Awake Blood Pressure Variability, Inflammatory Markers and Target Organ Damage in Newly Diagnosed Hypertension

Cardiovascular variability, sociodemographics, and biomarkers of disease: the MIDUS study

Introduction: Like heart rate, blood pressure (BP) is not steady but varies over intervals as long as months to as short as consecutive cardiac cycles. This blood pressure variability (BPV) consists of regularly occurring oscillations as well as less well-organized changes and typically is computed as the standard deviation of multiple clinic visit-to-visit (VVV-BP) measures or from 24-h ambulatory BP recordings (ABPV). BP also varies on a beat-to-beat basis, quantified by methods that parse variation into discrete bins, e.g., low frequency (0.04-0.15 Hz, LF). However, beat-to-beat BPV requires continuous recordings that are not easily acquired. As a result, we know little about the relationship between LF-BPV and basic sociodemographic characteristics such as age, sex, and race and clinical conditions. Methods: We computed LF-BPV during an 11-min resting period in 2,118 participants in the Midlife in the US (MIDUS) study. Results: LF-BPV was negatively associated with age, greater in men than women, and unrelated to race or socioeconomic status. It was greater in participants with hypertension but unrelated to hyperlipidemia, hypertriglyceridemia, diabetes, elevated CRP, or obesity. LF-diastolic BPV (DBPV), but not-systolic BPV (SBPV), was negatively correlated with IL-6 and s-ICAM and positively correlated with urinary epinephrine and cortisol. Finally, LF-DBPV was negatively associated with mortality, an effect was rendered nonsignificant by adjustment by age but not other sociodemographic characteristics. Discussion: These findings, the first from a large, national sample, suggest that LF-BPV differs significantly from VVV-BP and ABPV. Confirming its relationship to sociodemographic risk factors and clinical outcomes requires further study with large and representative samples.

The relationship between the systemic immune-inflammation index and reverse-dipper circadian pattern in newly diagnosed hypertensive patients

Although hypertension is considered high intravascular pressure, impairing circadian blood pressure (BP) has been shown to potentially contribute to poor clinical outcomes. Systemic immune-inflammation index (SII), based on platelet, neutrophil, and lymphocyte counts, has been established as a strong prognostic marker in cardiovascular disease. The role of inflammation in the pathogenesis of hypertension is a well-known issue and inflammatory markers are associated with BP variability. We aimed to investigate whether there is a relationship between circadian BP changes and SII in newly diagnosed hypertensive patients. The study population consisted of 196 newly diagnosed hypertensive patients without LVH. In total, 76 (38%) patients had a dipper BP pattern, 60 (31%) patients had a non-dipper BP pattern, and 60 (31%) patients had a reverse-dipper BP pattern. SII was calculated according to Multivariate logistic regression analysis revealed SII and HDL-C as an independent predictors of reverse-dipper circadian pattern in newly diagnosed hypertensive patients. The cut-off value of the SII for reverse-dipper hypertension in a ROC curve analysis was >639.73 with 63.3% sensitivity and 84.2% specificity. Our study showed that the SII level was higher in the reverse-dipper hypertension patient group than in the dipper and non-dipper hypertension groups. Furthermore, SII was an independent predictor of newly diagnosed reverse-dipper hypertensive patients. The high SII value in newly diagnosed hypertensive patients can be used as an early warning parameter to identify reverse-dipper hypertension patients.

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.

Systemic Immune-Inflammation Index: A Novel Predictor for Non-dipper Hypertension

Introduction

The non-dipper hypertension (HT) pattern is associated with more end-organ damage and cardiovascular events than is dipper HT. Inflammation is widely established to play a role in the pathophysiology of HT. Recently, a new inflammatory and prognostic marker called the systemic immune-inflammation index (SII) has emerged. Our goal is to determine whether there is a relationship between non-dipper HT and SII.

Methods

Our study is a single-center retrospective and ninety-one patients with HT were included. All patients were analyzed with simultaneous 24-hour ambulatory blood pressure monitoring and laboratory parameters. Thirty-five patients had dipper HT while 56 patients had non-dipper HT. SII was calculated according to neutrophil, platelet, and lymphocyte counts.

Results

The median age was 48 (45-61 interquartile range (IQR)) in the non-dipper HT group, whereas it was 54 (44-64 IQR) in the dipper HT group. Although the neutrophil level, neutrophil-lymphocyte ratio, platelet lymphocyte ratio, SII, sleeping systolic blood pressure (BP), and sleeping diastolic BP were higher (p=0.020, p=0.041, p=0.046, p=0.019, p<0.001, and p=0.001, respectively) in the non-dipper HT group, the lymphocyte level was lower (p=0.040). A multivariate logistic regression model shows that SII (odds ratio (OR)=1.023, 95% confidence interval (CI)=1.002-1.112, p=0.012) may be an independent predictor of non-dipper HT.

Conclusion

Our study showed that the SII level was higher in the non-dipper HT patient group than in the dipper HT group. Furthermore, SII was an independent predictor of non-dipper HT. The high SII value in hypertension patients can be used as an early warning parameter to identify non-dipper HT patients.

Hypertension and cognitive function: a review of life-course factors and disparities

PURPOSE OF REVIEW

Dementia is a life-course condition with modifiable risk factors many from cardiovascular (CV) origin, and disproportionally affects some race/ethnic groups and underserved communities in the USA. Hypertension (HTN) is the most common preventable and treatable condition that increases the risk for dementia and exacerbates dementia pathology. Epidemiological studies beginning in midlife provide strong evidence for this association. This study provides an overview of the differences in the associations across the lifespan, and the role of social determinants of health (SDoH).

RECENT FINDINGS

Clinical trials support HTN management in midlife as an avenue to lower the risk for late-life cognitive decline. However, the association between HTN and cognition differs over the life course. SDoH including higher education modify the association between HTN and cognition which may differ by race and ethnicity. The role of blood pressure (BP) variability, interactions among CV risk factors, and cognitive assessment modalities may provide information to better understand the relationship between HTN and cognition.

SUMMARY

Adopting a life-course approach that considers SDoH, may help develop tailored interventions to manage HTN and prevent dementia syndromes. Where clinical trials to assess BP management from childhood to late-life are not feasible, observational studies remain the best available evidence.

Visit-to-visit blood pressure variability and the risk of stroke in the Netherlands: A population-based cohort study

BACKGROUND

Apart from blood pressure level itself, variation in blood pressure has been implicated in the development of stroke in subgroups at high cardiovascular risk. We determined the association between visit-to-visit blood pressure variability and stroke risk in the general population, taking into account the size and direction of variation and several time intervals prior to stroke diagnosis.

METHODS AND FINDINGS

From 1990 to 2016, we included 9,958 stroke-free participants of the population-based Rotterdam Study in the Netherlands. This is a prospective cohort study including participants aged 45 years and older. Systolic blood pressure (SBP) variability was calculated as absolute SBP difference divided by mean SBP over 2 sequential visits (median 4.6 years apart). Directional SBP variability was defined as SBP difference over 2 visits divided by mean SBP. Using time-varying Cox proportional hazards models adjusted for age, sex, mean SBP, and cardiovascular risk factors, hazard ratios (HRs) for stroke up to January 2016 were estimated per SD increase and in tertiles of variability. We also conducted analyses with 3-, 6-, and 9-year intervals between variability measurement and stroke assessment. These analyses were repeated for diastolic blood pressure (DBP). The mean age of the study population was 67.4 ± 8.2 years and 5,776 (58.0%) were women. During a median follow-up of 10.1 years, 971 (9.8%) participants had a stroke, including 641 ischemic, 89 hemorrhagic, and 241 unspecified strokes. SBP variability was associated with an increased risk of hemorrhagic stroke (HR per SD 1.27, 95% CI 1.05-1.54, p = 0.02) and unspecified stroke (HR per SD 1.21, 95% CI 1.09-1.34, p < 0.001). The associations were stronger for all stroke subtypes with longer time intervals; the HR for any stroke was 1.29 (95% CI 1.21-1.36, p < 0.001) at 3 years, 1.47 (95% CI 1.35-1.59, p < 0.001) at 6 years, and 1.38 (95%CI 1.24-1.51, p < 0.001) at 9 years. For DBP variability, we found an association with unspecified stroke risk. Both the rise and fall of SBP and the fall of DBP were associated with an increased risk for unspecified stroke. Limitations of the study include that, due to an average interval of 4 years between visits, our findings may not be generalizable to blood pressure variability over shorter periods.

CONCLUSIONS

In this population-based study, we found that visit-to-visit blood pressure variation was associated with an increased risk of unspecified and hemorrhagic stroke, independent of direction of variation or mean blood pressure.

Are Differences in Inflammatory Markers between Patients with and without Hypertension-Mediated Organ Damage Influenced by Circadian Blood Pressure Abnormalities?

We aimed to explore the influence that the circadian blood pressure (BP) profile could exert on the correlation between some inflammatory markers and hypertension-mediated organ damage (HMOD). This was a cross-sectional study that included patients with primary arterial hypertension older than 18 years old. We included some parameters of 24 h ambulatory blood pressure monitoring collection and several inflammatory markers, as follows: platelet count (PTC), erythrocyte sedimentation rate (ESR), ultrasensitive C-reactive-protein, ferritin, fibrinogen, and uric acid. Myocardial hypertrophy, albuminuria, carotid intima-media thicknesses and ankle brachial index were assessed as HMOD presentations. Individuals were divided into two groups: patients with and without HMOD. We included 522 patients (47% women, mean age of 54 years). Multivariate logistic regression analysis showed that male patients older than 50 years old with uric acid levels above 7 mg/dL, ESR higher than 20 mm/h, fibrinogen greater than 320 mg/dL and PTC lower than 275 × 103/µL were associated with HMOD (p < 0.05). The circadian BP profile (dipper versus non-dipper pattern) did reach neither statistical significance nor influence the odds ratio of those inflammatory markers for HMOD. We found that differences in some inflammatory markers between patients with and without HMOD were not explained by a different circadian BP profile.

E-Selectin Is Associated with Daytime and 24-Hour Diastolic Blood Pressure Variability in Type 2 Diabetes

E-selectin is an endothelial cell adhesion molecule involved in vascular inflammation. Elevated E-selectin has been reported in patients with high blood pressure and diabetes. Given the increasing clinical relevance of parameters derived from ambulatory blood pressure monitoring, further investigation of their relationships with E-selectin is of interest. In this study, we aimed to investigate the association between serum E-selectin, office blood pressure and 24 h ambulatory blood pressure parameters in patients with type 2 diabetes. Blood pressure variability was assessed by computing the standard deviation of mean systolic and diastolic blood pressure separately for daytime and nighttime during 24 h ambulatory blood pressure monitoring in a cohort of patients with type 2 diabetes (n = 132). Additionally, were assessed nighttime systolic dipping and pulse pressure separately for daytime, nighttime, and 24 h. Serum E-selectin was measured using the enzyme-linked immunosorbent assay technique. We found that E-selectin was consistently associated with 24 h diastolic blood pressure variability (r = 0.238; p = 0.019) and daytime diastolic blood pressure variability (r = 0.258; p = 0.012), after adjustment for confounding factors. No association of E-selectin with office blood pressure and other 24 h ambulatory blood pressure parameters was observed. In conclusion, endothelial activation indicated by elevated serum E-selectin is associated with increased ambulatory diastolic blood pressure variability in patients with type 2 diabetes.

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

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

Can Systemic Immune-Inflammation Index Detect the Presence of Exxaggerated Morning Blood Pressure Surge in Newly Diagnosed Treatment-Naive Hypertensive Patients?

Background: The exaggerated morning blood pressure surge (MS) is associated with target organ damage and cardiovascular events. Systemic immune-inflammation index (SII) has been detected as a useful marker in tumors and cardiovascular diseases. The role of inflammation in the pathogenesis of hypertension is a well-known issue. We aimed to investigate whether there is an association between SII and exaggerated MS in newly diagnosed treatment-naive hypertensive patients.Material and Methods: In total, 343 newly diagnosed in clinical and 24-h ambulatory blood pressure (BP) monitoring treatment-naive hypertensive patients were included in this study. Morning surge was defined as the difference between morning BP, which was the mean of BP during 2 h after wake-up, and the lowest BP, which was the mean of three lowest BP during nighttime. A cutoff value of 52.1 mmHg was used to discriminate the high- and low value MS groups. SII was calculated based on neutrophil, platelet, and lymphocyte counts.Results: Neutrophil, platelet, SII, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) were higher, whereas lymphocyte counts were lower in the high-value MS than the low-value MS. These indices were all independently associated with exaggerated MS and SII was superior to all other indices for detecting the presence of exaggerated MS. SII was moderately correlated with morning BP surge (r: 0.489, p < 0.0001).Conclusion: SII was higher in patients with exaggerated MS and was independently associated with exaggerated MS. Furthermore, SII might be a better indicator than platelet, neutrophil, lymphocyte, NLR, and PLR for the presence of exaggerated MS.

Blood pressure variability and microvascular dysfunction: the Maastricht Study

BACKGROUND

Microvascular dysfunction (MVD) contributes to stroke, dementia, depression, retinopathy and chronic kidney disease. However, the determinants of MVD are incompletely understood. Greater blood pressure variability (BPV) may be one such determinant.

METHODS AND RESULTS

We used cross-sectional data of The Maastricht Study (n = 2773, age 59.9 years; 51.9% men) to investigate whether greater very short- to mid-term BPV is associated with various MVD measures. We standardized and averaged within-visit, 24-h and 7-day BPV into a systolic and a diastolic BPV composite score. MVD measures included a composite score of MRI cerebral small vessel disease (CSVD) features (total brain parenchymal volume, white matter hyperintensity volume, lacunar infarcts and cerebral microbleeds), a composite score of flicker light-induced retinal arteriolar and venular dilation response, albuminuria, heat-induced skin hyperemia and a composite score of plasma biomarkers of MVD (sICAM-1, sVCAM-1, sE-selectin and von Willebrand Factor). We used linear regression adjusted for age, sex, glucose metabolism status, mean 24-h systolic or DBP, cardiovascular risk factors and antihypertensive medication. We found that higher systolic and diastolic BPV composite scores (per SD) were associated with higher albuminuria [higher ratio, 1.04 (95% CI 1.00-1.08) and 1.07 (1.03-1.11), respectively], but not with other measures of MVD tested.

CONCLUSION

Greater systolic and diastolic BPV was associated with higher albuminuria, but not with CSVD features, flicker light-induced retinal arteriolar and venular dilation response, heat-induced skin hyperemia and plasma biomarkers of MVD. This suggests that the microvasculature of the kidneys is most vulnerable to the detrimental effects of greater BPV.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT00133692.

Blood Pressure Variability and Dementia: A State-of-the-Art Review

Accumulating evidence demonstrates that blood pressure variability (BPV) may contribute to target organ damage, causing coronary heart disease, stroke, and renal disease independent of the level of blood pressure (BP). Several lines of evidence have also linked increased BPV to a higher risk of cognitive decline and incident dementia. The estimated number of dementia cases worldwide is nearly 50 million, and this number continues to grow with increasing life expectancy. Because there is no effective treatment to modify the course of dementia, targeting modifiable vascular factors continues as a top priority for dementia prevention. A clear understanding of the role of BPV in dementia may shed light on the etiology, early prevention, and novel therapeutic targets of dementia, and has therefore gained substantial attention from researchers and clinicians. This review summarizes state-of-art evidence on the relationship between BPV and dementia, with a specific focus on the epidemiological evidence, the underlying mechanisms, and potential intervention strategies. We also discuss challenges and opportunities for future research to facilitate optimal BP management and the clinical translation of BPV for the risk assessment and prevention of dementia.

Prognostic importance of long-term SBP variability in high-risk hypertension

OBJECTIVE

In addition to high blood pressure variability (BPV), low BPV was associated with adverse cardiovascular prognosis in selected high-risk patients. We explored this issue in the Systolic Blood Pressure Intervention Trial (SPRINT) using a nonlinear approach with BPV as a continuous variable.

METHODS

Long-term systolic BPV (SBPV) (coefficient of variation, CoV %) was calculated on quarterly visits until a fatal/nonfatal cardiovascular event or all-cause mortality, excluding titration period and patients with missing visits. We used Cox proportional hazard models with penalized smoothing splines to shape the risk of outcomes against the continuum of SBPV (independent variable). Adjusted hazard ratios (aHR, 95% CI) were calculated using the reference range derived from the nonlinear model. Sensitivity analysis based on propensity score matching (PSM) was performed.

RESULTS

The association of SBPV with fatal/nonfatal cardiovascular events was J-shaped, whereas that with all-cause mortality was linear. After multivariate adjustment, however, the only significant associations remained that of low SBPV (CoV <5%) with cardiovascular events (hazard ratio 1.85, 95% CI 1.24-2.75, P = 0.003), and of high SBPV (CoV >10%) with the composite of cardiovascular events and all-cause mortality (hazard ratio 1.35, 95% CI 1.02-1.80; P = 0.037). Low SBPV was associated with ischemic heart disease (hazard ratio 2.76, 95% CI 1.55-4.91; P < 0.001). There was a significant U-shaped association of SBPV with cardiovascular events in the PSM cohort.

CONCLUSION

Nonlinear modeling indicates that low and high long-term SBPV have prognostic relevance in high-risk hypertensive individuals from SPRINT. Randomized trials are needed to test these findings and their potential therapeutic implications.

From short-term blood pressure variability to atherosclerosis: Relative roles of vascular stiffness and endothelial dysfunction

Both arterial blood pressure (BP) average levels and short-term BP variability (BPV) relate to hypertension-mediated organ damage, in particular increased carotid artery intima-media thickness (IMT) and carotid-femoral pulse wave velocity (PWV). Endothelial dysfunction possibly mediates such damage. The authors aimed at further investigating such role in hypertensive patients. In 189 recently diagnosed, untreated hypertensive patients the authors evaluated, in a cross-sectional design, the relationships of BP average levels and short-term systolic (S) BPV (standard deviation of awake SBP or of 24-hour-weighted SBP) with IMT and PWV, and how much these relationships are explained by endothelial function parameters-brachial artery flow-mediated dilation (FMD) and digital reactive hyperemia index (RHI). Multivariable models assessed the strength of these relationships to derive a plausible pathogenetic sequence. Both average SBP values and our measures of SBPV were significantly related to IMT (24-hour mean SBP: r = .156, P = .034; 24-hour-weighted SBPV: r = .157, P = .033) and to PWV (24-hour mean SBP: r = .179, P = .015; 24-hour-weighted SBPV: r = .175; P = .018), but only poorly related to FMD or RHI (P > .05 for all). At univariable regression analysis, FMD and RHI were both related to IMT, (P < .001), but not to PWV. When FMD and RHI were added to average SBP and SBPV parameters in a multivariable model, both significantly (P < .005) contributed to predict IMT, but not PWV. Thus, endothelial dysfunction relates to IMT independently of BP parameters, but appears to play a minor role in the association between BP variability-related variables and arterial stiffening.

Role of 24-Hr Blood Pressure Variability as a Target Therapeutic Risk Factor for Poor Functional Outcome of Acute Ischemic Stroke

Background and Purpose:

The present study aims to evaluate the role of blood pressure variability (BPV) as a target therapeutic risk factor for poor outcome of ischemic stroke by finding the association between the two and by finding the population attributable risk (PAR) of BPV compared to other baseline outcome predictors.

Methods:

A prospective observational study was carried out at GMCH, Nagpur, India from January to June 2019 in 75 patients diagnosed with acute ischemic stroke. BP was recorded hourly for the first 24 hours of admission and base line factors were collected along with measurement of stroke severity. BPV was measured by index of average real-time variability (ARV) while discharge outcome was measured by Barthel Index.

Results:

36.5% of patients had poor outcome at discharge. A significant association was found between 24-hr ARV of systolic BP and poor outcome (P = 0.002, 95% CI = 2.22-23.5). Five factors were found to be independent outcome predictors on multiple logistic regression (OR, 95% CI): age (1.07, 1.03–1.10), NIHSS score (1.12, 1.04–1.27), on admission SBP (5.12, 4.01–16.23), on admission RBS (2.23, 1.92–6.49) and 24 Hr ARV-SBP (9.65, 3.02–20.1). The PAR of 24 hr ARV-SBP was 23.6%, second only to NIHSS score (26.4%).

Conclusions:

Reduction in BP variability might have a beneficial impact on the outcome of patients with acute ischemic stroke. There is further scope to explore optimum therapeutic strategies to minimize BPV in the management of acute ischemic stroke.

The Association Between Selected Molecular Biomarkers and Ambulatory Blood Pressure Patterns in African Chronic Kidney Disease and Hypertensive Patients Compared With Normotensive Controls: Protocol for a Longitudinal Study

Background

Chronic kidney disease (CKD) is a burgeoning epidemic in sub-Saharan Africa. Abnormal blood pressure variations are prevalent in CKD and potentiate the risk of cardiovascular morbidity and mortality. Certain genetic variants (angiotensin II receptor type 1 1166 A>C and angiotensin-converting enzyme insertion and deletion polymorphisms) and biomarkers such as interleukin–6, tumor necrosis factor, soluble (s) E-selectin, homocysteine, and highly sensitive C-reactive protein have been shown to affect blood pressure variability among non-African CKD, hypertensive. and nonhypertensive CKD population. However, the contributions of the pattern, genetic, and environmental determinants of ambulatory blood pressure in African CKD have not been characterized. Understanding these interactions may help to develop interventions to prevent major cardiovascular events among people with CKD.

Objective

The overarching objective of this study is to identify, document, and develop approaches to address related phenomic, genetic, and environmental determinants of ambulatory blood pressure patterns in African CKD and non-CKD hypertensive patients compared with normotensive controls.

Methods

This is a longitudinal short-term follow-up study of 200 adult subjects with CKD and 200 each of age-matched hypertensives without CKD and apparently healthy controls. Demographic information, detailed clinical profile, electrocardiography, echocardiography, and 24-hr ambulatory blood pressure measurements will be obtained. Blood samples will be collected to determine albumin-creatinine ratio, fasting plasma glucose, lipid profile, electrolytes, urea and creatinine, C-reactive protein, serum homocysteine, fibroblast growth factor–23, and complete blood count, while 2 mL blood aliquot will be collected in EDTA (ethylenediaminetetraacetic acid) tubes and mixed using an electronic rolling system to prevent blood clots and subsequently used for DNA extraction and genetic analysis.

Results

A total of 239 participants have been recruited so far, and it is expected that the recruitment phase will be complete in June 2020. The follow-up phase will continue with data analysis and publications of results.

Conclusions

This study will help stratify Nigerian CKD patients phenotypically and genotypically in terms of their blood pressure variations with implications for targeted interventions and timing of medications to improve prognosis.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14820

Analyse biochimique multi-paramétrique révélant une augmentation de l'homocystéinémie et du NT-ProBNP chez les patients hypertendus à Bamako (Mali)

Introduction

L'hypertension artérielle est un problème majeur de santé publique en Afrique subsaharienne par sa fréquence élevée et le risque cardiovasculaire qu'elle entraine. L'objectif de cette étude était d'évaluer la prévalence des facteurs de risques cliniques et biologiques de l'hypertension artérielle à Bamako (Mali).

Méthodes

Il s'agit d'une étude cas-témoin, stratifiée en fonction du sexe, portant sur 72 participants dont 36 hypertendus et 36 contrôles. Vingt-deux paramètres biochimiques plasmatiques ont été mesurés et analysés par des tests univariés et multivariés.

Résultats

Une hyperhomocystéinémie a été retrouvée chez 55,6% des femmes (p = 0,03) et 100% des hommes (p = 0,007) hypertendus. Le N-terminal pro B-type natriuretic peptide (NT-Pro-BNP) était également augmenté chez 16,7% des femmes (VIP > 1 dans le modèle multivarié) et des hommes hypertendus (p = 0,00006). Un bon modèle multivarié prédictif (OPLS-DA) a uniquement été obtenu chez les femmes hypertendues, avec un Q²cum = 0,73, attestant ainsi d'un important dimorphisme sexuel associé à l'hypertension artérielle. Ce modèle impliquait huit paramètres dont la concentration plasmatique était modifiée (homocystéine, NT-Pro-BNP, potassium, urée, glycémie, sodium, chlore et protéines totales).

Conclusion

Nous avons noté une association significative entre l'hyperhomocystéinémie et l'hypertension artérielle. Par conséquent, le dosage de l'homocystéine associé à une bonne prise en charge diminuerait le risque cardiovasculaire tout en améliorant la qualité de vie des patients hypertendus.

Higher concentration of serum C-terminal cross-linking telopeptide of type I collagen is positively related with inflammatory factors in postmenopausal women with H-type hypertension and osteoporosis

OBJECTIVE

To investigate the changes of inflammatory factors and bone metabolism markers in postmenopausal women with H-type hypertension and to assess the relationship between them.

METHODS

Postmenopausal women who were diagnosed with osteoporosis were selected as observation objects. Participants were divided into three groups: only osteoporosis group (osteoporosis group), hypertension combined with osteoporosis group (hypertension group), and H-type hypertension combined with osteoporosis group (H-type hypertension group). The changes in bone mineral density and bone metabolic markers (osteocalcin [OC], procollagen type I N-terminal propeptide (PINP), and C-terminal cross-linking telopeptide of type I collagen [CTX]) and inflammatory factors (interleukin-6 [IL-6] and tumor necrosis factor-α [TNF-α]) were compared among three groups.

RESULTS

In the hypertension group and the H-type hypertension group, the bone mineral density of the lumbar spine (0.647 ± 0.038 vs 0.638 ± 0.034 vs 0.668 ± 0.047, P < 0.05) and the femoral neck (0.567 ± 0.047 vs 0.552 ± 0.053 vs 0.618 ± 0.059, P < 0.05) was significantly lower than that in the osteoporosis group. The concentrations of CTX (266.61 ± 64.65 vs 293.09 ± 72.34 vs 235.48 ± 62.85, P < 0.05), IL-6 (44.36 ± 6.45 vs 48.05 ± 8.04 vs 39.06 ± 7.95, P < 0.05) and TNF-α (30.53 ± 6.28 vs 34.52 ± 7.15 vs 28.66 ± 6.19, P < 0.01) in the hypertension group and in the H-type hypertension group were significantly higher than those in the osteoporosis group. The concentrations of OC (30.59 ± 6.43 vs 27.10 ± 6.51, P < 0.05) and PINP (36.36 ± 6.16 vs 33.16 ± 6.77, P < 0.05) in the H-type hypertension group were increased dramatically. The concentration of CTX was positively correlated with the concentration of IL-6 (r = 0.587, P < 0.01) and TNF-α (r = 0.474, P < 0.01) and negatively related with the concentration of OC (r = -0.591, P < 0.01) and PINP (r = -0.646, P < 0.01) and the bone mineral density of the lumbar spine (r = -0.470, P < 0.01) and the femoral neck (r = -0.509, P < 0.01).

CONCLUSION

Higher concentration of serum CTX is found in postmenopausal women with H-type hypertension, which is positively correlated with inflammatory factors. Besides, H-type hypertension could further enhance the activity of osteoclasts and increase the expressions of inflammatory factors, resulting in the aggravation of osteoporosis.

Markers of endothelial injury and subclinical inflammation in children and adolescents with primary hypertension

Introduction

Adhesion molecules: E-selectin and intercellular adhesion molecule 1 (ICAM-1) are well-established markers of endothelial injury. The aim of the study was to assess the relation between E-selectin and ICAM-1 and clinical and biochemical parameters in children and adolescents with primary hypertension (PH).

Material and methods

In 77 patients with PH (15.04 ±2.62 years, 50 boys, 27 girls) we evaluated serum E-selectin, ICAM-1, and selected clinical and biochemical parameters including inflammatory indicators and ambulatory blood pressure monitoring (ABPM).

Results

The E-selectin concentration was 55.63 ±26.49 ng/ml and the ICAM-1 concentration was 302.17 ±67.14 ng/ml. E-selectin and ICAM-1 correlated (p < 0.05) with BMI Z-score (r = 0.24, r = 0.29), ICAM-1 also with uric acid (r = 0.35), HDL-cholesterol (r = –0.28), platelet-to-lymphocyte ratio (r = 0.26), and systolic and mean blood pressure variability (r = 0.24, r = 0.24); in boys ICAM-1 correlated with mean platelet volume (r = 0.29). In multivariate analysis the only significant predictor of E-selectin was mean arterial pressure during 24 hours (β = 0.329, 95% CI: 0.012-0.646) and of ICAM-1 – uric acid (β = 0.430, 95% CI: 0.040-0.819). In 27 children with newly diagnosed PH E-selectin correlated negatively with diastolic blood pressure dipping (r = –0.54, p = 0.004) and positively with ambulatory arterial stiffness index (r = 0.51, p = 0.012).

Conclusions

Elevated mean arterial pressure and hyperuricemia are risk factors of endothelial damage in paediatric patients with primary hypertension. In children with untreated primary hypertension there may be a relation between endothelial damage and disturbed circadian blood pressure profile.

Intercellular adhesion molecule-1 (ICAM-1) associates with 24-hour ambulatory blood pressure variability in type 2 diabetes and controls

BACKGROUND AND AIM

Endothelial dysfunction is a common feature in hypertension and type 2 diabetes. Whether blood pressure (BP) variability is influencing serum intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) remains to be clarified. We aimed to assess the association between the circulating adhesion molecules and ambulatory blood pressure variability in patients with type 2 diabetes and controls.

PATIENTS AND METHODS

The study included data from type 2 diabetes with controlled BP (n = 55), type 2 diabetes with uncontrolled BP (n = 55) and control subjects (n = 28). ICAM-1 and VCAM-1 were measured with specific enzyme-linked immunosorbent assay method. BP variability was assessed using standard deviation of mean systolic and diastolic BP evaluated during 24-hour ambulatory BP monitoring.

RESULTS

The uncontrolled BP type 2 diabetes group had significantly higher serum ICAM-1 and VCAM-1 levels compared to controlled BP type 2 diabetes and control groups. In linear regression analysis, after adjustment, higher ICAM-1 was consistently associated with higher daytime and 24-hour diastolic BP variability, and daytime systolic BP variability in the study population. VCAM-1 was associated only with daytime systolic BP variability.

CONCLUSIONS

Our study evaluating the association of serum ICAM-1 and VCAM-1 with 24-hour ambulatory BP variability in patients with type 2 diabetes and controls might offer better understanding of the mechanisms generating endothelial dysfunction. Elevated 24-hour ambulatory BP variability might induce endothelial activation by increasing circulating adhesion molecules levels.

C-reactive protein and blood pressure variability in type 2 hypertensive diabetic patients

OBJECTIVE

Increased blood pressure (BP) variability and inflammation are included among the factors recognized as potential predictors of cardiovascular events in type 2 diabetes and hypertension. This study aimed to evaluate whether C-reactive protein (CRP) is associated with increased BP variability in diabetic-hypertensive patients.

PATIENTS AND METHODS

We carried out a cross-sectional study with 285 diabetic-hypertensive patients, evaluating laboratory characteristics and 24-h ambulatory BP monitoring. SD, coefficient of variation (CV%), time-rate index of 24-h systolic BP (SBP), and 24-h BP patterns were evaluated. Pearson's χ-test, Student's t-test, and the Mann-Whitney test were used to compare the groups. Groups were defined by CRP of up to 3 mg/l (low) and more than 3 mg/l (high).

RESULTS

The age of the patients was 59 (54-62) years; 101 (35%) were men. There was an increase in office SBP [137 (127-148) vs. 145 (130-157) mmHg] and DBP [79 (73-86) vs. 82 (76-91) mmHg] in the high CRP group. Blood pressure variability indexes were not different among groups [SD: 11.2 (9-15) vs. 12.2 (10-15) mmHg; CV%: 8.6 (7-11) vs. 9.4 (7-12); time rate: 0.55±0.12 vs.12.2 (10-15) mmHg/min]. In addition, BMI (29.3±3.8 vs. 30.9±3.6 kg/m), total cholesterol [166 (148-190) vs. 177 (156-210) mg/dl], and HbA1c [7.5% (6.6-8.9) vs.8.3% (7.1-9.9)] were higher in the high CRP group.

CONCLUSION

In patients with diabetes and hypertension, higher CRP levels are linked to cardiometabolic derangements, although they are not associated with increased BP variability.

Blood Pressure Variability Predicts Adverse Events and Cardiovascular Outcomes in Chronic Kidney Disease: A Post-Hoc Analysis of the SPRINT Trial

BACKGROUND

Visit-to-visit blood pressure variability has been associated with adverse cardiovascular outcomes. Using the SPRINT trial data set, we explored the relationship between blood pressure variability, cardiovascular outcomes, and hypoperfusion-related adverse events of antihypertensive therapy in patients with chronic kidney disease (CKD) enrolled in the study.

METHODS

The analyses included patients with CKD randomized in SPRINT who reached the target systolic blood pressure for their respective groups (intensive <120 mm Hg; standard <140 mm Hg). Coefficients of variation (CV) for diastolic blood pressure (DBP) for each subject characterized variability. Cox proportional hazards regression was used to identify independent predictors of the SPRINT primary outcome (including acute coronary syndrome, stroke, acute heart failure, and death from cardiovascular causes) and the 3 major side effects of therapy-hypotension, syncope, and acute kidney injury (AKI). P <0.15 on univariate analysis was required to enter the model, and P <0.05 to remain in it.

RESULTS

Overall, 2,488 subjects (1,273 standard; 1,124 intensive) met inclusion criteria. DBP CV predicted a greater hazard for primary outcome (hazard ratio [HR] 1.126, P < 0.0001) in the overall model as well as in separate analyses by treatment arms (standard group HR 1.107, P < 0.0001; intensive group HR 1.100, P = 0.0004). DBP CV also independently predicted a greater hazard for AKI (HR 1.117), syncope (HR 1.111), and hypotensive events (HR 1.104).

CONCLUSION

Visit-to-visit DBP variability independently predicts worse cardiovascular outcomes and hypoperfusion-related adverse events in patients with CKD enrolled in SPRINT.

Prognostic Value of Variability in Systolic Blood Pressure Related to Vascular Events and Premature Death in Type 2 Diabetes Mellitus: The ADVANCE-ON Study

Visit-to-visit variability in systolic blood pressure (SBP) is a risk factor for cardiovascular events. However, whether it provides additional predictive information beyond traditional risk factors, including mean SBP, in the long term is unclear. The ADVANCE trial (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation) was a randomized controlled trial in patients with type 2 diabetes mellitus; ADVANCE-ON (ADVANCE-Observational) followed-up patients subsequently. In these analyses, 9114 patients without major macrovascular or renal events or death during the first 24 months were included. Data on SBP from 6 visits during the first 24 months after randomization were used to estimate visit-to-visit variability in several ways: the primary measure was the standard deviation. Events accrued during the following 7.6 years. The primary outcome was a composite of major macrovascular and renal events and all-cause mortality. Standard deviation of SBP was log-linearly associated with an increased risk of the primary outcome (P<0.001) after adjustment for mean SBP and other cardiovascular risk factors. The hazard ratio (HR; 95% confidence interval [CI]) in the highest, compared with the lowest, tenth of the standard deviation was 1.39 (1.15-1.69). Results were similar for major macrovascular events alone and all-cause mortality alone (both P<0.01). Addition of standard deviation of SBP significantly improved 8-year risk classification (continuous net reclassification improvement, 5.3%). Results were similar for other measures of visit-to-visit variability, except maximum SBP. Visit-to-visit variability in SBP is an independent predictor of vascular complications and death, which improves risk prediction beyond that provided by traditional risk factors, including mean SBP.

Correlation between ambulatory blood pressure variability and vasodilator function in middle-aged normotensive individuals

OBJECTIVE

The aim of this study was to investigate the association between ambulatory blood pressure variability and vasodilator function in a cohort of normotensive middle-aged individuals.

PARTICIPANTS AND METHODS

This was a cross-sectional study of 285 randomly selected 40-59-year-old normotensive participants who underwent 24-h ambulatory blood pressure monitoring and brachial artery ultrasound assessment. Systolic and diastolic blood pressure variability (BPV) of 24-h, daytime, and night-time were calculated using the coefficients of variation (CV) and the average real variability (ARV) index. Brachial arterial endothelium-dependent vasodilation (EDD) was assessed in response to increased flow and endothelium-independent vasodilation (EID) was assessed in response to nitroglycerin. Relationships were explored using univariate and multivariate linear regression.

RESULTS

The EDD were negatively associated with the CV of 24-h systolic blood pressure (SBP), the ARV of 24-h SBP, and diastolic blood pressure (DBP) in univariate analysis. However, the CV and ARV of 24-h SBP remained associated independently with % EDD in multivariate analysis. In addition, the mean levels of 24-h SBP and DBP, the CV of 24-h SBP and DBP, the ARV of 24-h SBP and DBP, the CV of daytime SBP, and the ARV of daytime DBP were all associated with % EID. However, in a multiple linear regression model, adjusting for covariates, only the CV and ARV of 24-h SBP, and the ARV of 24-h DBP were correlated negatively but weakly with % EID.

CONCLUSION

Our results indicated that a higher 24-h BPV was associated independently with decreased endothelial-dependent and endothelial-independent vasodilator functions in a middle-aged normotensive population. Although 24-h BPV was associated with vasodilator function, relationships were attenuated after adjusting for covariates.

Determinants of the impact of blood pressure variability on neurological outcome after acute ischaemic stroke

INTRODUCTION

Increased blood pressure variability (BPV) is detrimental after acute ischaemic stroke, but the interaction between BPV and neuroimaging factors that directly influence stroke outcome has not been explored.

METHODS

We retrospectively reviewed inpatients from 2007 to 2014 with acute anterior circulation ischaemic stroke, CT perfusion and angiography at hospital admission, and a modified Rankin Scale (mRS) 30-365 days after stroke onset. BPV indices included SD, coefficient of variation and successive variation of the systolic blood pressure between 0 and 120 hours after admission. Ordinal logistic regression models were fitted to mRS with predictor variables of BPV indices. Models were further stratified by CT perfusion volumetric measurements, proximal vessel occlusion and collateral score.

RESULTS

110 patients met the inclusion criteria. The likelihood of a 1-point rise in the mRS increased with every 10 mm Hg increase in BPV (OR for the 3 BPV indices ranged from 2.27 to 5.54), which was more pronounced in patients with larger ischaemic core volumes (OR 8.37 to 18.0) and larger hypoperfused volumes (OR 6.02 to 15.4). This association also held true for patients with larger mismatch volume, proximal vessel occlusion and good collateral vessels.

CONCLUSIONS

These results indicate that increased BPV is associated with worse neurological outcome after stroke, particularly in patients with a large lesion core volume, concurrent viable ischaemic penumbra, proximal vessel occlusion and good collaterals. This subset of patients, who are often not candidates for or fail acute stroke therapies such as intravenous tissue plasminogen activator or endovascular thrombectomy, may benefit from interventions aimed at reducing BPV.

Active hexose correlated compound modulates LPS-induced hypotension and gut injury in rats

We hypothesized that AHCC; (Amino UP Chemical Co., Ltd., Sapporo, Japan), a mushroom mycelium extract obtained from liquid culture of Lentinula edodes, restores immune function in LPS-induced inflammation in the gut, especially when the nitric oxide signaling pathway is impaired. This is the first inter-disciplinary proposal to identify molecular mechanisms involved in LPS-induced immune dysfunction in the gut in conscious animals treated or non-treated with AHCC, a promoter of immune support. Specifically, we have tested the effects of AHCC on LPS-induced deleterious effects on blood pressure and gut injury in conscious rats. The time course of biological markers of innate/acquired immune responses, and inflammation/oxidative stress is fully described in the present manuscript. Rats were randomly assigned into 3 groups (N=6 per group). Group 1 received 10% of AHCC in drinking water for 5days; Group 2 received lipopolysaccharide (LPS; Escherichia coli 0111:B4 purchased from Sigma) only at 20mg/kg IV; Group 3 received combined treatments (AHCC + LPS). LPS was administered at 20mg/kg IV, 5days following AHCC treatment. We have demonstrated that AHCC decreased the LPS-deleterious effects of blood pressure and also decreased inflammatory markers e.g., cytokines, nitric oxide and edema formation. Finally, AHCC diminished lymphocyte infiltration, restoring gut architecture. Because AHCC was administered prior to LPS, our results indicate the potential impact of AHCC's prophylactic effects on LPS inflammation. Consequently, additional experiments are warrant to assess its therapeutic effects in sepsis-induced inflammation.

Impact of awake blood pressure variability on cerebrovascular atherosclerosis in Chinese patients with acute ischemic stroke

BACKGROUND

Blood pressure (BP) variability has been shown to be an independent risk factor of stroke and target organ damage because of hypertension, but so far, there have been very few studies investigating the impact of BP variability on cerebrovascular atherosclerosis.

METHODS

A total of 409 participants were enrolled and classified according to patterns of cerebrovascular atherosclerosis (i.e. large or small artery atherosclerosis; extracranial; or intracranial artery atherosclerosis). Coefficient of variation (CV) was used as a marker of BP variability. Multivariate binary logistical regression was used to analyze the associations between BP variability and the risk of different patterns of cerebrovascular atherosclerosis.

RESULTS

The risk of large artery atherosclerosis and extracranial arterial stenosis, respectively, had a dose-responsive positive relationship with the tertiles of awake systolic blood pressure (SBP) CVs [large artery atherosclerosis, the second tertile, adjusted odds ratio (OR)=2.839, 95% confidence interval (CI) 1.593-5.059, P<0.001; the third tertile, adjusted OR=4.010, 95% CI 1.859-8.651, P<0.001; extracranial arterial stenosis, the second tertile, adjusted OR=2.274, 95% CI 1.189-4.348, P=0.013; the third tertile, adjusted OR=2.568, 95% CI 1.230-5.360, P=0.012, when referenced to the first tertile], but not with those of mean awake SBP. The third tertile of awake SBP CVs indicated a significantly higher risk of intracranial arterial stenosis (adjusted OR=2.253, 95% CI 1.118-4.538, P=0.023) and advanced intracranial arterial stenosis (adjusted OR=5.073, 95% CI 2.064-12.466, P<0.001) when referenced to the first tertile.

CONCLUSION

In Chinese patients with acute atherosclerotic stroke, higher awake BP variability (measured in the subacute stage) might be associated with a higher risk of large artery atherosclerosis.

Visit-to-Visit Variability of BP and CKD Outcomes: Results from the ALLHAT

BACKGROUND AND OBJECTIVES

Increased visit-to-visit variability of BP is associated with cardiovascular disease risk. We examined the association of visit-to-visit variability of BP with renal outcomes among 21,245 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We measured mean BP and visit-to-visit variability of BP, defined as SD, across five to seven visits occurring 6-28 months after participants were randomized to chlorthalidone, amlodipine, or lisinopril. The composite outcome included incident ESRD after assessment of SD of systolic BP or ≥50% decline in eGFR between 24 months and 48 or 72 months after randomization. We repeated the analyses using average real variability and peak value of systolic BP and for visit-to-visit variability of diastolic BP.

RESULTS

Over a mean follow-up of 3.5 years, 297 outcomes occurred. After multivariable adjustment, including baseline eGFR and mean systolic BP, the hazard ratios for the composite end point were 1.29 (95% confidence interval [95% CI], 0.75 to 2.22), 1.76 (95% CI, 1.06 to 2.91), 1.46 (95% CI, 0.88 to 2.45), and 2.05 (95% CI, 1.25 to 3.36) for the second through fifth (SD of systolic BP =6.63-8.82, 8.83-11.14, 11.15-14.56, and >14.56 mmHg, respectively) versus the first (SD of systolic BP <6.63 mmHg) quintile of SD of systolic BP, respectively (P trend =0.004). The association was similar when ESRD and a 50% decline in eGFR were analyzed separately, for other measures of visit-to-visit variability of systolic BP, and for visit-to-visit variability of diastolic BP.

CONCLUSIONS

Higher visit-to-visit variability of BP is associated with higher risk of renal outcomes independent of mean BP.

Association of Serum Uric Acid Level With Blood Pressure Variability in Newly Diagnosed Essential Hypertension

Serum uric acid (UA) is independently associated with hypertension and blood pressure (BP) variability (BPV) is associated with cardiovascular events and mortality in hypertensive patients. The aim of the present study was to assess the association of serum UA with BPV in 300 untreated essential hypertension patients (mean age 57.3±13.6 years). BPV was quantified as the standard deviation (SD) of the 24-hour, daytime, and nighttime mean values obtained by using ambulatory BP monitoring. In correlation analysis, log UA values were found to be positively correlated with 24-hour systolic BPV and nighttime systolic and diastolic BPV (Pearson coefficients of 0.246, 0.280, and 0.353, respectively; P<.001 for all). In multivariate analysis, log UA had an independent association with 24-hour systolic BPV and nighttime systolic and diastolic BPV. This study show for the first time that increased serum UA is independently associated with BPV in untreated essential hypertension patients.

Optimal indicators of home BP variability in perimenopausal women and associations with albuminuria and reproducibility: The J-HOT home BP study

BACKGROUND

This study investigated the associations between various indicators of home blood pressure (BP) variability and albuminuria as well as the reproducibility of these indicators in perimenopausal women, who are likely to exhibit increased BP variability.

METHODS

As a measure of organ damage, urinary albumin/creatinine ratio (UACR) was examined at baseline in 151 women aged 40-59 years. Home BP was measured in duplicate in both morning and evening for 12 weeks using a home BP monitor. The following home BP variability indicators were calculated biweekly: mean, maximum, minimum, difference between maximum and minimum, average real variability (ARV), SD, and coefficient of variation.

RESULTS

In simple correlation, the ARV of systolic BP (SBP) (morning + evening and morning), maximum SBP (evening), and maximum diastolic BP (all time points) were most strongly correlated with UACR. In multivariate linear regression, the maximum, minimum, and ARV of SBP (morning) and both mean and maximum SBP (evening) were significantly associated with Box-Cox transformed UACR after adjustment for age, body mass index, and lifestyle. In particular, maximum SBP had the lowest P value among those BP indicators. Furthermore, maximum morning SBP tended to distinguish high-normal albuminuria (UACR ≥ 10 mg/g Cr) more clearly than mean morning SBP. The mean, maximum, and minimum values of home BP demonstrated the greatest reproducibility among all indicators.

CONCLUSION

Maximum home BP is associated with UACR and exhibits high reproducibility in perimenopausal women. These findings raise the hypothesis that maximum home SBP may be suitable to detect kidney damage.

Biological correlates of blood pressure variability in elderly at high risk of cardiovascular disease

BACKGROUND

Visit-to-visit variability in blood pressure is an independent predictor of cardiovascular disease. This study investigates biological correlates of intra-individual variability in blood pressure in older persons.

METHODS

Nested observational study within the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) among 3,794 male and female participants (range 70-82 years) with a history of, or risk factors for cardiovascular disease. Individual visit-to-visit variability in systolic and diastolic blood pressure and pulse pressure (expressed as 1 SD in mm Hg) was assessed using nine measurements over 2 years. Correlates of higher visit-to-visit variability were examined at baseline, including markers of inflammation, endothelial function, renal function and glucose homeostasis.

RESULTS

Over the first 2 years, the mean intra-individual variability (1 SD) was 14.4mm Hg for systolic blood pressure, 7.7mm Hg for diastolic blood pressure, and 12.6mm Hg for pulse pressure. After multivariate adjustment a higher level of interleukin-6 at baseline was consistently associated with higher intra-individual variability of blood pressure, including systolic, diastolic, and pulse pressure. Markers of endothelial function (Von Willebrand factor, tissue plasminogen activator), renal function (glomerular filtration rate) and glucose homeostasis (blood glucose, homeostatic model assessment index) were not or to a minor extent associated with blood pressure variability.

CONCLUSION

In an elderly population at risk of cardiovascular disease, inflammation (as evidenced by higher levels of interleukin-6) is associated with higher intra-individual variability in systolic, diastolic, and pulse pressure.

Chromogranin A: a paradoxical player in angiogenesis and vascular biology

Half a century after the discovery of chromogranin A as a secreted product of the catecholamine storage granules in the bovine adrenal medulla, the physiological role for the circulating pool of this protein has been recently coined, namely as an important player in vascular homeostasis. While the circulating chromogranin A since 1984 has proved to be a significant and useful marker of a wide range of pathophysiological and pathological conditions involving the diffuse neuroendocrine system, this protein has now been assigned a physiological "raison d'etre" as a regulator in vascular homeostasis. Moreover, chromogranin A processing in response to tissue damage and blood coagulation provides the first indication of a difference in time frame of the regulation of angiogenesis evoked by the intact chromogranin A and its two major peptide products, vasostatin-1 and catestatin. The impact of these discoveries on vascular homeostasis, angiogenesis, cancer, tissue repair and cardio-regulation will be discussed.

The clinical association of the blood pressure variability with the target organ damage in hypertensive patients with chronic kidney disease

It is known that blood pressure variability (BPV) can independently affect target organ damage (TOD), even with normal blood pressure. There have been few studieson chronic kidney disease (CKD) patients. We evaluated the relationship between BPV and TOD in a cross-sectional, multicenter study on hypertensive CKD patients. We evaluated 1,173 patients using 24-hr ambulatory blood pressure monitoring. BPV was defined as the average real variability, with a mean value of the absolute differences between consecutive readings of systolic blood pressure. TOD was defined as left ventricular hypertrophy (LVH) (by the Romhilt-Estes score ≥4 in electrocardiography) and kidney injury (as determined from an estimated glomerular filtration rate [eGFR]<30 mL/min/1.73 m(2) and proteinuria).The mean BPV of the subjects was 15.9±4.63 mmHg. BPV displayed a positive relationship with LVH in a univariate analysis and after adjustment for multi-variables (odds ratio per 1 mmHg increase in BPV: 1.053, P=0.006). In contrast, BPV had no relationship with kidney injury. These data suggest that BPV may be positively associated with LVH in hypertensive CKD patients.

Increased central arterial stiffness explains baroreflex dysfunction in spinal cord injury

After cervical spinal cord injury (SCI), orthostatic hypotension and intolerance commonly ensue. The cardiovagal baroreflex plays an important role in the acute regulation of blood pressure (BP) and is associated with the onset of presyncope. The cardiovagal baroreflex is dysfunctional after SCI; however, this may be influenced by either increased stiffening of the arteries containing the stretch-receptors (which has been shown in SCI) or a more downstream neural mechanism (i.e., solitary nucleus, sinoatrial node). Identifying where along this pathway baroreflex dysfunction occurs may highlight a potential therapeutic target. This study examined the relationship between spontaneous cardiovagal baroreflex sensitivity (BRS) and common carotid artery (CCA) stiffness in those with high level SCI before and after midodrine (alpha1-agonist) administration, as well as in able-bodied controls, to evaluate: (1) the role arterial stiffening plays mediating baroreflex function after SCI and (2) the effect of normalizing BP on these parameters. Three to five min recordings of beat-by-beat BP and heart rate, as well as 30 sec duration recordings of CCA diameter were used for analysis. All participants were tested supine and during upright-tilt. Arterial stiffness (β-stiffness index) was elevated in those with SCI when upright (+12%; p<0.05). Further, β-stiffness index was negatively related to reduced BRS in those with SCI when upright (R2=0.55; p<0.05), but not in able-bodied persons. Normalizing BP did not improve BRS or CCA stiffness. This study clearly shows that reduced BRS is closely related to increased arterial stiffness in the population with SCI.

Increased short-term blood pressure variability is associated with early left ventricular systolic dysfunction in newly diagnosed untreated hypertensive patients

BACKGROUND AND AIM

Twenty-four-hour blood pressure (BP) variability, by ambulatory BP monitoring (ABPM), has been related to left ventricular hypertrophy, independent of mean BP values. We tested the hypothesis that short-term BP variability (BPV) is also related to subclinical left ventricular systolic dysfunction.

METHODS

We assessed 24-h SBP and DBP variabilities, quantified as standard deviation (SD) of daytime (awake) BP values and as weighted SD of 24-h BP (24-h-weighted BPV), in 309 recently (<6 months) diagnosed, prospectively recruited, and untreated hypertensive patients. Patients were included only if with normal (≥55%) left ventricular ejection fraction (LVEF). Left ventricular systolic function was assessed by echocardiography measuring midwall fractional shortening (MFS), circumferential end-systolic stress (cESS), MFS/cESS, peak systolic wall stress, left ventricular fractional shortening (LVFS), and LVEF.

RESULTS

At multivariate analysis, awake and 24-h-weighted SBP variabilities (directly, P = 0.038 and P = 0.002, respectively) as well as relative wall thickness (RWT) (inversely, P = 0.001) were significantly related to cESS. Awake and 24-h SBP average values (inversely, P = 0.011 and P = 0.002, respectively), awake and 24-h-weighted SBP variabilities (inversely, P = 0.017 and P = 0.024, respectively), and RWT (directly, P = 0.001) were all significantly related to MFS/cESS. Finally, awake and 24-h average SBP (directly, P = 0.01 for both), awake and 24-h-weighted SBP variability (directly, P = 0.001 and P = 0.032, respectively), and RWT (inversely, P = 0.001) were all significantly and independently related to peak systolic wall stress.

CONCLUSION

In newly diagnosed never-treated hypertensive patients, in the absence of LVEF changes and independent of left ventricular mass index, higher awake, or 24-h-weighted short-term SBP variabilities are associated with early depressed left ventricular systolic function.

Left ventricular mass in dialysis patients, determinants and relation with outcome. Results from the COnvective TRansport STudy (CONTRAST)

BACKGROUND AND OBJECTIVES

Left ventricular mass (LVM) is known to be related to overall and cardiovascular mortality in end stage kidney disease (ESKD) patients. The aims of the present study are 1) to determine whether LVM is associated with mortality and various cardiovascular events and 2) to identify determinants of LVM including biomarkers of inflammation and fibrosis.

DESIGN SETTING PARTICIPANTS & MEASUREMENTS

Analysis was performed with data of 327 ESKD patients, a subset from the CONvective TRAnsport STudy (CONTRAST). Echocardiography was performed at baseline. Cox regression analysis was used to assess the relation of LVM tertiles with clinical events. Multivariable linear regression models were used to identify factors associated with LVM.

RESULTS

Median age was 65 (IQR: 54-73) years, 203 (61%) were male and median LVM was 227 (IQR: 183-279) grams. The risk of all-cause mortality (hazard ratio (HR) = 1.73, 95% CI: 1.11-2.99), cardiovascular death (HR = 3.66, 95% CI: 1.35-10.05) and sudden death (HR = 13.06; 95% CI: 6.60-107) was increased in the highest tertile (>260 grams) of LVM. In the multivariable analysis positive relations with LVM were found for male gender (B = 38.8±10.3), residual renal function (B = 17.9±8.0), phosphate binder therapy (B = 16.9±8.5), and an inverse relation for a previous kidney transplantation (B = -41.1±7.6) and albumin (B = -2.9±1.1). Interleukin-6 (Il-6), high-sensitivity C-reactive protein (hsCRP), hepcidin-25 and connective tissue growth factor (CTGF) were not related to LVM.

CONCLUSION

We confirm the relation between a high LVM and outcome and expand the evidence for increased risk of sudden death. No relationship was found between LVM and markers of inflammation and fibrosis.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN38365125.

Low correlation between visit-to-visit variability and 24-h variability of blood pressure

visit-to-visit variability (VVV) of clinic systolic blood pressure (SBP) has been associated with cardiovascular disease risk. Given the need for obtaining blood pressure (BP) at multiple visits to calculate VVV, substituting BP variability from ambulatory blood pressure monitoring (ABPM) may be a practical alternative. We assessed the correlation between VVV of BP and BP variability from ABPM using data from 146 untreated, mostly normotensive participants (mean age 47.9 years), in a substudy of the ongoing Masked Hypertension Study. VVV of SBP and diastolic blood pressure (DBP) was estimated by the standard deviation (s.d.vvv) and average real variability (ARVvvv) from six study visits over a median of 216 days. ABPM data were used to calculate the day-night s.d. (s.d.dn), and the ARV of SBP and DBP over 24 h (ARV24). For SBP, the mean s.d.vvv and s.d.dn were 6.3 (s.d.=2.5) and 8.8 mm Hg (s.d.=1.8), respectively, and mean ARVvvv and ARV24 were 7.2 (s.d.=3.2) and 8.4 mm Hg (s.d.=2.1), respectively. Spearman's correlation coefficient between s.d.vvv and s.d.dn of SBP was rs=0.25, and between ARVvvv and ARV24 was rs=0.17. Participants in the highest quartile of s.d.dn of SBP were 1.66 (95% CI: 0.93-2.75) times more likely to be in the highest quartile of s.d.vvv of SBP. The observed-to-expected ratio between the highest quartiles of ARVvvv and ARV24 of SBP was 0.89 (95% CI: 0.41-1.69). The correlations for s.d.vvv and s.d.dn, and ARVvvv and ARV24 of DBP were minimal. These data suggest VVV and 24-h variability are weakly correlated and not interchangeable.

Blood pressure variability in chronic kidney disease patients

'Usual' blood pressure (BP) levels are known to be directly related to cardiovascular (CV) risk in the general population and patients with essential hypertension. However, there is increasing evidence that, apart from usual BP, BP variability across visits may also be an important risk factor for death and CV events in healthy subjects and in essential hypertensive patients. In chronic kidney disease (CKD) patients the relationship between hypertension and clinical outcome is still controversial. Moreover, high visit-to-visit BP variability was very recently found to predict death and CV events in this high-risk patient population. This review focuses on the available evidence about the link between high visit-to-visit BP variability and clinical outcomes in CKD patients and describes some hypothetical mechanisms that could explain such a relationship.

Long-term visit-to-visit office blood pressure variability increases the risk of adverse cardiovascular outcomes in patients with chronic kidney disease

Long-term visit-to-visit blood pressure (BP) variability predicts a high risk for cardiovascular events in patients with essential hypertension. Whether long-term visit-to-visit BP variability holds the same predictive power in predialysis patients with chronic kidney disease (CKD) is unknown. Here we tested the relationship between long-term visit-to-visit office BP variability and a composite end point (death and incident cardiovascular events) in a cohort of 1618 patients with stage 2-5 CKD. Visit-to-visit systolic BP variability was significantly and independently related to baseline office, maximal, and average systolic BPs, age, glucose, estimated glomerular filtration rate, and albumin, and to the number of visits during the follow-up. Both the standard deviation of systolic BP (hazard ratio: 1.11, 95% confidence interval: 1.01-1.20) and the coefficient of variation of systolic BP (hazard ratio: 1.15, 95% confidence interval: 1.02-1.29) were significant predictors of the combined end point independent of peak and average systolic BP, cardiovascular comorbidities, Framingham risk factors, and CKD-related risk factors. Antihypertensive treatment (β-blockers and sympatholytic drugs) significantly abrogated the excess risk associated with high systolic BP variability. Thus, large visit-to-visit systolic BP variability in patients with CKD predicts a higher risk of death and nonfatal cardiovascular events independent of underlying BP levels.

Interindividual relationships between blood pressure and cerebral blood flow variability with intact and blunted cerebrovascular control

The relationships between blood pressure variability (BPV) and cerebral blood flow variability (CFV) across individuals in the presence of intact and blunted cerebrovascular control are poorly understood. This study sought to characterize the interindividual associations between spontaneous BPV and CFV under conditions of normal and blunted [calcium channel blockade (CCB)] cerebrovascular control in healthy humans. We analyzed blood pressure and flow velocity data from 12 subjects treated with CCB (60 mg oral nimodipine) and 11 subjects treated with a placebo pill. Spontaneously occurring fluctuations in mean arterial blood pressure (MAP) and middle cerebral artery flow velocity (MCAvmean; transcranial Doppler) were characterized using power spectral and transfer function analysis in the very-low- (0.02–0.07 Hz), low- (0.07–0.20 Hz), and high-frequency (0.20–0.40 Hz) ranges. Across our study sample, MAP and MCAvmean power were positively correlated in all three frequency ranges, both before ( R2 = 0.34–0.67, all P < 0.01) and after CCB ( R2 = 0.53–0.61, all P < 0.02). Compared with placebo, CCB reduced very-low-frequency MAP ( P < 0.05) and MCAvmean power ( P < 0.01) and the low-frequency cross-spectral phase angle ( P < 0.05). The magnitude of change in MAP and MCAvmean power with CCB (i.e., change scores) was positively related in the very-low-frequency range. Collectively, these findings indicate that CFV may be an explanatory factor in the association between elevated BPV and adverse cerebrovascular outcomes and support the possibility of using CCB to improve hemodynamic stability under resting conditions.

Within-visit variability of blood pressure and all-cause and cardiovascular mortality among US adults

The association between within-visit variability of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and all-cause and cardiovascular (CVD) mortality was examined using the Third National Health and Nutrition Survey (n=15,317). Three SBP and DBP readings were taken by physicians during a single medical evaluation. Within-visit variability for each participant was defined using the standard deviation of SBP and DBP across these measurements. Mortality was assessed over 14 years (n=3848 and n=1684 deaths from all causes and CVD, respectively). After age, sex, and race-ethnicity adjustment, the hazard ratios (95% confidence intervals) for all-cause mortality associated with the 4 highest quintiles of within-visit standard deviation of SBP (2.00-2.99 mm Hg, 3.00-3.99 mm Hg, 4.00-5.29 mm Hg, and ≥5.30 mm Hg) compared with participants in the lowest quintile of within-visit standard deviation of SBP (<2.0 mm Hg) were 1.04 (0.87-1.26), 1.09 (0.92-1.29), 1.06 (0.88-1.28), and 1.13 (0.95-1.33), respectively (P=.136). The analogous hazard ratios for CVD mortality were 0.95 (0.69-1.32), 0.96 (0.67-1.36), 0.95 (0.74-1.23), and 1.04 (0.80-1.35), respectively (P=.566). No association with mortality was present after further adjustment and when modeling within-visit standard deviation of SBP as a continuous variable. Standard deviation of DBP was not associated with mortality.

A common missense single nucleotide polymorphism in the E-selectin gene is significantly associated with essential hypertension in the Han population but only weakly associated in the Uygur population

Experimental and clinical observations suggest that E-selectin could have an important role in essential hypertension (EH), but the relationship between common E-selectin variants and EH has not been extensively studied in the Chinese population. In this study, we explored the association between two common variants in the E-selectin gene (rs5361A/C and rs5355C/T) and EH in the Uygur, Kazakh and Han populations in the Xinjiang area. A case-control study was conducted to explore the association between these two single-nucleotide polymorphisms and EH in a large sample size, including 941 EH subjects (309 Uygur, 264 Kazakh and 368 Han individuals) and 924 control subjects (300 Uygur, 275 Kazakh and 349 Han individuals). Univariate analysis showed that the rs5361 A/C polymorphism was significantly associated with EH in the Uygur (P=0.002) and Han (P=3.6 × 10(-7)) populations. The CC genotype of this SNP was present only in patients with EH in all of the three nationalities studied. Han individuals who carry the CC genotype of rs5361 were more susceptible to EH, according to the dominant models (P=1.13 × 10(-4), odds ratio=3.812, 95% confidence interval: 1.685-7.792), but there was no association of genotype with EH for the other ethnicities. No significant difference in rs5355 C/T polymorphism rate was found between the EH and control groups. Our results indicate that the common variant rs5361 is strongly associated with EH in Han individuals and weakly associated in Uygur individuals. The CC genotype of rs5361 might be an independent risk factor for EH among Uygur, Kazakh and Han individuals in the Xinjiang area.

Ambulatory blood pressure variability is associated with restenosis after percutaneous coronary intervention in normotensive patients

BACKGROUND

Previous studies have showed that BP variability is associated with cardiovascular events. However, no data were available regarding binary restenosis as an end-point after percutenous coronary intervention (PCI).

METHODS AND RESULTS

This multicenter study included 100 consecutive normotensive patients with stable coronary artery disease who were planned for PCI. Before the index procedure, office BP and 24-h ambulatory BP measurements were performed. BP variability indices including systolic and diastolic 24-h average, the day and the night values of standard deviation (SD) and variation coefficient (VC) were measured and calculated. All patients underwent repeat coronary angiography at 6-month. According to angiographic results, 2 groups were formed; a restenosis group (n=30) with binary restenosis of the stented segment and a control group (n=70) with a stenosis diameter of <50% in stented segment. Systolic SD and VC values for 24-h average (14.0±2.8mmHg vs. 9.5±1.6mmHg, p<0.001 and 16%±3 vs. 11%±2, p<0.001, respectively), the day (15.2±3.9mmHg vs. 10.6±1.7mmHg, p<0.001 and 17%±4 vs. 12%±2, p<0.001, respectively), and the night (12.8±4.1mmHg vs. 8.4±2.4mmHg, p<0.001 and 14%±5 vs. 11%±3, p=0.004, respectively) values were significantly higher in restenosis group compared to control group. Similarly, diastolic SD and VC values for 24-h average (10.6±2.5mmHg vs. 8.1±1.5mmHg, p<0.001 and 12%±3 vs. 9%±2, p=0.001, respectively), the day (11.1±2.9mmHg vs. 9.0±1.8mmHg, p=0.003 and 12%±3 vs. 10%±2, p=0.006, respectively), and the night (10.0±3.6mmHg vs. 7.2±2.0mmHg, p=0.001 and 11%±5 vs. 9%±3, p=0.059, respectively) values were significantly higher in restenosis group compared to no restenosis group except for diastolic VC night. All systolic and diastolic BP variability indices except diastolic VC night were found to be independent predictors of risk of restenosis in multivariate analysis. In addition, the cut-off values of 11.4mmHg and 13% for 24-h systolic SD and VC, respectively, were found to be highly sensitive (93% for both) and specific (94% and 91%, respectively) for predicting binary restenosis at 6-month after PCI.

CONCLUSIONS

BP variability indices are significantly and independently associated with binary restenosis and higher values can predict restenosis after PCI sensitively and specifically.