Visit-to-visit blood pressure variability in patients with type 2 diabetes with and without previous history of cardiovascular disease

Visit-to-visit variability of blood pressure and risk of macrovascular and microvascular complications in patients with type 2 diabetes: A Chinese primary-care cohort study

BACKGROUND

We evaluated the effects of visit-to-visit variability of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on macrovascular and microvascular complications among patients with type 2 diabetes.

METHODS

A total of 11 043 patients with type 2 diabetes from primary healthcare institutions between January 2010 and June 2020 were included. The visit-to-visit blood pressure variability was calculated using three metrics: SD, coefficient of variation (CV), and average real variability (ARV), obtained over a 12-month measurement period. The associations of visit-to-visit blood pressure variability with macrovascular and microvascular complications were evaluated using multivariate-adjusted Cox proportional hazards models, and hazard ratio (HR) with 95% confidence interval (CI) were reported.

RESULTS

There were 330 macrovascular events and 542 microvascular events. Compared to those for participants with the lowest quartile of SD of SBP and DBP, increased risks were observed in patients with the highest quartile of SD of SBP and DBP for macrovascular complications (SD-SBP: HR = 1.78, 95% CI: 1.24-2.57; SD-DBP: HR = 2.20, 95% CI: 1.50-3.25) and microvascular complications (SD-SBP: HR = 1.85, 95% CI: 1.39-2.46; SD-DBP: HR = 1.82, 95% CI: 1.36-2.44). CV and ARV of SBP and DBP also had statistically significant associations with macrovascular and microvascular complications. The optimal variability of blood pressure target was SD of SBP <6.45 mm Hg and SD of DBP <4.81 mm Hg.

CONCLUSIONS

Visit-to-visit blood pressure variability may be a potential predictor for macrovascular and microvascular complications in patients with type 2 diabetes.

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

OBJECTIVES

to map methods and devices used to assess very short-, short-, medium-, and long-term pressure variability in adults with type 1 or 2 diabetes mellitus.

METHODS

scoping review conducted in January and February 2021 in MEDLINE, Web of Science, CINAHL, LILACS, PubMed, and Embase databases. Studies conducted within the last ten years analyzing pressure variability in adult and older patients with diabetes mellitus type 1 or 2 were included. Studies that used discontinued devices were excluded.

RESULTS

the sample was composed of 25 articles published since 2017, with the majority developed in Japan (n=11); with the predominance of the oscillometric method (n=22); the most used devices were from the Omron® brand (n=14); the most detected type was long-term variability (n=10).

CONCLUSIONS

we observed the increasing application of the oscillometric method for pressure variability analysis with various brands and models of automatic devices.

Blood pressure visit-to-visit variability and outcomes in patients with heart failure with preserved ejection fraction

AIMS

Previous studies report that blood pressure (BP) variability is associated with increased risk of adverse outcomes in patients diagnosed with cardiovascular disease. However, studies have not fully explored this association in patients with heart failure with preserved ejection fraction (HFpEF). This study sought to explore the association between visit-to-visit variability (VVV) of BP and clinical outcomes in patients with HFpEF.

METHODS AND RESULTS

A total of 1988 patients (mean age of 67.73 ± 9.22, 51.7% female) from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial were included in this study. BP-VVV was determined by standard deviation (SD) of mean systolic BP (SBP-SD) from six measurements (baseline and months 1, 2, 4, 8, and 12) during the first 12 months after randomization. Mean on-treatment SBP during the first 12 months was 127.77 ± 10.42 mmHg, and the median of SBP-SD was 8.15 mmHg. A total of 192 (9.7%) patients met the primary outcome during the subsequent median follow-up of 35.16 months, including a composite of cardiovascular death, heart failure hospitalization, or aborted cardiac arrest. Multiple Cox regression analysis showed that SBP-SD was independently associated with the increased risk of the primary outcome after adjusting for age, gender, method of BP measurement, treatment, renal function and common co-morbidities, and the mean SBP during the first 12 months [hazard ratio (HR) for fourth vs. first quartile, 1.63; 95% confidence interval (CI), 1.07-2.49; P = 0.024]. Analysis showed that SBP-SD as continuous variable was associated with a 23% increase in the risk of primary outcome (HR 1.23, 95% CI 1.06-1.43; P = 0.006).

CONCLUSIONS

The findings of the current study show that high SBP-VVV in patients with HFpEF is associated with an increased risk of adverse outcomes independent of the mean on-treatment SBP.

Effectiveness of statin intensive therapy in type 2 diabetes mellitus with high visit-to-visit blood pressure variability

BACKGROUND

Intensive lipid-lowering therapy is recommended in type 2 diabetes mellitus (T2DM) patients with target organ damage. However, the evidence is insufficient to stratify the patients who will benefit from the intensive therapy among them. High visit-to-visit variability in systolic blood pressure (SBP) is associated with increased risk of cardiovascular events. We investigated the effectiveness of intensive versus standard statin therapy in the primary prevention of cardiovascular events among T2DM patients with retinopathy stratified by visit-to-visit SBP variability.

METHODS

The standard versus intensive statin therapy for hypercholesterolemic patients with diabetic retinopathy study was the first trial comparing statin intensive therapy targeting low-density lipoprotein cholesterol (LDL-C) <70 mg/dl and standard therapy targeting LDL-C ≥100 to <120 mg/dl in T2DM patients with retinopathy without known cardiovascular disease. Using this dataset, we divided the patients into two subpopulations based on standard deviation (SD) and average real variability (ARV) of clinic SBP within the initial 6 months.

RESULTS

In a total of 4899 patients, 240 composite cardiovascular events were observed during a median follow-up of 37.3 months. In multivariable-adjusted model comparing intensive versus standard therapy, the hazard ratios for composite cardiovascular events were 0.64 (95% CI 0.45-0.90) and 1.21 (95% CI 0.82-1.80) in patients with high and low SBP variability as defined by SD, respectively. Interaction between SBP variability and statin therapy was significant (P = 0.018). The analysis using ARV of SBP showed similar results.

CONCLUSION

Statin intensive therapy targeting LDL-C <70 mg/dl had benefits in primary prevention of cardiovascular events compared with standard therapy among T2DM patients with retinopathy having high, but not low, visit-to-visit SBP variability.

Seasonal variation in estimated cardiovascular risk in patients with type 2 diabetes

BACKGROUND AND AIMS

Seasonal variations in several risk factors for cardiovascular events (CVD) were described. Here, we evaluate the impact of seasonal variations in blood pressure (BP), lipid profile and glycemic control on estimated CVD risk in patients with type 2 diabetes (T2D).

METHODS AND RESULTS

Retrospective monocentric study of patients with T2D who were visited at least once in the winter period and once in the summer period, less than 8 months apart, for which data related to systolic (S) BP, diastolic (D) BP, body mass index, glycosylated hemoglobin (HbA1c), total cholesterol, HDL cholesterol and smoking habit were available on both occasions. The 10-year CVD risk was calculated using the UKPDS risk engine and the ASCVD risk estimator. As many as 411 patients were included in the study. Significant within-patient differences between summer and winter were found for the absolute risk of events assessed with both calculators (Δs-w UKPDS-CHD: -1.33%, Δs-w UKPDS-Stroke: -0.84%, Δs-w ASCVD: -2.21%). The seasonal change in SBP was the main responsible for the change in risk estimated with both the UKPDS-Stroke (r² = 0.43) and the ASCVD (r² = 0.50) scores, while the change in total cholesterol was the main determinant of the change in risk for the UKPDS-CHD (r² = 0.34). A significant correlation was identified between changes in temperature and changes in SBP (ρ = 0.130, p = 0.008), but not in other risk factors.

CONCLUSIONS

Seasonal variations in the classic CVD risk factors influence the risk estimated using validated calculators.

Structured hypertension education program for people with type 2 diabetes, the SHED study

OBJECTIVES

There is enough evidence that patient education and lifestyle modification has shown benefits in diabetes care, however the evidence is less for improving care of hypertension. Our study is the first in the UK to assess the impact of a structured hypertension education program in subjects with type 2 diabetes.

DESIGN

Prospective randomised controlled study.

SETTING AND INTERVENTION

From a diabetes clinic in a district and general hospital in UK 132 participants were equally randomised into intervention group and control group. Intervention included a once weekly education session for 4 weeks together with home blood pressure monitoring and dose changes in antihypertensives. Base line data was recorded with follow up after 3 and 6 months.

RESULTS

More participants achieved target BP in the intervention group versus control. This difference appeared early at the 3rd months (48.8% versus 20.4% respectively, p = 0.007) and remained at the 6th month (58.1% versus 20.4% respectively, p < 0.001). The change in number of pills was significantly lower in the intervention group. The mean increase in antihypertensive pills was 0.22 ± 0.48 (13 ± 30% increase) in the intervention group versus 0.62 ± 0.68 (41 ± 60% increase) in the routine group (p = 0.014), denoting less need to escalate treatment.

CONCLUSION

We demonstrated that our structured education program has led to a significantly higher percentage of participants achieving the BP target, early after intervention, together with a significant reduction in the number of antihypertensive pills.