Long-term prognostic implications of visit-to-visit blood pressure variability in patients with ischemic stroke

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.

Pulse pressure variability and the risk of fragility fracture: The Kailuan prospective cohort study in China

OBJECTIVES

To investigated the association of PPV, considering its magnitude and direction, with the incidence of fragility fracture in the general population.

METHODS

This was a prospective cohort study of the on-the-job and retired Kailuan Group employees who attended health check-ups continuously from 2006 to 2010, and were followed up until 31st December 2021. A total of 56,129 participants who completed health checkups were selected and grouped according to Pulse pressure variability (PPV), using the variability coefficient of variation (CV) quartiles, standard deviation (SD), variation independent of mean (VIM), and average real variability (ARV) was used as measures of pulse pressure variability. The cumulative incidence of fragility fracture in the four groups was calculated, the impact of PPV on the risk of fragility fracture was analyzed using a multivariate Cox regression model, and the direction of the variation was further assessed.

RESULTS

During the median follow-up of 11 years, there were 671 cases of fragility fracture (1.2 %). In the multivariable-adjusted model, the hazard ratios and 95 % CIs of fragility fracture was 1.37 (1.11-1.70) for the highest quartile of variability coefficient of variation of pulse pressure versus the lowest quartile of CV of PP. There was a linear association between higher PPV and fragility fracture. Consistent results were noted for higher PPV and the risk of the fragility fracture using other indices of variability and in various sensitivity and subgroup analyses.

CONCLUSIONS

Higher PPV is a risk factor for fragility fracture, independently of blood pressure and PPV direction. Reducing PPV may be a target for preventing fragility fractures in the general population.

Remote Patient Monitoring of Blood Pressure Is Feasible Poststroke and Can Facilitate Triage of Care

BACKGROUND AND PURPOSE

Strict blood pressure (BP) control is a universally accepted therapeutic intervention in the prevention of secondary stroke, yet this remains difficult when patients return home postinjury. This study aimed to investigate the application of the remote patient monitoring (RPM) of BP in patients after stroke, or who were at immediate risk of stroke, and the subsequent outcomes relating to triage and escalation of care.

METHODS

This was a single-center proof-of-concept study. Participants were patients aged 18 years and older with a diagnosis of stroke or who were at immediate risk of stroke. Patients were enrolled into the precision recovery program (PRP) and asked to assess their BP and heart rate daily and enter values into a MyCap application for the RPM program. These data were reviewed daily by an assigned PRP clinician, and weekly Zoom meetings were held with the patient. Care was triaged and escalated to a physician as indicated.

RESULTS

Twelve patients (5 [42%] female, aged mean [range] 63 [43-84] years) met the inclusion criteria and continued in the program for median (range) 136 (8-227) days. The median (range) number of excursions of BP above limits per participant was 19 (0-79) for systolic and 36 (0-104) for diastolic. A total of 16 triage events (median [range] 1 [0-3]) were initiated for escalation of care.

CONCLUSIONS

This study demonstrated that RPM is feasible in patients poststroke or at immediate risk of stroke, and facilitates the triage of care when BP is elevated above recommended limits.

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.

Visit-to-visit variability of blood pressure and cardiovascular events among the working-age population in Japan: findings from the Japan Epidemiology Collaboration on Occupational Health Study

Increased visit-to-visit variability (VVV) of blood pressure, which is calculated based on several readings, has been suggested to be a significant predictor of cardiovascular events and mortality, independent of mean blood pressure. This study examined associations between the VVV of systolic blood pressure (SBP) measured annually and cardiovascular disease (CVD) events among 72,617 Japanese subjects. Data were obtained from the Japan Epidemiology Collaboration on Occupational Health Study, which is an ongoing epidemiological survey of workers in Japan. VVV was calculated as the coefficient of variation of SBP readings from 2008 to 2011; information on fatal and nonfatal CVD events was collected from registries of specific outcomes between April 2012 and March 2019. A Cox proportional hazards model was applied to investigate associations after adjusting for mean SBP between 2008 and 2011 and covariates. During the 7-year follow-up period, there were 63 CVD fatalities and 314 CVD events (combining fatal and nonfatal events). The results showed that a one-standard deviation increase in VVV was associated with a significant increase in the risk of CVD mortality (hazard ratio [HR] = 1.42; 95% confidence interval [CI] = 1.32-1.54); those in the highest tertile had a 3.20 times (95% CI = 1.26-8.17) higher risk of CVD mortality than those in the lowest tertile. We found less pronounced associations regarding CVD events (HR = 1.08, 95% CI = 1.02-1.15). In conclusion, VVV was significantly associated with CVD mortality in our Japanese working population.

Association between Blood Pressure, Blood Pressure Variability, and Post-Stroke Cognitive Impairment

After stroke, dynamic changes take place from necrotic-apoptotic continuum, inflammatory response to poststroke neurogenesis, and remodeling of the network. These changes and baseline brain pathology such as small vessel disease (SVD) and amyloid burden may be associated with the occurrence of early or late poststroke cognitive impairment (PSCI) or dementia (PSD), which affect not only stroke victims but also their families and even society. We reviewed the current concepts and understanding of the pathophysiology for PSCI/PSD and identified useful tools for the diagnosis and the prediction of PSCI in serological, CSF, and image characteristics. Then, we untangled their relationships with blood pressure (BP) and blood pressure variability (BPV), important but often overlooked risk factors for PSCI/PSD. Finally, we provided evidence for the modifying effects of BP and BPV on PSCI as well as pharmacological and non-pharmacological interventions and life style modification for PSCI/PSD prevention and treatment.

Predictive value of visit-to-visit blood pressure variability for cardiovascular events in patients with coronary artery disease with and without diabetes mellitus

Background

High blood pressure is a major risk factor for cardiovascular disease. Visit-to-visit blood pressure variability (BPV) has recently been shown to predict cardiovascular outcomes. We investigated the predictive value of BPV for major adverse cardiovascular events (MACE) among patients with coronary artery disease (CAD), with and without type 2 diabetes mellitus (T2DM).

Methods

Patients with stable CAD were enrolled and monitored for new MACE. Visit-to-visit BPV was defined as the coefficient of variation (CV) of systolic and diastolic BP across clinic visits. Multivariable logistic regression analysis was performed to evaluate the association of BPV with MACE. Area under the receiver operating characteristic curve (AUC) was used to assess its predictive ability.

Results

Among 1140 Chinese patients with stable CAD, 192 (17%) experienced a new MACE. In multivariable analyses, the risk of MACE was significantly associated with CV of systolic BP (odds ratio [OR] for highest versus lowest quartile, 3.30; 95% CI 1.97–5.54), and diastolic BP (OR for highest versus lowest quartile, 2.39; 95% CI 1.39–4.11), after adjustment for variables of the risk factor model (age, gender, T2DM, hypertension, antihypertensive agents, number of BP measurements) and mean BP. The risk factor model had an AUC of 0.70 for prediction of MACE. Adding systolic/diastolic CV into the risk factor model with mean BP significantly increased the AUC to 0.73/0.72 (P = 0.002/0.007). In subgroup analyses, higher CV of systolic BP remained significantly associated with an increased risk for MACE in patients with and without T2DM, whereas the association of CV of diastolic BP with MACE was observed only in those without T2DM.

Conclusions

Visit-to-visit variability of systolic BP and of diastolic BP was an independent predictor of new MACE and provided incremental prognostic value beyond mean BP and conventional risk factors in patients with stable CAD. The association of BPV in CAD patients without T2DM with subsequent risk for MACE was stronger than in those with T2DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01280-z.

Visit-to-visit variability in blood pressure among cannabis users participating in the Third National Health and Nutrition Examination Survey

OBJECTIVE

Blood pressure variability (BPV) has emerged as an important predictor of cardiovascular morbidity and mortality. Plausible biological mechanisms link cannabis use and blood pressure (BP) regulation. Here, we assess the relationship between cannabis use and BPV, measured by the SD and coefficient of variation across three separate study visits.

METHODS

Data for individuals (17-59 years, n = 758) participating in the United States Third National Health and Nutrition Examination Survey substudy were used. Associations between cannabis use and mean BP, SBP and DBP variability were estimated. Participants were classified according to recency or lifetime frequency of cannabis use. Generalized linear regressions were used to model BPV as the outcome and cannabis use status as the exposure, adjusting for potential confounding variables.

RESULTS

Compared with nonuse, active cannabis use was associated with higher SD (mmHg) of mean BP [β = 0.97; 95% confidence interval (CI) = 0.22, 1.73], SBP (β = 0.95; 95% CI = 0.04, 1.85) and DBP (β = 1.18; 95% CI = 0.28, 2.08). Similar conclusions were obtained when the coefficient of variation was modelled as the outcome. A robust association was not observed for lifetime use frequency. The association between active cannabis use and SBP variability was stronger in the tobacco smoking subgroup, whereas the association between active cannabis use and DBP variability was stronger in the tobacco nonsmoking subgroup.

CONCLUSION

Active cannabis use is associated with BPV. Future research is needed to understand the effects of cannabis use on BP regulation.

Visit-to-visit blood pressure variability is associated with arterial stiffness in Chinese adults: A prospective analysis

Blood pressure (BP) variability may have its effect on the development of vascular disease. The authors aimed to examine the association between the visit-to-visit variability (VVV) of BP and arterial stiffness in Chinese adults. The authors included 1407 participants from a prospective cohort study of community residents who were ≥40 years, without a history of myocardial infarction or stroke, and with data at the baseline, the second and the third visits in 2008, 2009, and 2013. The VVV of BP was defined as the standard deviation (SD), the coefficient of variation (CV), the average successive variability (ASV), and the variability independent of the mean (VIM) in BP levels at the 3 visits. Arterial stiffness was measured by brachial-ankle pulse wave velocity (ba-PWV) at the 2nd and the 3rd visits. Levels of ba-PWV change and the occurrence of an elevated ba-PWV increased significantly in the highest tertile of VVV measures of systolic BP (SBP) and pulse pressure (PP) compared with the lowest tertile, respectively. The multivariable regression analysis revealed that VVV measures of SBP and PP were significantly associated with levels of ba-PWV change and the risks of developing an elevated ba-PWV. The odds ratios (ORs) and 95% confidence intervals (CIs) for the risk were 2.12 (1.57-3.12) and 1.92 (1.38-2.68) in participants with the highest versus the lowest tertile of SBP-SD and PP-SD, respectively. No significant association was found for diastolic BP variability measures. The increased long-term variabilities of SBP and PP were associated with an increased risk of arterial stiffness.

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.

Visit-to-visit blood pressure variability and hip fracture risk in older persons

We investigated the association between blood pressure variability measured by the coefficient of variation (CV) of blood pressure and hip fracture in older persons with diabetes. After excluding patients with acute complications and comorbidities, a positive association with similar magnitude of strength was found between BP variability and hip fracture, compared with that in the original analysis.

INTRODUCTION

Hypertension is a risk factor of osteoporosis and hip fracture, but studies have yet to investigate whether blood pressure variability measured by the CV of blood pressure can predict hip fracture in older persons with diabetes.

METHODS

We conducted a retrospective cohort study on 21,160 patients who suffered from type 2 diabetes (age ≥ 50 years) and participated in the National Diabetes Care Management Program in Taiwan. The patients' 1-year variability in systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the baseline and subsequent hip fracture incidence for 8.2 years were analyzed.

RESULTS

There were 937 recorded incident hip fractures. SBP-CV and DBP-CV were classified based on their tertiles. After multivariate adjustment was conducted, SBP-CV found to be a predictor of hip fracture, and its hazard ratio was 1.18 (95% CI 1.00-1.40) for the third tertile compared with the first tertile.

CONCLUSIONS

Our study suggests SBP stability is a predictor for hip fracture incidence in older persons with type 2 diabetes.

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.

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.

Visit-to-visit blood pressure variability is a risk factor for all-cause mortality and cardiovascular disease: a systematic review and meta-analysis

OBJECTIVE

Clinical cohort studies have reported that visit-to-visit variability (VVV) of blood pressure (BP) is associated with cardiovascular disease (CVD) or mortality. However, the results were not consistent in all studies. The current study is, therefore, aimed to conduct a systematic review and meta-analysis to determine the association between VVV of BP and CVD and all-cause mortality.

METHOD

PubMed and EMBASE were searched through 18 May 2014, using the following terms: VVV, BP, CVD, coronary heart disease (CHD), myocardial ischemia, stroke, and mortality. Overall, 84 records were identified, and 23 publications were enrolled into the current study. Data were extracted from selected publications, and meta-analysis was performed using a random effect model.

RESULT

VVV of SBP was significantly associated with outcomes of all-cause mortality with the relative risk (RR) and 95% confidence interval (CI) 1.14 (1.09, 1.18), CVD incidence (RR = 1.12, 95% CI: 1.05, 1.09), CVD mortality (RR = 1.18, 95% CI: 1.09, 1.28), CHD incidence (RR = 1.12, 95% CI: 1.06, 1.19), and stroke incidence (RR = 1.34, 95% CI: 1.11, 1.61).

CONCLUSION

In summary, among the wide heterogenetic population, modest associations between VVV of SBP and all-cause mortality, CVD incidence, CVD mortality, CHD incidence, and stroke incidence were found. Findings of the current study suggested that standardized approaches of monitoring VVV in the high-risk population, including patients with cardiac infarction, diabetes, stroke, and patients with chronic kidney disease or in dialysis, are necessary in designing a prospective clinical study on the association of VVV and patients' prognosis.

Mid-Term Blood Pressure Variability Is Associated With Clinical Outcome After Ischemic Stroke

BACKGROUND

The aim of this study was to investigate the relation between mid-term blood pressure (BP) variability (BPV) within 7 days of onset and the prognosis in acute stroke patients.

METHODS

Total 873 acute ischemic stroke patients were included in this study. Mid-term BPV was evaluated through the calculations of coefficient of variation (CV) of the systolic BP (SBP) and diastolic BP (DBP) within 7 days of onset. Clinical outcomes were assessed using the recovery situations of neurological function at 3 months, the primary outcome (symptomatic recurrent stroke) and the secondary outcomes (recurrent stroke, all-cause mortality, and the composite of cardiovascular events) within 12 months.

RESULTS

Among 873 patients with ischemic stroke, 83 died, 125 developed recurrent stroke, and 212 developed cardiovascular events during 12 months' follow-up. At 3 months, systolic or diastolic BPV (within 7 days of onset) was associated with the recovery situations of neurological function in three models (all P < 0.05). Both higher CV of SBP and CV of DBP were significantly correlated with the increased risk of recurrent stroke (hazard ratio [HR] = 2.32, 95% confidence interval [CI]: 1.29-4.18, P = 0.005 for CV of SBP; HR = 2.33, 95% CI: 1.29-4.19, P = 0.005 for CV of DBP) and composite cardiovascular events (HR = 2.22, 95% CI: 1.41-3.48, P = 0.001 for CV of SBP; HR = 2.21, 95% CI: 1.41-3.47, P = 0.001 for CV of DBP) during 12 months' follow-up.

CONCLUSIONS

After acute ischemic stroke, high systolic or diastolic BPV within 7 days of onset was associated with the recovery situations of neurological function at 3 months, and recurrent stroke and composite cardiovascular events within 12 months.

CLINICAL TRIAL REGISTRATION

URL: http://www.chictr.org.cn. Unique identifier: ChiCTR-TRC-14004804.

Midterm Blood Pressure Variability Is Associated with Poststroke Cognitive Impairment: A Prospective Cohort Study

Objective

The aim of this study was to investigate the relationship between blood pressure variability (BPV) and poststroke cognitive impairment (PSCI).

Methods

Seven-hundred ninety-six patients with acute ischemic stroke were included in this study. Midterm BPV was evaluated by calculating the SD and coefficient of variation (CV, 100 × SD/mean) of systolic blood pressure (SBP) and diastolic blood pressure during the 7 days after stroke onset. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) at admission and at all follow-up visits. Patients with MoCA scores <26 were considered to have PSCI.

Results

The incidence of PSCI reached its peak (72%) 3 months after stroke onset and decreased to 30.3% at 12 months poststroke. After adjusting for covariables, the increase in the prevalence of PSCI at 3 months was independently associated with increases in the CV of blood pressure during the 7 days after stroke [odds ratios and 95% CI for patients in the second to fifth quintiles of SBP CV were 2.28 (1.18, 4.39), 2.33 (1.18, 4.62), 2.69 (1.31, 5.53), and 4.76 (1.95, 11.67), respectively]. Sub-analysis of the MoCA scores revealed that the patients had impairments in visuoperceptual abilities and executive functions, as well as in naming and delayed recall (p < 0.05).

Conclusion

Midterm BPV during the early phase of acute ischemic stroke is independently associated with PSCI, especially in the visuoperceptual, executive, and delayed recall domains.

Clinical Trial Registration

http://www.chictr.org.cn, identifier ChiCTR-TRC-14004804.

Short-term blood pressure variability and long-term blood pressure variability: which one is a reliable predictor for recurrent stroke

The relationship between blood pressure variability (BPV) and stroke recurrence is controversial. This study aimed to evaluate the predictive value of short-term and long-term BPV for stroke recurrence. The data from blood pressure and clinical outcome in TIA or ischemic stroke (BOSS) study included participants with acute ischemic stroke or transient ischemic attack (TIA) within 7 days after onset. Short-term BPV was measured by 24-h ambulatory BP measurement during hospitalisation. Long-term BPV, based on home blood pressure measurement, was measured by patients or their families from discharge to 90 days after qualifying events onset (twice daily). Variability for systolic blood pressure (SBP) was assessed as the s.d., coefficients of variance (CV). The clinical outcome was recurrent stroke within 1 year. Cox proportional hazards models were used to test the association of short-term BPV, long-term BPV and stroke recurrence. Among 1764 participants, the mean age was 62.45±10.99 years, and 32.1% were females, during 1-year follow-up, 106 (6.0%) participants experienced recurrent stroke. Indices of long-term BPV were significantly associated with stroke recurrence (s.d.: adjusted HR: 1.939, 95% CI: 1.122-3.351; CV: adjusted HR 1.955, 95% CI: 1.174-3.255), independent of mean SBP. However, all indices of short-term BPV (s.d., CV) were not associated with stroke recurrence (s.d.: adjusted HR: 1.245, 95% CI: 0.680-2.280; CV: adjusted HR: 1.142, 95% CI: 0.640-2.038). In conclusion, long-term variation of SBP is a better predictor than short-term variation of SBP for recurrent stroke after acute ischemic stroke or TIA.

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.

Psychiatric correlates of blood pressure variability in the elderly: The Three City cohort study

BACKGROUND

The modifiable factors associated with blood pressure variability (BPV) are still being established and their clinical relevance is poorly understood. Generalized anxiety disorder (GAD) and depression have been implicated with higher BPV in the short term (e.g. hours, days) however their effects on BPV over longer periods are unknown.

METHODS

In a prospective cohort study, 1454 elderly participants (age 78.5±3.78years, 59% women) underwent structured interview for GAD and major depression. Participants performed home blood pressure monitoring (HBPM) over 3 consecutive days and underwent serial clinic BP measures on 4 separate follow-ups over an 8year period. Systolic and diastolic BPV was calculated using the coefficient of variation (CV) and standard deviation method. Generalized linear models assessed the association between GAD and depression with BPV over an 8year period.

RESULTS

GAD was associated with significantly increased systolic BPV over 8years in age, sex and mean systolic BP (β=0.25, SE=0.09; p=0.007) and fully adjusted models (β=0.23, SE=0.10; p=0.017). BPV from HBPM was strongly associated with 8year systolic BPV in age-sex (β=3.10, SE=0.82; p<0.001) and fully adjusted models (β=3.09, SE=0.84; p<0.001). The association between GAD and longer term BPV was consistent when analyzing morning and evening HBPM measures of BPV. There was no association between diastolic BPV over 8years with GAD or depression.

CONCLUSIONS

GAD but not depression was associated with increased systolic BPV over an 8year period controlling for HBPM. GAD has clinical relevance for control of systolic BPV in elderly participants.

Effect of visit-to-visit blood pressure variability on cardiovascular events in patients with coronary artery disease and well-controlled blood pressure

This post hoc analysis of CAMELOT and PREVENT analyzed the impact of blood pressure variability (BPV, assessed as within-subject standard deviation of SBP from 12 weeks onward) on the incidence of major adverse cardiovascular events (MACE, defined according to original studies). Patients (n = 1677 CAMELOT; n = 776 PREVENT) were stratified by BPV quartile. Regardless of study, BPV was significantly lower for amlodipine versus other treatments. In CAMELOT, a significant association between BPV quartile and MACE was observed with amlodipine treatment. Significant associations between BPV quartile and MACE were observed for both studies, when analyzed overall (adjusting for treatment). In CAMELOT, with amlodipine treatment, an increased risk for MACE was observed with high (BPV ≥ Q3) versus low BPV (< Q1; adjusting for characteristics and risk factors). In both studies, increased risk for MACE was observed for BPV ≥ Q3 versus BPV < Q1 (analyzed overall, adjusting for treatment and covariates). For both studies, BPV, but not mean SBP, was associated with cardiovascular events. BPV was associated with cardiovascular outcomes in patients with CAD and well-controlled BP.

Blood pressure variability and cardiovascular disease: systematic review and meta-analysis

OBJECTIVE

 To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality.

DATA SOURCES

 Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

 Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation.

RESULTS

 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively).

CONCLUSIONS

 Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date.

SYSTEMATIC REVIEW REGISTRATION

 PROSPERO CRD42014015695.

No Association Observed Between Blood Pressure Variability During the Acute Phase of Ischemic Stroke and In-Hospital Outcomes

BACKGROUND

Recent data suggest that blood pressure (BP) variability confers increased cardiovascular risk independently of BP. We aimed to evaluate the association between BP variability during the acute phase of ischemic stroke and the in-hospital outcome.

METHODS

We prospectively studied 608 consecutive patients admitted with acute ischemic stroke (39.5% males, age: 79.1±6.6 years). Variability in BP was assessed with the SD and with the coefficient of variation of systolic (SBP) and diastolic BP (DBP) during the first 2 and the first 3 days of hospitalization. The outcome was assessed with dependency rates at discharge and with in-hospital mortality.

RESULTS

Patients who were dependent at discharge did not differ from patients who were independent in any index of BP variability. Independent predictors of dependency at discharge were age (relative risk (RR) 1.17, 95% confidence interval (CI) 1.09-1.25, P < 0.001), history of prior ischemic stroke (RR 2.08, 95% CI 1.02-4.24, P = 0.04), and National Institutes of Health Stroke Scale (NIHSS) at admission (RR 1.64, 95% CI 1.44-1.86, P < 0.001). Patients who died during hospitalization did not differ in any index of BP variability from patients who were discharged. DBP at admission was independently and directly associated with in-hospital mortality (RR 1.06, 95% CI 1.03-1.09, P < 0.001). Other independent predictors of in-hospital mortality were history of atrial fibrillation (RR 3.30, 95% CI 1.46-7.49, P = 0.004) and NIHSS at admission (RR 1.18, 95% CI 1.13-1.23, P < 0.001).

CONCLUSIONS

Our data do not support the hypothesis of an association between BP variability and in-hospital outcomes among patients admitted for ischemic stroke.

Change in Systolic Blood Pressure During Stroke, Functional Status, and Long-Term Mortality in an Elderly Population

BACKGROUND

Elevated systolic blood pressure (SBP) recorded by 24-hour blood pressure monitoring (24H BPM) on the first day of acute stroke is associated in elderly patients, with an unfavorable outcome. Herein, we assessed, by 24H BPM, the impact of the change in SBP levels during the first week of stroke on short-term functional status and long-term mortality in elderly patients.

METHODS

One hundred and fifty acute stroke patients (69 males), mean age at admission 83.6±5.5 years, 82% with ischemic stroke, were investigated. 24H BPM was recorded within 24 hours of admission and 1 week later. After 7 days, patients were assessed for functional status according to the modified Rankin scale (mRS) and were subsequently followed for mortality up to 7.5 years (mean 3.16±2.29).

RESULTS

After 7 days, SBP decreased from 147±21 to 140±20 mm Hg (P < 0.001). Functional status improved and mRS decreased from 4.2 to 3.7. During follow-up, 58 patients (17 males and 41 females) had died. Mortality rate was higher in females (69% vs. 45%; P < 0.01) and in patients with a history of congestive heart failure. The average admission SBP predicted short-term functional status and long-term mortality. However, the change in SBP corrected for admission levels, gender, age and other variables was not associated with short-term functional status and long-term mortality.

CONCLUSION

There is no evidence of association between change in SBP during the first week of stroke and short-term functional status and long-term mortality in this group of stroke patients.

Visit-to-Visit Variability of Systolic Blood Pressure and Cardiovascular Disease

Visit-to-visit variability of blood pressure (VVV of BP) is gaining interest as a prognostic marker for stroke, cardiovascular disease, and all-cause mortality. In this review, we discuss different metrics used to define VVV of BP, explore the potential sources of this phenomenon including patient characteristics and antihypertensive medication classes, and discuss recent evidence of its relation with cardiovascular outcomes. Current evidence relies on secondary analyses of clinical trials or on observational studies, none of which was designed to examine VVV of BP specifically. More research is required to develop standardized definitions of VVV of BP, to confirm the value of VVV as a prognostic indicator, and to ascertain whether efforts to reduce VVV of BP in addition to mean BP will improve outcomes.

Visit-to-visit variability in LDL- and HDL-cholesterol is associated with adverse events after ST-segment elevation myocardial infarction: A 5-year follow-up study

INTRODUCTION

We evaluated the relationship between visit-to-visit low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) variability and 5-year clinical outcomes in patients who presented with ST-segment elevation myocardial infarction (STEMI).

METHODS

130 patients presenting with STEMI and surviving to discharge were analyzed. Visit-to-visit LDL-C and HDL-C variability was evaluated from 2 months after discharge on the basis of corrected variation independent of mean (cVIM, primary measure), coefficient of variation and standard deviation. Major adverse cardiac event (MACE) included death, myocardial infarction, stroke, unplanned revascularization, and heart failure admission.

RESULTS

After an average of 62.4 ± 30.5 months follow-up, 41 patients (31.5%) had experienced MACE. Compared with the non-MACE group, the MACE group had a higher visit-to-visit LDL-C variability (cVIM: 0.23 ± 0.11 vs. 0.19 ± 0.08; p = 0.049; coefficient of variation: 0.24 ± 0.12 vs. 0.19 ± 0.00; p = 0.019; standard deviation: 24.1 ± 14.5 vs. 17.6 ± 10.0; p = 0.006), mean follow-up LDL-C (p = 0.033) and a higher prevalence of diabetes mellitus (p = 0.012). After adjusting for mean follow-up cholesterol levels and diabetes mellitus, each 0.01 cVIM increase in LDL-C and HDL-C variability increased the risk of MACE by 3.4% (HR: 1.034; 95% CI: 1.004 to 1.065; p = 0.025) and 6.8% (HR: 1.068; 95% CI: 1.003 to 1.137; p = 0.04), respectively. Results derived from coefficient of variation and standard deviation as measures of cholesterol variability were similar.

CONCLUSION

This is the first report to show an independent association between visit-to-visit LDL-C and HDL-C variability and long-term MACE in patients presenting with STEMI.

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

Visit-to-visit variability of blood pressure (BP) has been associated with cardiovascular disease (CVD) and mortality in some but not all studies. We conducted a systematic review and meta-analysis to examine the association between visit-to-visit variability of BP and CVD and all-cause mortality. Medical databases were searched through June 4, 2014, for studies meeting the following eligibility criteria: adult participants; BP measurements at ≥3 visits; follow-up for CVD, coronary heart disease, stroke, or mortality outcomes; events confirmed via database, death certificate, or event ascertainment committee; and adjustment for confounders. Data were extracted by 2 reviewers and pooled using a random-effects model. Overall, 8870 abstracts were identified of which 37 studies, representing 41 separate cohorts, met inclusion criteria. Across studies, visit-to-visit variability of systolic BP and diastolic BP showed significant associations with outcomes in 181 of 312 (58.0%) and 61 of 188 (32.4%) analyses, respectively. Few studies provided sufficient data for pooling risk estimates. For each 5 mm Hg higher SD of systolic BP, the pooled hazard ratio for stroke across 7 cohorts was 1.17 (95% confidence interval [CI], 1.07-1.28), for coronary heart disease across 4 cohorts was 1.27 (95% CI, 1.07-1.51), for CVD across 5 cohorts was 1.12 (95% CI, 0.98-1.28), for CVD mortality across 5 cohorts was 1.22 (95% CI, 1.09-1.35), and for all-cause mortality across 4 cohorts was 1.20 (95% CI, 1.05-1.36). In summary, modest associations between visit-to-visit variability of BP and CVD and all-cause mortality are present in published studies. However, these findings are limited by the small amount of data available for meta-analysis.