Blood pressure variability with different measurement methods: Reliability and predictors. A proof of concept cross sectional study in elderly hypertensive hospitalized patients

Blood pressure variability associated with falls in nursing home residents

BACKGROUND

High variations in serially measured blood pressures (BPs) portend a variety of adverse clinical events including dementia, cardiovascular sequelae and frailty. In this study, systolic blood pressure variability (BPV) was examined for its association with fall frequency and time to next fall among older adults living in nursing homes.

METHODS

BP values and falls over time were extracted from medical records of nursing home residents aged ≥65 years over a 10-month period. BPV was measured as the standard deviation of 17 to 20 systolic values, and its correlation with falls and time to next fall were evaluated according to quartile values.

RESULTS

One hundred patient charts were analyzed with nearly 2000 BP data points. All older adults had at least one fall incident. Higher BPV was related to more falls, shorter time between the first and second fall and fewer average days between falls. Subgroups of high BP and different diagnoses affected this association between BPV and falls.

CONCLUSIONS

People who fall often show a high variability in BP; as the number of falls increases, the BPV also increases. This study suggests that BPV may be marker for patients who might benefit from more aggressive application of fall reduction strategies. Geriatr Gerontol Int 2024; ••: ••-••.

Reliability of beat-to-beat blood pressure variability in older adults

Blood pressure variability (BPV) is emerging as an important risk factor across numerous disease states, including cerebrovascular and neurodegenerative disease in older adults. However, there is no current consensus regarding specific use cases for the numerous available BPV metrics. There is also little published data supporting the ability to reliably measure BPV across metrics in older adults. The present study derived BPV metrics from continuous beat-to-beat blood pressure monitoring data. Two sequential 7 min waveforms were analyzed. Absolute and relative reliability testing was performed. Differences between antihypertensive medication users and non-users on BPV metric reliability was also assessed. All sequence and dispersion based BPV metrics displayed good test-retest reliability. A measure of BP instability displayed only moderate reliability. Systolic and diastolic average real variability displayed the highest levels of reliability at ICC = 0.87 and 0.82 respectively. Additionally, systolic average real variability was the most reliable metric in both the antihypertensive use group, and the no antihypertensive use group. In conclusion, beat-to-beat dispersion and sequence-based metrics of BPV can be reliably obtained in older adults using noninvasive continuous blood pressure monitoring. Average real variability may be the most reliable and specific beat-to-beat blood pressure variability metric due to its decreased susceptibility to outliers and low frequency blood pressure oscillations.

Beat-to-beat blood pressure variability, hippocampal atrophy, and memory impairment in older adults

Visit-to-visit blood pressure variability (BPV) predicts age-related hippocampal atrophy, neurodegeneration, and memory decline in older adults. Beat-to-beat BPV may represent a more reliable and efficient tool for prospective risk assessment, but it is unknown whether beat-to-beat BPV is similarly associated with hippocampal neurodegeneration, or with plasma markers of neuroaxonal/neuroglial injury. Independently living older adults without a history of dementia, stroke, or other major neurological disorders were recruited from the community (N = 104; age = 69.5 ± 6.7 (range 55-89); 63% female). Participants underwent continuous blood pressure monitoring, brain MRI, venipuncture, and cognitive testing over two visits. Hippocampal volumes, plasma neurofilament light, and glial fibrillary acidic protein levels were assessed. Beat-to-beat BPV was quantified as systolic blood pressure average real variability during 7-min of supine continuous blood pressure monitoring. The cross-sectional relationship between beat-to-beat BPV and hippocampal volumes, cognitive domain measures, and plasma biomarkers was assessed using multiple linear regression with adjustment for demographic covariates, vascular risk factors, and average systolic blood pressure. Elevated beat-to-beat BPV was associated with decreased left hippocampal volume (P = .008), increased plasma concentration of glial fibrillary acidic protein (P = .006), and decreased memory composite score (P = .02), independent of age, sex, average systolic blood pressure, total intracranial volume, and vascular risk factor burden. In summary, beat-to-beat BPV is independently associated with decreased left hippocampal volume, increased neuroglial injury, and worse memory ability. Findings are consistent with prior studies examining visit-to-visit BPV and suggest beat-to-beat BPV may be a useful marker of hemodynamic brain injury in older adults.

Regional cerebral oxygen saturation variability and brain injury in preterm infants

Objective

To examine whether variation of regional cerebral oxygen saturation (rScO2) within three days after delivery predicts development of brain injury (intraventricular/cerebellar hemorrhage or white matter injury) in preterm infants.

Study design

A prospective study of neonates <32 weeks gestational age with normal cranial ultrasound admitted between 2018 and 2022. All received rScO2 monitoring with near-infrared spectroscopy at admission up to 72 h of life. To assess brain injury a magnetic resonance imaging was performed at term-equivalent age. We assessed the association between rScO2 variability (short-term average real variability, rScO2ARV, and standard deviation, rScO2SD), mean rScO2 (rScO2MEAN), and percentage of time rScO2 spent below 60% (rScO2TIME<60%) during the first 72 h of life and brain injury.

Results

The median [IQR] time from birth to brain imaging was 68 [59-79] days. Of 81 neonates, 49 had some form of brain injury. Compared to neonates without injury, in those with injury rScO2ARV was higher during the first 24 h (P = 0.026); rScO2SD was higher at 24 and 72 h (P = 0.029 and P = 0.030, respectively), rScO2MEAN was lower at 48 h (P = 0.042), and rScO2TIME<60% was longer at 24, 48, and 72 h (P = 0.050, P = 0.041, and P = 0.009, respectively). Similar results were observed in multivariable logistic regression. Although not all results were statistically significant, increased rScO2 variability (rScO2ARV and rScO2SD) and lower mean values of rScO2 were associated with increased likelihood of brain injury.

Conclusions

In preterm infants increased aberration of rScO2 in early postdelivery period was associated with an increased likelihood of brain injury diagnosis at term-equivalent age.

Visit-to-visit blood pressure variability is associated with intrinsic capacity decline: Results from the MAPT Study

BACKGROUND

The effectiveness of the body physiological regulatory mechanisms declines in late life, and increased Blood Pressure Variability (BPV) may represent an alteration in cardiovascular homeostatic patterns. Intrinsic Capacity (IC) has been proposed by the World Health Organization as a marker of healthy aging, based on individual's functional abilities and intended at preserving successful aging. We aimed to investigate the association of visit-to-visit BPV with IC decline in a population of community-dwelling older adults.

METHODS

The study population consisted of 1407 community-dwelling participants aged ≥70 years from the MAPT study evaluated during the 5-year follow-up. Systolic BPV (SBPV) and diastolic BPV (DBPV) were determined through six indicators. Cognition, psychology, locomotion and vitality constituted the four IC domains assessed. Total IC Z-score resulted from the sum of the four domains Z-scores divided by 4. The incidence of domain impairment over time was also assessed.

RESULTS

Higher SBPV was significantly associated with poorer IC Z-scores in all linear mixed models [1-SD increase of CV%: β(SE)=-0.010(0.001), p < 0.01]. Similar results were observed for DBPV [1-SD increase of CV%: β(SE)=-0.003(0.001), p = 0.02]. Incident IC impairment was significantly higher in participants with greater SBPV, [HR=1.16 (95 % CI, 1.01-1.33), p = 0.03], while greater DBPV did not show a higher risk of incident IC impairment.

CONCLUSIONS

Greater BPV is associated with IC decline over time. Our findings support BP instability as a presumable index of altered cardiovascular homeostatic mechanism, suggesting that BPV might be a clinical marker of aging and addressable risk factor for promoting healthy aging.

Procedural blood pressure and contrast extravasation on dual energy computed tomography after endovascular stroke treatment

BACKGROUND

Blood brain barrier disruption (BBBD) can be visualized by contrast extravasation (CE) after endovascular treatment (EVT) in patients with acute ischemic stroke. Elevated blood pressure is a risk factor for BBBD. However, the association between procedural blood pressure and CE post-EVT is unknown.

METHODS

In this single-center retrospective study, we analyzed 501 eligible patients who received a dual energy CT (DECT) immediately post-EVT for acute ischemic stroke. Procedural blood pressure values (SBPmean, SBPmax, SBPmax-min, and MAPmean) were collected. CE was quantified by measuring the maximum parenchymal iodine concentration on DECT iodine overlay map reconstructions. As a measure for the extent of BBBD, we created CE-ASPECTS by deducting one point per hyperdense ASPECTS region on iodine overlay maps. The association between blood pressure and CE was assessed using multivariable linear regression.

RESULTS

The procedural SBPmean, SBPmax, and MAPmean were 150 ± 26 mmHg, 173 ± 29 mmHg, and 101 ± 17 mmHg, respectively. The median maximum iodine concentration on post-EVT DECT was 1.2 mg/ml (IQR 0.7-2.0), and median CE-ASPECTS was 8 (IQR 5-11). The maximum iodine concentration was not associated with blood pressure. SBPmean, SBPmax, and MAPmean were significantly associated with CE-ASPECTS (per 10 mmHg, β = -0.2, 95 % CI -0.31 to -0.09, β = -0.15, 95 % CI -0.25 to -0.06, β = -0.33, 95 % CI -0.49 to -0.17, respectively).

CONCLUSION

In acute ischemic stroke patients undergoing EVT, particularly in patients achieving successful recanalization, SBPmean, SBPmax, and MAPmean are associated with the extent of BBBD on immediate post-EVT DECT, but not with maximum iodine concentration.

A Population-Based Scoring System to Assess the Impact of Individual Risk Factors on Vascular Health

Arterial stiffness is an indicator of vascular health, influenced by both pathological conditions and physiological determinants, noticeably age. Augmentation index (AI) and pulse wave velocity (PWV) are used among others to assess arterial stiffness. Several risk factors may contribute to pathologically increase arterial stiffness and produce early vascular aging. Our study aims to assess the impact of individual risk factors on vascular health, evaluating the distribution of PWV and AI values in a cohort of adult people without modifiable cardiovascular risk factors while analyzing their role in accelerating vascular ageing. We performed a secondary analysis of a Swiss population-based research project, which took place in 2017 and 2018. Of the 1202 participants originally enrolled, 1097 were included in the final sample. The population was divided into without (n=388) and with risk factors (n=709), based on the presence of the following: smoking, diabetes, previous cardiovascular disease (CVD), chronic kidney disease stage 3 or more, LDL cholesterol ≥ 4.11 or treatment with hypolipidemic drugs, hypertension or treatment with antihypertensive drugs, and metabolic syndrome. Tonometric and oscillometric devices were employed to assess PWV, and the 75th percentiles of PWV and AI in the population without risk factors were calculated to identify cut-offs for the logistic regression analysis. We developed nomograms by assigning a numerical score to each independent prognostic factor; the total score estimating the probability of PWVs and AIs being over the defined cut-offs. Patients with hypertension, diabetes, and obesity showed higher PWV values (p < 0.001). In the univariate logistic regression, factors predictive for higher PWV values were diabetes, CVDs, hypercholesterolemia, and hypertension, while CVDs, antihyperlipidemic treatment, hypertension, and increased BMI were predictive in the multivariate logistic regression. Smoking did not significantly influence arterial stiffness parameters. The present study provides reference values for PWV and AI in subjects without modifiable cardiovascular risk factors and, through nomograms, a risk score stratification to assess the impact of individual risk factors on vascular health.

Reliability of beat-to-beat blood pressure variability in older adults

Blood pressure variability (BPV) is emerging as an important risk factor across numerous disease states, including cerebrovascular and neurodegenerative disease in older adults. However, there is no current consensus regarding specific use cases for the numerous available BPV metrics. There is also little published data supporting the ability to reliably measure BPV across metrics in older adults. BPV metrics were derived from continuous beat-to-beat blood pressure monitoring data. Two sequential 7-minute waveforms were analyzed. Absolute and relative reliability testing was performed. Differences between antihypertensive medication users and non-users on BPV metric reliability was also assessed. All sequence and dispersion based BPV metrics displayed good test-retest reliability. A measure of BP instability displayed only moderate reliability. Systolic and diastolic average real variability displayed the highest levels of reliability at ICC= .87 and .82 respectively. Additionally, systolic average real variability was the most reliable metric in both the antihypertensive use group, and the no antihypertensive use group. Beat-to-beat dispersion and sequence-based metrics of BPV can be reliably obtained from older adults using noninvasive continuous blood pressure monitoring. Average real variability may be the most reliable and specific beat-to-beat blood pressure variability metric due to its decreased susceptibility to outliers and low frequency blood pressure oscillations.

Ambulatory blood pressure monitoring in pheochromocytoma - paraganglioma: A single center experience

CONTEXT/AIMS

Pheochromocytoma and paraganglioma (PPGL) are rare tumors, and data on ambulatory blood pressure monitoring (ABPM) in these patients and the effect of blocking on ABPM parameters is limited. We aimed to describe ABPM parameters in a cohort of PPGL at our center in western India.

METHODS

Retrospective study of patients with PPGL whose ABPM data was available. Demographic details, secretory status, and ABPM data were retrieved. Coefficient of variability (CV) was calculated as standard deviation/mean in percentage.

RESULTS

In the 39 included patients, mean age at presentation was 39.3 ± 14.2 yr; 20 (51.3%) were males, 25 (64.1%) hypertensive, and mean tumor diameter was 5.3 cm. In 18 patients whose baseline ABPM was done without medications, those with nocturnal blood pressure dipping (6/18, 33%) had higher serum metanephrines (median 313.2 vs. 34.7 pg/ml, P = 0.028). Despite normal office blood pressure (BP), 8.9% of systolic BP readings were >140 mmHg, and 1.2% were >160 mmHg. Among 29 patients with both pre and post-block ABPM, mean BP (systolic 121.6 vs. 132.5 mmHg, P = 0.014; diastolic 68.9 vs. 76.4 mmHg, P = 0.005) and percentage of BP readings above 140 mmHg (median 9.4% vs. 24.4%, P = 0.016) were significantly lowered after the preoperative blockade in hypertensive ( n = 19) patients, whereas CV was similar. The post-blockade ABPM characteristics were similar in patients blocked with amlodipine or prazosin.

CONCLUSION

ABPM provides additional information about BP characteristics in PPGL. The preoperative blocking decreases the magnitude of BP excursions but does not affect BP variability.

Procedural Blood Pressure and Intracranial Hemorrhage on Dual-Energy Computed Tomography After Endovascular Stroke Treatment

PURPOSE

Optimal systolic blood pressure (SBP) management during endovascular treatment (EVT) for acute ischemic stroke remains a topic of debate. Though BP is associated with worse functional outcome, the relationship between BP and post-procedural intracranial hemorrhage (ICH) is less well-known. We aimed to investigate the association between BP during EVT and post-procedural ICH on dual-energy CT (DECT).

METHODS

We included all patients who underwent EVT for an anterior circulation large vessel occlusion between 2010 and 2019, and received DECT < 3 h post-EVT. All BP measurements during the EVT procedure were used to calculate mean arterial pressure (MAPmean), mean SBP (SBPmean), and SBPmax-min (highest minus lowest). ICH was assessed using virtual post-procedural unenhanced DECT reconstructions and classified as intraparenchymal or extraparenchymal. Symptomatic ICH was scored according to the Heidelberg criteria. The association between different BP parameters and ICH was assessed using multivariable logistic regression.

RESULTS

We included 478 patients. Seventy-six patients (16%) demonstrated ICH on DECT, of which 26 (34%) were intraparenchymal. Symptomatic intraparenchymal and extraparenchymal ICH occurred in 10 (38%) and 4 (8%) patients. SBPmax, SBPmean, and MAPmean were associated with intraparenchymal ICH with an adjusted odds ratio of 1.19 (95%CI, 1.02-1.39), 1.22 (95%CI, 1.03-1.46), and 1.40 (95%CI, 1.09-1.81) per 10 mmHg, while BP was not significantly associated with extraparenchymal ICH. BP did not differ between asymptomatic and symptomatic ICH.

CONCLUSION

Procedural BP is associated with intraparenchymal ICH on post-EVT DECT but not with extraparenchymal ICH. Future studies should evaluate whether individual procedural BP management reduces post-EVT ICH and improves clinical outcome.

Optimization of time interval for the measurement of plasma lipids for cardiovascular disease risk assessment

BACKGROUND

Lipid testing for atherosclerotic cardiovascular disease (ASCVD) risk is often performed every 4-6 years, but we hypothesized that the optimum time interval may vary depending on baseline risk.

RESEARCH DESIGN AND METHODS

Using lipid values and other risk factors from the National Health and Nutrition Examination Survey (NHANES) (n = 9,704), we calculated a 10-year risk score with the pooled-cohort equations. Future risk scores were predicted by increasing age and projecting systolic blood pressure (SBP) and lipid changes, using the mean-percentile age group change in NHANES for SBP (n = 17,329) and the Lifelines Cohort study for lipids (n = 133,540). The crossing of high and intermediate-risk thresholds were calculated by time to determine optimum intervals for lipid testing.

RESULTS

Time to crossing risk thresholds depends on baseline risk, but the mean increase in the risk score plateaus at 1% per year for those with a baseline 10-year risk greater than 15%. Based on these findings, we recommend the following maximum time intervals for lipid testing: baseline risk < 15%: 5-years, 16%: 4-years, 17%: 3-years, 18%: 2-years, and 19%: ≤1-year.

CONCLUSIONS

Testing patients for lipids who have a higher baseline risk more often could identify high-risk patients sooner, allowing for earlier and more effective therapeutic intervention.

A comparative analysis of ambulatory blood pressure characteristics in acute stroke and non-stroke Indian patients

OBJECTIVE

The objective of this study is to identify 24-h blood pressure (BP) characteristics after acute stroke in Indian hospitalized patients.

METHODS

In total, 769 patients [284 women (36.9%)] admitted at a hospital in South India were analyzed. Of these, 364 patients (47.3%) had recently experienced stroke. All patients underwent ambulatory blood pressure measurement (ABPM) so that ABPM patterns and ABPM risk parameters of stroke and non-stroke patients could be compared. Additionally, to investigate the relationship between ABPM parameters and stroke, a stepwise logistic regression analysis was employed.

RESULTS

Stroke patients had significantly higher BP than non-stroke patients (24-h ABP: 145.0 ± 22.1 vs. 133.7 ± 20.5 mmHg, P < 0.001), with similar dipping status. ABPM parameters mostly associated with stroke (all P < 0.001) were: nighttime [odds ratios (OR): 1.587, 95% confidence interval (95% CI): 1.341-1.885], 24-h (1.584, 1.34-1.881), minimum nighttime (1.582, 1.339-1.879), daytime (1.540, 1.304-1.827), and morning SBP (1.517, 1.287-1.797). Non-dipping status was relatively more common in stroke patients (79% vs. 71%, P < 0.05) but dipping percentage did not show a significant linear relationship with stroke.

CONCLUSION

Several ABPM characteristics were strongly associated with stroke in Indian hospitalized patients. Specifically, minimum nighttime and average morning SBP may be considered as important and practical parameters for its relationship with stroke.

Use of Antihypertensives, Blood Pressure, and Estimated Risk of Dementia in Late Life: An Individual Participant Data Meta-Analysis

Importance

The utility of antihypertensives and ideal blood pressure (BP) for dementia prevention in late life remains unclear and highly contested.

Objectives

To assess the associations of hypertension history, antihypertensive use, and baseline measured BP in late life (age >60 years) with dementia and the moderating factors of age, sex, and racial group.

Data Source and Study Selection

Longitudinal, population-based studies of aging participating in the Cohort Studies of Memory in an International Consortium (COSMIC) group were included. Participants were individuals without dementia at baseline aged 60 to 110 years and were based in 15 different countries (US, Brazil, Australia, China, Korea, Singapore, Central African Republic, Republic of Congo, Nigeria, Germany, Spain, Italy, France, Sweden, and Greece).

Data Extraction and Synthesis

Participants were grouped in 3 categories based on previous diagnosis of hypertension and baseline antihypertensive use: healthy controls, treated hypertension, and untreated hypertension. Baseline systolic BP (SBP) and diastolic BP (DBP) were treated as continuous variables. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-Analyses of Individual Participant Data reporting guidelines.

Main Outcomes and Measures

The key outcome was all-cause dementia. Mixed-effects Cox proportional hazards models were used to assess the associations between the exposures and the key outcome variable. The association between dementia and baseline BP was modeled using nonlinear natural splines. The main analysis was a partially adjusted Cox proportional hazards model controlling for age, age squared, sex, education, racial group, and a random effect for study. Sensitivity analyses included a fully adjusted analysis, a restricted analysis of those individuals with more than 5 years of follow-up data, and models examining the moderating factors of age, sex, and racial group.

Results

The analysis included 17 studies with 34 519 community dwelling older adults (20 160 [58.4%] female) with a mean (SD) age of 72.5 (7.5) years and a mean (SD) follow-up of 4.3 (4.3) years. In the main, partially adjusted analysis including 14 studies, individuals with untreated hypertension had a 42% increased risk of dementia compared with healthy controls (hazard ratio [HR], 1.42; 95% CI 1.15-1.76; P = .001) and 26% increased risk compared with individuals with treated hypertension (HR, 1.26; 95% CI, 1.03-1.53; P = .02). Individuals with treated hypertension had no significant increased dementia risk compared with healthy controls (HR, 1.13; 95% CI, 0.99-1.28; P = .07). The association of antihypertensive use or hypertension status with dementia did not vary with baseline BP. There was no significant association of baseline SBP or DBP with dementia risk in any of the analyses. There were no significant interactions with age, sex, or racial group for any of the analyses.

Conclusions and Relevance

This individual patient data meta-analysis of longitudinal cohort studies found that antihypertensive use was associated with decreased dementia risk compared with individuals with untreated hypertension through all ages in late life. Individuals with treated hypertension had no increased risk of dementia compared with healthy controls.

The sine transform is the sine qua non of the pulmonary and systemic pressure relationship

Assessment of therapeutic interventions in patients with pulmonary arterial hypertension (PAH) suffers from several commonly encountered limitations: (1) patient studies are often too small and short-term to provide definitive conclusions, (2) there is a lack of a universal set of metrics to adequately assess therapy and (3) while clinical treatments focus on management of symptoms, there remain many cases of early loss of life in a seemingly arbitrary distribution. Here we provide a unified approach to assess right and left pressure relationships in PAH and pulmonary hypertension (PH) patients by developing linear models informed by the observation of Suga and Sugawa that pressure generation in the ventricle (right or left) approximately follows a single lobe of a sinusoid. We sought to identify a set of cardiovascular variables that either linearly or via a sine transformation related to systolic pulmonary arterial pressure (PAPs) and systemic systolic blood pressure (SBP). Importantly, both right and left cardiovascular variables are included in each linear model. Using non-invasively obtained cardiovascular magnetic resonance (CMR) image metrics the approach was successfully applied to model PAPs in PAH patients with an r2 of 0.89 (p < 0.05) and SBP with an r2 of 0.74 (p < 0.05). Further, the approach clarified the relationships that exist between PAPs and SBP separately for PAH and PH patients, and these relationships were used to distinguish PAH vs. PH patients with good accuracy (68%, p < 0.05). An important feature of the linear models is that they demonstrate that right and left ventricular conditions interact to generate PAPs and SBP in PAH patients, even in the absence of left-sided disease. The models predicted a theoretical right ventricular pulsatile reserve that in PAH patients was shown to be predictive of the 6 min walk distance (r2 = 0.45, p < 0.05). The linear models indicate a physically plausible mode of interaction between right and left ventricles and provides a means of assessing right and left cardiac status as they relate to PAPs and SBP. The linear models have potential to allow assessment of the detailed physiologic effects of therapy in PAH and PH patients and may thus permit cross-over of knowledge between PH and PAH clinical trials.

Blood Pressure Variability in Clinical Practice: Past, Present and the Future

Recent advances in wearable technology through convenient and cuffless systems will enable continuous, noninvasive monitoring of blood pressure (BP), heart rate, and heart rhythm on both longitudinal 24-hour measurement scales and high-frequency beat-to-beat BP variability and synchronous heart rate variability and changes in underlying heart rhythm. Clinically, BP variability is classified into 4 main types on the basis of the duration of monitoring time: very-short-term (beat to beat), short-term (within 24 hours), medium-term (within days), and long-term (over months and years). BP variability is a strong risk factor for cardiovascular diseases, chronic kidney disease, cognitive decline, and mental illness. The diagnostic and therapeutic value of measuring and controlling BP variability may offer critical targets in addition to lowering mean BP in hypertensive populations.

Blood pressure variability: methodological aspects, clinical relevance and practical indications for management - a European Society of Hypertension position paper ∗

Blood pressure is not a static parameter, but rather undergoes continuous fluctuations over time, as a result of the interaction between environmental and behavioural factors on one side and intrinsic cardiovascular regulatory mechanisms on the other side. Increased blood pressure variability (BPV) may indicate an impaired cardiovascular regulation and may represent a cardiovascular risk factor itself, having been associated with increased all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia incidence. Nonetheless, BPV was considered only a research issue in previous hypertension management guidelines, because the available evidence on its clinical relevance presents several gaps and is based on heterogeneous studies with limited standardization of methods for BPV assessment. The aim of this position paper, with contributions from members of the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and from a number of international experts, is to summarize the available evidence in the field of BPV assessment methodology and clinical applications and to provide practical indications on how to measure and interpret BPV in research and clinical settings based on currently available data. Pending issues and clinical and methodological recommendations supported by available evidence are also reported. The information provided by this paper should contribute to a better standardization of future studies on BPV, but should also provide clinicians with some indications on how BPV can be managed based on currently available data.

Comparison of Blood Pressure Variability among Clinical Subtypes in Irritable Bowel Syndrome Patients with Hypertension

Objective: In this study, we aimed to compare blood pressure variability among irritable bowel syndrome subtypes. Methods: Patients with newly diagnosed irritable bowel syndrome and existing hypertension were included in the study. Average real variability (ARV) was calculated by consecutive one week home blood pressure measurements. Groups were compared for blood pressure variability. Results: While diastolic ARV was found to be similar among subtypes (p=0.919), a significant difference was found between them in terms of systolic ARV (p&lt;0.001). Conclusion: Since irritable bowel syndrome patients with constipation-predominant subtype have higher systolic blood pressure variability, these patients can be followed more closely for cardiovascular complications.

Treatment and Implications of Vascular Endothelial Growth Factor Inhibitor-Induced Blood Pressure Rise: A Clinical Cohort Study

Background Anti-cancer vascular endothelial growth factor inhibitors (VEGFI) frequently induce a rise in blood pressure (BP). The most effective treatment of this BP rise is currently unknown, and risk factors and its association with survival remain inconclusive. Methods and Results Baseline characteristics and BP readings were retrospectively collected from oncology patients who received oral VEGFI treatment (sorafenib, sunitinib, pazopanib, regorafenib, lenvatinib, or cabozantinib). Risk factors for a clinically relevant BP rise (increase of ≥20 mm Hg in systolic BP or ≥10 mm Hg in diastolic BP) were investigated via logistic regression (relative), efficacy of antihypertensives via unpaired t-tests, and association of BP rise with survival via Cox regression analysis. In total, 162 (47%) of 343 included patients developed a clinically relevant BP rise ≥7 days after VEGFI treatment initiation. Both calcium channel blockers and renin-angiotensin system inhibitors effectively reduced systolic BP (-24.1 and -18.2 mm Hg, respectively) and diastolic BP (-12.0 and -11.0 mm Hg, respectively). Pazopanib therapy (odds ratio, 2.71 [95% CI, 1.35-5.42; P=0.005], compared with sorafenib) and estimated glomerular filtration rate <60 mL/min per 1.73 m² (OR, 1.75 [95% CI, 0.99-3.18, P=0.054]) were risk factors for a BP rise, whereas a baseline BP ≥140/90 mm Hg associated with a lower risk (OR, 0.39 [95% CI, 0.25-0.62, P<0.001]). Only for renal cell carcinoma, BP rise was associated with a substantially improved median overall survival compared with no BP rise: 45.4 versus 20.3 months, respectively, P=0.003. Conclusions The type of VEGFI, baseline BP, and baseline estimated glomerular filtration rate determine the VEGFI-induced BP rise. Both calcium channel blockers and renin-angiotensin system inhibitors are effective antihypertensive treatments. Particularly in patients with renal cell carcinoma, a BP rise is associated with improved overall survival.

Biomarkers of mitochondrial dysfunction and inflammaging in older adults and blood pressure variability

Most physiopathological mechanisms underlying blood pressure variability (BPV) are implicated in aging. Vascular aging is associated with chronic low-grade inflammation occurring in late life, known as "inflammaging" and the hallmark "mitochondrial dysfunction" due to age-related stress. We aimed to determine whether plasma levels of the pleiotropic stress-related mitokine growth/differentiation factor 15 (GDF-15) and two inflammatory biomarkers, interleukin 6 (IL-6) and tumor necrosis factor receptor 1 (TNFR-1), are associated with visit-to-visit BPV in a population of community-dwelling older adults. The study population consisted of 1096 community-dwelling participants [median age 75 (72-78) years; 699 females, 63.7%] aged ≥ 70 years from the MAPT study. Plasma blood sample was collected 12 months after enrolment and BP was assessed up to seven times over a 4-year period. Systolic (SBPV) and diastolic BPV (DBPV) were determined through several indicators taking into account BP change over time, the order of measurements and formulas independent of mean BP levels. Higher values of GDF-15 were significantly associated with increased SBPV (all indicators) after adjustment for relevant covariates [adjusted 1-SD increase in GDF-15: β (SE) = 0.07 (0.04), p < 0.044, for coefficient of variation%]. GDF-15 levels were not associated with DBPV. No significant associations were found between IL-6 and BPV, whereas TNFR1 was only partially related to DBPV. Unlike inflammation biomarkers, higher GDF-15 levels were associated with greater SBPV. Our findings support the age-related process of mitochondrial dysfunction underlying BP instability, suggesting that BPV might be a potential marker of aging.

Effect of 3, 2-Drug Combinations of Antihypertensive Therapies on Blood Pressure Variability in Black African Patients: Secondary Analyses of the CREOLE Trial

Background:

The effect of 3 commonly recommended combinations of anti-hypertensive agents—amlodipine plus hydrochlorothiazide (calcium channel blocker [CCB]+thiazide), amlodipine plus perindopril (CCB+ACE [angiotensin-converting enzyme]-inhibitor), and perindopril plus hydrochlorothiazide (ACE-inhibitor+thiazide) on blood pressure variability (V) are unknown.

Methods:

We calculated the blood pressure variability (BPV) in 405 patients (130, 146, and 129 randomized to ACE-inhibitor+thiazide, CCB+thiazide, and CCB+ACE-inhibitor, respectively) who underwent ambulatory blood pressure monitoring after 6 months of treatment in the Comparisons of Three Combinations Therapies in Lowering Blood Pressure in Black Africans trial (CREOLE) of Black African patients. BPV was calculated using the SD of 30-minute interval values for 24-hour ambulatory BPs and for confirmation using the coefficient of variation. Linear mixed model regression was used to calculate mean differences in BPV between treatment arms. Within-clinic BPV was also calculated from the mean SD and coefficient of variation of 3 readings at clinic visits.

Results:

Baseline distributions of age, sex, and blood pressure parameters were similar across treatment groups. Participants were predominately male (62.2%) with mean age 50.4 years. Those taking CCB+thiazide had significantly reduced ambulatory systolic and diastolic BPV compared with those taking ACE-inhibitor+thiazide. The CCB+thiazide and CCB+ACE-inhibitor groups showed similar BPV. Similar patterns of BPV were apparent among groups using within-clinic blood pressures and when assessed by coefficient of variation.

Conclusions:

Compared with CCB-containing combinations, ACE-inhibitor plus thiazide was associated with higher levels, generally significant, of ambulatory and within-clinic systolic and diastolic BPV. These results supplement the differential ambulatory blood pressure–lowering effects of these therapies in the CREOLE trial.

Isometric handgrip exercise impacts only on very short-term blood pressure variability, but not on short-term blood pressure variability in hypertensive individuals: A randomized controlled trial

Background: The effect of a single isometric handgrip exercise (IHG) on blood pressure (BP) variability (BPV) has not been addressed. This randomized controlled trial evaluated the effect of IHG vs. sham on BPV and BP. Methods: Hypertensive patients using up to two BP-lowering medications were randomly assigned to IHG (4 × 2 min; 30% of maximal voluntary contraction, MVC, with 1 min rest between sets, unilateral) or sham (protocol; 0.3% of MVC). Systolic and diastolic BP were assessed beat-to-beat in the laboratory before, during, and post-intervention and also using 24-h ambulatory BP monitoring (ABPM). BPV was expressed as average real variability (ARV) and standard deviation (SD). Results: Laboratory BPV, ARV and SD variability, had marked increase during the intervention, but not in the sham group, decreasing in the post-intervention recovery period. The overall change in ARV from pre- to 15 min post-intervention were 0.27 ± 0.07 (IHG) vs. 0.05 ± 0.15 (sham group), with a statistically significant p-value for interaction. Similarly, mean systolic BP increased during the intervention (IHG 165.4 ± 4.5 vs. sham 152.4 ± 3.5 mmHg; p = 0.02) as did diastolic BP (104.0 ± 2.5 vs. 90.5 ± 1.7 mmHg, respectively; p < 0.001) and decreased afterward. However, neither the short-term BPV nor BP assessed by ABPM reached statistically significant differences between groups. Conclusion: A single session of IHG reduces very short-term variability but does not affect short-term variability. IHG promotes PEH in the laboratory, but does not sustain 24-h systolic and diastolic PEH beyond the recovery period.

Multiparametric cloth-based wearable, SimpleSense, estimates blood pressure

Targeted maintenance of blood pressure for hypertensive patients requires accurate monitoring of blood pressure at home. Use of multiparametric vital signs ECG, heart sounds, and thoracic impedance for blood pressure estimation at home has not been reported previously. In an observational multi-site study, 120 subjects (female (N = 61, 52%)) between 18 and 83 years of age were recruited with the following stratification (Normal (20%), prehypertensive (37%), stage 1(26%), and stage 2 (18%). From these subjects, 1686 measurements of blood pressure from a sphygmomanometer were associated with simultaneously acquired signals from the SimpleSense device. An ensemble of tree-based models was trained with inputs as metrics derived from the multiparametric and patient demographics data. A test Mean Absolute Difference (MAD) of ± 6.38 mm of Hg and ± 5.10 mm of Hg were obtained for systolic and diastolic blood pressures (SBP; DBP), respectively. Comparatively, the MAD for wrist-worn blood pressure cuff OMRON BP6350 (GUDID—10073796266353) was ± 8.92 mm of Hg and ± 6.86 mm of Hg, respectively. Machine learning models trained to use multiparametric data can monitor SBP and DBP without the need for calibration, and with accuracy levels comparable to at-home cuff-based blood pressure monitors.

The Effect of Blood Pressure Variability on Coronary Atherosclerosis Plaques

Hypertension is one of the most important risk factors for coronary heart disease (CHD). The regulation of blood pressure plays a significant role in the development and prognosis of CHD. Blood pressure variability (BPV) refers to the degree of fluctuation of blood pressure over a period of time and is an important indicator of blood pressure stability. Blood pressure fluctuations are complex physiological phenomena, being affected by physiological and pharmacological effects and regulated by behavioral, environmental, hydrodynamic, and neural factors. According to the different time periods for measuring BPV, it can be divided into very short-term, short-term, mid-term, and long-term. Multiple cardiovascular disease animal models and clinical experiments have consistently indicated that abnormal BPV is closely related to coronary events and is a risk factor for CHD independently of average blood pressure. Thrombosis secondary to plaque rupture (PR) or plaque erosion can cause varying blood flow impairment, which is the main pathological basis of CHD. Plaque morphology and composition can influence the clinical outcome, treatment, and prognosis of patients with CHD. Research has shown that PR is more easily induced by hypertension. After adjusting for the traditional factors associated with plaque development, in recent years, some new discoveries have been made on the influence of abnormal BPV on the morphology and composition of coronary plaques and related mechanisms, including inflammation and hemodynamics. This article reviews the impact of BPV on coronary plaques and their related mechanisms, with a view to prevent the occurrence and development of CHD by controlling BPV and to provide new prevention and treatment strategies for the clinical treatment of abnormal blood pressure.

Blood pressure variability assessed by office, home, and ambulatory measurements: comparison, agreement, and determinants

The present study compared the blood pressure variability (BPV) among office (OBP), home (HBP), and ambulatory blood pressure (ABP) measurements and assessed their determinants, as well as their agreement in identifying individuals with high BPV. Individuals attending a hypertension clinic had OBP measurements (2-3 visits) and underwent HBP monitoring (3-7 days, duplicate morning and evening measurements) and ABP monitoring (24 h, 20-min intervals). BPV was quantified using the standard deviation (SD), coefficient of variation (CV), and variability independent of the mean (VIM) using all BP readings obtained by each method. A total of 626 participants were analyzed (age 52.8 ± 12.0 years, 57.7% males, 33.1% treated). Systolic BPV was usually higher than diastolic BPV, and out-of-office BPV was higher than office BPV, with ambulatory BPV giving the highest values. BPV was higher in women than men, yet it was not different between untreated and treated individuals. Associations among BPV indices assessed using different measurement methods were weak (r 0.1-0.3) but were stronger between out-of-office BPV indices. The agreement between methods in detecting individuals with high BPV was low (30-40%) but was higher between out-of-office BPV indices. Older age was an independent determinant of increased OBP variability. Older age, female sex, smoking, and overweight/obesity were determinants of increased out-of-office BPV. These data suggest that BPV differs with different BP measurement methods, reflecting different pathophysiological phenomena, whereas the selection of the BPV index is less important. Office and out-of-office BP measurements appear to be complementary methods in assessing BPV.

Neurovascular Compression in Arterial Hypertension: Correlation of Clinical Data to 3D-Visualizations of MRI-Findings

Aims:

In this study, we attempted to identify clinical parameters predicting the absence or presence of Neurovascular Compression (NVC) at the Ventrolateral Medulla (VLM) in arterial hypertension (HTN) in MRI findings.

Background:

Cardiovascular and pulmonary afferences are transmitted through the left vagus and glossopharyngeal nerve to the brain stem and vasoactive centers. Evidence supports the association between HTN and NVC at the left VLM. Several independent studies indicate a reduction of HTN after Microvascular Decompression (MVD) of the left. Several independent studies indicate a reduction of HTN after Microvascular Decompression (MVD) of the left VLM. Image processing of MRI provides comprehensible detection of NVC. HTN affects hemodynamic parameters and organs.

Objective:

This study analyzes and correlates clinical data and MRI findings in patients with and without NVC at the VLM in treatment resistant HTN to obtain possible selection criteria for neurogenic hypertension.

Methods:

In 44 patients with treatment resistant HTN, we compared MRI findings of neurovascular imaging to demographic, clinical and lifestyle data, office and 24-hour ambulatory Blood Pressure (BP), and cardiovascular imaging and parameters.

Results:

Twenty-nine (66%) patients had evidence of NVC at the VLM in MRI. Sixteen patients (36%) had unilateral NVC on the left side, 7 (16%) unilateral right and 6 (14%) bilateral NVC. Fifteen (34%) had no evidence of NVC at the VLM. Patients with left sided NVC were significantly younger, than those without NVC (p=0.034). They showed a statistically significant variance in daytime (p=0.020) and nighttime diastolic BP (p<0.001) as the mean arterial pressure (p=0.020). Other measured parameters did not show significant differences between the two groups.

Conclusion:

We suggest to examine young adults with treatment resistant HTN for the presence of NVC at VLM, before signs of permanent organ damage appear. Clinical and hemodynamic parameters did not emerge as selection criteria to predict NVC. MVD as a surgical treatment of NVC in HTN is not routine yet as a surgical treatment of NVC in HTN is not routine yet. Detection of NVC by imaging and image processing remains the only criteria to suggest MVD, which should be indicated on an individual decision.

Exploring the accuracy and precision of BP measurements

ABSTRACT

Accurate and precise BP measurements are crucial to clinical decision-making and interventions as healthcare professionals aim to prevent complications from hypertension, yet the literature provides no gold standard for measuring BP. This article discusses the additional research necessary to develop best practices and improve patient outcomes.

Beat-to-beat blood pressure variability: an early predictor of disease and cardiovascular risk

Blood pressure (BP) varies on the long, short and very-short term. Owing to the hidden physiological and pathological information present in BP time-series, increasing interest has been given to the study of continuous, beat-to-beat BP variability (BPV) using invasive and noninvasive methods. Different linear and nonlinear parameters of variability are employed in the characterization of BP signals in health and disease. Although linear parameters of beat-to-beat BPV are mainly measures of dispersion, such as standard deviation (SD), nonlinear parameters of BPV quantify the degree of complexity/irregularity- using measures of entropy or self-similarity/correlation. In this review, we summarize the value of linear and nonlinear parameters in reflecting different information about the pathophysiology of changes in beat-to-beat BPV independent of or superior to mean BP. We then provide a comparison of the relative power of linear and nonlinear parameters of beat-to-beat BPV in detecting early and subtle differences in various states. The practical advantage and utility of beat-to-beat BPV monitoring support its incorporation into routine clinical practices.