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

Prediction of preoperative in-hospital mortality rate in patients with acute aortic dissection by machine learning: a two-centre, retrospective cohort study

OBJECTIVES

To conduct a comprehensive analysis of demographic information, medical history, and blood pressure (BP) and heart rate (HR) variability during hospitalisation so as to establish a predictive model for preoperative in-hospital mortality of patients with acute aortic dissection (AD) by using machine learning techniques.

DESIGN

Retrospective cohort study.

SETTING

Data were collected from the electronic records and the databases of Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and the First Affiliated Hospital of Anhui Medical University between 2004 and 2018.

PARTICIPANTS

380 inpatients diagnosed with acute AD were included in the study.

PRIMARY OUTCOME

Preoperative in-hospital mortality rate.

RESULTS

A total of 55 patients (14.47%) died in the hospital before surgery. The results of the areas under the receiver operating characteristic curves, decision curve analysis and calibration curves indicated that the eXtreme Gradient Boosting (XGBoost) model had the highest accuracy and robustness. According to the SHapley Additive exPlanations analysis of the XGBoost model, Stanford type A, maximum aortic diameter >5.5 cm, high variability in HR, high variability in diastolic BP and involvement of the aortic arch had the greatest impact on the occurrence of in-hospital deaths before surgery. Moreover, the predictive model can accurately predict the preoperative in-hospital mortality rate at the individual level.

CONCLUSION

In the current study, we successfully constructed machine learning models to predict the preoperative in-hospital mortality of patients with acute AD, which can help identify high-risk patients and optimise the clinical decision-making. Further applications in clinical practice require the validation of these models using a large-sample, prospective database.

TRIAL REGISTRATION NUMBER

ChiCTR1900025818.

Blood Pressure Variability and the Progression of Chronic Kidney Disease: a Systematic Review and Meta-Analysis

BACKGROUND

Blood pressure variability (BPV) is a risk factor for poor prognosis including cardiovascular events, chronic kidney disease, and mortality, independent of elevated BP.

METHODS

We searched PubMed/Medline, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to November 23, 2022. Cohort studies reporting the association between BPV and chronic kidney disease (CKD) progression were selected. Hazard ratios were pooled using a random-effects model. Meta-regression, subgroup analyses, and sensitivity analyses were conducted.

RESULTS

A total of 23 studies were included in this systematic review and meta-analysis. Increased BPV was associated with progression of CKD (HR: 1.21, 95% CI: 1.09-1.33) and incidence of ESRD (HR: 1.08, 95% CI: 1.08-1.30). Among the different BPV metrics, high variation independent of mean (VIM), coefficient of variation (CV), standard deviation (SD), and average real variability (ARV) were indicated as predictors of CKD progression.

DISCUSSION

Increased BPV was associated with CKD progression.

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

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

High night-to-night variability in sleep apnea severity is associated with uncontrolled hypertension

Obstructive sleep apnea (OSA) severity can vary markedly from night-to-night. However, the impact of night-to-night variability in OSA severity on key cardiovascular outcomes such as hypertension is unknown. Thus, the primary aim of this study is to determine the effects of night-to-night variability in OSA severity on hypertension likelihood. This study uses in-home monitoring of 15,526 adults with ~180 nights per participant with an under-mattress sleep sensor device, plus ~30 repeat blood pressure measures. OSA severity is defined from the mean estimated apnea-hypopnoea index (AHI) over the ~6-month recording period for each participant. Night-to-night variability in severity is determined from the standard deviation of the estimated AHI across recording nights. Uncontrolled hypertension is defined as mean systolic blood pressure ≥140 mmHg and/or mean diastolic blood pressure ≥90 mmHg. Regression analyses are performed adjusted for age, sex, and body mass index. A total of 12,287 participants (12% female) are included in the analyses. Participants in the highest night-to-night variability quartile within each OSA severity category, have a 50-70% increase in uncontrolled hypertension likelihood versus the lowest variability quartile, independent of OSA severity. This study demonstrates that high night-to-night variability in OSA severity is a predictor of uncontrolled hypertension, independent of OSA severity. These findings have important implications for the identification of which OSA patients are most at risk of cardiovascular harm.

Relationship between Short- and Mid-Term Glucose Variability and Blood Pressure Profile Parameters: A Scoping Review

Background. Increased variability of glucose (GV) and blood pressure (BPV) is linked to a higher risk of macro- and microvascular complications and other hard endpoints. This scoping review aims to summarize the existing evidence regarding the association between the parameters of the blood pressure (BP) profile, especially BPV, with indices of short- and mid-term GV. Methods. A literature search was conducted in the MEDLINE/PubMed, Cochrane, Embase, Web of Science, and Wiley Online Library databases. Results. The main findings of this review are as follows: (i) 13 studies were included, mainly with small sample sizes; (ii) there was a considerable degree of heterogeneity in the characteristics of the study participants (age range, individuals with normoglycemia, type 1 or 2 diabetes, normal BP, or hypertension), as well as in the methodologies (mainly in terms of the duration of the data collection period) and variability indices examined (mean amplitude of glycemic excursions and coefficient of glucose variation most frequently reported); and (iii) the results were heterogeneous regarding the association between GV and the parameters of the BP profile. Conclusions. There is a significant lack of evidence on the association between GV and BPV. Future research implementing a standardized methodology should focus on the determinants, association, and clinical relevance of GV and BPV.

The association between blood pressure variability and perihematomal edema after spontaneous intracerebral hemorrhage

Background

Perihematomal edema (PHE) after spontaneous intracerebral hemorrhage (sICH) is associated with clinical deterioration, but the etiology of PHE development is only partly understood.

Aims

We aimed to investigate the association between systemic blood pressure (BP) variability (BPV) and formation of PHE.

Methods

From a multicenter prospective observational study, we selected patients with sICH who underwent 3T brain MRI within 21 days after sICH, and had at least 5 BP measurements available in the first week after sICH. Primary outcome was the association between coefficient of variation (CV) of systolic BP (SBP) and edema extension distance (EED) using multivariable linear regression, adjusting for age, sex, ICH volume and timing of the MRI. In addition, we investigated the associations of mean SBP, mean arterial pressure (MAP), their CVs with EED and absolute and relative PHE volume.

Results

We included 92 patients (mean age 64 years; 74% men; median ICH volume 16.8 mL (IQR 6.6–36.0), median PHE volume 22.5 mL (IQR 10.2–41.4). Median time between symptom onset and MRI was 6 days (IQR 4–11), median number of BP measurements was 25 (IQR 18–30). Log-transformed CV of SBP was not associated with EED (B = 0.050, 95%-CI −0.186 to 0.286, p = 0.673). Furthermore, we found no association between mean SBP, mean and CV of MAP and EED, nor between mean SBP, mean MAP or their CVs and absolute or relative PHE.

Discussion

Our results do not support a contributing role for BPV on PHE, suggesting mechanisms other than hydrostatic pressure such as inflammatory processes, may play a more important role.

Association of disrupted sleep with 24-hour blood pressure variability in caregivers

BACKGROUND

A growing body of research highlights the negative impact of caregiving on cardiovascular disease (CVD) risk.

OBJECTIVES

This study aimed to examine associations of psychological symptoms and sleep quality with 24-hour blood pressure variability (BPV), which is an independent predictor of CVD, among family caregivers of community-dwelling individuals with chronic illness.

METHODS

For this cross-sectional study, we assessed caregiving burden and depressive symptoms using questionnaires and 7-day sleep quality (i.e., number of awakenings, wake after sleep onset, sleep efficiency) using an actigraph. The participants carried out a 24-hour ambulatory BP monitoring for systolic and diastolic BPV over 24 h and during awake/sleep times. We performed Pearson's correlations and multiple linear regression.

RESULTS

The analytic sample consisted of 30 caregivers (25 female; mean age 62 years). The number of awakenings during sleep was positively correlated with systolic BPV-awake (r = 0.426, p = 0.019) and diastolic BPV-awake (r = 0.422, p = 0.020). Sleep efficiency was negatively correlated with diastolic BPV-awake (r = -0.368, p = 0.045). Caregiving burden and depressive symptoms were not correlated with BPV. After controlling for age and mean arterial pressure, the number of awakenings was significantly associated with increased systolic BPV-24 h (β = 0.194, p = 0.018) and systolic BPV-awake (β = 0.280, p = 0.002), respectively.

CONCLUSIONS

Caregivers' disrupted sleep may play a role in increased CVD risk. While these findings should be confirmed in large clinical studies, improving sleep quality would need to be considered in CVD prevention for caregivers.

Significance of pulse pressure variability in predicting functional outcome in acute ischemic stroke: a retrospective, single-center, observational cohort study

This study aimed to determine the association between pulse pressure variability (PPV) and short- and long-term outcomes of acute ischemic stroke (AIS) patients. We studied 203 tertiary stroke center patients with AIS. PPV during 72 h after admission was analyzed using different variability parameters including standard deviation (SD). Patients' outcome was assessed after 30 and 90 days post-stroke with modified Rankin Scale. The association between PPV and outcome was investigated using logistic regression analysis with adjustment for potential confounders. The predictive significance of PPV parameters was determined using area under the curve (AUC) of receiver operating characteristics. In the unadjusted logistic regression analysis, all PPV indicators were independently associated with unfavorable outcome at 30 days (i.a. Odds ratio (OR) = 4.817, 95%CI 2.283-10.162 per 10 mmHg increase in SD, p = 0.000) and 90 days (i.a. OR = 4.248, 95%CI 2.044-8.831 per 10 mmHg increase in SD, p = 0.000). After adjustment for confounders, ORs for all PPV indicators remained statistically significant. On the basis of AUC values, all PPV parameters were found relevant outcome predictors (p < 0.01). In conclusion, elevated PPV during first 72 h after admission due to AIS is associated with unfavorable outcome at 30 and 90 days, independent of mean blood pressure levels.

Adding Core Muscle Contraction to Wrist-Ankle Rhythmical Skeletal Muscle Tension Increases Respiratory Sinus Arrhythmia and Low-Frequency Power

Paced breathing and rhythmical skeletal muscle tension (RSMT) at an individual's resonance frequency [~ 6 breaths or contractions per min (cpm)] can stimulate the arterial and vascular tone baroreflexes. Lehrer (Appl Psychophysiol Biofeedback 1-10, 2022, https://doi.org/10.1007/s10484-022-09535-5 ) has explained that the stimulation rate is important, not the modality. Early RSMT protocols differed in the muscles recruited and whether legs were crossed or uncrossed (in France et al. Clin Physiol Funct Imaging 26: 21-25, 2006, https://doi.org/10.1111/j.1475-097X.2005.00642.x ; Leher et al. Biol Psychol 81: 24-30, 2009, https://doi.org/10.1016/j.biopsycho.2009.01.003 ; Vaschillo et al. Psychophysiology, 48: 927-936, 2011, https://doi.org/10.1111/j.1469-8986.2010.01156.x ). Whereas core muscle RSMT with crossed legs and wrist-ankle RSMT with uncrossed legs produced resonance effects, researchers have not directly compared the effect of these exercises on respiratory sinus arrhythmia (RSA) and low-frequency (LF) power. The current within-subjects experiment investigated whether crossing the legs and recruiting core muscles enhances wrist-ankle RSMT effects on RSA and LF power. We trained 35 participants to complete 6-cpm wrist-ankle RSMT (ankles uncrossed), 6-cpm wrist-core-ankle RSMT (ankles crossed), and a control condition in which participants sat quietly (ankles uncrossed) without performing RSMT. We predicted that 6-cpm wrist-core-ankle RSMT would produce greater heart rate (HR), HR Max-HR Min, and LF power than the other conditions. The experimental findings supported our predictions. Both RSMT conditions produced greater HR, HR Max-HR Min, and LF power than the control condition. Wrist-core-ankle yielded greater HR and HR Max-HR Min than wrist-ankle RSMT. Future research should compare wrist-ankle and wrist-core-ankle RSMT with legs crossed. The practical implication for HRV biofeedback training is that wrist-core-ankle RSMT with legs crossed may more powerfully stimulate the baroreflex than wrist-ankle RSMT with legs uncrossed.

Inter-arm systolic blood pressure difference: non-persistence and association with incident cardiovascular disease in the Multi-ethnic Study of Atherosclerosis

We investigated inter-arm systolic blood pressure (sIAD) difference, reproducibility, and incident cardiovascular disease (CVD). We hypothesized that higher sIAD values have low prevalence and nonpersistence over years, but that CVD risk is higher starting from the time of first high absolute sIAD. In Multi-Ethnic Study of Atherosclerosis participants (n = 6725, 53% female, 45-84 years old), Doppler systolic blood pressure (SBP) measurements were made in both arms (10-minute interval) thrice over 9.5 years. Proportional hazards for CVD (coronary heart disease, heart failure, stroke, peripheral arterial disease (PAD)) over 16.4 years were tested according to time-varying absolute inter-arm difference with covariates: (1) age, gender, race, and clinic; (2) model 1 plus height, heart rate, BP, antihypertensives, BMI, smoking status, lipids, lipid lowering medication, and diabetes. High sIAD was not persistent across exams. Maximum absolute sIAD ≥ 15 mmHg was found at least once in 815 persons. Maximum absolute sIAD had a graded relationship with incident stroke or PAD: 6.2% events; model 2 hazard ratio per 10 mmHg 1.34 (95% CI, 1.15-1.56) and this risk was approximately doubled for maximum absolute sIAD ≥ 15 mmHg vs 0-4 mmHg. Total CVD risk (18.4% events) was increased only for maximum absolute sIAD ≥25 mmHg. Associations with incident CVD did not differ for higher SBP in left vs right arm. A higher maximum absolute sIAD at any exam was associated with greater risk for stroke and PAD especially for values ≥ 15 mmHg, and ≥25 mmHg for other CVD. Measuring SBP between arms may help identify individuals at risk for CVD.

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

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

Is remote blood pressure monitoring and management a better approach for patients with hypertension? A narrative review

Hypertension is a global public health problem which affects the physical and mental health of individuals. The management of hypertension is a long-term process that requires the cooperation of both doctors and patients, and the blood pressure variability is closely related to the clinical prognosis. In recent years, the development of telemedicine has promoted better blood pressure monitoring and management for patients, as well as better medical intervention and health education for patients by medical staff. This article provides a review of remote blood pressure monitoring and management.

Cardiovagal baroreflex sensitivity, blood pressure and blood pressure variability - the Maastricht study

OBJECTIVE

Low baroreflex sensitivity (BRS) has been hypothesized to underlie high blood pressure (BP) and greater BP variability on the longer term, but evidence is scarce. In addition, these associations may differ by sex and (pre)diabetes. Therefore, we investigated whether cardiovagal BRS is associated with short- to mid-term mean BP and BP variability, and differs according to sex and (pre)diabetes.

METHODS

Cross-sectional data from the population-based Maastricht study (age 60 ± 8 years, 52% men), where office ( n  = 2846), 24-h ( n  = 2404) and 7-day BP measurements ( n  = 2006) were performed. Spontaneous BRS was assessed by cross-correlating systolic BP and instantaneous heart rate. We used linear regression with adjustments for age, sex, BP or BP variability, and cardiovascular risk factors.

RESULTS

With regard to BP, 1-SD (standard deviation) lower BRS (-5.75 ms/mmHg) was associated with higher office, 24-h and 7-day systolic BP (2.22 mmHg [95% confidence interval [CI]: 1.59; 2.80], 0.95 mmHg [0.54; 1.36], and 1.48 mmHg [0.99; 1.97], respectively) and diastolic BP (1.31 mmHg [0.97; 1.66], 0.57 mmHg [0.30; 0.84], and 0.86 mmHg [0.54; 1.17], respectively). Per 1-SD lower BRS, these associations were stronger in women (0.5-1.5 mmHg higher compared to men), and weaker in those with type 2 diabetes (1-1.5 mmHg lower compared to normal glucose metabolism). With regard to BP variability, BRS was not consistently associated with lower BP variability.

CONCLUSIONS

Lower cardiovagal BRS is associated with higher mean BP from the short- to mid-term range, and not consistently with BP variability. The associations with mean BP are stronger in women and weaker in those with type 2 diabetes.

Age-related patterns of ambulatory blood pressure in a large cohort of individuals referred to Italian community pharmacies: results from the templar project

OBJECTIVES

Ambulatory blood pressure monitoring (ABPM) provides extensive information on several BP parameters other than the average BP during daily life. Through this analysis of the TEMPLAR study, we sought to understand better the features of age-related changes in ABP patterns and phenotypes.

METHODS

ABPMs were obtained in 53 350 individuals visiting 866 Italian community pharmacies (age 3-101 years, 54.3% female individuals). ABPM patterns were assessed across 10-year age categories.

RESULTS

SBP steadily increased with age. DBP increased from the youth to the middle adulthood and then declined. Daytime BP was higher than night-time BP, but the difference narrowed with aging, reducing the prevalence of dippers. An enhanced SBP morning surge and increased prevalence of abnormal morning rise were observed with aging. SBP and DBP variabilities increased with age with a typical U or J shape, more evident in the case of DBP. The proportion of participants with ambulatory hypertension increased with age. However, an elevated daytime BP was more common in younger individuals and elevated night-time hypertension in older individuals. The prevalence of white-coat hypertension remained stable or slightly declined through the age groups, whereas that of masked hypertension steadily increased.

CONCLUSION

Our results confirm that ABP patterns interplay and change in a complex way with age. Such changes, particularly the age-related increase in BP variability and prevalence of nocturnal hypertension, nondipping, enhanced morning rise, and masked hypertension, may increase the risk of cardiovascular events and must be carefully considered by the physician when managing BP in the elderly.

Development and validation of a nomogram model for individualized prediction of hypertension risk in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) with hypertension (DH) is the most common diabetic comorbidity. Patients with DH have significantly higher rates of cardiovascular disease morbidity and mortality. The objective of this study was to develop and validate a nomogram model for the prediction of an individual's risk of developing DH. A total of 706 T2DM patients who met the criteria were selected and divided into a training set (n = 521) and a validation set (n = 185) according to the discharge time of patients. By using multivariate logistic regression analysis and stepwise regression, the DH nomogram prediction model was created. Calibration curves were used to evaluate the model's accuracy, while decision curve analysis (DCA) and receiver operating characteristic (ROC) curves were used to evaluate the model's clinical applicability and discriminatory power. Age, body mass index (BMI), diabetic nephropathy (DN), and diabetic retinopathy (DR) were all independent risk factors for DH (P < 0.05). Based on independent risk factors identified by multivariate logistic regression, the nomogram model was created. The model produces accurate predictions. If the total nomogram score is greater than 120, there is a 90% or higher chance of developing DH. In the training and validation sets, the model's ROC curves are 0.762 (95% CI 0.720-0.803) and 0.700 (95% CI 0.623-0.777), respectively. The calibration curve demonstrates that there is good agreement between the model's predictions and the actual outcomes. The decision curve analysis findings demonstrated that the nomogram model was clinically helpful throughout a broad threshold probability range. The DH risk prediction nomogram model constructed in this study can help clinicians identify individuals at high risk for DH at an early stage, which is a guideline for personalized prevention and treatments.

Long-term variability in physiological measures in relation to mortality and epigenetic aging: prospective studies in the USA and China

BACKGROUND

Visit-to-visit body weight variability (BWV), pulse rate variability (PRV), and blood pressure variability (BPV) have been respectively linked to multiple health outcomes. The associations of the combination of long-term variability in physiological measures with mortality and epigenetic age acceleration (EAA) remain largely unknown.

METHODS

We constructed a composite score of physiological variability (0-3) of large variability in BWV, PRV, and BPV (the top tertiles) in 2006/2008-2014/2016 in the Health and Retirement Study (HRS) and 2011-2015 in the China Health and Retirement Longitudinal Study (CHARLS). All-cause mortality was documented through 2018. EAA was calculated using thirteen DNA methylation-based epigenetic clocks among 1047 participants in a substudy of the HRS. We assessed the relation of the composite score to the risk of mortality among 6566 participants in the HRS and 6906 participants in the CHARLS by Cox proportional models and then investigated its association with EAA using linear regression models.

RESULTS

A higher score of variability was associated with higher mortality risk in both cohorts (pooled hazard ratio [HR] per one-point increment, 1.27; 95% confidence interval [CI], 1.18, 1.39; P-heterogeneity = 0.344), after adjustment for multiple confounders and baseline physiological measures. Specifically, each SD increment in BWV, PRV, and BPV was related to 21% (95% CI: 15%, 28%), 6% (0%, 13%), and 12% (4%, 19%) higher hazard of mortality, respectively. The composite score was significantly related to EAA in second-generation clocks trained on health outcomes (e.g., standardized coefficient = 0.126 in the Levine clock, 95% CI: 0.055, 0.196) but not in most first-generation clocks trained on chronological age.

CONCLUSIONS

Larger variability in physiological measures was associated with a higher risk of mortality and faster EAA.

CRISPR/Cas9 therapeutics: progress and prospects

Clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) gene-editing technology is the ideal tool of the future for treating diseases by permanently correcting deleterious base mutations or disrupting disease-causing genes with great precision and efficiency. A variety of efficient Cas9 variants and derivatives have been developed to cope with the complex genomic changes that occur during diseases. However, strategies to effectively deliver the CRISPR system to diseased cells in vivo are currently lacking, and nonviral vectors with target recognition functions may be the focus of future research. Pathological and physiological changes resulting from disease onset are expected to serve as identifying factors for targeted delivery or targets for gene editing. Diseases are both varied and complex, and the choice of appropriate gene-editing methods and delivery vectors for different diseases is important. Meanwhile, there are still many potential challenges identified when targeting delivery of CRISPR/Cas9 technology for disease treatment. This paper reviews the current developments in three aspects, namely, gene-editing type, delivery vector, and disease characteristics. Additionally, this paper summarizes successful examples of clinical trials and finally describes possible problems associated with current CRISPR applications.

Quanduzhong capsules for the treatment of grade 1 hypertension patients with low-to-moderate risk: A multicenter, randomized, double-blind, placebo-controlled clinical trial

Background: Duzhong [DZ (Eucommia ulmoides Oliv.)] is regarded as a traditional Chinese medicine with a history dating back more than 2000 years. This herb is considered a nourishing herb in China and is commonly used as a tonic to strengthen muscles and bones, nourish the kidneys and liver, and soothe miscarriages. Moreover, there is evidence that DZ is capable of regulating blood pressure (BP), and several compounds isolated from DZ have been shown to have a BP-lowering effect. Quanduzhong capsules contain an extract of DZ [Eucommia ulmoides Oliv. (Eucommiaceae; Eucommiae cortex)] that is effective in treating hypertension. This multicenter, randomized, double-blind, placebo-controlled clinical trial sought to evaluate the clinical efficacy of Quanduzhong capsules in the treatment of low-to-moderate risk grade 1 hypertension patients. Materials and methods: A total of 60 patients from 3 centers with documented low-to-moderate risk grade 1 hypertension were randomly assigned in a 1:1 ratio to the test group or the control group. After a 1 week lead-in period using sham Quanduzhong capsules, all patients who met the entry criteria (29 cases in the test group and 29 cases in the control group) entered the 4 week test period. The test group took Quanduzhong capsules, and the control group continued to take sham Quanduzhong capsules. The primary endpoints [24-h mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) determined via 24-h ambulatory blood pressure monitoring (ABPM); office SBP and DBP] and secondary endpoints [mean arterial pressure; mean pulse; daytime mean SBP and DBP; nocturnal mean SBP and DBP; SBP and DBP load; area under the blood pressure (BP) curve; morning peak BP; early morning SBP and DBP; smoothness index of SBP and DBP; 24 h BP mean coefficient of variation (CV); percentage of patients with circadian restoration in ABPM; home BP; quality of life evaluated by WHO Quality of Life-BREF questionnaire; grading and quantitative evaluation of hypertension symptoms; values of plasmatic renin activity, angiotensin II, aldosterone, β-2 microglobulin and homocysteine] were assessed following the treatment. Drug-related adverse events and adverse drug reactions were also compared. Results: After a 4 week test period, a significant difference in the DBP CV between the two groups was observed (-2.49 ± 4.32 vs. 0.76 ± 4.3; p < .05). Moreover, the mean office SBP change was -7.62 ± 9.32 mmHg, and the mean DBP change was -4.66 ± 6.03 (p < .05). Among the three subjects with abnormal homocysteine levels in the test group, homocysteine levels decreased by 6.23 ± 9.15 μmol/L after treatment. No differences were observed between the two groups in any other indicators. After 4 weeks of treatment, there were no significant differences between the groups in terms of safety indicators (p > .05). No abnormal vital signs (except BP) or severe liver or renal function impairment were observed during the treatment periods; in addition, adverse events and drug reactions were mild. Conclusion: Treatment with Quanduzhong capsules reduced office SBP and DBP as well as DBP CV determined by 24-h ambulatory BP monitoring in patients with grade 1 hypertension at low-to-moderate risk. Clinical Trial Registration: https://www.chictr.org.cn/showproj.aspx?proj=32531, identifier ChiCTR1900021699.

Analysis of Mechanisms for Increased Blood Pressure Variability in Rats Continuously Infused with Angiotensin II

Objective

We reported that rats infused with angiotensin II (Ang II) are not only a model of hypertension but also of augmented 24 h blood pressure variability (BPV). In this study, we examined the mechanisms for Ang II-induced BPV, focusing on BP, heart rate (HR), baroreceptor reflex sensitivity (BRS), and medial area of the aortic arch.

Methods

Nine-week-old male Wistar rats were infused with subcutaneous 5.2 μg/kg/h Ang II with or without oral administration with 30 mg/kg/day azelnidipine for 14 days. BP and HR were recorded every 15 min under an unrestrained condition by a radiotelemetry system, while BPV was evaluated by standard deviation of BP. BRS was quantified by a sequence analysis, and medial thickness of the aortic arch was measured by microscopic examination.

Results

BPV increased at days 7 and 14 following continuous infusion of Ang II. Before the infusion, a positive correlation was found between BP and HR, but it became negative at day 7 and then weakened or disappeared at day 14. BRS was slightly impaired at day 7 and significantly lowered at day 14, a phenomenon accompanied by thickened medial area of the aortic arch in Ang II-infused rats. Those Ang II-induced alterations were all significantly attenuated by azelnidipine.

Conclusions

The present findings suggest sequential changes in the mechanisms behind augmented BPV in rats continuously infused with Ang II over 14 days.

Metabolic and Vascular Risk Factor Variability Over 25 Years Relates to Midlife Brain Volume and Cognition

BACKGROUND

Metabolic and vascular risk factors (MVRF) are associated with neurodegeneration and poor cognition. There is a need to better understand the impact of these risk factors on brain health in the decades that precede cognitive impairment. Longitudinal assessments can provide new insight regarding changes in MVRFs that are related to brain imaging features.

OBJECTIVE

To investigate whether longitudinal changes in MVRF spanning up to 25 years would be associated with midlife brain volume and cognition.

METHODS

Participants were from the CARDIA study (N = 467, age at year 25 = 50.6±3.4, female/male = 232/235, black/white = 161/306). Three models were developed, each designed to capture change over time; however, we were primarily interested in the average real variability (ARV) as a means of quantifying MVRF variability across all available assessments.

RESULTS

Multivariate partial least squares that used ARV metrics identified two significant latent variables (partial correlations ranged between 0.1 and 0.26, p < 0.01) that related MVRF ARV and regional brain volumes. Both latent variables reflected associations between brain volume and MVRF ARV in obesity, cholesterol, blood pressure, and glucose. Subsequent bivariate correlations revealed associations among MVRF factors, aggregate brain volume and cognition.

CONCLUSION

This study demonstrates that MVRF variability over time is associated with midlife brain volume in regions that are relevant to later-life cognitive decline.

Within-Person Blood Pressure Variability During Hospitalization and Clinical Outcomes Following First-Ever Acute Ischemic Stroke

BACKGROUND

Uncertainty remains over the relationship between blood pressure (BP) variability (BPV), measured in hospital settings, and clinical outcomes following acute ischemic stroke (AIS). We examined the association between within-person systolic blood pressure (SBP) variability (SBPV) during hospitalization and readmission-free survival, all-cause readmission, or all-cause mortality 1 year after AIS.

METHODS

In a cohort of 862 consecutive patients (age [mean ± SD] 75 ± 15 years, 55% women) with AIS (2005-2018, follow-up through 2019), we measured SBPV as quartiles of standard deviations (SD) and coefficient of variation (CV) from a median of 16 SBP readings obtained throughout hospitalization.

RESULTS

In the cumulative cohort, the measured SD and CV of SBP in mmHg were 16 ± 6 and 10 ± 5, respectively. The hazard ratios (HR) for readmission-free survival between the highest vs. lowest quartiles were 1.44 (95% confidence interval [CI] 1.04-1.81) for SD and 1.29 (95% CI 0.94-1.78) for CV after adjustment for demographics and comorbidities. Similarly, incident readmission or mortality remained consistent between the highest vs. lowest quartiles of SD and CV (readmission: HR 1.29 [95% CI 0.90-1.78] for SD, HR 1.29 [95% CI 0.94-1.78] for CV; mortality: HR 1.15 [95% CI 0.71-1.87] for SD, HR 0.86 [95% CI 0.55-1.36] for CV).

CONCULSIONS

In patients with first AIS, SBPV measured as quartiles of SD or CV based on multiple readings throughout hospitalization has no independent prognostic implications for the readmission-free survival, readmission, or mortality. This underscores the importance of overall patient care rather than a specific focus on BP parameters during hospitalization for AIS.

Therapeutic target and clinical impact of day-to-day blood pressure variability in hypertensive patients with covid-19

Blood pressure variability (BPV) is essential in hypertensive patients and is frequently associated with organ damage. As of today, hypertension is still the most common comorbidity in COVID-19, but the impact of BPV and the therapeutic target of BPV on outcomes in COVID-19 patients with hypertension remain unclear. Therefore, this study investigated the relationship between BPV and severity of COVID-19, in-hospital mortality, hypertensive status, and efficacy of antihypertensives in suppressing hypertensive covid-19 patient BPV. This cohort retrospective study enrolled 351 patients hospitalized with COVID-19. Subjects were classified according to the severity of COVID-19, the presence of hypertension, and their BPV status. During hospitalization, mean arterial pressure (MAP) was measured at 6 a.m. and 6 p.m., and BPV was calculated as the coefficient of variation of MAP (MAPCV). MAPCV values above the median were defined as high BPV. In addition, we compared the hypertensive status, COVID-19 severity, in-hospital mortality, and antihypertensive agents between the BPV groups. The mean age was 53.85 ± 18.84 years old. Hypertension was significantly associated with high BPV with prevalence ratio (PR) = 1.38 (95% CI = 1.13-1.70; p = 0.003) or severe COVID-19 (PR = 1.39; 95% CI = 1.09-1.76; p = 0.005). In laboratory findings, high BPV group had lower Albumin, higher WBC, serum Cr, CRP, and creatinine to albumin ratio. High BPV status also significantly increased risk of mortality (HR = 2.30; 95% CI = 1.73-3.86; p < 0.001). Patients with a combination of severe COVID-19 status, hypertension, and high BPV status had the highest risk of in-hospital mortality (HR = 3.51; 95% CI = 2.32-4.97; p < 0.001) compared to other combination status groups. In COVID-19 patients with hypertension, combination therapy with calcium channel blockers (CCB) as well as CCB monotherapy significantly develop low BPV (PR = 2.002; 95 CI% = 1.33-3.07; p = 0.004) and low mortality (HR = 0.17; 95% CI = 0.05-0.56; p = 0.004). Hypertensive status and severe COVID-19 were significantly associated with high BPV, and these factors increased in-hospital mortality. CCBs might be antihypertensive agents that potentially effectively suppressing BPV and mortality in COVID-19 patients.

Effect of visit-to-visit blood pressure variability on mild cognitive impairment and probable dementia in hypertensive patients receiving standard and intensive blood pressure treatment

Background

High visit-to-visit blood pressure variability (BPV) and hypertension are risk factors for mild cognitive impairment (MCI) and probable dementia (PD). Few articles assessed the effect of BPV on the MCI and PD in intensive blood pressure treatment and the different functions of three types of visit-to-visit BPV: systolic blood pressure variability (SBPV), diastolic blood pressure variability (DBPV) and pulse pressure variability (PPV).

Methods

We performed a post hoc analysis of the SPRINT MIND trial. The primary outcomes were MCI and PD. BPV was measured by average real variability (ARV). The Kaplan-Meier curves were used to clarify the difference in tertiles of BPV. We fit Cox proportional hazards models to our outcome. We also did an interaction analysis between the intensive and standard groups.

Results

We enrolled 8,346 patients in the SPRINT MIND trial. The incidence of MCI and PD in the intensive group was lower than that in the standard group. 353 patients had MCI and 101 patients had PD in the standard group while 285 patients had MCI and 75 patients had PD in the intensive group. Tertiles with higher SBPV, DBPV and PPV in the standard group had a higher risk of MCI and PD (all p < 0.05). Meanwhile, higher SBPV and PPV in the intensive group were associated with an increased risk of PD (SBPV: HR(95%) = 2.1 (1.1-3.9), p = 0.026; PPV: HR(95%) = 2.0 (1.1-3.8), p = 0.025 in model 3) and higher SBPV in the intensive group was associated with an increased risk of MCI(HR(95%) = 1.4 (1.2-1.8), p < 0.001 in model 3). The difference between intensive and standard blood pressure treatment was not statistically significant when we considered the effect of the higher BPV on the risk of MCI and PD (all p for interaction >0.05).

Conclusion

In this post hoc analysis of the SPRINT MIND trial, we found that higher SBPV and PPV were associated with an increased risk of PD in the intensive group, and higher SBPV was associated with an increased risk of MCI in the intensive group. The effect of higher BPV on the risk of MCI and PD was not significantly different in intensive and standard blood pressure treatment. These findings emphasized the need for clinical work to monitor BPV in intensive blood pressure treatment.

Relationship of 24-h ambulatory blood pressure variability with micro and macrovascular parameters and hypertension status

OBJECTIVES

Increased blood pressure variability (BPV) has been associated with an increased risk of subclinical organ damage and cardiovascular events, independently of elevated average BP values. We aimed to investigate the association of BPV indices with micro- and macrovascular parameters, some of them not previously studied.

METHODS

We evaluated 344 individuals (233 never-treated/newly diagnosed hypertensive and 111 normotensive individuals). BPV was assessed using average real variability (ARV) during 24-h, daytime and night-time ambulatory blood pressure monitoring, and systolic weighted standard deviation (wSD). Retinal microvascular diameter was assessed by nonmydriatic retinal photography. Arterial stiffness was assessed by pulse wave velocity (PWV) and aortic augmentation index (AIx); subendocardial variability ratio (SEVR) was used as an index of myocardial perfusion. Carotid intima-media thickness (cIMT) was measured by ultrasound. Data were analyzed using multiple regression analysis.

RESULTS

After adjusting for potential confounders, PWV and cIMT were independently associated with ARV components in the total sample (P < 0.023 and P < 0.014, respectively). Within hypertensives only PWV and cIMT were independently associated with ARV components (P < 0.002 for PWV and P < 0.003 for cIMT). In contrast, within normotensives, only retinal parameters and AIx were associated with ARV components (P < 0.017 and P = 0.013, respectively). None of the univariate correlations between vascular parameters and wSD remained significant after adjustment for potential confounders.

CONCLUSION

Short-term BPV as assessed by ARV is independently associated with macrovascular parameters in untreated hypertensive patients, and with microvascular parameters in normotensive individuals.

Impact of oscillometric measurement artefacts in ambulatory blood pressure monitoring on estimates of average blood pressure and of its variability: a pilot study

OBJECTIVE

Ambulatory blood pressure monitoring (ABPM) plays an important role in the diagnosis of hypertension. However, methodological factors and the measurement conditions affect the results and may lead to incorrect classification of the patient. We performed a pilot study to evaluate the impact of oscillometric measurement artefacts on ABPM-derived variables.

METHODS

Four classes of artefacts have been detected: motor activity artefacts, cuff errors, cardiovascular arousals, and arrhythmias. The data consisted of uncorrected measurements (all data), corrected measurements (all artefact free data), and artefact affected data.

RESULTS

A total of 30 individuals (9 female/21 male), aged between 36 and 86 years, mean: 65.5 (standard deviation: 9.5) were included in the study. The average blood pressure (BP) was higher in artefacts-affected measurements compared the artefact-free measurements both for systolic (4.6 mmHg) and diastolic (1.3 mmHg) measurements. Further, artefact-affected systolic BP (SBP) was 6.4 mmHg higher than artefact-free measurements during daytime. Nocturnal measurements showed no artefact-depended differences. Individual comparisons yielded that 23% of the participants crossed the threshold for BP classification for either 24-h, daytime or nocturnal hypertension when comparing uncorrected and artefact-free measurements. Dipping classification changed within 24% of participants. BP variability was 21 and 12% higher for SPB and DBP, respectively, during daytime. These differences were even higher (27% for SBP and 21% for DPB) during night-time.

CONCLUSION

The study reveals that measurement artefacts are frequently present during cuff-based ABPM and do relevantly affect measurement outcome. Exclusion of measurement artefacts is a promising approach to improving cuff-based ABPM accuracy.

Ambulatory blood pressure monitoring in children: A retrospective single-center study

OBJECTIVES

(1) Compare 24-hour ambulatory blood pressure monitoring (ABPM) diagnoses in a pediatric population with the new 2022 guidelines to the original diagnoses with the 2014 guidelines. (2) Determine whether findings of hypertension from ABPM could be predicted from prior patient data. (3) Determine whether ABPM readings could predict left ventricular mass index (LVMI) in patients who obtained an echocardiogram (ECHO).

STUDY DESIGN

Single-center retrospective study on patients referred to Pediatric Nephrology Clinic for evaluation of elevated blood pressure who underwent ABPM from 2015 to 2018. Predictions of hypertension were obtained using a logistic regression model, and predictions of LVMI were performed using regression models including (a) the wake systolic and diastolic BP indices, or (b) additionally including the standard deviation (SD) of wake SBP and DBP.

RESULTS

With the change in 2022 to new ABPM guidelines from the AHA, comparing the old and new guidelines led to 70% of previous pre-hypertensive diagnoses now meeting criteria for diagnosis of hypertension, and a rise from 21% of the ABPMs meeting criteria for hypertension to 51% now meeting criteria. In a logistic regression model, prior patient data were not predictive of a diagnosis of hypertension from ABPM (Nagelkerke's R ² = 0.04). Among the individual variables studied, none were statistically significant. For prediction of LVMI, the SD of wake SBP and DBP were significantly associated with increased LVMI, but the wake SBP and DBP indices were not.

CONCLUSIONS

In our patient population, the new ABPM guidelines led to a significant increase in diagnoses of hypertension. Prior patient data was not sufficient to predict a diagnosis of hypertension by ABPM, supporting the need for evaluation by ABPM as the gold standard. Our analysis of the relationship between ABPM readings and LVMI supports the hypothesis that BP variability contributes to increased LVMI. These data are consistent with growing evidence in the adult literature that BP variability detected by ABPM is associated with left-ventricular hypertrophy.

Evaluation of Epigenetic Age Acceleration Scores and Their Associations with CVD-Related Phenotypes in a Population Cohort

We evaluated associations between nine epigenetic age acceleration (EAA) scores and 18 cardiometabolic phenotypes using an Eastern European ageing population cohort richly annotated for a diverse set of phenotypes (subsample, n = 306; aged 45-69 years). This was implemented by splitting the data into groups with positive and negative EAAs. We observed strong association between all EAA scores and sex, suggesting that any analysis of EAAs should be adjusted by sex. We found that some sex-adjusted EAA scores were significantly associated with several phenotypes such as blood levels of gamma-glutamyl transferase and low-density lipoprotein, smoking status, annual alcohol consumption, multiple carotid plaques, and incident coronary heart disease status (not necessarily the same phenotypes for different EAAs). We demonstrated that even after adjusting EAAs for sex, EAA-phenotype associations remain sex-specific, which should be taken into account in any downstream analysis involving EAAs. The obtained results suggest that in some EAA-phenotype associations, negative EAA scores (i.e., epigenetic age below chronological age) indicated more harmful phenotype values, which is counterintuitive. Among all considered epigenetic clocks, GrimAge was significantly associated with more phenotypes than any other EA scores in this Russian sample.

Urinary Sodium Excretion and Salt Intake Are Not Associated With Blood Pressure Variability in a White General Population

Background Salt restriction may lower blood pressure variability (BPV), but previous studies have shown inconsistent results. Therefore, we investigated in an observational study and intervention trial whether urinary sodium excretion and salt intake are associated with 24-hour BPV. Methods and Results We used data from the cross-sectional population-based Maastricht Study (n=2652; 60±8 years; 52% men) and from a randomized crossover trial (n=40; 49±11 years; 33% men). In the observational study, we measured 24-hour urinary sodium excretion and 24-hour BPV and performed linear regression adjusted for age, sex, mean blood pressure, lifestyle, and cardiovascular risk factors. In the intervention study, participants adhered to a 7-day low- and high-salt diet (50 and 250 mmol NaCl/24 h) with a washout period of 14 days, 24-hour BPV was measured during each diet. We used linear mixed models adjusted for order of diet, mean blood pressure, and body mass index. In the observational study, 24-hour urinary sodium excretion was not associated with 24-hour systolic or diastolic BPV (β, per 1 g/24 h urinary sodium excretion: 0.05 mm Hg [95% CI, -0.02 to 0.11] and 0.04 mm Hg [95% CI, -0.01 to 0.09], respectively). In the intervention trial, mean difference in 24-hour systolic and diastolic BPV between the low- and high-salt diet was not statistically significantly different (0.62 mm Hg [95% CI, -0.10 to 1.35] and 0.04 mm Hg [95% CI, -0.54 to 0.63], respectively). Conclusions Urinary sodium excretion and salt intake are not independently associated with 24-hour BPV. These findings suggest that salt restriction is not an effective strategy to lower BPV in the White general population. Registration URL: https://clinicaltrials.gov/ct2/show/NCT02068781.

Incremental value of risk factor variability for cardiovascular risk prediction in individuals with type 2 diabetes: results from UK primary care electronic health records

BACKGROUND

Cardiovascular disease (CVD) risk prediction models for individuals with type 2 diabetes are important tools to guide intensification of interventions for CVD prevention. We aimed to assess the added value of incorporating risk factors variability in CVD risk prediction for people with type 2 diabetes.

METHODS

We used electronic health records (EHRs) data from 83 910 adults with type 2 diabetes but without pre-existing CVD from the UK Clinical Practice Research Datalink for 2004-2017. Using a landmark-modelling approach, we developed and validated sex-specific Cox models, incorporating conventional predictors and trajectories plus variability of systolic blood pressure (SBP), total and high-density lipoprotein (HDL) cholesterol, and glycated haemoglobin (HbA1c). Such models were compared against simpler models using single last observed values or means.

RESULTS

The standard deviations (SDs) of SBP, HDL cholesterol and HbA1c were associated with higher CVD risk (P < 0.05). Models incorporating trajectories and variability of continuous predictors demonstrated improvement in risk discrimination (C-index = 0.659, 95% CI: 0.654-0.663) as compared with using last observed values (C-index = 0.651, 95% CI: 0.646-0.656) or means (C-index = 0.650, 95% CI: 0.645-0.655). Inclusion of SDs of SBP yielded the greatest improvement in discrimination (C-index increase = 0.005, 95% CI: 0.004-0.007) in comparison to incorporating SDs of total cholesterol (C-index increase = 0.002, 95% CI: 0.000-0.003), HbA1c (C-index increase = 0.002, 95% CI: 0.000-0.003) or HDL cholesterol (C-index increase= 0.003, 95% CI: 0.002-0.005).

CONCLUSION

Incorporating variability of predictors from EHRs provides a modest improvement in CVD risk discrimination for individuals with type 2 diabetes. Given that repeat measures are readily available in EHRs especially for regularly monitored patients with diabetes, this improvement could easily be achieved.

GFR Variability, Survival, and Cardiovascular Events in Older Adults

Rationale & Objective

Variability in estimated glomerular filtration rate (eGFR) over time is often observed, but it is unknown whether this variation is clinically important. We investigated the association between eGFR variability and survival free of dementia or persistent physical disability (disability-free survival) and cardiovascular disease (CVD) events (myocardial infarction, stroke, hospitalization for heart failure, or CVD death).

Study Design

Post hoc analysis.

Setting & Participants

12,549 participants of the ASPirin in Reducing Events in the Elderly trial. Participants were without documented dementia, major physical disability, previous CVD, and major life-limiting illness at enrollment.

Predictors

eGFR variability.

Outcomes

Disability-free survival and CVD events.

Analytical Approach

eGFR variability was estimated using the standard deviation of eGFR measurements obtained from participants' baseline, first, and second annual visits. Associations between tertiles of eGFR variability with disability-free survival and CVD events occurring after the eGFR variability estimation period were examined.

Results

During median follow-up of 2.7 years after the second annual visit, 838 participants died, developed dementia, or acquired a persistent physical disability; 379 had a CVD event. The highest tertile of eGFR variability had an increased risk of death/dementia/disability (HR, 1.35; 95% CI, 1.14-1.59) and CVD events (HR, 1.37; 95% CI, 1.06-1.77) compared with the lowest tertile after covariate adjustment. These associations were present in patients with and without chronic kidney disease at baseline.

Limitations

Limited representation of diverse demographics.

Conclusions

In older, generally healthy adults, higher variability in eGFR over time predicts increased risk of future death/dementia/disability and CVD events.

Prevalence and Clinical Characteristics including Patterns of Antihypertensive Drug Administration of the Different Home Blood Pressure Phenotypes in Treated Hypertensive Patients

Quality and quantity of home blood pressure (BP) control are important for optimizing hypertensive treatment. The prevalence and associated clinical characteristics of the different home blood pressure phenotypes in treated hypertensive patients were not elucidated. This study was conducted in Siriraj Hospital, Thailand from 2019 to 2020. We included treated hypertensive patients with ≥1 antihypertensive drug and had self-home BP measurement data. Both traditional (office BP < 140/90 mmHg and home BP < 130/80 mmHg) and new BP targets (office and home BP < 130/80 mmHg) were used for the classification of BP phenotypes. Home BP phenotypes consisted of controlled hypertension (all home BPs achieved home BP targets), isolated uncontrolled morning hypertension (MoHT) (only morning BP was above home BP targets), isolated uncontrolled evening hypertension (EHT) (only evening BP was above home BP targets), and combined morning-evening uncontrolled hypertension (MoEHT) (all home BPs were above home BP targets). Our study included 1,406 patients. The total mean age was 62.94 ± 13.97 years. There were 39.40% men. The prevalence of each home BP phenotype (by traditional BP target) was 55.76%, 12.66%, 7.40%, and 24.18% in controlled (home) hypertension, MoHT, EHT, and MoEHT, respectively. Classical BP control status was 35.21% well-controlled hypertension, 30.01% white-coat uncontrolled hypertension, 9.74% masked uncontrolled hypertension, and 25.04% sustained uncontrolled hypertension. The multivariable analysis showed the significantly associated factor of MoHT was the presence of previous cardiovascular disease (adjusted OR 5.54, 95% CI (2.02–15.22); $p$ value = 0.001). Taking once-daily long-acting antihypertensive drugs in the morning were significantly associated with both EHT (adjusted OR 0.20, 95% CI (0.05–0.82); $p$ value = 0.025) and MoEHT (adjusted OR 0.20, 95% CI (0.04–1.00); $p$ value = 0.049). These results were consistent in groups classified by new home BP target <130/80 mmHg.

Ambulatory Blood Pressure Variability after Adenotonsillectomy in Childhood Sleep Apnea

OBJECTIVE

To investigate the influence of adenotonsillectomy (T&A) on ambulatory blood pressure (BP) variability in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Prospective, interventional study.

METHODS

Children with OSA symptoms were recruited from a tertiary center. After OSA diagnosis was confirmed (ie, apnea-hypopnea index [AHI] > 1), these children underwent T&A for treatment. We performed polysomnography and 24-hour recordings of ambulatory BP before and 3 to 6 months postoperatively. Ambulatory BP variability was presented as the standard deviation of mean blood pressure in the 24-hour monitoring of ambulatory BP. Differences in BP variability among different subgroups were tested using a multivariable linear mixed model.

RESULTS

A total of 190 children were enrolled (mean age: 7.8 ± 3.3 years; 73% were boys; 34% were obese). The AHI significantly decreased from 12.3 ± 17.0 to 2.7 ± 5.5 events/hr after T&A. Overall, daytime, and nighttime ambulatory BP did not significantly change postoperatively, and overall, daytime, and nighttime ambulatory BP variability did not differ significantly preoperatively and postoperatively. In the subgroup analysis, children aged <6 years demonstrated a significantly greater decrease in ambulatory BP variability postoperatively than those aged >6 years (nighttime diastolic BP variability: 9.9 to 7.7 vs. 8.9 to 9.4). Children with hypertension also showed a significantly greater decrease in ambulatory BP variability than those without hypertension.

CONCLUSIONS

We concluded that overall ambulatory BP variability does not significantly change after T&A in children with OSA. Moreover, young-aged and hypertensive children demonstrate a significant decrease in BP variability after T&A.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:2491-2497, 2022.

Vigorous Physical Activity as a Risk Factor for Central Serous Chorioretinopathy

PURPOSE

To evaluate whether frequent vigorous physical activity (PA) is significantly associated with active central serous chorioretinopathy (CSCR) and may represent a risk factor for CSCR.

DESIGN

Case-control study.

METHODS

This was a multicenter study. The patient population comprised consecutive patients with active CSCR and a comparable control group of healthy participants. Both groups were interrogated about their PA using a shortened version of the International Physical Activity Questionnaire. The Ainsworth Compendium of Physical Activities was taken as a reference for the activities requiring vigorous effort and to quantify the energy expended, expressed in metabolic equivalent of task (MET). As a main outcome measure, a moderate/high practice of vigorous PA was opposed to an absent/low practice of vigorous PA in the 2 groups.

RESULTS

A total of 105 patients with CSCR and 105 healthy controls were included in the study. Moderate/high vigorous PA was observed in 63.5% of the patients with CSCR and in 26% of the controls (P = .0001). The MET values of vigorous PA were 2173.2 ± 2081.5 in the CSCR group and 1216.3 ± 524 in the control group (P = .029). The potential risk of disease associated with moderate/high vigorous PA was 5.58 (odds ratio; 95% confidence interval 3.01-10.69, P = .0001).

CONCLUSIONS

This study demonstrates a significant association of vigorous PA with CSCR, indicating an increased probability of disease by 5.58 times. Frequent and intense PA, with the hypertensive episodes that it entails, can break the precarious hemodynamic balance in the choroid of individuals predisposed to CSCR, thereby favoring choroidal vascular decompensation and active disease.

Prediabetes and incident heart failure in hypertensive patients: Results from the Swedish Primary Care Cardiovascular Database

BACKGROUNDS AND AIMS

The cardiovascular risk conferred by concomitant prediabetes in hypertension is unclear. We aimed to examine the impact of prediabetes on incident heart failure (HF) and all-cause mortality, and to describe time in therapeutic blood pressure range (TTR) in a hypertensive real-world primary care population.

METHODS AND RESULTS

In this retrospective cohort study, 9628 hypertensive individuals with a fasting plasma glucose (FPG) in 2006-2010 but no diabetes, cardiovascular or renal disease were followed to 2016; median follow-up was 9 years. Prediabetes was defined as FPG 5.6-6.9 mmol/L, and in a secondary analysis as 6.1-6.9 mmol/L. Study outcomes were HF and all-cause mortality. Hazard ratios (HR) were compared for prediabetes with normoglycemia using Cox regression. All blood pressure values from 2001 to the index date (first FPG in 2006-2010) were used to calculate TTR. At baseline, 51.4% had prediabetes. The multivariable-adjusted HR (95% confidence intervals) was 0.86 (0.67-1.09) for HF and 1.06 (0.90-1.26) for all-cause mortality. For FPG defined as 6.1-6.9 mmol/L, the multivariable-adjusted HR were 1.05 (0.80-1.39) and 1.42 (1.19-1.70), respectively. The prediabetic group had a lower TTR (p < 0.05).

CONCLUSIONS

Prediabetes was not independently associated with incident HF in hypertensive patients without diabetes, cardiovascular or renal disease. However, prediabetes was associated with all-cause mortality when defined as FPG 6.1-6.9 mmol/L (but not as 5.6-6.9 mmol/L). TTR was lower in the prediabetic group, suggesting room for improved blood pressure to reduce incident heart failure in prediabetes.

Towards a More Individually Tailored Exercise Prescription for Promoting Cardiovascular Health

The beneficial effects of exercise training (ET) in promoting cardiovascular health have been well established [...]

Association between fine particulate matter and coronary heart disease: A miRNA microarray analysis

Several studies have reported an association between residential surrounding particulate matter with an aerodynamic diameter ≤2.5 μm (PM_2.5) and coronary heart disease (CHD). However, the underlying biological mechanism remains unclear. To fill this research gap, this study enrolled a residentially stable sample of 942 patients with CHD and 1723 controls. PM_2.5 concentration was obtained from satellite-based annual global PM_2.5 estimates for the period 1998-2019. MicroRNA microarray and pathway analysis of target genes was performed to elucidate the potential biological mechanism by which PM_2.5 increases CHD risk. The results showed that individuals exposed to high PM_2.5 concentrations had higher risks of CHD than those exposed to low PM_2.5 concentrations (odds ratio = 1.22, 95% confidence interval: 1.00, 1.47 per 10 μg/m³ increase in PM_2.5). Systolic blood pressure mediated 6.6% of the association between PM_2.5 and CHD. PM_2.5 and miR-4726-5p had an interaction effect on CHD development. Bioinformatic analysis demonstrated that miR-4726-5p may affect the occurrence of CHD by regulating the function of RhoA. Therefore, individuals in areas with high PM_2.5 exposure and relative miR-4726-5p expression have a higher risk of CHD than their counterparts because of the interaction effect of PM_2.5 and miR-4726-5p on blood pressure.

Home Blood Pressure Monitoring And Nocturia In Adults

Although widely viewed as a urological condition, nocturia has been increasingly recognized to accompany various non-urological conditions such as hypertension and blood pressure (BP) elevation on office determination. Home BP monitoring (HBPM) has been shown superior to office-based readings and provides an opportunity to assess potential relationships between nocturia and novel indices derived from multiple BP recordings including BP load, BP variability, and arterial stiffness, which have prognostic significance. We retrospectively studied 103 home BP logs and nocturia frequencies provided by 61 stable cardiology patients ≥ 21 years without medication change. Nocturnal voids ranged from 0 to 5 voids per night, median: 1.5. Nocturia frequency was significantly correlated with home and office systolic BPs and with BP load, but not with diastolic BPs, BP variability or arterial stiffness. On Poisson regression analysis, the estimated prevalence ratio (PR) for home and office systolic BPs were 1.025 (CI: 1.01, 1.04; p < .001) and 1.01 (CI:1.00, 1.02; p = .019), indicating 2.5% and 1% increases in the risk of nocturia per mmHg increases in BP respectively. In conclusion, higher mean home and office systolic BPs are associated with self-reported nocturia frequency with stronger associations seen for home BP measurement. Nocturia frequency appears unrelated to mean home and office diastolic BPs. Nocturia may be related to BP load, (percentage of elevated BP values), but not to BP variability or arterial stiffness. Future prospective studies using HBPM are needed to confirm these findings and to contribute to the understanding of the elevated BP-nocturia link.

Non-invasive blood pressure estimation combining deep neural networks with pre-training and partial fine-tuning

Objective. Daily blood pressure (BP) monitoring is essential since BP levels can reflect the functions of heart pumping and vasoconstriction. Although various neural network-based BP estimate approaches have been proposed, they have certain practical shortcomings, such as low estimation accuracy and poor model generalization. Based on the strategy of pre-training and partial fine-tuning, this work proposes a non-invasive method for BP estimation using the photoplethysmography (PPG) signal.Approach. To learn the PPG-BP relationship, the deep convolutional bidirectional recurrent neural network (DC-Bi-RNN) was pre-trained with data from the public medical information mark for intensive care (MIMIC III) database. A tiny quantity of data from the target subject was used to fine-tune the specific layers of the pre-trained model to learn more individual-specific information to achieve highly accurate BP estimation.Main results.The mean absolute error and the Pearson correlation coefficient (r) of the proposed algorithm are 3.21 mmHg and 0.919 for systolic BP, and 1.80 mmHg and 0.898 for diastolic BP (DBP). The experimental results show that our method outperforms other methods and meets the requirements of the Association for the Advancement of Medical Instrumentation standard, and received an A grade according to the British Hypertension Society standard.Significance.The proposed method applies the strategy of pre-training and partial fine-tuning to BP estimation and verifies its effectiveness in improving the accuracy of non-invasive BP estimation.

Causal associations between blood pressure and the risk of myocardial infarction: A bidirectional Mendelian randomization study

Introduction

Many observational studies imply elevated blood pressure (BP) as a leading risk factor for incident myocardial infarction (MI), but whether this relationship is causal remains unknown. In this study, we used bidirectional Mendelian randomization (MR) to investigate the potential causal association of BP levels with the risk of MI.

Methods

Genetic variants associated with BP and MI traits were retrieved from the International Consortium of Blood Pressure (N = 7,57,601) and UKB (N = 3,61,194), obtaining 1,26,40,541 variants. We used two-sample MR (TSMR) analyses to examine the potential bidirectional causal association of systolic BP (SBP), diastolic BP (DBP) and pulse pressure (PP) with MI.

Results

The forward MR analysis identified a potentially causal association between MI and BP except PP[odds ratio (OR) SBP: 1.0008, P = 1.911 × 10−22; ORDBP: 1.0014, P = 1.788 × 10−28;odds ratio (OR)pp: 1.0092, P = 0.179]. However, the reverse analysis suggested no causal relation (betaSBP: 5.469, P = 0.763; betaDBP: 3.624, P = 0.588; betaPP: −0.074, P = 0.912). These findings were robust in sensitivity analyses such as the MR–Egger method, the maximum likelihood method and the MR pleiotropy residual sum and outlier test (MR-PRESSO). No horizontal pleiotropy (p = 0.869 for SBP, p = 0.109 for DBP and p = 0.978 for PP in the forward results and p = 0.168 for SBP, P = 0.892 for DBP and p = 0.989 for PP in the reverse results) was observed.

Conclusions

Elevated SBP or DBP levels increase the risk of MI, but there is no causal relationship between MI and changes in BP including PP. Independent of other risk factors, optimal BP control might represent an important therapeutic target for MI prevention in the general population.

Feasibility of Precision Medicine in Hypertension Management-Scope and Technological Aspects

Personalized management of diseases by considering relevant patient features enables optimal treatment, instead of management according to an average patient. Precision management of hypertension is important, because both susceptibility to complications and response to treatment vary between individuals. While the use of genomic and proteomic personal features for widespread precision hypertension management is not practical, other features, such as age, ethnicity, and cardiovascular diseases, have been utilized in guidelines for hypertension management. In precision medicine, more blood-pressure-related clinical and physiological characteristics in the patient's profile can be utilized for the determination of the threshold of hypertension and optimal treatment. Several non-invasive and simple-to-use techniques for the measurement of hypertension-related physiological features are suggested for use in precision management of hypertension. In order to provide precise management of hypertension, accurate measurement of blood pressure is required, but the available non-invasive blood pressure measurement techniques, auscultatory sphygmomanometry and oscillometry, have inherent significant inaccuracy-either functional or technological-limiting the precision of personalized management of hypertension. A novel photoplethysmography-based technique for the measurement of systolic blood pressure that was recently found to be more accurate than the two available techniques can be utilized for more precise and personalized hypertension management.

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Orthostatic Hypotension in Hypertensive Adults: Harry Goldblatt Award for Early Career Investigators 2021

Orthostatic hypotension affects roughly 10% of individuals with hypertension and is associated with several adverse health outcomes, including dementia, cardiovascular disease, stroke, and death. Among adults with hypertension, orthostatic hypotension has also been shown to predict patterns of blood pressure dysregulation that may not be appreciated in the office setting, including nocturnal nondipping. Individuals with uncontrolled hypertension are at particular risk of orthostatic hypotension and may meet diagnostic criteria for the condition with a smaller relative reduction in blood pressure compared with normotensive individuals. Antihypertensive medications are commonly de-prescribed to address orthostatic hypotension; however, this approach may worsen supine or seated hypertension, which may be an important driver of adverse events in this population. There is significant variability between guidelines for the diagnosis of orthostatic hypotension with regards to timing and position of blood pressure measurements. Clinically relevant orthostatic hypotension may be missed when standing measurements are delayed or when taken after a seated rather than supine position. The treatment of orthostatic hypotension in patients with hypertension poses a significant management challenge for clinicians; however, recent evidence suggests that intensive blood pressure control may reduce the risk of orthostatic hypotension. A detailed characterization of blood pressure variability is essential to tailoring a treatment plan and can be accomplished using both in-office and out-of-office monitoring.

Hypertension urgencies in the SPYRAL HTN-OFF MED Pivotal trial

The SPYRAL HTN-OFF MED Pivotal trial ( https://clinicaltrials.gov/ct2/show/NCT02439749 ) demonstrated significant reductions in blood pressure (BP) after renal denervation (RDN) compared to sham control in the absence of anti-hypertensive medications. Prior to the 3-month primary endpoint, medications were immediately reinstated for patients who met escape criteria defined as office systolic BP (SBP) ≥ 180 mmHg or other safety concerns. Our objective was to compare the rate of hypertensive urgencies in RDN vs. sham control patients. Patients were enrolled with office SBP ≥ 150 and < 180 mmHg, office diastolic BP (DBP) ≥ 90 mmHg and mean 24 h SBP ≥ 140 and < 170 mmHg. Patients had been required to discontinue any anti-hypertensive medications and were randomized 1:1 to RDN or sham control. In this post-hoc analysis, cumulative incidence curves with Kaplan-Meier estimates of rate of patients meeting escape criteria were generated for RDN and sham control patients. There were 16 RDN (9.6%) and 28 sham control patients (17.0%) who met escape criteria between baseline and 3 months. There was a significantly higher rate of sham control patients meeting escape criteria compared to RDN for all escape patients (p = 0.032), as well as for patients with a hypertensive urgency with office SBP ≥ 180 mmHg (p = 0.046). Rate of escape was similar between RDN and sham control for patients without a measured BP exceeding 180 mmHg (p = 0.32). In the SPYRAL HTN-OFF MED Pivotal trial, RDN patients were less likely to experience hypertensive urgencies that required immediate use of anti-hypertensive medications compared to sham control.

Temporal trends in prevalence and mortality for chronic kidney disease in China from 1990 to 2019: an analysis of the Global Burden of Disease Study 2019

Background

This study aimed to characterize the temporal trends of chronic kidney disease (CKD) burden in China during 1990-2019, evaluate their age, period and cohort effects, and predict the disease burden for the next 10 years.

Methods

Data were obtained from the Global Burden of Disease (GBD) 2019 study. Join-point regression model was used to estimate the average annual percentage change (AAPC) of CKD prevalence and mortality, and the age-period-cohort analysis was used to estimate the age, period and cohort effects. We extended the autoregressive integrated moving average (ARIMA) model to predict the disease burden of CKD in 2020-2029.

Results

In 2019, there were 150.5 million cases of (10.6%) and 196 726 deaths from (13.8 per 100 000 general population) CKD in China. Between 1990 and 2019, the prevalence and mortality rate of CKD increased significantly from 6.7% to 10.6%, and from 8.3/100 000 to 13.8/100 000. The AAPC was estimated as 1.6% and 1.8%, respectively. Females had a higher CKD prevalence of CKD but a lower mortality rate. Setting the mean level of age, period and cohort as reference groups, the risk of developing CKD increased with age [RR_age(15-19) = 0.18 to RR_age(85-89) = 2.45]. The cohort risk was significantly higher in the early birth cohort [RR_{cohort(1905-1909)} = 1.56]. In contrast, the increase in age-specific CKD mortality rate after 60-64 years was exponential [RR_age(60-64) = 1.24]. The cohort-based mortality risk remained high prior to the 1945-1949 birth cohorts (RR_cohort ranging from 1.69 to 1.89) and then declined in the 2000-2004 birth cohort [RR_{cohort(2000-2004)} = 0.22]. The CKD prevalence and mortality are projected to rise to 11.7% and 17.1 per 100 000, respectively, by 2029.

Conclusions

To reduce the disease burden of CKD, a comprehensive strategy that includes risk factors prevention at the primary care level, CKD screening among the elderly and high-risk population, and access to high-quality medical services is required.

The genetic architecture of blood pressure variability: A genome-wide association study of 9370 participants from UK Biobank

Long-term blood pressure variability (BPV) is a risk factor for cardiovascular diseases, dementia, and stroke. However, its genetic architecture is not fully understood. This study aims to explore its genetic factors and provide more evidence on the mechanisms and further pathological study of BPV. The genome-wide association study (GWAS) is based on the UK Biobank cohort. There were four data collection rounds from 2006 to 2020, and 9370 participants with more than three blood pressure measurements were included. They had a median age of 55 and a male percentage of 50.1%. The phenotypes (BPV) were calculated by four methods and the genetic data contains 6 884 260 single nucleotide polymorphisms (SNPs) after imputation and quality control. A linear regression model was performed with adjustments for sex, age, genotype array, and a significant principal component. Subgroup analysis was performed on hypertension-free participants. The significant and suggestive significant P thresholds were set as 5 × 10-8 and 1 × 10-6 . Six genetic loci (BAD, CCDC88B, GPR137, PLCB3, RPS6KA4 for systolic BPV, and WWC2 for diastolic BPV) were identified by coding region SNPs at the suggestive significant P threshold (1 × 10-6 ). Among them, gene CCDC88B and RPS6KA4 reached the significant P threshold (5 × 10-8 ), with the strongest signal of SNP rs1229536170 (P = 6.36 × 10-8 , β = -.29). The annotation results indicate that genes CCDC88B, GPR137, RPS6KA4, and BAD are associated with long-term SBPV. Their functions of inflammation, epithelial dysfunction, and apoptosis are related to artery stiffness, which was reported as potential mechanisms of BPV.

Effects of elevated systolic blood pressure on ischemic heart disease: a Burden of Proof study

High systolic blood pressure (SBP) is a major risk factor for ischemic heart disease (IHD), the leading cause of death worldwide. Using data from published observational studies and controlled trials, we estimated the mean SBP-IHD dose-response function and burden of proof risk function (BPRF), and we calculated a risk outcome score (ROS) and corresponding star rating (one to five). We found a very strong, significant harmful effect of SBP on IHD, with a mean risk-relative to that at 100 mm Hg SBP-of 1.39 (95% uncertainty interval including between-study heterogeneity 1.34-1.44) at 120 mm Hg, 1.81 (1.70-1.93) at 130 mm Hg and 4.48 (3.81-5.26) at 165 mm Hg. The conservative BPRF measure indicated that SBP exposure between 107.5 and 165.0 mm Hg raised risk by 101.36% on average, yielding a ROS of 0.70 and star rating of five. Our analysis shows that IHD risk was already increasing at 120 mm Hg SBP, rising steadily up to 165 mm Hg and increasing less steeply above that point. Our study endorses the need to prioritize and strengthen strategies for screening, to raise awareness of the need for timely diagnosis and treatment of hypertension and to increase the resources allocated for understanding primordial prevention of elevated blood pressure.

Variability in serum creatinine is associated with waitlist and post-liver transplant mortality in patients with cirrhosis

BACKGROUND AND AIMS

Kidney function in patients with cirrhosis is dynamic. After controlling for the presence of chronic kidney disease (CKD) and acute kidney injury (AKI), we investigated the impact of variation in clinical function on pre-liver transplantation (LT) and post-LT outcomes.

APPROACH AND RESULTS

We included adults listed for LT from 2011 through 2018. We excluded those with any exceptions, those on hemodialysis at listing, and those with fewer than three clinical updates in the United Network for Organ Sharing database. Our primary exposure was the serum creatinine coefficient of variation (sCr CoV). Logistic regression determined the associations between our exposures and higher sCr CoV. Competing risk regression determined the associations between our exposures and waitlist mortality, accounting for LT as a competing risk. Cox regression determined the associations between our exposures and either listing for kidney transplant or death. We divided our cohort into tertiles of sCr CoV: low variability, 8.8% (interquartile range [IQR], 6.6%-10.8%); intermediate variability, 17.4% (IQR, 14.8%-20.4%); high variability, 36.8% (IQR, 29.5%-48.8%). We demonstrate that women, those with CKD, and those with advanced liver disease were more likely to have a greater sCr CoV. Compared to those with low variability, those with high variability had significantly higher waitlist mortality (34.7% vs. 19.6% vs. 11.7%, p < 0.001). We highlight that the sCr CoV was associated with higher waitlist and post-LT mortality-an association independent of baseline sCr, the degree of underlying liver disease, the presence of AKI, or the presence of CKD.

CONCLUSION

This study informs the long-term impact of the variation in kidney function we all see in clinical practice. These data highlight that all fluctuations in sCr are associated with worse pre-LT and post-LT outcomes.

Blood Pressure Fluctuation During Hospitalization and Clinical Outcomes Within 3 Months After Ischemic Stroke

BACKGROUND

Increased blood pressure (BP) variability is positively associated with the risks of cerebral small-vessel disease, cardiovascular events and death. However, no large clinical trials have been published to demonstrate the effect of BP fluctuations during hospitalization on clinical outcomes after ischemic stroke.

METHODS

A total of 3972 patients with acute ischemic stroke from 26 participating hospitals were included in this study, and BP fluctuations were calculated using BP data collected during the hospitalization. The primary outcome was composite outcome of death or major disability (modified Rankin Scale score ≥3) within 3 months and secondary outcomes included death, vascular events, and composite outcomes (death or vascular events).

RESULTS

Compared with the lowest quartile of systolic BP fluctuations, the adjusted odds ratio associated with the highest quartile was 1.33 ([95% CI, 1.05-1.68]; P_trend=0.011) for primary outcome; the adjusted hazard ratios were 2.89 ([95% CI, 1.58-5.32]; P_trend<0.001) for death, 1.48 ([95% CI, 0.83-2.65]; P_trend=0.071) for vascular events, and 2.06 ([95% CI, 1.32-3.23]; P_trend<0.001) for composite outcome. Similar results were found for diastolic BP. Multivariable adjusted restricted cubic spline analysis showed a linear relationship between systolic BP fluctuations and the primary outcome (P for linearity=0.0009).

CONCLUSIONS

Larger BP fluctuations during hospitalization were associated with an increased risk of adverse outcomes at 3 months after ischemic stroke onset, independent of mean BP. These findings suggested that BP fluctuation should be a risk factor of adverse outcomes after ischemic stroke, which provided a new insight for BP management strategy.