linked with the National Death Registry dataset. The outcomes were analyzed by using Cox's proportional hazard models.

RESULTS

A total of 13,280 and 10,894 persons with T2DM in Taiwan and Taichung Diabetes Study, respectively, were included. SBP-CV, FPG-CV, and HbA1c-CV were significant predictors of stroke, CVD event or death, all-cause mortality, and expanded CVD mortality, whereas DBP-CV was a significant predictor of all-cause mortality and expanded and non-expanded CVD mortality. The joint effect of SBP, FPG, and HbA1c predicted the incidence of stroke and CVD event or death with increased risks of 16 %-35 %. In addition, the joint effect of SBP, DBP, FPG, and HbA1c was associated with all-cause and expanded CVD mortality with increased risks of 29 %-81 %.

CONCLUSIONS

The joint effect of BP and glucose variation improved the prediction of cardiovascular morbidity and mortality. Moreover, simultaneous measurement of visit-to-visit BP and glycemic variation may stratify persons with cardiovascular risks and may be regarded as important therapeutic goals in the care of T2DM.

Blood pressure variability in individuals with diabetes mellitus: a scoping review

ABSTRACT Objectives: to map methods and devices used to assess very short-, short-, medium-, and long-term pressure variability in adults with type 1 or 2 diabetes mellitus. Methods: scoping review conducted in January and February 2021 in MEDLINE, Web of Science, CINAHL, LILACS, PubMed, and Embase databases. Studies conducted within the last ten years analyzing pressure variability in adult and older patients with diabetes mellitus type 1 or 2 were included. Studies that used discontinued devices were excluded. Results: the sample was composed of 25 articles published since 2017, with the majority developed in Japan (n=11); with the predominance of the oscillometric method (n=22); the most used devices were from the Omron® brand (n=14); the most detected type was long-term variability (n=10). Conclusions: we observed the increasing application of the oscillometric method for pressure variability analysis with various brands and models of automatic devices.

Prognostic importance of visit-to-visit blood pressure variability for micro- and macrovascular outcomes in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. We aimed to evaluate it in a prospective long-term follow-up study with 632 individuals with type 2 diabetes.

METHODS

BP-VVV parameters (systolic and diastolic standard deviations [SD] and variation coefficients) were measured during the first 24-months. Multivariate Cox analysis, adjusted for risk factors and mean BP levels, examined the associations between BP-VVV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications (total cardiovascular events [CVEs], major adverse CVEs [MACE] and cardiovascular and all-cause mortality). Improvement in risk discrimination was assessed by the C-statistic and integrated discrimination improvement (IDI) index.

RESULTS

Over a median follow-up of 11.3 years, 162 patients had a CVE (132 MACE), and 212 patients died (95 from cardiovascular diseases); 153 newly-developed or worsened diabetic retinopathy, 193 achieved the renal composite outcome (121 newly-developed microalbuminuria and 95 deteriorated renal function), and 171 newly-developed or worsened peripheral neuropathy. Systolic BP-VVV was an independent predictor of MACE (hazard ratio: 1.25, 95% CI 1.03-1.51 for a 1-SD increase in 24-month SD), but not of total CVEs, cardiovascular and all-cause mortality, and of any microvascular outcome. However, no BP-VVV parameter significantly improved cardiovascular risk discrimination (increase in C-statistic 0.001, relative IDI 0.9%).

CONCLUSIONS

Systolic BP-VVV was an independent predictor of MACE, but it did not improve cardiovascular risk stratification. The goal of anti-hypertensive treatment in patients with type 2 diabetes shall remain in controlling mean BP levels, not on decreasing their visit-to-visit variability.

Association between blood pressure variability, cardiovascular disease and mortality in type 2 diabetes: A systematic review and meta-analysis

AIM

To investigate the associations of blood pressure variability (BPV), expressed as long-term (visit-to-visit) and short-term (ambulatory blood pressure monitoring [ABPM] and home blood pressure monitoring [HBPM]) and all-cause mortality, major adverse cardiovascular events (MACEs), extended MACEs, microvascular complications (MiCs) and hypertension-mediated organ damage (HMOD) in adult patients with type 2 diabetes.

MATERIALS AND METHODS

PubMed, Medline, Embase, Cinahl, Web of Science, ClinicalTrials.gov and grey literature databases were searched for studies including patients with type 2 diabetes, at least one variable of BPV (visit-to-visit, HBPM, ABPM) and evaluation of the incidence of at least one of the following outcomes: all-cause mortality, MACEs, extended MACEs and/or MiCs and/or HMOD. The extracted information was analyzed using random effects meta-analysis and meta-regression.

RESULTS

Data from a total of 377 305 patients were analyzed. Systolic blood pressure (SBP) variability was associated with a significantly increased risk of all-cause mortality (HR 1.12, 95% CI 1.04-1.21), MACEs (HR 1.01, 95% CI 1.04-1.17), extended MACEs (HR 1.07, 95% CI 1.03-1.11) and MiCs (HR 1. 12, 95% CI 1.01-1.24), while diastolic blood pressure was not. Associations were mainly driven from studies on long-term SBP variability. Qualitative analysis showed that BPV was associated with the presence of HMOD expressed as carotid intima-media thickness, pulse wave velocity and left ventricular hypertrophy. Results were independent of mean blood pressure, glycaemic control and serum creatinine levels.

CONCLUSIONS

Our results suggest that BPV might provide additional information rather than mean blood pressure on the risk of cardiovascular disease in patients with type 2 diabetes.

Association of Visit-to-Visit Variability of Blood Pressure with Cardiovascular Disease among Type 2 Diabetes Mellitus Patients: A Cohort Study

BACKGROUND

Increasing evidence has shown that visit-to-visit variability (VVV) of blood pressure (BP) is associated with an increased risk of cardiovascular disease (CVD). The objective of this study was to evaluate the impact of VVV of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on the risk of CVD among patients with type 2 diabetes mellitus (T2DM) in China.

METHODS

We conducted a retrospective cohort study of 10,163 T2DM patients who were not previously diagnosed with CVD from January 2008 to December 2012 in Ningbo, China. The VVV of BP was calculated using five metrics, including standard deviation (SD), coefficient of variation (CV), variation independent of mean, average real variability, and successive variability (SV) of measurements, obtained over a 24-month measurement period. Hazard ratios and 95% confidence intervals (CIs) were estimated by Cox proportional hazards regression models for the associations of variability in BP with risk of CVD.

RESULTS

A total of 894 CVD events were observed during a median follow-up of 49.5 months. The hazard ratio in the highest quintile of SD of SBP was 1.24 (95% CI, 1.01 to 1.52) compared with patients in the lowest quintile. The association between higher VVV of DBP and risk of CVD was not consistent across different metrics and sensitivity analyses.

CONCLUSION

Higher VVV of SBP was associated with an increased risk of CVD, irrespective of the mean SBP level. Future studies are needed to confirm these findings.

Prognostic impact of systolic blood pressure variability in people with diabetes

Objective

Blood pressure variability (BPV) has been associated with risk of cardiovascular events in observational studies, independently of mean BP levels. In states with higher autonomic imbalance, such as in diabetes, the importance of BP variability may theoretically be even greater. We aimed to investigate the incremental value of BPV for prediction of cardiovascular and all-cause mortality in patients with type 2 diabetes.

Methods

We identified 9,855 patients without pre-existing cardiovascular disease who did not change BP-lowering treatment during the observation period from a Swedish primary health care cohort of patients with type 2 diabetes. BPV was summarized as the standard deviation (SD), coefficient of variation (CV), or variation independent of mean (VIM). Patients were followed for a median of 4 years and associations with cardiovascular and all-cause mortality were investigated using Cox proportional hazards models.

Results

BPV was not associated with cardiovascular specific or all-cause mortality in the total sample. In patients who were not on BP-lowering drugs during the observation period (n = 2,949), variability measures were associated with all-cause mortality: hazard ratios were 1.05, 1.04 and 1.05 for 50% increases in SD, CV and VIM, respectively, adjusted for Framingham risk score risk factors, including mean BP. However, the addition of the variability measures in this subgroup only led to very minimal improvement in discrimination, indicating they may have limited clinical usefulness (change in C-statistic ranged from 0.000–0.003 in all models).

Conclusions

Although BPV was independently associated with all-cause mortality in diabetes patients in primary care who did not have pre-existing cardiovascular disease or BP-lowering drugs, it may be of minimal clinical usefulness above and beyond that of other routinely measured predictors, including mean BP.

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.

The combined effect of visit-to-visit variability in HbA1c and systolic blood pressure on the incidence of cardiovascular events in patients with type 2 diabetes

OBJECTIVE

To investigate the association between long-term visit-to-visit variability in glycated hemoglobin (HbA1c) and systolic blood pressure (SBP) and the incidence of cardiovascular disease (CVD) in patients with type 2 diabetes.

METHODS

We retrospectively enrolled 632 patients with type 2 diabetes and no history of CVD who first visited our hospital between 1995 and 1996, were followed-up for ≥1 year, attended at least 4 clinic visits and had at least 1 visit per year. Patients were followed until June 2012 at the latest, and mailed questionnaires.

RESULTS

During the median follow-up period (15.4 years), 81 patients developed CVD. Multivariate analysis revealed that the coefficient of variation (CV) and the variation independent of mean (VIM) for HbA1c and SBP were significant predictors of CVD incidence independent of mean HbA1c and SBP. Patients were classified into 4 groups by median HbA1cCV and SBPCV values and by median HbA1cVIM and SBPVIM values. Among these groups, the HRs were highest in the high-HbA1cCV/high-SBPCV and high-HbA1cVIM/high-SBPVIM groups and were significantly higher compared with those in the low-HbA1cCV/low-SBPCV and low-HbA1cVIM/low-SBPVIM groups, respectively. Among patients with mean SBP≥130 mm Hg, the HRs associated with HbA1cCV and HbA1cVIM were drastically elevated compared with those with mean SBP<130 mm Hg (interaction p<0.05).

CONCLUSIONS

Long-term visit-to-visit variability in HbA1c and SBP represented a combined and additive risk for CVD incidence in patients with type 2 diabetes. It is suggested that a synergistic effect exists between HbA1c variability and mean SBP levels for CVD incidence.