Visit-to-visit and ambulatory blood pressure variability as predictors of incident cardiovascular events in patients with hypertension

Long-term systolic blood pressure variability independent of mean blood pressure is associated with mortality and cardiovascular events: A systematic review and meta-analysis

The association between long-term systolic blood pressure variability (SBPV) and cardiovascular (CV) outcomes after being adjusted with mean blood pressure (BP) is questionable. This systematic review aims to evaluate the associations between mean BP adjusted long-term SBPV and CV outcomes. A systematic search was conducted on PubMed, Scopus, and Science Direct on January 4, 2023. A total of 9,944,254 subjects from 43 studies were included in this meta-analysis. Long-term SBPV increased the risk of all-cause mortality (HR 1.21 [95%CI 1.16-1.25], I2=100%), CV mortality (HR 1.10 [95%CI 1.07-11.4], I2 = 90%), MACE (HR 1.10 [1.07-1.13], I2 = 91%), cerebrovascular stroke (HR 1.22 [1.16-1.29], I2=100%), and myocardial infarction (HR 1.13 [95%CI (1.07-1.19)], I2=91%). European populations generally had higher risk compared to other continents. In conclusion, long-term SBPV is associated with all-cause mortality, CV mortality, MACE, MI, and stroke. Poor outcomes related to long-term SBPV seem more dominated by cerebrovascular than coronary events.

Importance of anemia in heart failure over blood pressure variability

BACKGROUND

The evaluation of arteriosclerosis (vascular function) is important when treating heart failure (HF). Vascular dysfunction is associated with anemia through renal function and endothelial nitric oxide synthase. Additionally, blood pressure (BP) variability (BPV) caused by vascular dysfunction is also associated with HF prognosis. However, how anemia and BPV may affect HF prognosis is unclear.

METHODS

Between January 2012 and July 2018, 214 patients with HF were hospitalized. The cardio-ankle vascular index (CAVI) as an index of arteriosclerosis of these patients was measured. The patients were divided into the elevated and preserved CAVI groups. We investigated the factors related to major adverse cardiovascular events (MACEs) as cardiovascular death or rehospitalization within 1 year after discharge.

RESULTS

In the elevated CAVI group, significant differences in body mass index (BMI), BPV, left ventricular dimension, and hemoglobin levels were observed between patients with and without MACEs. In the preserved CAVI group, significant differences in BMI, diastolic/mean BP, and hemoglobin levels were observed between those with and without MACEs. The multivariate analysis showed an independent association between hemoglobin levels and MACE occurrence in both the elevated and preserved CAVI groups (elevated CAVI group: hazard ratio [HR] = 0.800, p = .045 [model 1], HR = 0.802, p = .035 [model 2]; preserved CAVI group: HR = 0.783, p = .049 [model 1], HR = 0.752, p = .023 [model 2], and HR = 0.754, p = .024 [model 3]).

CONCLUSIONS

Anemia was independently associated with HF prognosis with or without arteriosclerosis.

Food consumption by degree of processing is associated with nocturnal dipping and blood pressure variability: The ELSA-Brasil study

BACKGROUND AND AIMS

Ambulatory blood pressure monitoring (ABPM) allows the assessment of cardiovascular risk markers that cannot be obtained by casual measurements; however, the evidence on the association between food consumption and blood pressure (BP) assessed by ABPM is scarce. We aimed to evaluate the association between food consumption by degree of processing and ambulatory BP.

METHODS AND RESULTS

Cross-sectional analysis (2012-2014) of data from a subsample (n = 815) of ELSA-Brasil cohort participants who performed 24-h ABPM was conducted. Systolic (SBP) and diastolic (DBP) BP means and variability during the 24 h and subperiods (sleep and wake), nocturnal dipping, and morning surge were evaluated. Food consumption was classified according to NOVA. Associations were tested by generalized linear models. The consumption of unprocessed, minimally processed foods, and culinary ingredients (U/MPF&CI) was 63.1% of daily caloric intake, 10.8% of processed (PF), and 24.8% of ultraprocessed (UPF). A negative association was found between U/MPF&CI consumption and extreme dipping (T2: odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.55-0.58; T3: OR = 0.55; 95% CI = 0.54-0.57); and between UPF consumption and nondipping (T2: OR = 0.68, 95% CI = 0.55-0.85) and extreme dipping (T2: OR = 0.63, 95% CI = 0.61-0.65; T3: OR = 0.95, 95% CI = 0.91-0.99). There was a positive association between PF consumption and extreme dipping (T2: OR = 1.22, 95% CI = 1.18-1.27; T3: OR = 1.34, 95% CI = 1.29-1.39) and sleep SBP variability (T3: Coef = 0.56, 95% CI = 0.03-1.10).

CONCLUSIONS

The high consumption of PF was associated with greater BP variability and extreme dipping, while the U/MPF&CI and UPF consumption were negatively associated with alterations in nocturnal dipping.

Severe fluctuation in mean perfusion pressure is associated with increased risk of in-hospital mortality in critically ill patients with central venous pressure monitoring: A retrospective observational study

BACKGROUND

The mean perfusion pressure (MPP) was recently proposed to personalize tissue perfusion pressure management in critically ill patients. Severe fluctuation in MPP may be associated with adverse outcomes. We sought to determine if higher MPP variability was correlated with increased mortality in critically ill patients with CVP monitoring.

METHODS

We designed a retrospective observational study and analyzed data stored in the eICU Collaborative Research Database. Validation test was conducted in MIMIC-III database. The exposure was the coefficient of variation (CV) of MPP in the primary analyses, using the first 24 hours MPP data recorded within 72 hours in the first ICU stay. Primary endpoint was in-hospital mortality.

RESULTS

A total of 6,111 patients were included. The in-hospital mortality of 17.6% and the median MPP-CV was 12.3%. Non-survivors had significantly higher MPP-CV than survivors (13.0% vs 12.2%, p<0.001). After accounting for confounders, the highest MPP-CV in decile (CV > 19.2%) were associated with increased risk of hospital mortality compared with those in the fifth and sixth decile (adjusted OR: 1.38, 95% Cl: 1.07-1.78). These relationships remained remarkable in the multiple sensitivity analyses. The validation test with 4,153 individuals also confirmed the results when MPP-CV > 21.3% (adjusted OR: 1.46, 95% Cl: 1.05-2.03).

CONCLUSIONS

Severe fluctuation in MPP was associated with increased short-term mortality in critically ill patients with CVP monitoring.

Epidemiology, Risk Factors, and Outcome of Cardiac Dysrhythmias in a Noncardiac Intensive Care Unit

Introduction

Several extrinsic factors contribute to the development of cardiac dysrhythmias. In intensive care unit (ICU) settings and among critically ill patients who are exposed to a large number of risk factors, cardiac disturbances are more common.

Objectives

This study aimed to examine the epidemiology, risk factors, and outcome of cardiac dysrhythmias in a non-cardiac ICU.

Methods

This is a retrospective, single-center, observational study conducted in a tertiary noncardiac ICU at Imam Khomeini Hospital in Ahvaz, Iran. Out of the 360 adult patients aged 18 years and older who were admitted to ICU for longer than 24 h, 340 cases who met the study inclusion criteria were recruited between March 2018 until October 2018.

Results

The most common nonsinus dysrhythmias were new-onset atrial fibrillation (NOAF) (12.9%) and ventricular tachycardia (21 patients—6.2%). According to our results, previous percutaneous coronary instrumentation, acute kidney injury, sepsis, and hyperkalemia act as risk factors in the development of cardiac dysrhythmias. Additionally, we found out that thyroid dysfunction and pneumonia can predict the development of NOAF in critically ill patients. The estimated mortality rate among patients with NOAF in this study was 15.7% (p < .05).

Conclusion

Cardiac dysrhythmias are common in ICU patients and treating the risk factors can help to prevent their development and improve patient management and outcome.

Determinants of visit-to-visit systolic blood pressure variability among Ghanaians with hypertension and diabetes mellitus

Objective

To identify the determinants of systolic blood pressure variability (SBPV) among Ghanaians.

Design

We undertook a secondary analysis of data collected in a prospective study.

Setting

The study involved patients with hypertension and or diabetes receiving care in five hospitals in Ghana.

Main outcome measures

We assessed determinants of SBPV among 2,785 Ghanaian patients. We calculated the standard deviation (SD) of systolic BP recordings of 3 to 10 visits per patient over 18 months as a measure of SBPV. A multivariate linear regression analysis was fitted to identify factors independently associated with risk visit-to-visit SBP standard deviation.

Results

The mean SD of individual patient visit-to-visit SBP overall was 14.8± 6.3 mm Hg. Those with hypertension and diabetes had the highest SD of 15.4 ±6.2 mm Hg followed by 15.2 ±6.5 mm Hg among those with hypertension only and then 12.0 ± 5.2 mm Hg among those with diabetes only, p<0.0001. Factors independently associated with SBPV with adjusted β coefficients (95% CI) included age: 0.06 (0.03 - 0.08) for each year rise in age, eGFR -0.03 (-0.05 - -0.02) for each ml/min rise, low monthly income of <210 Ghana cedis 1.45 (0.43-2.46), and secondary level of education -1.10 (-1.69, -0.50). Antihypertensive classes were associated with SBPV, the strongest associations being hydralazine 2.35 (0.03 - 4.68) and Methyldopa 3.08 (2.39 - 3.77).

Conclusion

Several socio-demographic and clinical factors are associated with SBPV. Future studies should assess the contribution of SBPV to CVD outcomes among indigenous Africans and identify actionable targets.

Funding

Funding for this study was provided by MSD, Novartis, Pfizer, Sanofi (each a Participant Company) and the Bill and Melinda Gates Foundation (collectively, the Funders) through the New Venture Fund (NVF). FSS and BO are also supported by funding from the National Heart, Lung, and Blood Institute (R01HL152188).

A multicenter prospective study of home blood pressure measurement (HBPM) during pregnancy in Japanese women

In the near future, hypertensive disorders of pregnancy (HDP) have been diagnosed by home blood pressure monitoring (HBPM) instead of clinic BP monitoring. A multicenter study of HBPM was performed in pregnant Japanese women in the non-high risk group for HDP. Participants were women (n = 218), uncomplicated pregnancy who self-measured and recorded their HBP daily. Twelve women developed HDP. HBP was appropriate (100 mmHg in systole and 63 mmHg in diastole), bottoming out at 17 to 21 weeks of gestation. It increased after 24 weeks of gestation and returned to non-pregnant levels by 4 weeks of postpartum. The upper limit of normal HBP was defined as the mean value +3 SD for systolic and mean +2 SD for diastolic with reference to the criteria for non-pregnant women. Using the polynomial equation, the hypertensive cut-off of systolic HBP was 125 mmHg at 15 weeks and 132 mmHg at 30 weeks of gestation, while it for diastolic HBP was 79 mmHg at 15 weeks and 81 mmHg at 30 weeks of gestation. Systolic HBP in women who developed HDP was higher after 24 weeks of gestation, and diastolic HBP was higher during most of the pregnancy compared to normal pregnancy. When the variability of individual HBP in women developed HDP compared to normal pregnant women was examined using the coefficient of variation (CV), the CV was lower in HDP before the onset of HDP. HBPM can be used not only for HDP determination, but also for early detection of HDP.

Home blood pressure monitoring: a position statement from the Korean Society of Hypertension Home Blood Pressure Forum

Home blood pressure measurement (HBPM) has the advantage of measuring blood pressure (BP) multiple times over a long period. HBPM effectively diagnoses stress-induced transient BP elevations (i.e., white coat hypertension), insufficient BP control throughout the day (i.e., masked hypertension), and even BP variability. In most cases, HBPM may increase self-awareness of BP, increasing the compliance of treatment. Cumulative evidence has reported better improved predictive values of HBPM in cardiovascular morbidity and mortality than office BP monitoring. In this position paper, the Korean Society of Hypertension Home Blood Pressure Forum provides comprehensive information and clinical importance on HBPM.

Impact of febuxostat on visit-to-visit blood pressure variability: insights from the randomised PRIZE Study

Objectives

Although uric acid lowering therapies, including xanthine oxidase (XO) inhibition, may reduce the absolute level of blood pressure (BP), the effect of XO inhibition on BP variability is largely unknown. The aim of the present analysis was to evaluate the impact of febuxostat, an XO inhibitor, on BP variability in a randomised trial setting.

Methods

This was a subanalysis of the PRIZE Study, a randomised trial to evaluate the potential effect of febuxostat on carotid intima–media thickness progression. Patients with hyperuricemia and carotid plaques were randomly assigned to the febuxostat or control group. During a 24-month period, office BP and pulse rate (PR) were measured ≥3 times. BP and PR variabilities were assessed with SD and coefficient of variation (CV). The effect of febuxostat on BP and PR variabilities was adjusted with age, sex and baseline BP or PR, expressed with 95% CIs.

Results

A total of 472 patients were included into the present subanalysis. During the 24-month follow-up period, the febuxostat group had a significantly lower adjusted mean systolic BP (128.4 (126.8–130.0) vs 130.7 (129.1–132.2) mm Hg, p=0.04) and CV of systolic BP (7.4 (6.7–8.0) vs 8.2 (7.6–8.8), p=0.04) than the control group. Adjusted SD of PR was also lower in the febuxostat group than their counterpart (5.95 (4.93–6.97) vs 7.33 (6.32–8.33), p=0.04).

Conclusion

XO inhibition with febuxostat was associated with reduced visit-to-visit BP variability as well as reduced PR variability in patients with hyperuricemia and carotid plaques.

Trial registration numbers

University Hospital Medical Information Network Clinical Trial Registry (UMIN000012911 and UMIN000041322).

DeepCNAP: A Deep Learning Approach for Continuous Noninvasive Arterial Blood Pressure Monitoring Using Photoplethysmography

Arterial blood pressure (ABP) monitoring may permit the early diagnosis and management of cardiovascular disease (CVD); however, existing methods for measuring ABP outside the clinic use inconvenient cuff sphygmomanometry, or do not estimate continuous ABP waveforms. This study proposes a novel deep learning model DeepCNAP for estimating continuous BP waveform from a noninvasively measured photoplethysmography (PPG) signal in real time. DeepCNAP was designed through the combination of deep convolutional networks and self-attention. The proposed method was constructed via 10-fold cross-validation based on the MIMIC database (the number of subjects = 942, recording time = 374.43 hours). The performance of DeepCNAP was evaluated from two perspectives: estimating ABP from PPG and classifying hemodynamically unstable events (i.e., hypertension, prehypertension, hypotension, and the normal state). The mean absolute errors of the BP estimates were 3.40 4.36 mmHg for systolic BP, 1.75 2.25 mmHg for diastolic BP, and 3.23 2.21 mmHg for the BP waveform, indicating that DeepCNAP satisfies the standards of both the British Hypertension Society (BHS) and the Association for the Advancement of Medical Instrumentation (AAMI). From the estimated BP, hypertension, prehypertension, hypotension, and the normal state were classified with 99.44, 97.58, 92.23, and 94.64% accuracy, respectively. DeepCNAP enables feasible real-time estimation of invasively measured ABP from noninvasive PPG. With its noninvasive nature, high accuracy, and clinical relevance, the proposed model could be valuable in general wards at hospitals and for wearable devices in daily life.

Blood Pressure Variability and the Risk of Fracture: A Nationwide Cohort Study

CONTEXT

Although blood pressure variability (BPV) is associated with various health outcomes, only 1 study suggested that BPV is correlated with hip fractures. As cardiovascular disease and fractures share similar pathophysiology, there might be a link between BPV and fractures.

OBJECTIVE

To investigate the association between BPV and the incident fractures.

DESIGN

Retrospective cohort study.

SETTING

Population-based, using the Korean National Health Insurance System database.

PATIENTS OR OTHER PARTICIPANTS

A total of 3 256 070 participants aged ≥50 who participated in ≥3 health examinations within the previous 5 years, including the index year (2009-2010), were included. Outcome data were obtained through the end of 2016.

EXPOSURE

BPV was calculated using variability independent of the mean. High variability was defined as the highest quartile of variability.

MAIN OUTCOME MEASURES

Newly diagnosed fractures.

RESULTS

During the median follow-up of 7.0 years, there were 337 045 cases of any fracture (10.4%). After adjusting for age, sex, income, lifestyle factors, and comorbidities, a higher risk of fracture was observed with higher quartiles of BPV than the lowest quartile group: the adjusted hazard ratios (95% CIs) for incident any fracture were 1.07 (1.06-1.08) in the higher quartile of systolic BPV, 1.06 (1.05-1.07) in that of diastolic BPV, and 1.07 (1.06-1.08) in that of both systolic and diastolic BPV. Consistent results were noted for vertebral fractures and hip fractures, as well as in various subgroup analyses.

CONCLUSIONS

A positive association was noted between higher BPV and fracture incidence. BPV is an independent predictor for developing fracture.

Blood pressure undulation of peripheral thrombolysis period in acute ischemic stroke is associated with prognosis

BACKGROUND

Evidence suggests that patients with higher blood pressure variability (BPV) have a higher risk for stroke but the relationship between BPV and stroke outcomes is unknown in those who underwent intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). The objective of this study is to investigate the association among BPV, BP values and stroke outcomes.

METHODS

A retrospective analysis of about 510 consecutive thrombolysis cases for AIS from January 2015 to March 2019 in a single-center database were done. Then, these patients were followed-up for 3 months. We used univariate and multivariable models to evaluate the relationship between mean BP values, BPV and the risk of stroke outcomes from prior IVT to 72 h after IVT. Meanwhile, we also used COX regression to assess the hazard ratios of stroke outcomes with BPV within 3 months. Furthermore, we tested the effect of BP level at various time-points (prior to IVT and at 0, 2, 4, 8, 12, 24, 48 and 72 h after IVT) on development of postthrombolytic stroke outcomes.

RESULTS

Higher BPV from prior IVT to 72 h after IVT was associated with higher risk of stroke outcomes within 3 months [SBPV of recurrent stroke: odds ratios (OR) = 5.298, 95% confidence interval (CI) 1.339-10.968, P = 0.018; DBPV of recurrent stroke: OR = 6.397, 95% CI 1.576-25.958, P = 0.009, respectively]. In addition, patients with recurrent stroke had significantly higher mean SBP (OR=1.037, 95% CI 1.006-1.069, P = 0.019). Furthermore, higher BP at different time points were associated with greater risk of recurrent stroke from prior IVT to 72 h after IVT.

CONCLUSION

Higher BPV and SBP from prior IVT to 72 h after IVT was associated with higher risk of stroke outcomes within 3 months.

Association of Circulating Osteoprotegerin Level with Blood Pressure Variability in Patients with Chronic Kidney Disease

Circulating osteoprotegerin (OPG) is a biomarker for cardiovascular complications that are closely related to chronic kidney disease (CKD). To investigate the association between circulating OPG level with long-term visit-to-visit blood pressure variability (BPV) in patients with pre-dialysis CKD, a total of 1855 subjects with CKD from stage 1 to pre-dialysis stage 5 from a prospective cohort were analyzed. Long-term visit-to-visit BPV was determined by average real variability (ARV), standard deviation (SD), and coefficient of variation (CoV) of systolic and diastolic blood pressure (SBP and DBP). ARV of SBP (Adjusted β coefficient 0.143, 95% confidence interval 0.021 to 0.264) was significantly associated with serum OPG level. Although SD and CoV of SBP were not significantly associated with serum OPG level in multivariate linear regression analyses, restricted cubic spline visualized the linear correlation of serum OPG level with all of ARV, SD, and CoV. The association between serum OPG level and DBP variability was not significant. Subgroup analyses revealed that the association of serum OPG with BPV is more prominent in the subjects with Charlson comorbidity index ≤3 and in the subjects without history of diabetes mellitus. In conclusion, circulating OPG level is potentially associated with long-term visit-to-visit BPV in patients with pre-dialysis CKD.

Association of Urinary Potassium Excretion with Blood Pressure Variability and Cardiovascular Outcomes in Patients with Pre-Dialysis Chronic Kidney Disease

Dietary potassium intake is a dilemma in patients with chronic kidney disease (CKD). We investigated the association of urine potassium excretion, a surrogate for dietary potassium intake, with blood pressure variability (BPV) and cardiovascular (CV) outcomes in patients with pre-dialysis CKD. A total of 1860 participants from a cohort of pre-dialysis CKD (KNOW-CKD) patients were divided into the quartiles by spot urine potassium-to-creatinine ratio. The first quartile (26.423 ± 5.731 mmol/gCr) was defined as low urine potassium excretion. Multivariate linear regression analyses revealed an independent association of low urine potassium excretion with high BPV (adjusted β coefficient 1.163, 95% confidence interval 0.424 to 1.901). Cox regression analyses demonstrated that, compared to high urine potassium excretion, low urine potassium excretion is associated with increased risk of CV events (adjusted hazard ratio 2.502, 95% confidence interval 1.162 to 5.387) but not with all-cause mortality. In conclusion, low urine potassium excretion is associated with high BPV and increased risk of CV events in patients with pre-dialysis CKD. The restriction of dietary potassium intake should be individualized in patients with pre-dialysis CKD.

Visit-to-visit office blood pressure variability combined with Framingham risk score to predict all-cause mortality: A post hoc analysis of the systolic blood pressure intervention trial

We aim to determine if visit‐to‐visit blood pressure variability (BPV) adds prognostic value for all‐cause mortality independently of the Framingham risk score (FRS) in the systolic blood pressure intervention trial (SPRINT). We defined BPV as variability independent of the mean (VIM) and the difference of maximum minus minimum (MMD) of the systolic blood pressure (SBP). Multivariable Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI). Based on FRS stratification, there were 1035, 2911, and 4050 participants in the low‐, intermediate‐, and high‐risk groups, respectively. During the trial, 230 deaths occurred since the 12th month with an average follow‐up of 2.5 years. In continuous analysis, 1‐SD increase of SBP VIM and MMD were significantly associated with all‐cause mortality (HR 1.18, 95% CI 1.05–1.32, p = .005; and HR 1.21, 95% CI 1.09–1.35, p < .001, respectively). In category analysis, the highest quintile of BPV compared with the lowest quintile had significantly higher risk of all‐cause mortality. Cross‐tabulation analysis showed that the 3rd tertile of SBP VIM in the high‐risk group had the highest HR of all‐cause mortality in total population (HR 4.99; 95% CI 1.57–15.90; p = .007), as well as in intensive‐therapy group (HR 7.48; 95% CI 1.01–55.45; p = .05) analyzed separately. Cross‐tabulation analysis of SBP MMD had the same pattern as VIM showed above. In conclusion, visit‐to‐visit BPV was an independent predictor of all‐cause mortality, when accounting for conventional risk factors or FRS. BPV combined with FRS conferred an increased risk for all‐cause mortality in the SPRINT trial.

Long-Term Visit-to-Visit Mean Arterial Pressure Variability and the Risk of Heart Failure and All-Cause Mortality

Background: Systolic or diastolic blood pressure (BP) variability is associated with an increased risk of cardiovascular events. We assessed whether BP variability measured by mean arterial pressure (MAP) was associated with increased risk of heart failure (HF) and death in individuals with or without hypertension. Methods: We evaluated 9,305 Atherosclerosis Risk in Communities (ARIC) study participants with or without hypertension and calculated BP variability based on MAP values from visit 1 to 4 [expressed as standard deviation (SD), average real variability (ARV), coefficient of variation (CV), and variability independent of the mean (VIM)]. Multivariate-adjusted Cox regression model and restricted cubic spline curve were used to evaluate the associations of MAP variability with all-cause mortality and HF. Results: During a median follow-up of 16.8 years, 1,511 had an HF event and 2,903 died. Individuals in the highest quartile of VIM were both associated with a 21% higher risk of all-cause mortality [hazard ratio (HR), 1.21; 95% CI, 1.09-1.35] and HF (HR, 1.21; 95% CI, 1.04-1.39) compared with the lowest quartile of VIM. Cubic spline curves reveal that the risk of deaths and HF increased with MAP variability when it reached a higher level. Results were similar in individuals with normotension (all-cause mortality: HR, 1.30; 95% CI, 1.09-1.55; HF, HR, 1.49; 95% CI, 1.12-1.98). Conclusions: In individuals with or without hypertension, greater visit-to-visit MAP variability was associated with a higher risk of all-cause mortality and HF, indicating that the BP variability assessed by MAP might be a potential risk factor for HF and death.

Association of 1-Year Blood Pressure Variability With Long-term Mortality Among Adults With Coronary Artery Disease: A Post Hoc Analysis of a Randomized Clinical Trial

Importance

Accumulating evidence indicates that higher blood pressure (BP) variability from one physician office visit to the next (hereafter referred to as visit-to-visit BP variability) is associated with poor outcomes. Short-term measurement (throughout 1 year) of visit-to-visit BP variability in high-risk older patients may help identify patients at increased risk of death.

Objective

To evaluate whether short-term visit-to-visit BP variability is associated with increased long-term mortality risk.

Design, Setting, and Participants

The US cohort of the International Verapamil SR-Trandolapril Study (INVEST), a randomized clinical trial of 16 688 patients aged 50 years or older with hypertension and coronary artery disease, was conducted between September 2, 1997, and December 15, 2000, with in-trial follow-up through February 14, 2003. The study evaluated a calcium antagonist (sustained-release verapamil plus trandolapril) vs β-blocker (atenolol plus hydrochlorothiazide) treatment strategy. Blood pressure measurement visits were scheduled every 6 weeks for the first 6 months and biannually thereafter. Statistical analysis was performed from September 2, 1997, to May 1, 2014.

Exposures

Visit-to-visit systolic BP (SBP) and diastolic BP variability during the first year of enrollment using 4 different BP variability measures: standard deviation, coefficient of variation, average real variability, and variability independent of the mean.

Main Outcomes and Measures

All-cause death, assessed via the US National Death Index, beginning after the exposure assessment period through May 1, 2014.

Results

For the present post hoc analysis, long-term mortality data were available on 16 688 patients (9001 women [54%]; mean [SD] age, 66.5 [9.9] years; 45% White patients, 16% Black patients, and 37% Hispanic patients). During a mean (SD) follow-up of 10.9 (4.2) years, 5058 patients (30%) died. All 4 variability measures for SBP were significantly associated with long-term mortality after adjustment for baseline demographic characteristics and comorbidities. After comparison of lowest vs highest variability measure quintiles, the magnitude of the association with death remained statistically significant even after adjustment for baseline demographic characteristics and comorbidities (average real variability: adjusted hazard ratio [aHR], 1.18; 95% CI, 1.08-1.30; standard deviation: aHR, 1.14; 95% CI, 1.04-1.24; coefficient of variation: aHR, 1.15; 95% CI, 1.06-1.26; variability independent of the mean: aHR, 1.15; 95% CI, 1.05-1.25). The signal was stronger in women compared with men. Associations of diastolic BP variability measures with death were weaker than for SBP and were not significant after adjustment.

Conclusions and Relevance

This study suggests that, in a large population of older patients with hypertension and coronary artery disease, short-term visit-to-visit SBP variability was associated with excess long-term mortality, especially for women. Efforts to identify and minimize visit-to-visit SBP variability may be important in reducing excess mortality later in life.

Trial Registration

ClinicalTrials.gov Identifier: NCT00133692.

Impact of Therapeutic Inertia on Long-Term Blood Pressure Control: A Monte Carlo Simulation Study

[Figure: see text].

Comparative effects of CPAP and mandibular advancement splint therapy on blood pressure variability in moderate to severe obstructive sleep apnoea

BACKGROUND

Obstructive sleep apnoea (OSA) is associated with increased blood pressure variability (BPV) and are risk factors for cardiovascular disease. We aimed to assess the comparative effects of two OSA therapies, continuous positive airway pressure (CPAP) and mandibular advancement splint (MAS), on BPV.

METHODS

This is a secondary analysis of data collected as part of a previously published randomised crossover trial of one month each of CPAP and MAS therapy. BPV was determined from 24-h-ambulatory blood pressure recordings in 92 patients with moderate to severe OSA at baseline and after one month of optimised treatment with each modality. BPV was assessed by three measures: Standard deviation of the mean (SD), Coefficient of variation (CoV), and the Average Real Variability (ARV) index.

RESULTS

Neither CPAP nor MAS therapy improved BPV, with no difference between treatments. BPV did not change in hypertensive OSA patients, however, there was a reduction in ARV of diastolic blood pressure in the effectively treated compared to ineffectively treated CPAP patients, Δ ARV 24-h-DBP (mmHg), -0.72 ± 2.14, 0.34 ± 1.52, P = 0.02, respectively. There was no difference between effective versus ineffective MAS treatment, Δ ARV 24-h-DBP (mmHg), -0.04 ± 2.4, 0.02 ± 1.9, P = 1.00, respectively.

CONCLUSIONS

One month of optimised CPAP or MAS therapy did not improve short term BPV in patients with moderate to severe OSA. The subgroup of patients on effective CPAP showed some improvement in BPV with CPAP but not MAS. Further work on the effect of OSA therapy on BPV following long-term therapy is needed.

Ambulatory blood pressure adaptations to high-intensity interval training: a randomized controlled study

OBJECTIVE

Hypertension remains the leading cause of cardiovascular disease and premature mortality globally. Although high-intensity interval training (HIIT) is an effective nonpharmacological intervention for the reduction of clinic blood pressure (BP), very little research exists regarding its effects on ambulatory BP. The aim of this study was to measure alterations in ambulatory and clinic BP following HIIT in physically inactive adults.

METHODS

Forty-one participants (22.8 ± 2.7 years) were randomly assigned to a 4-week HIIT intervention or control group. The HIIT protocol was performed on a cycle ergometer set against a resistance of 7.5% bodyweight and consisted of 3 × 30-s maximal sprints separated with 2-min active recovery. Clinic and ambulatory BP was recorded pre and post the control period and HIIT intervention.

RESULTS

Following the HIIT intervention, 24-h ambulatory BP significantly decreased by 5.1 mmHg in sBP and 2.3 mmHg in dBP (P = 0.011 and 0.012, respectively), compared with the control group. In addition, clinic sBP significantly decreased by 6.6 mmHg compared with the control group (P = 0.021), with no significant changes in dBP and mean BP (mBP). Finally, 24-h ambulatory diastolic, daytime sBP, mBP and dBP, and night-time sBP and mBP variability significantly decreased post-HIIT compared with the control group.

CONCLUSION

HIIT remains an effective intervention for the management of BP. Our findings support enduring BP reduction and improved BP variability, which are important independent risk factors for cardiovascular disease.

Association of dipping status of blood pressure, visual field defects, and retinal nerve fiber layer thickness in patients with normotensive glaucoma

The aim of this study was to evaluate the association between dipping status of blood pressure (BP), visual field defects (VFDs), and retinal nerve fiber layer (RNFL) thickness in patients with normotensive glaucoma (NTG). Our University echocardiography, electrocardiogram, 24-hour BP monitor and glaucoma database were reviewed from 2016 to 2018 to identify patients with NTG and hypertension (HTN). These NTG patients were followed for a mean 26.4 ± 13.6 months and were divided into 2 groups according to the absence or presence of VFDs. Among the 110 patients with NTG, 55 (50%) patients had VFDs. There were no differences of baseline characteristics between 2 groups. In univariate analysis, extreme dipper status at night in the 24-hour BP monitoring, HTN, age, diabetes mellitus, and hyperlipidemia were significantly associated with VFDs. In multivariate analysis, extreme dipper status at night in the 24-hour BP monitoring (odds ratio [OR] 4.094; P = .045) and HTN (OR 2.368; P = .048) were independent risk factors for VFDs at 2-year follow-up. Moreover, the RNFL thickness was thinner in NTG patients with VFDs (P < .001). VFDs group had more increased fluctuation of systolic and diastolic BP in 24-hour BP monitoring and that the extreme dipper status at night in the 24-hour BP monitoring and HTN itself were also associated with higher incidence of VFDs and thinning changes of the RNFL in patients with NTG, suggesting that more intensive medical therapy with close clinical follow-up will be required for these patients.

Cost-effectiveness analysis of combining traditional Chinese medicine in the treatment of hypertension: compound Apocynum tablets combined with Nifedipine sustained-release tablets vs Nifedipine sustained-release tablets alone

Background

We evaluated the long-term cost-effectiveness of antihypertensive traditional Chinese medicines (TCMs) and to compare the cost-effectiveness of a combined treatment consisting of compound Apocynum tablets and Nifedipine sustained-release tablets with the cost-effectiveness of treatment with Nifedipine sustained-release tablets alone.

Methods

A Markov model was used to simulate the potential incremental cost-effectiveness per quality-adjusted life year (QALY) to be gained from compound Apocynum tablets and Nifedipine sustained-release tablets compared with Nifedipine sustained-release tablets alone. Model parameter estimates were informed by previously published studies. The direct medical costs of outpatients with hypertension were estimated from the health care provider’s perspective. A 5% annual discount rate was applied to both costs and QALYs.

Results

TCMs combined with Nifedipine sustained-release tablets group generated a total 20-year cost of 11,517.94 RMB (US $1739.87), whereas Nifedipine sustained-release tablets alone group resulted in a 20-year cost of 7253.71 RMB (US $1095.73). TCMs combined with Nifedipine sustained-release tablets group resulted in a generation of 12.69 QALYs, whereas Nifedipine sustained-release tablets alone group resulted in 12.50. The incremental cost-utility ratio was 22,443.32 RMB (US $3390.23) per QALY. Considering the threshold of 1 GDP per capita in China in 2018 (US $9764.95), the combination of compound Apocynum tablets and Nifedipine sustained-release tablets was a cost-effective strategy. One-way and probabilistic sensitivity analysis showed unchanged results over an acceptable range.

Conclusions

Combining Traditional Chinese Medicines with chemical medicines is more cost-effective strategy in the treatment of hypertension.

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.

2020 Consensus Statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on Home Blood Pressure Monitoring for the Management of Arterial Hypertension

To facilitate the applications of home blood pressure (HBP) monitoring in clinical settings, the Taiwan Hypertension Society and the Taiwan Society of Cardiology jointly put forward the Consensus Statement on HBP monitoring according to up-to-date scientific evidence by convening a series of expert meetings and compiling opinions from the members of these two societies. In this Consensus Statement as well as recent international guidelines for management of arterial hypertension, HBP monitoring has been implemented in diagnostic confirmation of hypertension, identification of hypertension phenotypes, guidance of anti-hypertensive treatment, and detection of hypotensive events. HBP should be obtained by repetitive measurements based on the " 722 " principle, which is referred to duplicate blood pressure readings taken per occasion, twice daily, over seven consecutive days. The " 722" principle of HBP monitoring should be applied in clinical settings, including confirmation of hypertension diagnosis, 2 weeks after adjustment of antihypertensive medications, and at least every 3 months in well-controlled hypertensive patients. A good reproducibility of HBP monitoring could be achieved by individuals carefully following the instructions before and during HBP measurement, by using validated BP devices with an upper arm cuff. Corresponding to office BP thresholds of 140/90 and 130/80 mmHg, the thresholds (or targets) of HBP are 135/85 and 130/80 mmHg, respectively. HBP-based hypertension management strategies including bedtime dosing (for uncontrolled morning hypertension), shifting to drugs with longer-acting antihypertensive effect (for uncontrolled evening hypertension), and adding another antihypertensive drug (for uncontrolled morning and evening hypertension) should be considered. Only with the support from medical caregivers, paramedical team, or tele- monitoring, HBP monitoring could reliably improve the control of hypertension.

Identifying patterns of diurnal blood pressure variation among ELSA-Brasil participants

Ambulatory blood pressure monitoring (ABPM) is the gold standard method for the diagnosis of hypertension. ABPM provides a set of repeated measurements for blood pressure (BP), usually over 24 h. Traditional approaches characterize diurnal BP variation by single ABPM parameters such as average and standard deviation, regardless of the temporal nature of the data. In this way, information about the pattern of diurnal BP variation and relationship between parameters is lost. The objective of this study was to identify and characterize daily BP patterns considering the set of repeated measures from 24-h ABPM. A total of 859 adult participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) performed a 24-h ABPM record. Hypertension, sex, age, race/color, education, marital status, smoking, alcohol, physical activity, and BMI were the covariables analyzed. Techniques for longitudinal clustering, multinomial models, and models with mixed effects were used. Three daily BP patterns were identified. Daily BP patterns with high BP presented higher standard deviation and morning surge and lower nocturnal dipping. They showed greater systolic BP variability and faster rise than fall in diastolic BP during sleep. Hypertensive, "pardos," and men had greater odds to present these patterns. Daily BP patterns with high BP presented the worst profile concerning ABPM parameters associated with cardiovascular risk. The daily BP patterns identified contribute to the characterization of diurnal BP variation.

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.

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.

Effect of Blood Pressure Variability During the Acute Period of Subarachnoid Hemorrhage on Functional Outcomes

BACKGROUND

The association of blood pressure variation with poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH) is unknown.

OBJECTIVE

To evaluate the association of systolic blood pressure (SBP) variation and clinical outcomes in aSAH.

METHODS

We conducted a retrospective chart review of all aSAH patients treated at an academic institution between 2007 and 2016. Patient demographics, aSAH characteristics, and blood pressure observations for the first 24 h of admission in 4-h intervals were obtained. SBP variability metrics assessed were mean, standard deviation, maximum, minimum, peak, trough, coefficient of variation, and successive variation. The primary outcome was a composite of the modified Rankin scale as good (0-2) or poor (3-6) at last follow-up. Comparisons between outcome groups were performed. Logistic regression models for each significant SBP metric controlling for potential confounders were constructed.

RESULTS

The study population was 202 patients. The mean age was 57 yr; 66% were female. The median follow-up time was 18 mo; 57 (29%) patients had a poor outcome. Patients with poor outcomes had higher standard deviation (17.1 vs 14.7 mmHg, P = .01), peak (23.5 vs 20.0 mmHg, P = .02), trough (22.6 vs 19.2 mmHg, P &lt; .01), coefficient of variation (13.9 vs 11.8 mmHg, P &lt; .01), and lower minimum SBP (101.4 vs 108.4, P &lt; .01). The logistic regression showed that every 1-mmHg increase in the minimum SBP increased the odds of good outcomes (odds ratio = 1.03; 95% CI = 1.001-1.064; P = .04). Models including other SBP metrics were not significant.

CONCLUSION

Hypotension was found to be independently associated with poor outcomes in patients with aSAH.

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.

[Mechanisms for the Development of Blood Pressure Variability and the Potential of Antihypertensive Drugs in Their Correction]

Blood pressure variability (BPV) is the fluctuations of blood pressure over a certain period of time under the influence of various factors. The issue of increased BPV is of particular clinical importance due to high predictive value of this parameter as a risk factor for fatal and non-fatal cardiovascular, cerebrovascular and renal events. It is proved that in the BPV increasing, the key role is played by impairments in arterial baroreflexes, which, in turn, are mediated by increased vascular stiffness, impact of angiotensin II and the sympathetic nervous system, endothelial dysfunction, nitric oxide deficiency and aging, including the vascular aging. Antihypertensive drugs that targeting largest amount of pathophysiological mechanisms in BPV increasing have a most advantages in correcting excessive pressure fluctuations. In this regard such drugs are perindopril and amlodipine, which can eliminate almost the entire spectrum of increased BPV causes and, therefore, optimally reduce the cardiovascular risk.

The Association Between Stroke Mortality and Time of Admission and Participation in a Telestroke Network

OBJECTIVES

Acute ischemic stroke is one of the leading causes of death. Patient outcomes, such as in-patient mortality, may be impacted by the time of arrival to the hospital. Telestroke networks have been found to be effective and safe at treating acute ischemic strokes. This paper investigated the association between mortality and time of arrival and hospital's participation in a telestroke network.

METHODS

Data were collected on ischemic stroke patients who arrived at 15 nonteaching hospitals in Georgia's Paul Coverdell Acute stroke registry from 2009 to 2016. After controlling for patient and hospital characteristics, multivariate logistic regression was conducted to assess whether time of arrival and telestroke participation was associated with in-hospital mortality. Subgroup analysis was conducted based on hospital bed size.

RESULTS

Overall, a total of 19,759 admissions for acute ischemic stroke were included in this analysis. The odds of dying in the hospital when arriving during the nighttime are 1.22 times the odds of dying when arriving during the day (95% CI: 1.04-1.45) and the odds of dying at a telestroke hospital are 53% lower than at a nontelestroke hospital (OR .47, 95% CI .31-.71). The associations were more prominent in large hospitals.

CONCLUSIONS

Our study found that the hour of arrival for acute ischemic stroke is linked with in-hospital mortality in large hospitals, with patients more likely to die if they arrive during the nighttime hours as compared to the daytime hours. Telestroke participation is linked with lower odds of hospital mortality in all hospitals.

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.

Sympathetic Transduction in Type 2 Diabetes Mellitus

Approximately 60% of patients with type 2 diabetes mellitus (T2D) develop hypertension. Recent work also indicates greater blood pressure (BP) excursions throughout the day in T2D. Collectively, these findings suggest altered BP control in T2D. Although muscle sympathetic nerve activity (MSNA) recordings in T2D have provided equivocal results, quantification of MSNA alone does not account for ensuing vasoconstriction and BP responses elicited by MSNA. Thus, we tested the hypothesis that patients with T2D exhibit enhanced sympathetic transduction to BP. MSNA (microneurography) and beat-to-beat BP (Finometer) were measured at rest in 21 T2D and 13 age-matched and body mass index-matched control subjects and, signal-averaging was performed to quantify the mean arterial pressure and total vascular conductance responses to spontaneous bursts of MSNA. The peak mean arterial pressure and total vascular conductance responses to spontaneous MSNA were similar between T2D and control (both P>0.05). However, further analysis, separating T2D into those taking statins (n=13, T2D +statin) and not taking statins (n=8, T2D -statin), indicated that T2D -statin patients (4.2±0.6 mm Hg) exhibited greater peak mean arterial pressure responses compared with both T2D +statin patients (2.5±0.3 mm Hg, P=0.01) and control (control: 2.8±0.3 mm Hg, P=0.02). Likewise, nadir total vascular conductance responses to spontaneous MSNA bursts were greater in T2D -statin patients (T2D -statin: -3.3±0.6 mL/(min·mm Hg), T2D +statin: -1.6±0.3 mL/(min·mm Hg), P=0.03; control -2.2±0.3 mL/(min·mm Hg), P=0.08). Notably, T2D +statin patients exhibited similar peak mean arterial pressure and total vascular conductance responses to MSNA compared with control. Collectively, these findings demonstrate, for the first time, that patients with T2D exhibit augmented sympathetic transduction and this effect seems to be offset by statin therapy.

[Single Pill Indapamide and Perindopril Arginine Combination: Optimal Coupling of Vascular Protection and Hemodynamic Risk Factors Reduction in Patients with Essential Arterial Hypertension]

OBJECTIVE

to investigate the impact of indapamide / perindopril single-pill combination (I / P SPC) on arterial stiffness parameters, blood pressure (BP) level and BP variability (BPV) in middle-aged patients with stage II grade 1-2 essential arterial hypertension (EAH). Materials and methods. We retrospectively formed a group of patients with stage II grade 1-2 EAH who had not previously received regular antihypertensive therapy (AHT) (n=52, mean age 52.9±6.0 years). All patients were treated with I / P SPC and all of them achieved target office BP level (less than 140 / 90 mm Hg). After 12 weeks of follow-up (from the time of reaching the target BP) assessment of AHT effectiveness (general clinical data, ambulatory blood pressure monitoring [ABPM], volume sphygmography, echocardiography), and vascular stiffness evaluation were performed.

RESULTS

At the end of follow-up office systolic BP (SBP), diastolic BP (DBP), pulse BP, day-time, night-time and 24‑hour SBP and DBP significantly (p&lt;0.001 for all) decreased. According to the ABPM data day-time, nighttime, and 24‑hour systolic BPV significantly decreased (p=0.029, p=0.006 and p&lt;0.001, respectively); day-time and 24‑hour diastolic BPV also significantly decreased (p=0.001 and p&lt;0.001, respectively). Day-night standard deviation (SDdn) significantly decreased too (p=0.002 and p&lt;0.001, respectively). Volumetric sphygmography showed significant decrease of right cardio-ankle vascular index (CAVI) (from 8.20±1.29 to 7.58±1.44, p=0.001) and of left CAVI (from 8.13±1.40 to 7.46±1.43, p&lt;0.001), as well as reduction of the number o f patients with a right- and / or left-CAVI &gt;9.0 (from 32.7 to 11.5 %, p=0.018). According to assessment of arterial stiffness using the Vasotens24 software package, the arterial stiffness index (ASI) significantly (p&lt;0.001) decreased from 153.5±29.9 to 138.3±20.0 (by -9.2±13.1 %). Transthoracic echocardiography data demonstrated significant decrease (p&lt;0.001) in effective arterial elastance (from 1.82±0.43 to 1.58±0.36 mm Hg; by -11.85±16.29 %) and significant (p&lt;0.001) increase in the arterial compliance - from 1.27±0.34 to 1.54±0.38 mm Hg / ml (+26.95±38.06 %).

CONCLUSION

In AHT naive patients 40-65 years old with stage II grade 1-2 EAH therapy with I / P SPC provided effective 24‑hour BP control, reduced BPV and improved arterial stiffness parameters.

Association of Variability in Body Mass Index and Metabolic Health With Cardiometabolic Disease Risk

Background Metabolic syndrome is associated with high risk of cardiovascular disease, although risk may differ according to the specific conditions present and variability in those conditions. Methods and Results We defined obesity (body mass index [BMI] ≥30 kg/m2) and metabolic health (<2 nonobesity National Cholesterol Education Program Adult Treatment Panel III conditions) among 3632 Framingham Heart Study offspring cohort participants (mean age, 50.8 years; 53.8% women) who were followed up from 1987 to 2014. We defined participants whose variance independent of the mean for a metabolic syndrome-associated measure was in the top quintile as being "variable" for that measure. Variable metabolic health was defined as ≥2 variable nonobesity metabolic syndrome components. We investigated the interaction between obesity and metabolic health in their associations with cardiometabolic disease and cardiovascular disease using Cox proportional hazards regression. In addition, we estimated the associations of BMI variability and variable metabolic health with study outcomes within categories of obesity and metabolic health status, respectively. We observed 567 incident obesity (41 439 person-years), 771 incident metabolically unhealthy state (25 765 person-years), 272 incident diabetes mellitus (56 233 person-years), 503 incident hypertension (12 957 person-years), 589 cardiovascular disease (60 300 person-years), and 195 chronic kidney disease (47 370 person-years) events on follow-up. Obesity and being metabolically unhealthy were independently and positively associated with all outcomes. BMI variability, compared with stable BMI, was associated with 163%, 67%, 58%, and 74% higher risks of having obesity, becoming metabolically unhealthy, having diabetes mellitus, and having hypertension, respectively, among nonobese participants. Variable metabolic health, compared with stable metabolic health, was associated with a 28% higher risk of cardiovascular disease, among metabolically healthy participants. Conclusions We did not observe evidence for a positive interaction between obesity and metabolic health status with regard to study outcomes. BMI and metabolic health variability are associated with adverse health outcomes.

Blood pressure variability and brain morphology in elderly women without cardiovascular disease

OBJECTIVE

To examine the relationship between blood pressure (BP) variability (BPV), brain volumes, and cognitive functioning in postmenopausal women with few modifiable cardiovascular risk factors.

METHODS

Study participants consisted of postmenopausal women enrolled in the Women's Health Initiative Memory MRI study (WHIMS-MRI) without cardiovascular disease, diabetes mellitus, hypertension, or current smoking at baseline (1996-1999). BP readings were taken at baseline and each annual follow-up visit. BPV was defined as the SD associated with a participant's mean BP across visits and the SD associated with the participant's regression line with BP regressed across visits. Brain MRI scans were performed between 2004 and 2006. Cognitive functioning was assessed at baseline and annually thereafter with the Modified Mini-Mental State Examination (3MSE) scoring until 2008. The final sample consisted of 558 women (mean age 69 years, median follow-up time [interquartile range] 8 [0.8] years).

RESULTS

In adjusted models including mean systolic BP, women in the highest tertile of systolic BPV had lower hippocampal volumes and higher lesion volumes compared to women in the lowest tertile. No relationship between BPV and 3MSE scoring was detected.

CONCLUSIONS

In postmenopausal women with few modifiable cardiovascular risk factors, greater visit-to-visit systolic BPV was associated with reductions in hippocampal volume and increases in lesion volumes at later life. These data add evidence to the emerging importance of BPV as a prognostic indicator even in the absence of documented cardiovascular risk factors.

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.

The impact of volume loading-induced low pressure baroreflex activation on arterial baroreflex-controlled sympathetic arterial pressure regulation in normal rats

Although low pressure baroreflex (LPB) has been shown to elicit various cardiovascular responses, its impact on sympathetic nerve activity (SNA) and arterial baroreflex (ABR) function has not been fully elucidated. The aim of this study was to clarify how volume loading-induced acute LPB activation impacts on SNA and ABR function in normal rats. In 20 anesthetized Sprague-Dawley rats, we isolated bilateral carotid sinuses, controlled carotid sinus pressure (CSP), and measured central venous pressure (CVP), splanchnic SNA, and arterial pressure (AP). We infused blood stepwise (3 mL/kg/step) to activate volume loading-induced LPB. Under the ABR open-loop condition, stepwise volume loading markedly increased SNA by 76.8 ± 21.6% at CVP of 3.6 ± 0.2 mmHg. In contrast, further volume loading suppressed SNA toward the baseline condition. Bilateral vagotomy totally abolished the changes in SNA by volume loading. To assess the impact of LPB on ABR function, we changed CSP stepwise. Low volume loading (CVP = 3.6 ± 0.4 mmHg) significantly shifted the sigmoidal CSP-SNA relationship (central arc) upward from baseline, whereas high volume loading (CVP = 5.4 ± 0.4 mmHg) returned it to the baseline level. Volume loading shifted the linear SNA-AP relationship (peripheral arc) upward without significant changes in slope. In conclusions, volume loading-induced acute LPB activation evoked two-phase changes, an initial increase followed by decline from baseline value, in SNA via resetting of the ABR central arc. LPB may contribute greatly to stabilize AP in response to volume status.

Ambulatory blood pressure variability increases over a 19-year follow-up in a clinic on a solitary island

OBJECTIVE

This study investigated the changes of ambulatory blood pressure (ABP) profiles on the same participants over a 19-year follow-up.

PARTICIPANTS AND METHODS

This is a longitudinal study. We conducted 24-h ABP monitoring at baseline in November 1997 and at follow-up in November 2016 for the same participants who were outpatients in a solitary island clinic. To estimate ambulatory blood pressure variability (ABPV), SD, coefficient of variation, and average real variability of ABP were calculated. ABP levels and ABPV at baseline and follow-up were compared using paired t-test.

RESULTS

A total of 35 participants were recruited at follow-up (79.3±6.7 years at follow-up). Mean systolic blood pressure levels in 24-h, daytime, and night-time did not change significantly. However, ABPV of systolic/diastolic blood pressure in 24-h and daytime increased at follow-up compared with baseline (P<0.01 in all variables: SD, coefficient of variation, and average real variability), whereas ABPV in night-time did not change significantly.

CONCLUSION

Our observations suggested that 24-h and daytime ABPV increase with aging in community-dwelling elderly people.

Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE)

Hypertension is a common cardiovascular risk factor leading to heart failure (HF), coronary artery disease, stroke, peripheral artery disease and chronic renal insufficiency. Hypertensive heart disease can manifest as many cardiac arrhythmias, most commonly being atrial fibrillation (AF). Both supraventricular and ventricular arrhythmias may occur in hypertensive patients, especially in those with left ventricular hypertrophy (LVH) or HF. Also, some of the antihypertensive drugs commonly used to reduce blood pressure, such as thiazide diuretics, may result in electrolyte abnormalities (e.g. hypokalaemia, hypomagnesemia), further contributing to arrhythmias, whereas effective control of blood pressure may prevent the development of the arrhythmias such as AF. In recognizing this close relationship between hypertension and arrhythmias, the European Heart Rhythm Association (EHRA) and the European Society of Cardiology (ESC) Council on Hypertension convened a Task Force, with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE), with the remit to comprehensively review the available evidence to publish a joint consensus document on hypertension and cardiac arrhythmias, and to provide up-to-date consensus recommendations for use in clinical practice. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient.

Prognostic value of average home blood pressure and variability: 19-year follow-up of the Didima study

OBJECTIVE

The current general population study explored the prognostic value of home blood pressure (HBP) average and variability (BPV) versus office measurements (OBP).

METHODS

In 1997, 665 adults of Didima, Argolida, Greece were evaluated with OBP (two visits, six readings) and HBP (3 days, 12 readings) measurements. Total mortality and cardiovascular morbidity and mortality (CVD) were assessed after 19.0 ± 1.4 years. BPV was quantified by using SD and coefficient of variation.

RESULTS

During follow-up, 216 deaths (124 cardiovascular) and 146 cardiovascular events (fatal and nonfatal) were documented. Hazard ratios for total mortality were 1.39/1.20 (P < 0.01/ < 0.01) per 10/5 mmHg increase in systolic/diastolic HBP and 1.36/1.02 (P < 0.01/NS) for OBP (similar hazard ratios for CVD). After adjustment for baseline risk factors, OBP and HBP lost their prognostic ability, except from diastolic OBP that predicted CVD (hazard ratio 1.10, P = 0.03). Sustained, masked and white-coat hypertension were associated with increased risk of death and CVD (P < 0.01 versus normotensive participants). After adjustment, the risk of death remained significant for all, but CVD only for white-coat hypertension. Systolic home BPV (not diastolic) predicted total mortality (adjusted hazard ratios 1.18/1.17 for 1-SD increase in SD/coefficient of variation; P < 0.05) and CVD. Unadjusted systolic/diastolic office BPV predicted CVD outcome (for total mortality only systolic), yet not after adjustment. Systolic home BPV predicted total mortality and CVD independent of office BPV.

CONCLUSION

In this general population study with 19-year follow-up, average HBP predicted total mortality and CVD as reliably as OBP. Only normotension (low OBP and HBP) was associated with low risk. Systolic home BPV exhibited superior prognostic ability than OBP, deserving further research.

Morning blood pressure surge: pathophysiology, clinical relevance and therapeutic aspects

Morning hours are the period of the day characterized by the highest incidence of major cardiovascular events including myocardial infarction, sudden death or stroke. They are also characterized by important neurohormonal changes, in particular, the activation of sympathetic nervous system which usually leads to a rapid increase in blood pressure (BP), known as morning blood pressure surge (MBPS). It was hypothesized that excessive MBPS may be causally involved in the pathogenesis of cardiovascular events occurring in the morning by inducing hemodynamic stress. A number of studies support an independent relationship of MBPS with organ damage, cerebrovascular complications and mortality, although some heterogeneity exists in the available evidence. This may be due to ethnic differences, methodological issues and the confounding relationship of MBPS with other features of 24-hour BP profile, such as nocturnal dipping or BP variability. Several studies are also available dealing with treatment effects on MBPS and indicating the importance of long-acting antihypertensive drugs in this regard. This paper provides an overview of pathophysiologic, methodological, prognostic and therapeutic aspects related to MBPS.