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

Management of arterial hypertension with angiotensin receptor blockers: Current evidence and the role of olmesartan

Elevated blood pressure (BP) is a major determinant of morbidity and mortality burden related to cardio‐metabolic risk. Current guidelines indicate that controlling and lowering BP promotes cardiovascular (CV) risk reduction. Among antihypertensive agents, angiotensin receptor blockers (ARBs) are characterized by an efficacy profile equivalent to other antihypertensive agents and are provided with excellent tolerability and low discontinuation rates during chronic treatments. Moreover, CV outcomes are reduced by ARBs. Olmesartan is a long‐lasting ARB which proved to achieve a comparable or more effective action in lowering BP when compared to other ARBs. Olmesartan, in fact, displayed a larger and more sustained antihypertensive effect over the 24 hours, with a buffering effect on short‐term BP variability. These are important features which differentiate olmesartan from the other principles of the same class and that may help to control the increased CV risk in the presence of high BP variability. Olmesartan shows similar benefits as other ARBs in terms of all‐cause and CV mortality, and a favorable tolerability profile. Combination of olmesartan with long‐lasting calcium‐channel blockers and thiazide diuretics represents a rational and effective therapy. Thus, ARBs, including olmesartan, represent one of the most effective and safe treatments for patients with arterial hypertension.

Cerebral Aβ40 and systemic hypertension

Mid-life hypertension and cerebral hypoperfusion may be preclinical abnormalities in people who later develop Alzheimer's disease. Although accumulation of amyloid-beta (Aβ) is characteristic of Alzheimer's disease and is associated with upregulation of the vasoconstrictor peptide endothelin-1 within the brain, it is unclear how this affects systemic arterial pressure. We have investigated whether infusion of Aβ₄₀ into ventricular cerebrospinal fluid modulates blood pressure in the Dahl salt-sensitive rat. The Dahl salt-sensitive rat develops hypertension if given a high-salt diet. Intracerebroventricular infusion of Aβ induced a progressive rise in blood pressure in rats with pre-existing hypertension produced by a high-salt diet ( p < 0.0001), but no change in blood pressure in normotensive rats. The elevation in arterial pressure in high-salt rats was associated with an increase in low frequency spectral density in systolic blood pressure, suggesting autonomic imbalance, and reduced cardiac baroreflex gain. Our results demonstrate the potential for intracerebral Aβ to exacerbate hypertension, through modulation of autonomic activity. Present findings raise the possibility that mid-life hypertension in people who subsequently develop Alzheimer's disease may in some cases be a physiological response to reduced cerebral perfusion complicating the accumulation of Aβ within the brain.

Ambulatory blood pressure monitoring and neurocognitive function in children with primary hypertension

BACKGROUND

Children with primary hypertension have been reported to have diminished scores in measures of cognition. However, little is known about the relative correlation between office and ambulatory blood pressure (BP) and neurocognitive test performance, and whether short-term BP variability is associated with decreased neurocognitive function. We sought to determine whether ambulatory BP monitoring (ABPM) was more strongly associated with neurocognitive test performance compared with office BP, and whether increased short-term BP variability was associated with lower neurocognitive scores.

METHODS

Seventy-five subjects ages 10-18 years, with untreated primary hypertension, and 75 matched normotensive controls completed neurocognitive testing. All subjects had office BP and ABPM prior to neurocognitive testing.

RESULTS

On multivariate analyses, there was no significant association between office BP and neurocognitive tests. However, several ABPM parameters were significantly associated with neurocognitive test scores in the lower quartile, in particular 24 h SBP load and wake systolic blood pressure (SBP) index [Rey Auditory Verbal learning Test (RAVLT) List A Trial 1, 24 h SBP load, odds ratio (OR) = 1.02, wake SBP index, OR = 1.06; List A Total, 24 h SBP load, OR = 1.02, wake SBP index, OR = 1.06; Short Delay Recall, wake SBP index, OR = 1.06; CogState Maze delayed recall, 24 h SBP load, OR = 1.03, wake SBP index, OR = 1.08; Grooved Pegboard, 24 h SBP load, OR = 1.02; all p < 0.05]. In contrast, short-term BP variability measures were not associated with neurocognitive test performance.

CONCLUSIONS

ABPM is superior to office BP in distinguishing hypertensive youth with lower neurocognitive test performance.

Inverse correlation between daily outdoor temperature and blood pressure in six US cities

This study aims to evaluate the relationship between mean outdoor temperature and mean daily blood pressure (BP) and heart rate (HR) among six, large, geographically and climatically diverse US cities. We collected BP and HR data from Higi stations, located in a wide range of neighborhood grocery stores and retail pharmacies, from six US cities (Houston, Los Angeles, Miami, Boise, Chicago, and New York City). Outdoor daily temperature data were collected from the National Centers for Environmental Information's database. Pearson's correlation was used to assess the linear relationship between mean daily outdoor temperature and mean daily BP and HR for each city from May 2016 through April 2017. A total of 2 140 626 BP and HR readings were recorded in the six study cities. Mean outdoor temperature was inversely correlated with both mean daily average systolic (r=-0.69, P<0.0001) and diastolic (r=-0.71; P<0.0001) BPs, but not HR (r<0.0001, P=0.48). We also found that temperature change had a larger impact on BP in equatorial climates such as Miami compared with colder and more temperature variable cities like Chicago and Boise. Previous studies have found that BP varies seasonally, but few have looked at the impact of daily temperature on both BP and HR changes. Our study is one of the largest and most climatically diverse populations ever looking at this relationship. Our results suggest that temperature, and perhaps geography, should play a role in tailoring individualized evaluation and treatment for hypertensive diseases.

Visit-to-Visit Variability of Blood Pressure Is Associated With Hospitalization and Mortality in an Unselected Adult Population

BACKGROUND

Blood pressure variability (BPV) has been associated with poor health outcomes in high-risk patients, but its association with more general populations is poorly understood.

METHODS

We analyzed outcomes from 240,622 otherwise unselected patients who had 10 or more outpatient blood pressure readings recorded over a 3-year period and were aged from 20 to 100 years.

RESULTS

Whether calculated as SD, average change, or greatest change and systolic or diastolic blood pressure, we found that higher outpatient BPV was associated with subsequent hospitalization and mortality. Systolic pressure average change exceeding 10-12 mm Hg or diastolic exceeding 8 mm Hg significantly increased risk of hospitalization and death (odds ratios [ORs] from 2.0 to 4.5). Variability in the highest decile increased risks even more dramatically, with propensity-matched ORs from 4.4 to 42. A systolic change exceeding 35 mm Hg increased the relative risk of death 4.5-fold. Similarly, a diastolic change greater than 23-24 mm Hg almost tripled the risks of hospitalization and death. Neither stratification for hypertension nor propensity matching for risk factors within the database affected these associations.

CONCLUSIONS

Systolic and diastolic variabilities were each associated with subsequent adverse outcomes. Physicians should pay special attention to patients with swings in blood pressure between clinic visits. Electronic medical records should flag such variability.

Validation of the A&D BP UA-1200BLE device for home blood pressure measurement according to the ISO 81060-2: 2013 standard

OBJECTIVE

The aim of this study was to validate the UA-1200BLE device using the ISO 81060-2:2013 standard.

MATERIALS AND METHODS

Individuals aged more than 12 years were recruited from among the outpatients and volunteers of Jichi Medical University (Tochigi, Japan). Eighty-five patients were included in the final analyses. Validation was performed using the same-arm sequence protocol as per the ISO 81060-2:2013 standard.

RESULTS

The device performed well against the standard; the mean and SD values for the differences between device and observed systolic and diastolic blood pressure values fulfilled both criterion 1 and criterion 2 of the standard (criterion 1: -2.62±6.89 and -0.90±6.63 mmHg, respectively; criterion 2: -2.65±5.36 and -0.91±6.12 mmHg, respectively). The Bland-Altman plots did not show any systematic variation in the error.

CONCLUSION

The UA-1200BLE device had a high level of accuracy and fulfilled all ISO 81060-2:2013 standard requirements in adults with a wide range of arm circumference measurements. It is therefore suitable as a wireless blood pressure monitoring tool in patients with hypertension.

The effect of partial patients' adherence to antihypertensive drugs: scope for pharmacists' role in hypertension care

In many individuals, blood pressure varies between clinic visits conducted days, weeks, or months apart. This visit-to-visit variability (VVV) of blood pressure has been recently related with an increased risk of coronary heart disease, stroke, and mortality, independently of mean blood pressure. As for other chronical diseases, patients' adherence to hypertensive therapies remains low and partial adherence to antihypertensive treatment may constitute a source of VVV, as suggested by recent studies. This data should lead to a new clinical approach for hypertension care, based on patients' real adherence to treatment. Therapeutic strategies should include patients' adherence. In this context, the role of community pharmacists for patients' follow-up of hypertension should be reinforced, as they represent efficient and easily accessible health professionals.

Impact of treatment with glibenclamide or vildagliptin on glucose variability after aerobic exercise in type 2 diabetes: A randomized controlled trial

AIMS

To evaluate the glucose variability, oxidative stress, metabolic and cardiovascular responses after an aerobic exercise session in diabetic patients on treatment with metformin plus vildagliptin or glibenclamide.

METHODS

Parallel clinical trial including patients with type 2 diabetes treated with metformin plus vildagliptin or glibenclamide for 12 weeks. Glucose variability, oxidative stress, metabolic (plasma glucose, insulin and glucagon-like-peptide-1) and cardiovascular responses were evaluated at rest, during and after a 30 min aerobic exercise session (70% of the peak heart rate).

RESULTS

Thirteen patients were included, seven in vildagliptin group (METV) and six in glibenclamide group (METG), baseline glycated hemoglobin (HbA1c) 8.8 ± 0.3%. Treatment reduced HbA1c (1.2% and 1.5% for METV and METG, respectively). The aerobic exercise session did not change glucose variability in both groups. A decrease in glucose during exercise recovery was found, with area under the curve lower in the METG vs. METV (p = 0.04). After the intervention, systolic blood pressure (SBP) decreased in both groups. Patients treated with vildagliptin showed lower SBP variability compared to those treated with glibenclamide.

CONCLUSIONS

Besides improvement in glucose control and reduction of SBP obtained by both treatments, lower blood pressure variability was observed in patients receiving vildagliptin. Glucose variability remained unaffected by both interventions and the exercise session.

Association between hypertension and metabolic disorders among elderly patients in North Jordan

BACKGROUND

Hypertension (HTN), dyslipidemia and hyperglycemia are major risk factors for cardiovascular disease, accounting for the highest morbidity and mortality among the elderly Jordanian population. This study aimed to evaluate serum lipid and glucose profiles of hypertensive patients and normotensive controls, and determine the risk factors for HTN among elderly population in Jordan.

METHODS

A cross-sectional study was carried out among 200 participants, including 111 hypertensive patients and 89 normotensive controls from June to October 2017 in North Jordan. Data were collected on sociodemographic factors, anthropometric measurements, blood pressure, and lipid profile including total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL), high density lipoprotein (HDL) and fasting blood sugar (FBS).

RESULTS

Serum levels of TC, TG, LDL and FBS were higher while HDL levels were lower in hypertensive subjects compared to normotensives (p < 0.01). There were no differences between hypertensive and normotensives patients regarding their age, waist circumference (WC), waist-to-height ratio (WHtR) and body mass index (BMI). Anthropometric and biochemical parameters were significantly correlated only in normotensive group. Significant associations between blood pressure and biochemical parameters were seen only in the HTN group. Overweight/obesity, abdominal obesity (WHtR), hyperglycemia, hypertriglyceridemia and low HDL were found as the risk factors for HTN.

CONCLUSION

from our results, future strategies for preventing dyslipidemia, hyperglycemia and, consequently, HTN through modification of risk factors such as lifestyle changes and medical management. It's recommended for patients with HTN to measure the BP, lipid and glucose profiles regularly throughout their primary health care to prevent non-communicable diseases.

Ten-second central SBP variability predicts first and recurrent cardiovascular events

OBJECTIVE

Long-term (day-to-day or visit-to-visit) blood pressure variability (BPV) predicts elevated risk of cardiovascular events but represents just one BPV type. We examined whether 10-s BPV predicts cardiovascular events.

METHODS

In 4999 adults (58% men; aged 50-84 years; 670 with a prior cardiovascular event), we performed suprasystolic brachial pressure measurements over ∼10 s, yielding aortic pressure waveforms. BPV was calculated by average real variability (ARV), root mean square of successive differences, standard deviation (SD), coefficient of variation and relative range. Participants were followed up for 4.6 years (median), accruing 310 first and 187 recurrent cardiovascular events, respectively.

RESULTS

In multivariable-adjusted analyses, all central SBPV parameters were associated with first cardiovascular events: the standardized hazard ratio for each ranged from 1.25 to 1.29. The hazard ratio between the lowest and highest sextile ranged from 1.92 [95% confidence interval (CI) 1.31-2.80] for coefficient of variation to 2.19 (95% CI 1.38-3.46) for ARV. All central SBPV parameters also were associated with higher risk of recurrent cardiovascular events: adjusted standardized hazard ratio ranged from 1.16 to 1.21. Because of fewer recurrent events, these low-versus-high comparisons were based on tertiles; hazard ratios between the lowest and highest tertiles ranged from 1.50 (95% CI 1.02-2.23) for ARV to 1.76 (95% CI 1.20-2.60) for SD. The highest categorical net reclassification improvement for 5-year risk of first cardiovascular events was 13% (95% CI 7-18%) and substantially higher among those with intermediate (10-20%) risk: 39% (95% CI 26-52%).

CONCLUSION

Ten-second central SBPV parameters predict first and recurrent cardiovascular events.

Blood pressure variability predicts adverse events and cardiovascular outcomes in SPRINT

SPRINT (Systolic Blood Pressure Intervention Trial) highlighted the benefits of intensive targeted antihypertensive therapy but resulted in higher rates of treatment-related adverse events. Blood pressure (BP) variability has emerged as a significant predictor of outcomes over and above levels of BP. Using the SPRINT data set, we aimed to determine the relationship of BP variability with cardiovascular outcomes and side effects of antihypertensive therapy. The analyses included all participants randomized in SPRINT who reached the target systolic BP (SBP) for their respective groups (intensive < 120 mm Hg; standard < 140 mm Hg). Coefficients of variation (CV) for SBP, diastolic BP (DBP), and PP for each patient characterized variability. Student t test was used to compare treatment arms for each CV metric. Cox proportional hazards regression was used to identify independent predictors of the SPRINT primary outcome and adverse events. P < .15 on univariate analysis was required to enter the model and P < .05 to remain in it. A total of 8884 patients (4561 standard group; 4323 intensive group) met inclusion criteria. DBP CV differed between the groups (9.12 ± 3.20 standard group; 9.47 ± 3.49 intensive group [P < .0001]). DBP CV predicted a greater hazard for the primary outcome (hazard ratio [HR], 1.14) in the overall model as well as separate analyses by treatment arms (standard group HR, 1.15; intensive group HR, 1.19), each P < .0001. DBP CV also independently predicted a greater hazard for acute kidney injury (HR, 1.12) and hypotensive events (HR, 1.12). Visit-to-visit DBP variability independently predicted worse cardiovascular outcomes and hypoperfusion-related adverse events in SPRINT.

Use of machine-learning algorithms to determine features of systolic blood pressure variability that predict poor outcomes in hypertensive patients

Background

We re-analyzed data from the Systolic Blood Pressure Intervention Trial (SPRINT) trial to identify features of systolic blood pressure (SBP) variability that portend poor cardiovascular outcomes using a nonlinear machine-learning algorithm.

Methods

We included all patients who completed 1 year of the study without reaching any primary endpoint during the first year, specifically: myocardial infarction, other acute coronary syndromes, stroke, heart failure or death from a cardiovascular event (n = 8799; 94%). In addition to clinical variables, features representing longitudinal SBP trends and variability were determined and combined in a random forest algorithm, optimized using cross-validation, using 70% of patients in the training set. Area under the curve (AUC) was measured using a 30% testing set. Finally, feature importance was determined by minimizing node impurity averaging over all trees in the forest for a specific feature.

Results

A total of 365 patients (4.1%) reached the combined primary outcome over 37 months of follow-up. The random forest classifier had an AUC of 0.71 on the testing set. The 10 most significant features selected in order of importance by the automated algorithm included the urine albumin/creatinine (CR) ratio, estimated glomerular filtration rate, age, serum CR, history of subclinical cardiovascular disease (CVD), cholesterol, a variable representing SBP signals using wavelet transformation, high-density lipoprotein, the 90th percentile of SBP and triglyceride level.

Conclusions

We successfully demonstrated use of random forest algorithm to define best prognostic longitudinal SBP representations. In addition to known risk factors for CVD, transformed variables for time series SBP measurements were found to be important in predicting poor cardiovascular outcomes and require further evaluation.

Comparison of amlodipine versus other calcium channel blockers on blood pressure variability in hypertensive patients in China: a retrospective propensity score-matched analysis

Aim: Reducing the fluctuation of blood pressure has recently been recognized as a potential target for improving management of hypertension to prevent cardiovascular events, particularly for strokes. Some randomized controlled trials demonstrated that amlodipine can effectively reduce blood pressure as a well-established, long-acting calcium channel blocker (CCB). However, few data are available for amlodipine on blood pressure variability (BPV) in China in a real-world setting. This study aimed to assess the effect of amlodipine versus other CCB antihypertensive agents on BPV. Materials & methods: A retrospective propensity score-matched analysis was conducted, which retrieved the encounter data from 5582 hypertensive inpatients (with a median age of 69, female percentage of 48%, diastolic blood pressure ≥40 and <150 mmHg; systolic blood pressure (SBP) ≥70 mmHg and <260 mmHg), who had taken at least one antihypertensive agent and completed at least three SBP measurements during the visit. International Classification of Diseases was used to identify the hypertensive patients. BPV was calculated with standard deviation (SD) and coefficient of variation (CV) of SBP during a single inpatient visit. The Propensity Score Matching was used to balance the cohort of patients prescribed amlodipine or other CCBs. A series of appropriate statistical tests were applied to the propensity score-matched samples to examine the different effects on BPV. Additionally, the hypertensive patients with comorbidity such as coronary artery disease, diabetes mellitus, myocardial infarction, heart failure and chronic kidney disease were analyzed. Results: For the hypertensive patients (n = 1756, for each cohort), patients prescribed amlodipine showed lower BPV than patients prescribed other CCBs (12.90 vs 13.76 mmHg, p < 0.05 [SD] and 9.47 vs 10.06, p < 0.05 [CV]). For the hypertensive patients with comorbidity (n = 1080, for each cohort), patients prescribed amlodipine had lower BPV than patients prescribed other CCBs as well (13.24 vs 14.23 mmHg, p < 0.05 [SD] and 9.66 vs 10.28, p < 0.05 [CV]). Conclusion: amlodipine was associated with lower BPV than other CCBs for both hypertensive patients and hypertensive patients with comorbidity.

Visit-to-visit variability of blood pressure and cardiovascular outcomes in patients with stable coronary heart disease. Insights from the STABILITY trial

Aims

To study the relation between visit-to-visit variability of blood pressure (BP) and cardiovascular risk in patients with stable coronary heart disease.

Methods and results

In 15 828 patients from the STABILITY trial (darapladib vs. placebo in patients with established coronary heart disease), BP variability was assessed by the standard deviation (SD) of systolic BP, the SD of diastolic BP, maximum BP, and minimum BP, from 5 measurements (baseline and months 1, 3, 6, and 12) during the first year after randomisation. Mean (SD) average BP during the first year of study was 131.0 (13.7) mmHg over 78.3 (8.3) mmHg. Mean (SD) of the visit-to-visit SD was 9.8 (4.8) mmHg for systolic and 6.3 (3.0) mmHg for diastolic BP. During the subsequent median follow-up of 2.6 years, 1010 patients met the primary endpoint, a composite of time to cardiovascular death, myocardial infarction, or stroke. In Cox regression models adjusted for average BP during first year of study, baseline vascular disease, treatment, renal function and cardiovascular risk factors, the primary endpoint was associated with SD of systolic BP (hazard ratio for highest vs. lowest tertile, 1.30, 95% CI 1.10-1.53, P = 0.007), and with SD of diastolic BP (hazard ratio for highest vs. lowest tertile, 1.38, 95% CI 1.18-1.62, P < 0.001). Peaks and troughs in BP were also independently associated with adverse events.

Conclusion

In patients with stable coronary heart disease, higher visit-to-visit variabilities of both systolic and diastolic BP are strong predictors of increased risk of cardiovascular events, independently of mean BP.

Hypertension and intracerebral hemorrhage recurrence among white, black, and Hispanic individuals

OBJECTIVE

To clarify whether recurrence risk for intracerebral hemorrhage (ICH) is higher among black and Hispanic individuals and whether this disparity is attributable to differences in blood pressure (BP) measurements and their variability.

METHODS

We analyzed data from survivors of primary ICH enrolled in 2 separate studies: (1) the longitudinal study conducted at Massachusetts General Hospital (n = 759), and (2) the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study (n = 1,532). Participants underwent structured interview at enrollment (including self-report of race/ethnicity) and were followed longitudinally via phone calls and review of medical records. We captured systolic BP (SBP) and diastolic BP measurements, and quantified variability as SBP and diastolic BP variation coefficients. We used multivariable (Cox regression) survival analysis to identify risk factors for ICH recurrence.

RESULTS

We followed 2,291 ICH survivors (1,121 white, 529 black, 605 Hispanic, and 36 of other race/ethnicity). Both black and Hispanic patients displayed higher SBP during follow-up (p < 0.05). Black participants also displayed greater SBP variability during follow-up (p = 0.032). In univariable analyses, black and Hispanic patients were at higher ICH recurrence risk (p < 0.05). After adjusting for BP measurements and their variability, both Hispanic (hazard ratio = 1.51, 95% confidence interval 1.14-2.00, p = 0.004) and black (hazard ratio = 1.98, 95% confidence interval 1.36-2.86, p < 0.001) patients remained at higher risk of ICH recurrence.

CONCLUSION

Black and Hispanic patients are at higher risk of ICH recurrence; hypertension severity (average BP and its variability) does not fully account for this finding. Additional studies will be required to further elucidate determinants for this health disparity.

Blood pressure targets for hypertension in patients with type 2 diabetes

BACKGROUND

Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120-140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50-0.92], fatal (RR =0.41; 95% CI, 0.20-0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43-0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80-90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality.

CONCLUSIONS

We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120-130/80 mmHg, with close monitoring for all drug-related harms.

Optimal Schedule for Assessing Home BP Variability: The Finn-Home Study

BACKGROUND

Current guidelines make no recommendations on the optimal timing or number of measurements for assessing home blood pressure variability (HBPV). Our aim was to elucidate the optimal schedule for measuring HBPV in relation to cardiovascular risk.

METHODS

In total, 1,706 Finnish adults (56.5 ± 8.5 years; 54% women) self-measured their home blood pressure (HBP) twice in the morning and evening during 7 consecutive days. The participants were followed up for cardiovascular events. We examined the association between HBPV (coefficient of variation based on 2 through 7 measurement days) and cardiovascular events using Cox regression models adjusted for HBP and other cardiovascular risk factors.

RESULTS

During a follow-up of 11.8 ± 3.1 years, 216 cardiovascular events occurred. Systolic morning HBPV based on three (hazard ratio [HR], 1.039; 95% confidence interval, 1.006-1.074, model c statistic 0.737) through seven (HR, 1.057; 95% confidence interval, 1.012-1.104, model c statistic 0.737) measurement days was significantly associated with cardiovascular events. Agreement in classification to normal vs. increased morning day-to-day HBPV between consecutive measurement days became substantial (κ = 0.69 for systolic and κ = 0.68 for diastolic) after the fourth measurement day. The associations of diastolic HBPV, evening HBPV, all-day HBPV, and variability based on first measurements of each measurement occasion, with cardiovascular outcomes were nonsignificant or remained significant only after the sixth measurement day.

CONCLUSIONS

Our results suggest systolic HBP should be measured twice in the morning for at least 3 days when assessing HBPV. Increasing the number of measurement days from 3 to 7 results in marginal improvement in prognostic accuracy.

The joint influence of emotional reactivity and social interaction quality on cardiovascular responses to daily social interactions in working adults

OBJECTIVE

Social interaction quality is related to cardiovascular functioning. Trait emotional reactivity may amplify cardiovascular responses to social interactions, but is often examined as a tendency to react to negative events. We took a broader approach by examining the joint effects of positive and negative emotional reactivity and social interaction quality on ambulatory blood pressure (ABP) and heart rate (HR) responses to daily social interactions.

METHODS

Participants were part of a larger study on BP and cardiovascular health (N = 805; M_Age = 45.3; 40.1% male). Participants completed a measure of emotional reactivity (BIS/BAS) and 24-hour ABP monitoring accompanied by ecological momentary assessments (EMA) about just-experienced social interactions and their pleasantness. Multilevel models tested the associations of emotional reactivity, average pleasantness, and momentary pleasantness with BP and HR.

RESULTS

Participants who reported more pleasant interactions on average had lower BP (systolic BP: B = -0.51 mmHg; diastolic BP: B = -0.46 mmHg). These effects did not depend on emotional reactivity. The effect of momentary pleasantness depended on BIS/BAS; in less reactive participants, greater pleasantness was associated with lower HR, B = -0.13 bpm; in more reactive participants, greater pleasantness was associated with increased HR, B = 0.16).

CONCLUSIONS

Participants who had more pleasant social interactions throughout the day had lower mean ABP. The acute effect of a given social interaction on HR depended on emotional reactivity: HR increased for participants high in emotional reactivity during pleasant interactions. Thus, emotional reactivity may influence cardiovascular responses to social stimuli.

The timeline of blood pressure changes and hemodynamic responses during an experimental noise exposure

BACKGROUND

Noise exposure increases blood pressure and peripheral vascular resistance in both genders in an experimental setting, as previously reported by the authors.

OBJECTIVES

The aim of this re-analysis was to present the minute-by-minute timeline of blood pressure changes and hemodynamic events provoked by traffic noise in the young and healthy adults.

METHODS

The experiment consisted of three 10-min phases: rest in quiet conditions before noise (Leq = 40 dBA), exposure to recorded road-traffic noise (Leq = 89 dBA), and rest in quiet conditions after noise (Leq = 40 dBA). Participants' blood pressure, heart rate, and hemodynamic parameters (cardiac index and total peripheral resistance index) were concurrently measured with a thoracic bioimpedance device. The raw beat-to-beat data were collected from 112 participants, i.e., 82 women and 30 men, aged 19-32 years. The timeline of events was created by splitting each experimental phase into ten one-minute intervals (30 intervals in total). Four statistical models were fitted to answer the six study questions what is happening from one minute to another during the experiment.

RESULTS

Blood pressure decreased during quiet phase before noise, increased in the first minute of noise exposure and then decreased gradually toward the end of noise exposure, and continued to decline to baseline values after noise exposure. The cardiac index showed a gradual decrease throughout the experiment, whereas total vascular resistance increased steadily during and after noise exposure.

CONCLUSIONS

The timeline of events in this 30-min experiment provides insight into the hemodynamic processes underlying the changes of blood pressure before, during and after noise exposure.

Real World Home Blood Pressure Variability in Over 56,000 Individuals With Nearly 17 Million Measurements

BACKGROUND

Using the data from 56,365 individuals, from 185 countries, and a Nokia Health Wireless blood pressure (BP) monitor, we investigated real-world characteristics of BP variability (BPV).

METHODS

All included individuals self-measured and uploaded their BP using Bluetooth at least 20 times over a period of ≥1 month at a frequency and duration of their choosing. In total, 16,904,844 BP measurements were analyzed, with a median of 146 measurements per person (interquartile range [IQR] 73-321) over a median of 14 months (IQR 7-31). SD, coefficient of variation, maximum BP, and maximum minus minimum BP difference were all calculated as measures of BPV.

RESULTS

BPV showed a distinct pattern, influenced by season of year, day of week, and time of day. BPV index was higher in females compared with males (P < 0.001) and increased with age (P < 0.001). Compared to the weekend, the weekday BPV index was significantly higher, and this finding was more prominent in females (P = 0.001). In multivariate analysis, BPV index were significantly associated with age, gender, geographic location, and mean BP values.

CONCLUSION

Using the largest BP data set we are aware of, with the benefits and limitations of real-world measurement, we could show the pattern of BPV and provide reference values that may be helpful in understanding the nature of BPV as self-measurement at home becomes more common, and help guide individualized management.

Prognostic impact of systolic blood pressure variability in people with diabetes

Objective

Blood pressure variability (BPV) has been associated with risk of cardiovascular events in observational studies, independently of mean BP levels. In states with higher autonomic imbalance, such as in diabetes, the importance of BP variability may theoretically be even greater. We aimed to investigate the incremental value of BPV for prediction of cardiovascular and all-cause mortality in patients with type 2 diabetes.

Methods

We identified 9,855 patients without pre-existing cardiovascular disease who did not change BP-lowering treatment during the observation period from a Swedish primary health care cohort of patients with type 2 diabetes. BPV was summarized as the standard deviation (SD), coefficient of variation (CV), or variation independent of mean (VIM). Patients were followed for a median of 4 years and associations with cardiovascular and all-cause mortality were investigated using Cox proportional hazards models.

Results

BPV was not associated with cardiovascular specific or all-cause mortality in the total sample. In patients who were not on BP-lowering drugs during the observation period (n = 2,949), variability measures were associated with all-cause mortality: hazard ratios were 1.05, 1.04 and 1.05 for 50% increases in SD, CV and VIM, respectively, adjusted for Framingham risk score risk factors, including mean BP. However, the addition of the variability measures in this subgroup only led to very minimal improvement in discrimination, indicating they may have limited clinical usefulness (change in C-statistic ranged from 0.000–0.003 in all models).

Conclusions

Although BPV was independently associated with all-cause mortality in diabetes patients in primary care who did not have pre-existing cardiovascular disease or BP-lowering drugs, it may be of minimal clinical usefulness above and beyond that of other routinely measured predictors, including mean BP.

Association between B-type natriuretic peptide and within-visit blood pressure variability

BACKGROUND

Blood pressure variability (BPV) has been shown to predict cardiovascular events. Within-visit BPV is the simplest and easiest measure of BPV, but previous studies have shown conflicts as to whether within-visit BPV correlates with target organ damage. We aimed to evaluate whether within-visit BPV correlates with B-type natriuretic peptide (BNP) in a general population.

HYPOTHESIS

Within-visit BPV correlates with BNP in a general population.

METHODS

This was a cross-sectional study that included 633 individuals, randomly selected, age 45 to 99 years, registered in the primary care program from an urban medium-sized town. Patients were scheduled for a single-day visit that consisted of clinical evaluation and laboratory tests. Three blood pressure (BP) readings, 1 minute apart, were done, and within-visit BPV was determined as the coefficient of variation (CV) of the 3 BP measures. Our main outcome was to correlate BNP and within-visit BPV. A multivariable model was estimated using a generalized linear model to evaluate the independent effects of different variables on BNP levels.

RESULTS

The median age was 57 years. Median BNP was 16 pg/mL, and the median systolic and diastolic BP-CV were, respectively, 3.9% and 3.5%. There was a weak but positive correlation between BNP and both systolic BP-CV and diastolic BP-CV (r = 0.107 and P = 0.007 and r = 0.092 and P = 0.019, respectively). In multiple regression equation, systolic BP, diastolic BP-CV, body mass index, and estimated glomerular filtration rate were associated with BNP.

CONCLUSIONS

In the present study, there was a positive, albeit weak, correlation between within-visit BPV and BNP. In addition, diastolic BPV was associated with BNP even after adjustment for multiple confounders.

Guidance on home blood pressure monitoring: A statement of the HOPE Asia Network

Hypertension is an important modifiable cardiovascular risk factor and a leading cause of death throughout Asia. Effective prevention and control of hypertension in the region remain a significant challenge despite the availability of several regional and international guidelines. Out-of-office measurement of blood pressure (BP), including home BP monitoring (HBPM), is an important hypertension management tool. Home BP is better than office BP for predicting cardiovascular risk and HBPM should be considered for all patients with office BP ≥ 130/85 mm Hg. It is important that HBPM is undertaken using a validated device and patients are educated about how to perform HBPM correctly. During antihypertensive therapy, monitoring of home BP control and variability is essential, especially in the morning. This is because HBPM can facilitate the choice of individualized optimal therapy. The evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for HBPM in Asia.

Exaggerated blood pressure variability is associated with memory impairment in very elderly patients

We investigated the association between working memory (WM) impairment and blood pressure variability (BPV) in very elderly patients. Japanese outpatients ≥80 years who engaged in normal activities of daily living were the study cohort. WM function was evaluated by a simple visual WM test consisting of 3 figures. We considered the number of figures recalled by the patient his/her test score. We defined the patients with a score of 0 or 1 as those with WM impairment and those with scores of 2 or 3 as those without. To investigate the relative risk of WM impairment, we evaluated each patient's 24 hour ambulatory systolic blood pressure (SBP) and its weighted standard deviation (SD_SBP ), office SBP, and the visit-to-visit SD_SBP during the 1 year period from the patient's enrollment. A total of 66 patients (mean 84 ± 3.6 years) showed WM impairment, and 431 patients (mean 83 ± 3.1 years) showed no WM impairment. There were no significant differences in 24 hour ambulatory SBP or office SBP between these two groups. However, the WM impairment patients showed significantly higher weighted SD_SBP and visit-to-visit SD_SBP values compared to the no-impairment group even after adjusting for age. Among these ≥80-year-old patients, those with the highest quartile of both weighted SD_SBP (≥21.4 mm Hg) and visit-to-visit SD_SBP (≥14.5 mm Hg) showed the highest relative risk (odds ratio 3.52, 95% confidence interval 1.42-8.72) for WM impairment. Exaggerated blood pressure variability parameters were significantly associated with working memory impairment in very elderly individuals.

Association of visit-to-visit blood pressure variability with the risk of all-cause mortality and cardiovascular events in general population

The association between blood pressure variability (BPV) and the risk of all-cause mortality and cardiovascular diseases (CVD) is not well understood. The Kailuan study is a prospective longitudinal cohort study on cerebrovascular events and cardiovascular factors. In this study, resting blood pressure was measured at baseline and every 2 years from 2006 to 2007. BPV is mainly defined as the coefficient of variation (CV). Hazard ratio (HR), with 95% confidence intervals (CI) was calculated using Cox regression model. Among 52 387 participants, we identified 1817 who ended up with all-cause death and 1198 with CVD. Each 4.68% increase in BPV was associated with a 13% increase in the risk of mortality (HR = 1.13, 95% CI = 1.09-1.18) and a 7% increase in CVD (HR = 1.07, 95% CI = 1.02-1.13), respectively. After adjustment of confounding factors, the HR of comparing participants in the highest versus lowest quartile of CV of systolic blood pressure (SBP) was 1.37 (1.19, 1.57) for all-cause death, 1.18 (1.01, 1.39) for CVD. Similar results were also observed when BPV was measured by different parameters. We concluded that visit-to-visit BPV was associated with all-cause death and cardiovascular and cerebrovascular events in Chinese general population.

Effect of psychostimulants on blood pressure profile and endothelial function in narcolepsy

Objective

To assess the effect of psychostimulant treatments on the 24-hour blood pressure (BP) profile of patients with narcolepsy type 1 (NT1).

Methods

Heart rate (HR) and BP were monitored for 24 hours and morning endothelial function was evaluated in 160 consecutive patients with NT1: 68 untreated (41 male, median age 34.9 years), 54 treated (32 male, median age 40.9 years), and 38 evaluated twice (21 male, median age 32 years), before and during treatment.

Results

Patients treated for NT1 showed higher 24-hour, daytime, and nighttime diastolic BP and HR values compared with the untreated group. Similarly, HR as well as 24-hour and daytime systolic BP were increased during treatment in the group evaluated twice. The combination of stimulant and anticataplectic drugs showed a synergistic effect on BP, without differences among stimulant categories. Based on 24-hour BP monitoring, hypertension was diagnosed in 58% of treated patients and in 40.6% of untreated patients. After adjustments for age, sex, and body mass index, the percentage of REM sleep remained associated with 24-hour hypertension in untreated and treated patients. Endothelial function was comparable in treated and untreated patients.

Conclusions

The finding that patients with NT1 treated with psychostimulants have higher diastolic BP and HR than untreated patients suggests an increased long-term risk of cardiovascular diseases that requires careful follow-up and specific management.

The effect of labetalol and nifedipine MR on blood pressure in women with chronic hypertension in pregnancy

AIM

To compare the blood pressure (BP) lowering effects of labetalol and nifedipine modified release (MR) in hypertensive pregnant women. We also investigated the effect on the heart rate (HR) and determined the proportion of time spent in target.

METHODS

This was an exploratory study. Women with chronic hypertension taking either labetalol or nifedipine were offered 24-h ambulatory blood pressure monitoring (ABPM). Sleep, wake and drug ingestion times were self-reported. An indirect response model was used to analyse the systolic BP (SBP), diastolic BP (DBP) and HR time-series; the effect of gestation and type of drug was evaluated.

RESULTS

Forty-eight women were recruited: 24 in each group. There was no difference in clinical characteristics. In women taking nifedipine there was a positive association between the dose of nifedipine and pre-dose BP p = .002, this was not present in the labetalol group. There was a difference between the drug effects on both the SBP and DBP time-series (p = .014). In comparison to labetalol, there was less variation in day time BP in those women prescribed nifedipine. Women on labetalol spent a larger proportion of time with their DBP below target (<80 mmHg). The HR dynamics were qualitatively different, a stimulatory effect was found with nifedipine compared to an inhibitory effect with labetalol.

CONCLUSION

There are significant and important differences between the BP lowering effects of nifedipine and labetalol. A large randomised control trial is required to investigate the relationship between BP variability and time in target on pregnancy outcomes.

Blood-pressure variability in patients with obstructive sleep apnea: current perspectives

Obstructive sleep apnea (OSA) is often associated with hypertension and other cardiovascular diseases. Blood pressure (BP) variability is part of the assessment of cardiovascular risk. In OSA, BP variability has been studied mainly as very short-term (beat-by-beat) and short-term (24-hour BP profile) variability. BP measured on consecutive heartbeats has been demonstrated to be highly variable, due to repeated peaks during sleep, so that an accurate assessment of nocturnal BP levels in OSA may require peculiar methodologies. In 24-hour recordings, BP frequently features a "nondipping" profile, ie, <10% fall from day to night, which may increase cardiovascular risk and occurrence of major cardiovascular events in the nocturnal hours. Also, BP tends to show a large "morning BP surge", a still controversial negative prognostic sign. Increased very short-term BP variability, high morning BP, and nondipping BP profile appear related to the severity of OSA. Treatment of OSA slightly reduces mean 24-hour BP levels and nocturnal beat-by-beat BP variability by abolishing nocturnal BP peaks. In some patients OSA treatment turns a nondipping into a dipping BP profile. Treatment of arterial hypertension in OSA usually requires both antihypertensive pharmacological therapy and treatment of apnea. Addressing BP variability could help improve the management of OSA and reduce cardiovascular risk. Possibly, drug administration at an appropriate time would ensure a dipping-BP profile.

Visit-to-visit variability of lipid measurements as predictors of cardiovascular events

BACKGROUND

Higher visit-to-visit variability in risk factors such as blood pressure and low-density lipoprotein (LDL)-cholesterol are associated with an increase in cardiovascular (CV) events.

OBJECTIVE

The purpose of this study was to determine whether variability in high-density lipoprotein cholesterol (HDL-C) and triglyceride levels predicted coronary and CV events in a clinical trial population with known coronary disease.

METHODS

We assessed intraindividual variability in fasting high-density lipoprotein (HDL)-cholesterol, triglyceride, and LDL-cholesterol measurements among 9572 patients in the Treating to New Targets trial and correlated the results with coronary events over a median follow-up of 4.9 years.

RESULTS

In the fully adjusted Cox model, 1 standard deviation of average successive variability, defined as the average absolute difference between successive values, was associated with an increased risk of a coronary event for HDL-cholesterol (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.11-1.21, P < .0001), for triglycerides (HR 1.09, 95% CI 1.04-1.15, P = .0005), and for LDL-cholesterol (HR 1.14, 95% CI 1.09-1.19, P < .0001). Similar results were found for the 3 other measures of variability, standard deviation, coefficient of variability, and variability independent of the mean. Similar results were seen for CV events, stroke, and nonfatal myocardial infarction. Higher variability in triglyceride and LDL-cholesterol, but not HDL-cholesterol, was predictive of incident diabetes. The correlation among the variability of the 3 lipid measurements was weak.

CONCLUSION

Visit-to-visit variability in fasting measurements of HDL-cholesterol, triglycerides, and LDL-cholesterol are predictive of coronary events, CV events, and for triglyceride and low-density lipoprotein cholesterol variability, incident diabetes. The mechanisms accounting for these associations remain to be determined.

Home Monitoring of Blood Pressure: Short-Term Changes During Serial Measurements for 56398 Subjects

Hypertension is one of the greatest contributors to premature morbidity and mortality worldwide. It has been demonstrated that lowering blood pressure (BP) by just a few mmHg can bring substantial clinical benefits, reducing the risk of stroke and ischemic heart disease. Properly managing high BP is one of the most pressing global health issues, but accurate methods to continuously monitoring BP at home are still under discussion. Indeed, the BP for any given individual can fluctuate significantly during intervals as short as a few minutes. In clinical settings, the guidelines suggest to wait for 5 or 10 minutes in seated rest before taking the measure, in order to alleviate the effect of the stress induced by the clinical environment. Alternatively, BP measured in the home environment is thought to provide a more accurate measure free of the stress of a clinical environment, but there is currently a lack of extensive studies on the trajectory of serial BP measurements over minutes in the home setting. In this paper, we aim at filling this gap by analyzing a large dataset of more than 16 million BP measurements taken at home with commercial BP monitoring devices. In particular, we propose new techniques to analyze this dataset, taking into account the limitations due to the uncontrolled data collection, and we study the characteristics of the BP trajectory for consecutive measures over several minutes. We show that the BP values significantly decrease after 10 minutes minutes from the initial measurement (4.1 and 6.6 mmHg for the diastolic and systolic BP, respectively), and continue to decrease for about 25 minutes. We also describe statistically the clinical relevance of this change, observing more than 50% misclassifications for measurements in the hypertension region. We then propose a model to study the inter-subject variability, showing significant variations in the expected decrease in systolic BP. These results may provide the initial evidence for future large clinical studies using participant-monitored BP.

[Effect of a fixed-dose combination of perindopril arginine/amlodipine on the level and variability of blood pressure according to its office visit-to-visit measurements and self-measurements at home: A subanalysis of the PREVOSHODSTVO (SUPERIORITY) program]

AIM

To study the effect of a fixed-dose combination of perindopril arginine/amlodipine (prestans) on the goal levels and variability of blood pressure (BP) according to its office visit-to-visit measurements and self-measurement (OVVM and SM) in a subgroup of 483 people from the population of the Russian observational SUPERIORITY program, most cases of whom are given the combination replacing the previously ineffective mono- and combination antihypertensive therapy (AHT).

SUBJECTS AND METHODS

The subanalysis included data on 483 patients (34% men) aged 57.9±10.8 years with uncontrolled hypertension, who were both untreated and treated with antihypertensive mono- or combination therapy using a free or fixed-dose combination of 2-3 antihypertensive drugs and in whom the physicians decided to use prestans to correct AHT. The follow-up period was 24 weeks.

RESULTS

At the end of the investigation, the patients received prestans in the following doses: 5/5 mg (34% of the patients), 10/5 mg (39.5%), 5/10 mg (3.9%), and 10/10 mg (22%). In the analyzed patient group, the baseline BP was 160.8±8.8/92.6±7.4 mm Hg and dropped to 125.9±7.9/77.8±5.0 mm Hg at 24 weeks (p<0.001). According to SM, the morning BP significantly decreased from 147.0±13.3/85.6±7.2 to 127.5±8.3/78,9±5.6 mm Hg at 24 weeks (p<0.001). The evening BP readings showed the similar trends. Target BP was achieved in 93 and 78% of the patients, as shown by OVVM and SM, respectively. According to SCM, the day-to-day variability of BP significantly decreased from 5.1±3.2/3.4±2.3 Hg mm at Visit 2 to 2.7±2/0/2,3±1/5 mm Hg at Visit 5 (p<0.001).

CONCLUSION

The use of the fixed-dose combination of perindopril arginine/amlodipine in hypertensive patients just at the beginning of treatment, by switching from insufficiently effective mono- or combination AHT to the fixed-dose combination of perindopril arginine/amlodipine, is an effective way to optimize AHT in clinical practice, which lowers the BP level and variability, as evidenced by both OVVM and SM.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Clinical Trial Registration

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

Validity of a protocol to estimate patients' pre-morbid basal blood pressure

PURPOSE

The pre-illness basal mean arterial BP (MAP) is an important reference point to gauge the degree of relative hypotension among unwell patients. We aimed to assess mean bias, correlation, and agreement between basal MAP measured during nighttime ambulatory BP monitoring (ABPM) and basal MAP estimated using a standardized protocol.

MATERIALS AND METHODS

For a cohort of 137 consecutive patients, aged ≥40 years, who recently underwent ABPM, a blinded investigator estimated basal MAP from up to five most recent clinic BP measurements. Both basal MAP values, measured and estimated, were compared pairwise for each participant.

RESULTS

We traced a median of 4 [interquartile range 3-5] previous BP measurements per patient over a median period of 132 [interquartile range 55-277] days up until the ABPM test. The estimated basal MAP (mean 88 ± 8 mmHg) was linearly related (Pearson's r = 0.41, p = 0.0001) to the measured basal MAP (mean 88 ± 12 mmHg). Bland-Altman plot revealed a mean bias of 0.3 mmHg with agreement limits of ±22 mmHg.

CONCLUSIONS

The mean bias between estimated and measured values for basal MAP was insignificant and modest. When a recent nighttime ABPM is unavailable, a protocol based on recent clinic BP readings can be used to estimate patient's basal MAP.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613001382763.

Hypertension and blood pressure variability management practices among physicians in Singapore

Purpose

There are limited data on blood pressure variability (BPV) in Singapore. The absence of updated local guidelines might contribute to variations in diagnosis, treatment and control of hypertension and BPV between physicians. This study evaluated BPV awareness, hypertension management and associated training needs in physicians from Singapore.

Materials and methods

Physicians from Singapore were surveyed between September 8, 2016, and October 5, 2016. Those included were in public or private practice for ≥3 years, cared directly for patients ≥70% of the time and treated ≥30 patients for hypertension each month. The questionnaire covered 6 main categories: general blood pressure (BP) management, BPV awareness/diagnosis, home BP monitoring (HBPM), ambulatory BP monitoring (ABPM), BPV management and associated training needs.

Results

Responses from 60 physicians (30 general practitioners [GPs], 20 cardiologists, 10 nephrologists) were analyzed (77% male, 85% aged 31–60 years, mean 22 years of practice). Approximately 63% of physicians considered white-coat hypertension as part of BPV. The most common diagnostic tool was HBPM (overall 77%, GPs 63%, cardiologists 65%, nephrologists 70%), but ABPM was rated as the tool most valued by physicians (80% overall), especially specialists (97%). Withdrawn Singapore guidelines were still being used by 73% of GPs. Approximately 48% of physicians surveyed did not adhere to the BP cutoff recommended by most guidelines for diagnosing hypertension using HBPM (>135/85 mmHg). Hypertension treatment practices also varied from available guideline recommendations, although physicians did tend to use a lower BP target for patients with diabetes or kidney disease. There were a number of challenges to estimating BPV, the most common of which was patient refusal of ABPM/HBPM. The majority of physicians (82%) had no training on BPV, but stated that this would be useful.

Conclusion

There appear to be gaps in knowledge and guideline adherence relating to the assessment and management of BPV among physicians in Singapore.