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

Potassium variability during hospitalization and outcomes after discharge in patients with acute myocardial infarction

BACKGROUND

The variability of metabolic biomarkers has been determined to provide incremental prognosis information, but the implications of electrolyte variability remained unclear.

METHODS

We investigate the relationships between electrolyte fluctuation and outcomes in survivors of acute myocardial infarction (n = 4386). Ion variability was calculated as the coefficient of variation, standard deviation, variability independent of the mean (VIM) and range. Hazard ratios (HR) were estimated using the multivariable-adjusted Cox proportional regression method.

RESULTS

During a median follow-up of 12 months, 161 (3.7%) patients died, and heart failure occurred in 550 (12.5%) participants after discharge, respectively. Compared with the bottom quartile, the highest quartile potassium VIM was associated with increased risks of all-cause mortality (HR = 2.35, 95% CI: 1.36-4.06) and heart failure (HR = 1.32, 95% CI: 1.01-1.72) independent of cardiac troponin I (cTnI), N terminal pro B type natriuretic peptide (NT-proBNP), infarction site, mean potassium and other traditional factors, while those associations across sodium VIM quartiles were insignificant. Similar trend remains across the strata of variability by other three indices. These associations were consistent after excluding patients with any extreme electrolyte value and diuretic use.

CONCLUSIONS

Higher potassium variability but not sodium variability was associated with adverse outcomes post-infarction. Our findings highlight that potassium variability remains a robust risk factor for mortality regardless of clinical dysnatraemia and dyskalaemia.

The differential impact of aerobic and isometric handgrip exercise on blood pressure variability and central aortic blood pressure

BACKGROUND

Blood pressure variability and central SBP are independent markers of cardiovascular risk. Data on lifestyle-interventions to reduce these parameters are sparse. The present work reports the differential effects of aerobic vs. isometric handgrip exercise on blood pressure variability and central SBP in a prospective randomized trial.

METHODS

Seventy-five hypertensive patients were randomized to one of the following 12-week programs: isometric handgrip training five times weekly; 'Sham-handgrip training' five times weekly; aerobic exercise training (30 min three to five times/week). Blood pressure variability was assessed by the coefficient of variation in 24-h ambulatory blood pressure monitoring (ABPM). Central SBP was measured noninvasively by the SphygmoCor device (AtCor Medical, Australia).

RESULTS

The aerobic exercise program significantly decreased systolic daytime variability (12.1 ± 2.5 vs. 10.3 ± 2.8, P = 0.04), whereas diastolic daytime blood pressure variability was not significantly altered (P = 0.14). Night-time variability was not significantly affected (P > 0.05). Central SBP was reduced from 145±15 to 134 ± 19 mmHg (P = 0.01). Isometric handgrip and sham-handgrip exercise did not significantly affect blood pressure variability (P > 0.05 each). Isometric exercise tended to reduce central SBP (142 ± 19 to 136 ± 17 mmHg, P = 0.06). ANCOVA revealed significant intergroup differences for the change of daytime SBP and DBP variability (P = 0.048 and 0.047, respectively).

CONCLUSION

Aerobic exercise reduces blood pressure variability and central SBP. Isometric handgrip exercise does not reduce blood pressure variability but tends to lower central SBP in this hypertensive population.

Differences in exercise-induced blood pressure changes between young trained and untrained individuals

There are no studies assessing short‐term blood pressure (BP) changes induced by daily exercise load in young trained individuals. The authors enrolled 25 healthy, trained (mean age 19.7 ± 0.1 years, 36% female) and 26 healthy, untrained (mean age 20.4 ± 0.3 years, 50% female) individuals and measured BP after the Master two‐step test. Among them, 42 individuals underwent echocardiography after BP measurements to assess left ventricular mass index (LVMI). The baseline systolic BP (SBP) levels of trained and untrained individuals were 122.7 ± 2.9 versus 117.4 ± 1.5 mmHg, respectively (p = .016). Trained individuals showed a significant suppression of the SBP increase soon after exercise loads and lower SBP levels at 1, 2, and 3 min after exercise loads compared with untrained individuals. The peak SBP level over the study period was also significantly lower in trained individuals than in untrained individuals: 156.4 ± 3.3 versus 183.7 ± 5.2 mmHg (p < .001). Trained individuals showed significantly higher LVMI compared with untrained individuals: 129.4 versus 101.6 g/m² (p < .001). These findings demonstrated that trained individuals showed significant suppression of short‐term BP variability in response to by daily exercise loads and prompt SBP recovery from acute exercise loads compared with untrained individuals. Our results would be useful to understand short‐term BPV and LV hypertrophy induced by adaptive responses of the heart to regular exercise loads.

Short-term blood pressure variability, arterial stiffness, and cardiovascular events: results from the Bordeaux cohort

OBJECTIVE

Short-term blood pressure variability derived from 24-h ambulatory monitoring is associated with poor cardiovascular prognosis. However, previous analyses of this have clearly been influenced by clinical cofounders, particularly blood pressure (BP) level. Arterial stiffness is a powerful marker of cardiovascular risk, which may influence BP variability. In this study, we assessed the prognostic value of BP variability based on 24-h ambulatory measurements and adjusted for arterial stiffness.

METHODS

Population: Bordeaux cohort of hypertensive patients. Inclusion criteria were 24-h ambulatory BP monitoring at baseline with measurements every 15' day and night, determination of wake-up time and bedtime, and assessment of arterial stiffness with monitoring of Korotkoff sound arrival time. A total of 969 patients (age 54 ± 14 years) with an average follow up of 120 ± 78 months and 178 cardiovascular recorded events were included.

RESULTS

In univariate survival analyses, the standard deviations of day, night, and 24-h SBP were associated with the occurrence of cardiovascular events. The standard deviation of night-time SBP showed the strongest association with the outcome variable and was entered into multivariate analyses. In multivariate analyses, night-time SBP variability remained significantly associated with the occurrence of cardiovascular events after adjusting for major cardiovascular risk factors, 24-h SBP, and arterial stiffness. BP variability and arterial stiffness showed no significant association.

CONCLUSION

Our results suggest that variability of night-time SBP is an important marker of the risk of cardiovascular events in hypertensive patients, independently of average 24-h BP and arterial stiffness.

Use of advanced statistical techniques to predict all-cause mortality in the Systolic Blood Pressure Intervention Trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) was conducted in patients with hypertension and additional risk for cardiovascular disease who were randomized to the intensive blood pressure group targeting systolic blood pressure (SBP) less than 120 mm Hg and to the standard group where the target was less than 140 mm Hg. Analyses were done in the matched group of participants with the same gender, same age (±2 years) and same SBP (±3 mm Hg) at three months of treatment regardless of initial randomization to intensive or standard group (shaded area in Figure 1).

Methods and results

During 3.26 years of follow-up, intensive group participants had 14.8 mm Hg lower SBP and received on average one more (2.8 vs. 1.8) blood pressure lowering medications. This was associated with lower all-cause mortality in the intensive treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90, p = 0.003). The effect on SBP was achieved at 3 months and remained unchanged thereafter. This paper addresses two questions with respect to all-cause mortality in SPRINT in the matched set. 1) What is the effect of receiving more than one drug on all-cause mortality. Conditional logistic regression for all-cause mortality with respect to number of drugs indicated that during the 3.26 years of follow-up persons who received more than one drug were more likely to die (coefficient = 0.5039, OR = 1.6552, p = 0.0322) than patients who received one drug. 2) Was there a U curve relationship between on treatment SBP and all-cause mortality? A U curve fitting a quadratic equation (parabola) of SBP and all-cause death was observed. This was seen in the patients randomized to the standard target group in unadjusted analyses as well as in analyses adjusted for demographics or all covariates (p < 0.001 for all). The U curves in the combined group and the intensive treatment group were less pronounced.

Conclusion

SPRINT participants who were matched for gender, age, and SBP at 3 months, and received more than one drug had higher all-cause mortality during the 3.26 years of follow-up. Those who were randomized to standard treatment target had a U curve relationship between SBP at three months and all-cause mortality. The U curves in the combined group and the intensive treatment group were less pronounced.

Glucose variability and diabetes complications: Risk factor or biomarker? Can we disentangle the "Gordian Knot"?

« Variability in glucose homoeostasis » is a better description than « glycaemic variability » as it encompasses two categories of dysglycaemic disorders: i) the short-term daily glucose fluctuations and ii) long-term weekly, monthly or quarterly changes in either HbA1c, fasting or postprandial plasma glucose. Presently, the relationship between the "variability in glucose homoeostasis" and diabetes complications has never been fully clarified because studies are either observational or limited to retrospective analysis of trials not primarily designed to address this issue. Despite the absence of definitive evidence from randomized controlled trials (RCTs), it is most likely that acute and long-term glucose homoeostasis "cycling", akin to weight and blood pressure "cycling" in obese and hypertensive individuals, are additional risk factors for diabetes complications in the presence of sustained ambient hyperglycaemia. As hypoglycaemic events are strongly associated with short- and long-term glucose variability, two relevant messages can be formulated. Firstly, due consideration should be given to avoid within-day glucose fluctuations in excess of 36% (coefficient of variation) at least for minimizing the inconvenience and dangers associated with hypoglycaemia. Secondly, it seems appropriate to consider that variability in glucose homoeostasis is not only associated with cardiovascular events but is also a causative risk factor via hypoglycaemic episodes as intermediary step. Untangling the" Gordian Knot", to provide confirmation about the impact of variability in glucose homoeostasis and diabetes complications remains a daunting prospect.

Association of Blood Pressure Patterns in Young Adulthood With Cardiovascular Disease and Mortality in Middle Age

Importance

Determining blood pressure (BP) patterns in young adulthood that are associated with cardiovascular disease (CVD) events in later life may help to identify young adults who have an increased risk for CVD.

Objective

To determine whether the long-term variability of BP across clinical visits and the rate of change in BP from young adulthood to midlife are associated with CVD and all-cause mortality by middle age, independently of mean BP during young adulthood and a single BP in midlife.

Design, Setting, and Participants

This prospective cohort study included a community-based sample of 3394 African American and white participants in the Coronary Artery Risk Development in Young Adults (CARDIA) Study, enrolled from March 1985 through June 1986. Patterns of systolic BP (SBP) were evaluated with measurements at year 0 (baseline) and 2, 5, 7, and 10 years after baseline. Visit-to-visit SBP variability was estimated as BP variability independent of the mean (VIM). Data were collected from March 1985 through August 2015 and analyzed from June through October 2019.

Main Outcomes and Measures

Cardiovascular disease and all-cause mortality experienced through August 2015 were adjudicated. The associations of each SBP pattern with CVD events and all-cause mortality were determined using Cox proportional hazards regression models.

Results

At year 10, the mean (SD) age of the 3394 participants was 35.1 (3.6) years; 1557 (45.9%) were African American; 1892 (55.7%) were women; and 103 (3.0%) were taking antihypertensive medication. During a median follow-up of 20.0 (interquartile range, 19.4-20.2) years, 162 CVD events and 181 deaths occurred. When all BP pattern measurements were entered into the same model including a single SBP measurement at the year 10 examination, the hazard ratios for CVD events for each 1-SD increase in SBP measures were 1.25 (95% CI, 0.90-1.74) for mean SBP, 1.23 (95% CI, 1.07-1.43) for VIM SBP, and 0.99 (95% CI, 0.81-1.26) for annual change of SBP. The VIM for SBP was the only BP pattern associated with all-cause mortality (hazard ratio, 1.24; 95% CI, 1.09-1.41).

Conclusions and Relevance

The results of this study suggest that the assessment of visit-to-visit SBP variability may help identify young adults at increased risk for CVD and all-cause mortality later in life.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

Uric Acid Variability and All-Cause Mortality: A Prospective Cohort Study in Northern China

OBJECTIVES

Uric acid(UA) is related with cardiovascular disease, but the association of UA variability with all-cause mortality is rarely known. This study aimed to investigate the relationship between UA variability and all-cause mortality in Kailuan cohort study in northern China.

DESIGN

Cohort study.

SETTING

Kailuan community hospitals in Tangshan, Hebei province, Northern China.

PARTICIPANTS

A total of 55717 participants from Kailuan Study were enrolled, and our study followed up biennially from 2006 to 2010.

MEASUREMENTS

Clinical records of the participants enrolled were analyzed. UA variation independent of mean (UAVIM) values were calculated and all the participants were quartile grouped into four groups as: Q1(UAVIM<0.68), Q2(0.68≤UAVIM<1.10), Q3(1.10≤UAVIM<1.67) and Q4(UAVIM≥1.67). The endpoint event was all-cause death. Cox regression model was performed to evaluate the hazard ratios(HRs) of all-cause mortality based on UAVIM groups.

RESULTS

During a median follow-up of 6.83 years, 2926 deaths occurred. The accumulated mortality rates were 4.6%, 4.8%, 5.4% and 6.1% in group Q1, Q2, Q3 and Q4 respectively. When adjusted potential confounders, the highest risk for all-cause mortality was in group Q4 and the adjusted HRs and 95% confidence intervals(CIs) of group Q2-Q4 for all-cause death were 1.044(0.937, 1.164), 1.182(1.064, 1.314) and 1.353(1.220, 1.501) compared with group Q1, respectively. Further analysis showed that the risk for all-cause death increased as UAVIM value increased. Sensitive analysis still showed the similar results when excluding participants with hyperuricemia or severe chronic kidney diseases. Sub-group analysis by age, gender, BMI or hypertension history also indicated analogous results.

CONCLUSION

Elevated UAVIM was related with increased all-cause mortality and UAVIM was an independent risk factor for all-cause mortality in the community cohort study.

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

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

Blood Pressure Variation and Subclinical Brain Disease

BACKGROUND

Large blood pressure (BP) variability may contribute to stroke and dementia, but the mechanisms are largely unknown.

OBJECTIVES

This study investigated the association of BP variation, considering its magnitude and direction, with the presence and progression of subclinical brain disease in the general population.

METHODS

This study included 2,348 participants age ≥55 years from a prospective cohort study. BP was measured at each visit every 3 to 4 years from 1990 onward. Brain magnetic resonance imaging (MRI) was performed at all visits from 2005 onward. The authors primarily assessed variation as the absolute difference in BP divided by the mean over 2 sequential visits for both systolic BP (SBP) and diastolic BP (DBP), and further assessed the direction of the variation. The authors investigated the multivariate-adjusted associations of BP variation with subsequent measurements of MRI markers of cerebral small vessel disease, brain tissue volumes, and white matter microstructural integrity. Longitudinal changes in these markers also were assessed.

RESULTS

A large SBP variation (top vs. bottom tertiles), measured on average 7 years preceding brain MRI, was associated with higher odds of having severe white matter hyperintensities (WMH) (odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.21 to 1.43), lacunes (OR: 1.25; 95% CI: 1.04 to 1.48), and microbleeds (OR: 1.16; 95% CI: 1.03 to 1.31). Similarly, this variation was associated with smaller total brain volume and worse white matter microstructural integrity (all p < 0.001). A large SBP variation was also associated with the progression of WMH (rate ratio [RR]: 1.14; 95% CI: 1.02 to 1.27). Higher burdens of these brain imaging markers were observed with both large rises and falls in SBP. Similar findings were observed for DBP variation.

CONCLUSIONS

Elevated BP variation was associated with a wide range of subclinical brain structural changes, including MRI markers of cerebral small vessel disease, smaller brain tissue volumes, and worse white matter microstructural integrity. These subclinical brain changes could be the underlying mechanisms linking BP variation to dementia and stroke.

Impact of Blood Pressure Visit-to-Visit Variability on Adverse Events in Patients With Nonvalvular Atrial Fibrillation: Subanalysis of the J-RHYTHM Registry

Background

Blood pressure (BP) variability has reportedly been a risk factor for various clinical events. To clarify the influence of BP visit‐to‐visit variability on adverse events in patients with nonvalvular atrial fibrillation, a post hoc analysis of the J‐RHYTHM Registry was performed.

Methods and Results

Of 7406 outpatients with nonvalvular atrial fibrillation from 158 institutions, 7226 (age, 69.7±9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6±5.0 times) during the 2‐year follow‐up period or until occurrence of an event, constituted the study group. SD and coefficient of variation of BP values were calculated as BP variability. Thromboembolism, major hemorrhage, and all‐cause death occurred in 110 (1.5%), 121 (1.7%), and 168 (2.3%) patients, respectively. When patients were divided into quartiles of systolic BP‐SD (<8.20, 8.20–10.49, 10.50–13.19, and ≥13.20 mm Hg), hazard ratios (HRs) for all adverse events were significantly high in the highest quartile compared with the lowest quartile (HR, 2.00, 95% CI, 1.15–3.49, P=0.015 for thromboembolism; HR, 2.60, 95% CI, 1.36–4.97, P=0.004 for major hemorrhage; and HR, 1.85, 95% CI, 1.11–3.07, P=0.018 for all‐cause death) after adjusting for components of the CHA₂DS₂‐VASc score, warfarin and antiplatelet use, atrial fibrillation type, BP measurement times, and others. These findings were consistent when BP‐coefficient of variation was used instead of BP‐SD.

Conclusions

Systolic BP visit‐to‐visit variability was significantly associated with all adverse events in patients with nonvalvular atrial fibrillation. Further studies are needed to clarify the causality between BP variability and adverse outcomes in patients with nonvalvular atrial fibrillation.

Registration

URL: https://www.umin.ac.jp/ctr/; Unique Identifier: UMIN000001569.

Cardioautonomic control in healthy singleton and twin pregnancies

In conjunction with significant cardiovascular adaptation, changes in cardioautonomic balance, specifically greater sympathetic activation and vagal withdrawal, are considered normal adaptations to healthy singleton pregnancy. Cardiovascular adaptation to twin pregnancy is more profound than that of singleton pregnancies; however, the changes in cardioautonomic control during multifetal gestation are unknown. To address this gap, beat-by-beat blood pressure (photoplethysmography) and heart rate (lead II electrocardiogram) were measured continuously in 25 twin pregnancies and 25 singleton pregnancies (matched for age, prepregnancy body mass index, and gestational age) during 10 min of rest. Data extracted from a 3- to 5-min period were used to analyze heart rate variability (HRV), blood pressure variability (BPV), cardiovagal baroreflex gain, and cardiac intervals as indicators of cardioautonomic control. Independent t tests were used to determine statistical differences between groups (α = 0.05), and the false rate discovery was determined to adjust for multiple comparisons. Resting heart rate was greater in twin compared with singleton pregnancies (91 ± 10 vs. 81 ± 10 beats/min; P = 0.001), but blood pressure was not different. Individuals with twin pregnancies had lower HRV, evidenced by lower standard deviation of R-R intervals (32 ± 11 vs. 47 ± 18 ms; P = 0.001), total power (1,035 ± 810 vs. 1,945 ± 1,570 ms²; P = 0.004), and high frequency power (224 ± 262 vs. 810 ± 806 ms²; P < 0.001) compared with singleton pregnancies. There were no differences in cardiac intervals, BPV, and cardiovagal baroreflex gain between groups. Our findings suggest that individuals with twin pregnancies have greater sympathetic and lower parasympathetic contributions to heart rate and that cardiac, but not vascular, autonomic control is impacted during twin compared with singleton pregnancy.NEW & NOTEWORTHY Individuals with healthy twin pregnancies had lower overall heart rate variability compared with those with singleton pregnancies at similar gestational ages. These results suggest a greater sympathetic and reduced parasympathetic contribution to cardiac control in twin pregnancies. Baseline heart rate was elevated, while arterial pressure and spontaneous cardiovagal baroreflex gain were not different between groups. This was result of the upward resetting of the cardiovagal baroreflex during healthy twin pregnancy, thus maintaining arterial pressure.

The recent effects of small dose of folic acid on lipoprotein-associated phospholipase A2 and systolic blood pressure variability in coronary heart disease patients with hyperhomocysteinemia: A single-center prospective cohort study

To Investigate the recent effects of small dose of folic acid on lipoprotein-associated phospholipase A2 (LP-PLA2) and systolic blood pressure variability in coronary heart disease (CHD) patients with hyperhomocysteinemia.In this prospective cohort study, a total of 167 CHD patients with hyperhomocysteinemia were consecutively enrolled, and they were divided into Group A (without folic acid intervention, n = 99), Group B (with 0.4 mg of folic acid intervention, n = 34), Group C (0.8 mg of folic acid intervention, n = 34). General information, fasting blood glucose, and blood lipid, folic acid, homocysteine, Lp-PLA2, and blood pressure variability were compared among 3 groups. The above indicators were reviewed after 3 months of treatment.There were no statistically significant differences of age, gender, blood pressure, incidence of type 2 diabetes mellitus, fasting blood glucose, folic acid, homocysteine, Lp-PLA2, total cholesterol, 3 acyl glycerin, apolipoprotein B, lipoprotein (a), high density lipoprotein cholesterol, and low density lipoprotein cholesterol were found among 3 groups (P > .05); however, after being treated for 3 months, there was statistically significant difference in folic acid among 3 groups (P < .05), there was statistically significant difference in apolipoprotein A between Group A and Group B (t = 0.505, P = .039), and also between Group A and Group C (t = 0.052, P = .017). There were statistically significant differences in Lp-PLA2 (t = 24.320, P = .016) and systolic blood pressure variability (t = 0.154, P = .018) between Group A and Group C.For CHD patients with hyperhomocysteinemia, the higher dose (0.8 mg) of folic acid supplement was beneficial for increasing the apolipoprotein A, reducing the Lp-PLA2, and improving the systolic blood pressure variation, which might help to improve the prognosis in these patients.

A cohort-based comprehensive characterization of different patterns of very short-term, within-visit, blood pressure variability

AIM

To characterize different patterns of variability of three repeated within-visit blood pressure (BP) readings and to determine the prevalence of specific variation trends in systolic (SBP), diastolic (DBP) blood pressure and pulse pressure (PP).

METHODS

Data from 53 737 subjects from the National Health and Nutrition Examination Survey were analyzed. In each subject, three consecutive BP measurements were performed with a minimum time-interval of at least 30 s. We propose three patterns of within-visit BP variability (separately for SBP, DBP and PP): (1) increasing trend (BP3 > BP2 > BP1); (2) decreasing trend (BP1 > BP2 > BP3) and (3) no trend (BP3 ≈ BP2 ≈ BP1). A threshold of minimum change (ΔP > 3 mmHg) between BP1-BP2 and BP2-BP3 was also applied as a prerequisite for the definition of these trends.

RESULTS

An increasing trend was observed among three consecutive measurements of SBP, DBP and PP in 7.4, 10.4 and 10.2%, respectively. When a minimum threshold of 3 mmHg was set the respective increasing trends were observed in 1.8, 2.9 and 4.4%, respectively. There was a higher prevalence of decreasing trend within three consecutive SBP, DBP and PP readings: 17, 13.1 and 16.2%, respectively, whereas using a threshold of ΔP >3 mmHg the respective prevalence was 6.3, 4.1 and 7.7%. A maximum absolute difference >10 mmHg within triplicate of SBP/DBP/PP readings was observed in 12.9, 13 and 29.4%, respectively. In the era of personalized medicine, these patterns are well worth further investigation concerning their pathophysiologic and clinical relevance.

Big data and real-world data-based medicine in the management of hypertension

Big data has been a hot topic in medical and healthcare research. Big data in healthcare is considered to comprise massive amounts of information from various sources, including electronic health records (EHRs), administrative or claims data, and data from self-monitoring devices. Biomedical research has also generated a significant portion of big data relevant to healthcare. Other large datasets arise from cohorts that are recruited and followed on the basis of specific questions, although such research questions may later be expanded to enable other investigations. While the availability of big data offers many possibilities for an improved understanding of disease and treatment, the need for careful and productive use of statistical concepts should be kept in mind. Patient data routinely collected via electronic means are called real-world data (RWD) and are becoming common in healthcare research. RWD and big data are not synonymous with each other, but the two terms seem to be used without distinction with respect to observational studies. In this article, we review hypertension-related papers that use big data or RWD. There are many other sources of big data or RWD that are not covered here, each of which may pose special challenges and opportunities. While randomized clinical trials (RCTs) are considered to be the criterion standard for generating clinical evidence, the use of real-world evidence (RWE) to evaluate the efficacy and safety of medical interventions is gaining interest. On-going efforts to make use of RWD to generate RWE for regulatory decisions, as well as the challenges confronted, including reliability (quality) and relevance (fitness for purpose) of data, will also be addressed.

[Hypertension in the elderly: What we need to know]

More than two thirds of people over 65 are hypertensive. Along with the high prevalence, hypertension is associated by comorbidities that originates a heterogeneous elderly population in relation to their autonomy and functional capacity. At this age, hypertension has special characteristics that make its management difficult, highlighting by isolated systolic hypertension due to the vascular stiffness typical of aging. Although decision-making is based on the clinical measurement of blood pressure, it is known that in the elderly pressure is subject to numerous influences: temporal (absence of night dipping), of the environment (exacerbation of the white coat phenomenon) and of the position (orthostatic hypotension). These circumstances must be taken into account when evaluating and deciding on therapy. At this age, there is sufficient evidence that treatment reduces both cardiovascular morbimortality and all-cause mortality.

Machine Learning-Based Risk Assessment for Cancer Therapy-Related Cardiac Dysfunction in 4300 Longitudinal Oncology Patients

Background The growing awareness of cardiovascular toxicity from cancer therapies has led to the emerging field of cardio-oncology, which centers on preventing, detecting, and treating patients with cardiac dysfunction before, during, or after cancer treatment. Early detection and prevention of cancer therapy-related cardiac dysfunction (CTRCD) play important roles in precision cardio-oncology. Methods and Results This retrospective study included 4309 cancer patients between 1997 and 2018 whose laboratory tests and cardiovascular echocardiographic variables were collected from the Cleveland Clinic institutional electronic medical record database (Epic Systems). Among these patients, 1560 (36%) were diagnosed with at least 1 type of CTRCD, and 838 (19%) developed CTRCD after cancer therapy (de novo). We posited that machine learning algorithms can be implemented to predict CTRCDs in cancer patients according to clinically relevant variables. Classification models were trained and evaluated for 6 types of cardiovascular outcomes, including coronary artery disease (area under the receiver operating characteristic curve [AUROC], 0.821; 95% CI, 0.815-0.826), atrial fibrillation (AUROC, 0.787; 95% CI, 0.782-0.792), heart failure (AUROC, 0.882; 95% CI, 0.878-0.887), stroke (AUROC, 0.660; 95% CI, 0.650-0.670), myocardial infarction (AUROC, 0.807; 95% CI, 0.799-0.816), and de novo CTRCD (AUROC, 0.802; 95% CI, 0.797-0.807). Model generalizability was further confirmed using time-split data. Model inspection revealed several clinically relevant variables significantly associated with CTRCDs, including age, hypertension, glucose levels, left ventricular ejection fraction, creatinine, and aspartate aminotransferase levels. Conclusions This study suggests that machine learning approaches offer powerful tools for cardiac risk stratification in oncology patients by utilizing large-scale, longitudinal patient data from healthcare systems.

Acute and chronic effects of combined exercise on ambulatory blood pressure and its variability in hypertensive postmenopausal women

The aim of this study was to investigate the acute and chronic effects, and their correlation, after combined aerobic and resistance exercises in blood pressure (BP) and its variability (BPV) in hypertensive postmenopausal women. Fourteen hypertensive postmenopausal women monitored BP at rest and during 24 h by ambulatory BP monitoring in a control day without exercise performance a pretraining (baseline), after an acute exercise session (acute), and after a chronic exercise training for 10 weeks (chronic). After exercise training, systolic BP (SBP, Δ = -150 mmHg.24 h), diastolic BP (DBP, Δ = -96 mmHg.24 h), and mean BP (MBP, Δ = -95 mmHg.24 h) area under the curve were smaller than baseline measurements (P < 0.05) with no difference between acute and baseline measurements. The SBP (ΔSD₂₄ = -2, ΔSD_dn = -1.7, and ΔARV₂₄ = -1.9 mmHg), DBP (ΔSD₂₄ = -0.9, ΔSD_dn = -0.8, and ΔARV₂₄ = -0.9 mmHg), and MBP (ΔSD₂₄ = -1.5, ΔSD_dn = -1.3, and ΔARV₂₄ = -1.2 mmHg) variability reduced in acute session in relation to baseline, with no chronic effects. There are moderate correlations between acute and chronic responses in wake SBP, sleep DBP, and SD₂₄. In conclusion, combined exercise reduces ambulatory BP chronically but not acutely. In contrast, BPV decreases after an acute session but not chronically. Awake SBP, sleep DBP, and SD₂₄indices are promising candidates to predict individual cardiovascular responses to exercise.

24-h ambulatory blood pressure variability and hypertensive nephropathy in Han Chinese hypertensive patients

Blood pressure (BP) is characterized by spontaneous oscillation over time, which is described as BP variability (BPV). The current study aimed to investigate whether short‐term BPV was correlated with hypertensive nephropathy in Han Chinese individuals with hypertension. A single‐center prospective cohort study of 300 Han Chinese participants with hypertension was conducted in Taiwan. Five different BPV parameters were derived from ambulatory BP monitoring (ABPM), including standard deviation (SD), weighted SD (wSD), coefficient of variation (CoV), successive variation (SV), and average real variability (ARV). Renal event was defined as > 50% reduction in baseline estimated glomerular filtration rate (eGFR). The average age of the participants was 63.5 years. The baseline eGFR was 84.5 mL/min/1.73 m². The participants were divided into two groups according to the wSD of systolic BP (SBP). Survival was assessed via a Kaplan‐Meier analysis. During the 4.2‐year follow‐up, the participants with the highest SBP wSD tertile had a greater number of renal events (6.0%) than their counterparts (0.5%) (log‐rank test, p = .007). The Cox proportional hazard regression model was used to assess the independent effects of BPV, and results showed that 24‐h SBP (HR = 1.105; 95% CI = 1.020–1.197, p = .015) and 24‐h DBP (HR = 1.162; 95% CI = 1.004–1.344, p = .044) were independently associated with renal events. However, BPV parameters were only associated with renal events univariately, but not after adjusting for baseline characteristics, 24‐h mean BP, and office BP. Therefore, the risk of hypertensive nephropathy was independently associated with 24‐h mean BP, but not with ambulatory BPV, in Han Chinese participants with hypertension.

Age and sex distribution of beat-to-beat blood pressure variability after transient ischemic attack and minor stroke: A population-based study

Background

Beat-to-beat blood pressure variability is associated with increased stroke risk but its importance at different ages is unclear.

Aims

To determine the age-sex distribution of blood pressure variability in patients with transient ischemic stroke or minor stroke.

Methods

In consecutive patients within six weeks of transient ischemic stroke or non-disabling stroke (Oxford Vascular Study), non-invasive blood pressure was measured beat-to-beat over five minutes (Finometer). The age-sex distribution of blood pressure variability (residual coefficient of variation) was determined for systolic blood pressure and diastolic blood pressure. The risk of top-decile blood pressure variability was estimated (logistic regression), unadjusted, and adjusted for age, sex, and cardiovascular risk factors.

Results

In 908 of 1013 patients, excluding 54 in atrial fibrillation and 51 with low quality recordings, residual coefficient of variation was positively skewed with a median systolic residual coefficient of variation of 4.2% (IQR 3.2–5.5) and diastolic residual coefficient of variation of 3.9% (3.0–5.5), with 90th centile thresholds of 7.2 and 7.3%. Median systolic residual coefficient of variation was higher in patients under 50 years (4.5 and 3.0–5.3) compared to 60–70 years (4.1 and 3.2–5.2), but rose to 4.5% (3.5–6.9) above 80 years, with an increasingly positive skew. The proportion of patients with markedly elevated blood pressure variability in the top-decile increased significantly per decade (OR 1.72, p < 0.001), after adjustment for sex and risk factors.

Conclusions

Median beat-to-beat blood pressure variability fell in midlife, reflecting loss of physiological, organized blood pressure variability. However, rates of markedly elevated blood pressure variability significantly increased with greater age, suggesting that blood pressure variability may be particularly important in older patients.

Comorbidity patterns among people living with HIV: a hierarchical clustering approach through integrated electronic health records data in South Carolina

Comorbidity among people living with HIV (PLWH) is understudied although identifying its patterns and socio-demographic predictors would be beneficial for comorbidity management. Using electronic health records (EHR) data, 8,490 PLWH diagnosed between January 2005 and December 2016 in South Carolina were included in the current study. An initial list of 86 individual diagnoses of chronic conditions was extracted in the EHR data. After grouping individual diagnoses with a pathophysiological similarity, 24 diagnosis groups were generated. Hierarchical cluster analysis was applied to these 24 diagnosis groups and yielded four comorbidity clusters: "substance use and mental disorder" (e.g., alcohol use, depression, and illicit drug use); "metabolic disorder" (e.g., hypothyroidism, diabetes, hypertension, and chronic kidney disease); "liver disease and cancer" (e.g., hepatitis B, chronic liver disease, and non-AIDS defining cancers); and "cerebrovascular disease" (e.g., stroke and dementia). Multivariable logistic regression was conducted to investigate the association between socio-demographic factors and multimorbidity (defined as concurrence of ≥ 2 comorbidity clusters). The multivariable logistic regression showed that age, gender, transmission risk, race, initial CD4 counts, and viral load were significant factors associated with multimorbidity. The results suggested the importance of integrated clinical care that addresses the complexities of multiple, and potentially interacting comorbidities among PLWH.

Machine learning-based models to support decision-making in emergency department triage for patients with suspected cardiovascular disease

BACKGROUND

Accurate differentiation and prioritization in emergency department (ED) triage is important to identify high-risk patients and to efficiently allocate of finite resources. Using data available from patients with suspected cardiovascular disease presenting at ED triage, this study aimed to train and compare the performance of four common machine learning models to assist in decision making of triage levels.

METHODS

This cross-sectional study in the second Affiliated Hospital of Guangzhou Medical University was conducted from August 2015 to December 2018 inclusive. Demographic information, vital signs, blood glucose, and other available triage scores were collected. Four machine learning models - multinomial logistic regression (multinomial LR), eXtreme gradient boosting (XGBoost), random forest (RF) and gradient-boosted decision tree (GBDT) - were compared. For each model, 80 % of the data set was used for training and 20 % was used to test the models. The area under the receiver operating characteristic curve (AUC), accuracy and macro- F₁ were calculated for each model.

RESULTS

In 17,661 patients presenting with suspected cardiovascular disease, the distribution of triage of level 1, level 2, level 3 and level 4 were 1.3 %, 18.6 %, 76.5 %, and 3.6 % respectively. The AUCs were: XGBoost (0.937), GBDT (0.921), RF (0.919) and multinomial LR (0.908). Based on feature importance generated by XGBoost, blood pressure, pulse rate, oxygen saturation, and age were the most significant variables for making decisions at triage.

CONCLUSION

Four machine learning models had good discriminative ability of triage. XGBoost demonstrated a slight advantage over other models. These models could be used for differential triage of low-risk patients and high-risk patients as a strategy to improve efficiency and allocation of finite resources.

Long-Term Blood Pressure Variability and Risk of Cardiovascular Disease Events Among Community-Dwelling Elderly

High office blood pressure variability (OBPV) in midlife increases the risk of cardiovascular disease (CVD), but the impact of OBPV in older adults without previous CVD is unknown. We conducted a post hoc analysis of ASPREE trial (Aspirin in Reducing Events in the Elderly) participants aged 70-years and older (65 for US minorities) without history of CVD events at baseline, to examine risk of incident CVD associated with long-term, visit-to-visit OBPV. CVD was a prespecified, adjudicated secondary end point in ASPREE. We estimated OBPV using within-individual SD of mean systolic BP from baseline and first 2 annual visits. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% CI for associations with CVD events. In 16 475 participants who survived to year 2 without events, those in the highest tertile of OBPV had increased risk of CVD events after adjustment for multiple covariates, when compared with participants in the lowest tertile (HR, 1.36 [95% CI, 1.08-1.70]; P=0.01). Similar increased risk was observed for ischemic stroke (HR, 1.56 [95% CI, 1.04-2.33]; P=0.03), heart failure hospitalization, or death (HR, 1.73 [95% CI, 1.07-2.79]; P=0.02), and all-cause mortality (HR, 1.27 [95% CI, 1.04-1.54]; P=0.02). Findings were consistent when stratifying participants by use of antihypertensive drugs, while sensitivity analyses suggested the increased risk was especially for individuals whose BP was uncontrolled during the OBPV estimation period. Our findings support increased OBPV as a risk factor for CVD events in healthy older adults with, or without hypertension, who have not had such events previously. Registration- URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01038583; URL: https://www.isrctn.com; Unique identifiers: ISRCTN83772183.

2020 Consensus Statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on Home Blood Pressure Monitoring for the Management of Arterial Hypertension

To facilitate the applications of home blood pressure (HBP) monitoring in clinical settings, the Taiwan Hypertension Society and the Taiwan Society of Cardiology jointly put forward the Consensus Statement on HBP monitoring according to up-to-date scientific evidence by convening a series of expert meetings and compiling opinions from the members of these two societies. In this Consensus Statement as well as recent international guidelines for management of arterial hypertension, HBP monitoring has been implemented in diagnostic confirmation of hypertension, identification of hypertension phenotypes, guidance of anti-hypertensive treatment, and detection of hypotensive events. HBP should be obtained by repetitive measurements based on the " 722 " principle, which is referred to duplicate blood pressure readings taken per occasion, twice daily, over seven consecutive days. The " 722" principle of HBP monitoring should be applied in clinical settings, including confirmation of hypertension diagnosis, 2 weeks after adjustment of antihypertensive medications, and at least every 3 months in well-controlled hypertensive patients. A good reproducibility of HBP monitoring could be achieved by individuals carefully following the instructions before and during HBP measurement, by using validated BP devices with an upper arm cuff. Corresponding to office BP thresholds of 140/90 and 130/80 mmHg, the thresholds (or targets) of HBP are 135/85 and 130/80 mmHg, respectively. HBP-based hypertension management strategies including bedtime dosing (for uncontrolled morning hypertension), shifting to drugs with longer-acting antihypertensive effect (for uncontrolled evening hypertension), and adding another antihypertensive drug (for uncontrolled morning and evening hypertension) should be considered. Only with the support from medical caregivers, paramedical team, or tele- monitoring, HBP monitoring could reliably improve the control of hypertension.

Blood pressure monitoring in sleep: time to wake up

Hypertension is a highly common condition with well-established adverse consequences. Ambulatory blood pressure monitoring has repeatedly been shown to better predict cardiovascular outcomes and mortality, compared to single office visit blood pressure. Non-dipping of sleep-time blood pressure is an independent marker for increased cardiovascular risk. We review blood pressure variability and the challenges of blood pressure monitoring during sleep. Although pathological sleep such as obstructive sleep apnea has been associated with non-dipping of sleep-time blood pressure, blood pressure is not routinely measured during sleep due to lack of unobtrusive blood pressure monitoring technology. Second, we review existing noninvasive continuous blood pressure monitoring technologies. Lastly, we propose including sleep-time blood pressure monitoring during sleep studies and including sleep studies in patients undergoing ambulatory blood pressure monitoring.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Blood pressure variability in normotensive perimenopausal women: Non-dipping status, maximum blood pressure and arterial stiffness

BACKGROUND

Postmenopausal women are more likely to have uncontrolled hypertension and are at higher risk of cardiovascular disease compared with age-matched men. Blood pressure variability is emerging as a predictor of adverse cardiovascular outcomes and may be implicated in the relationship between menopause and worsened vascular health in women. We conducted an observational study, BRAVE (Blood pRessure And Vascular hEalth around menopause) to study this relationship.

METHOD

Normotensive perimenopausal women were recruited. Blood pressure variability was measured through 24-h blood pressure monitoring. Vascular health was assessed through arterial stiffness (carotid-femoral pulse wave velocity), carotid intima-media thickness and endothelial function (reactive hyperemic index). Multivariate models were performed to identify factors associated with blood pressure variability and arterial stiffness in perimenopausal women.

RESULTS

Forty-nine healthy women (mean age 52.9 ± 4.0, 63% postmenopausal) were recruited. There was a high prevalence (40%) of night non-dipping, a measure of an abnormal pattern of blood pressure variability. Aside from night dipping, other measures of blood pressure variability were similar between premenopausal and postmenopausal women. In the multivariate analysis, body mass index was the only factor associated independently with different measures of blood pressure variability, including the maximum overnight blood pressure (ß = 1.95, p < 0.01). The latter was also significantly associated with arterial stiffness (ß = 0.035, p = 0.048). Finally, poor sleep was independently associated with an increase in arterial stiffness.

CONCLUSIONS

Abnormal blood pressure variability, particularly night non-dipping, is common in normotensive perimenopausal women. Maximum overnight blood pressure is independently associated with arterial stiffness and may identify women at higher cardiovascular risk.

Patient-Specific Hemodynamics of New Coronary Artery Bypass Configurations

PURPOSE

This study aims to quantify the patient-specific hemodynamics of complex conduit routing configurations of coronary artery bypass grafting (CABG) operation which are specifically suitable for off-pump surgeries. Coronary perfusion efficacy and local hemodynamics of multiple left internal mammary artery (LIMA) with sequential and end-to-side anastomosis are investigated. Using a full anatomical model comprised of aortic arch and coronary artery branches the optimum perfusion configuration in multi-vessel coronary artery stenosis is desired.

METHODOLOGY

Two clinically relevant CABG configurations are created using a virtual surgical planning tool where for each configuration set, the stenosis level, anastomosis distance and angle were varied. A non-Newtonian computational fluid dynamics solver in OpenFOAM incorporated with resistance boundary conditions representing the coronary perfusion physiology was developed. The numerical accuracy is verified and results agreed well with a validated commercial cardiovascular flow solver and experiments. For segmental performance analysis, new coronary perfusion indices to quantify deviation from the healthy scenario were introduced.

RESULTS

The first simulation configuration set;-a CABG targeting two stenos sites on the left anterior descending artery (LAD), the LIMA graft was capable of 31 mL/min blood supply for all the parametric cases and uphold the healthy LAD perfusion in agreement with the clinical experience. In the second end-to-side anastomosed graft configuration set;-the radial artery graft anastomosed to LIMA, a maximum of 64 mL/min flow rate in LIMA was observed. However, except LAD, the obtuse marginal (OM) and second marginal artery (m2) suffered poor perfusion. In the first set, average wall shear stress (WSS) were in the range of 4 to 35 dyns/cm² for in LAD. Nevertheless, for second configuration sets the WSS values were higher as the LIMA could not supply enough blood to OM and m2.

CONCLUSION

The virtual surgical configurations have the potential to improve the quality of operation by providing quantitative surgical insight. The degree of stenosis is a critical factor in terms of coronary perfusion and WSS. The sequential anastomosis can be done safely if the anastomosis angle is less than 90 degrees regardless of degree of stenosis. The smaller proposed perfusion index value, O(0.04 - 0) × 10², enable us to quantify the post-op hemodynamic performance by comparing with the ideal healthy physiological flow.

In-Hospital Blood Pressure Variability: A Novel Prognostic Marker of Renal Function Decline and Cardiovascular Events in Patients with Coronary Artery Disease

INTRODUCTION

Several measures of blood pressure (BP) variability have been associated with kidney disease and cardiovascular events. Although BP is routinely measured during hospitalization in daily practice, the prognostic impact of in-hospital BP and its variability are uncertain.

METHODS

A total of 226 participants who underwent elective percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) were included. BP was measured by trained nurses during the 4-day hospitalization for PCI. BP variability was assessed by standard deviation (SD) and coefficient variation of systolic BP. Estimated glomerular filtration rate (eGFR) was calculated at baseline and follow-up (≥6 months). The cardiovascular end point was defined as a composite of cardiovascular death, acute coronary syndrome, stroke, heart failure hospitalization, and any coronary revascularization.

RESULTS

In-hospital BP was measured 9.5 ± 0.8 times. During a median follow-up period of 1.7 years, mean eGFR change was -1.7 mL/min/1.73 m2 per year, and 35 (15.5%) participants met the cardiovascular end point. Mean systolic BP and SD were negatively correlated with eGFR change. In the receiver operating characteristic curve analysis, SD of systolic BP predicted the cardiovascular end point (AUC 0.63, best cutoff value 14.2 mm Hg, p = 0.003). Kaplan-Meier analysis demonstrated a significantly higher incidence of the cardiovascular end point in patients with SD of systolic BP ≥14.2 mm Hg compared to their counterpart (p = 0.003). A multivariable analysis showed SD of systolic BP as an independent predictor for the cardiovascular end point. When assessed with coefficient variation, BP variability was similarly related to eGFR change and clinical outcomes.

CONCLUSION

Greater in-hospital BP variability was associated with renal function decline and cardiovascular events in patients with stable CAD.

Antihypertensive therapy and short-term blood pressure variability

BACKGROUND AND AIM

Blood pressure variability (BPV) is recognized as a prognostic contributor in hypertension. We aimed to assess differences in short-term BPV in treated hypertensive patients depending on the number, classes, combinations and individual compounds of the antihypertensive treatment.

METHODS

We selected 38 188 treated patients from the Spanish Ambulatory BP Monitoring (ABPM) Registry. SBP and DBP standard deviations (SD) from 24-h, daytime and night-time, weighted SD (WSD), and average real variability (ARV) were calculated through ABPM. They were compared (after adjustment for clinical confounders and BP) depending on the number of antihypertensive drugs, antihypertensive drug classes and compounds (in 13 765 patients on monotherapy), or combinations (in 12 716 patients treated with two drugs and 7888 treated with three drugs).

RESULTS

Systolic and diastolic BPV significantly increased in patients treated with multiple drugs with respect to monotherapy. Among drug classes, calcium channel blockers, especially amlodipine, and diuretics were associated with lower systolic BPV, including daytime and night-time SD, WSD and ARV, compared with beta blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Likewise, in patients treated with two-drug and three-drug combinations, those which included a calcium channel blocker showed lower BPV in comparison to those without such drug class.

CONCLUSION

Treatment with calcium channel blockers, especially amlodipine, and with diuretics is associated with slight, but significant lower values of short-term BPV in comparison to other major drug classes, both in monotherapy and in combination. These results could be helpful when considering BPV reduction as an additional treatment target.

Vasculo-Neuronal Coupling and Neurovascular Coupling at the Neurovascular Unit: Impact of Hypertension

Components of the neurovascular unit (NVU) establish dynamic crosstalk that regulates cerebral blood flow and maintain brain homeostasis. Here, we describe accumulating evidence for cellular elements of the NVU contributing to critical physiological processes such as cerebral autoregulation, neurovascular coupling, and vasculo-neuronal coupling. We discuss how alterations in the cellular mechanisms governing NVU homeostasis can lead to pathological changes in which vascular endothelial and smooth muscle cell, pericyte and astrocyte function may play a key role. Because hypertension is a modifiable risk factor for stroke and accelerated cognitive decline in aging, we focus on hypertension-associated changes on cerebral arteriole function and structure, and the molecular mechanisms through which these may contribute to cognitive decline. We gather recent emerging evidence concerning cognitive loss in hypertension and the link with vascular dementia and Alzheimer’s disease. Collectively, we summarize how vascular dysfunction, chronic hypoperfusion, oxidative stress, and inflammatory processes can uncouple communication at the NVU impairing cerebral perfusion and contributing to neurodegeneration.

Blood Pressure Variability during Angiography in Patients with Ischemic Stroke and Intracranial Artery Stenosis

Our aim was to investigate factors predicting blood pressure (BP) variability during diagnostic cerebral angiography and associations between BP variability and clinical outcomes in patients with acute and subacute ischemic stroke and intracranial artery stenosis. 114 patients with ischemic stroke and intracranial artery stenosis (stenosis rate >50%) were recruited. Patients who underwent cerebral angiography within 3 days and 3-14 days of disease onset are referred to be Group A and Group S, respectively. BP variability in Group A was defined as the coefficient of variance (CV) of BP. Univariate and multivariate regression analyses were used to identify predictors of CV of BP and associations between CV of BP and clinical outcomes at discharge. In Group A patients, advanced age was associated with increased CV of SBP and diastolic blood pressure (DBP), and antihypertensive use was associated with lower CV of SBP. Male was associated with lower CV of DBP. In Group S, higher CV of SBP was associated with hypertension and antihypertensive use. Males had lower CV of SBP than females. The calcium channel blocker was associated with lower CV of DBP. Higher scores of the Stroke Scale at admission were significantly associated with poor clinical outcomes for both groups, while BP variability was not. Factors associated with BP variability are significantly different between stroke patients undergoing angiography within 3 days vs. 3-14 days after disease onset. BP variability is not significantly associated with clinical outcomes at discharge.

Effect of visit-to-visit blood pressure variability on cardiovascular events in populations with different body mass indexes: a prospective cohort study

OBJECTIVE

This study was performed to explore the effects of visit-to-visit blood pressure variability (BPV) on cardiovascular events (CVEs) in people with various body mass indexes (BMIs).

DESIGN

Prospective cohort study.

SETTING

The average real variability of systolic blood pressure (ARV_SBP) was the indicator for visit-to-visit BPV. The participants were divided into three groups: normal weight, overweight and obesity. We further divided these groups into four subgroups based on the ARV_SBP. A Cox regression model was used to calculate the HRs of the ARV_SBP on CVEs in the same and different BMI groups. Additionally, a competitive risk model was used to calculate the HRs of the ARV_SBP on CVEs in the same BMI group.

PARTICIPANTS

In total, 41 043 individuals met the inclusion criteria (no historical CVEs or tumours, no incidence of CVEs or tumours and no death during the four examinations) and had complete systolic blood pressure and BMI data.

RESULTS

A total of 868 CVEs occurred. The cumulative incidence of CVEs increased as ARV_SBP rose in both the normal weight and overweight groups. In same BMI groups, the risk of CVEs significantly increased as ARV_SBP increased only in the normal weight group (highest quartiles of ARV_SBP: HR (95% CI) 2.20 (1.46-3.31)). In the different BMI groups, the risk of CVEs in the ARV_SBP subgroup in each BMI group was higher than that the least quintile of ARV_SBP in the normal weight group (highest quartiles of ARV_SBP in obesity: HR (95% CI) 2.28 (1.47-3.55)). The result of the competitive risk model did not change.

CONCLUSIONS

As BMI and ARV_SBP increase, the risk of CVEs increases. However, the risk of visit-to-visit BPV on CVEs varies in different BMI groups, especially in people of normal weight.

TRIAL REGISTRATION NUMBER

CHiCTR-TNC1100 1489.

Von Willebrand factor, its cleaving protease (ADAMTS13), and inflammation in young adults: The African-PREDICT study

BACKGROUND

The role of inflammation in the early development of vascular dysfunction remains complex. Interleukin-6 (IL-6) and C-reactive protein (CRP) can cause an acute imbalance in the von Willebrand factor (vWF)-ADAMTS13 interaction, indicating a possible link between markers of haemostasis and low-grade inflammation. To better understand these inter-relationships in the early phases of disease development, we investigated whether vWF and ADAMTS13 associate with the pro-inflammatory markers, IL-6 and CRP in healthy young adults. We considered the role of blood types, sex and race on these relationships.

METHODS

In healthy black and white men and women (n = 1113; 24 ± 5 years; no previous diagnosis or medication use for chronic diseases) we analysed von Willebrand factor antigen (vWF_ag), ADAMTS13, IL-6 and CRP, and grouped blood types as non-O (A, B and AB) and O. Covariates included socioeconomic status, age, estimated glomerular filtration rate, 24-hour systolic blood pressure, waist circumference, glucose, total cholesterol, platelet count, γ-glutamyl transferase and total energy expenditure.

RESULTS

In the total group, vWF_ag was highest in the third tertile of both IL-6 and CRP (p ≤ 0.014), while ADAMTS13 was lowest in the third compared to the first IL-6 tertile (p = 0.006). In multivariate regression, vWF_ag associated positively with IL-6 (Adj R² = 0.169; β = 0.123; p = 0.001) and CRP (Adj R² = 0.163; β=0.094; p = 0.019) in the total group, in the O blood group (all p ≤ 0.051) and white men (all p ≤ 0.035). ADAMTS13 associated negatively with IL-6 (Adj R² = 0.053; β = -0.154; p = 0.015) and CRP (Adj R² = 0.055; β = -0.177; p = 0.009), only in the O blood group.

CONCLUSIONS

Markers of haemostasis associated independently with low-grade inflammation in the O type blood group and white men. An interplay between the haemostatic and inflammatory systems may already exist in young healthy adults and is dependent on blood groups, sex and race. This extends our understanding on the role of inflammation in the early development of vascular dysfunction prior to cardiovascular compromise.

In-hospital day-by-day systolic blood pressure variability during rehabilitation: a marker of adverse outcome in secondary prevention after myocardial revascularization

OBJECTIVE

Although it is known that increased visit-to-visit or home day-by-day variability of blood pressure (BP), independently of its average value, results in an increased risk of cardiovascular events, the prognostic value of in-hospital day-by-day BP variability in secondary cardiovascular prevention has not yet been established.

METHODS

We studied 1440 consecutive cardiac patients during a cardiovascular rehabilitation program of about 12 days after coronary artery bypass graft (CABG) and/or valve surgery. We measured auscultatory BP at the patient bed in each rehabilitation day twice, in the morning and the afternoon. We correlated SBP variability assessed as standard deviation (SBP-SD) and coefficient of variation (SBP-CoV) of the daily measures with overall mortality, cardiovascular mortality and major adverse cardiocerebrovascular events (MACCEs) after a mean follow-up of 49 months by Cox hazard analysis.

RESULTS

In our patients (age 68 ± 11years, 61% hypertensive patients) the ranges of SBP-SD tertiles were: 4.1-9.1, 9.2-11.5 and 11.6-24.5 mmHg. Fifty-five percent of the patients underwent CABG, 33% underwent valve surgery, 12% both CABG and valve surgery. In CABG patients, the highest SBP-SD tertile showed the highest overall mortality, cardiovascular mortality and MACCEs (P < 0.01). Results remained significant after multivariate analysis adjusting for age, sex, mean SBP, BMI, hypertension, hyperlipidaemia, and diabetes. No association between SBP-SD and mortality or MACCEs was found in valve surgery patients.

CONCLUSION

In-hospital day-by-day SBP variability predicts mortality and MACCEs in CABG patients, possibly representing a target during rehabilitation and treatment in secondary cardiovascular prevention.

Relationship between saline infusion and blood pressure variability in non-critically patients with hypertension: A retrospective study

Saline is a commonly used intravenous solvent, however, its excessive infusion may increase drug-induced sodium intake. To investigate the effects of saline infusion on blood pressure variability (BPV) in patients with hypertension, a retrospective study was performed in 1010 patients with hypertension. The patients who received saline infusion before surgery for continuous 3 to 5 days were divided into 2 groups according to the saline infusion volume during the hospitalization, which are >500 mL per day group and <500 mL per day group. The overall incidence of abnormal BPV was 11.58%. As for the incidence of abnormal BPV in the <500 mL per day group with 698 patients was 9.17%, while that in the >500 mL per day group with 312 patients was as high as 16.99%. Additionally, >500 mL of daily saline infusion for continuous 3 to 5 days (P for trend = .004, odds ratio [OR] = 1.911, 95% confidence interval [CI] for OR 1.226-2.977), medical history of diabetes mellitus (P < .001, OR = 4.856, 95% CI for OR 3.118-7.563) and cardiovascular diseases (P < .001, OR = 2.498, 95% CI for OR 1.549-4.029) may be risk factors of abnormal BPV; while anti-hypertensive therapy with diuretics (P < .001, OR = 0.055, 95% CI for OR 0.024-0.125) may be the protective factor. Our study suggests that >500 mL of daily saline infusion for continuous 3 to 5 days may have disadvantages in the blood pressure control for hypertensive patients, especially for the patients with diabetes mellitus and cardiovascular diseases.

TRPC6 participates in the development of blood pressure variability increase in sino-aortic denervated rats

Increased blood pressure variability (BPV) has been proved to be associated with cardiovascular morbidity and mortality. It is of great significance to elucidate the mechanism of BPV increase. The cation channel transient receptor potential canonical 6 (TRPC6) is involved in a series of cardiovascular disease. Our experiment aimed to explore the role of TRPC6 in the development of BPV increase. Sino-aortic denervation (SAD) operation was applied to establish the model of BPV increase in rats. The BPV was presented as the standard deviation to the mean of systolic or diastolic blood pressure every 1 h during 12 h of the light period. SAD was performed in male Sprague Dawley (SD) rats at the age of 10 weeks. At 8 weeks after SAD operation, the hemodynamic parameters were determined non-invasively via a Rodent Blood Pressure Analysis System. The TRPC6 expressions in myocardial and thoracic aortic tissue was determined utilizing Western Blot, immunofluorescence and quantitative RT-PCR. The expression of TRPC3 was detected as well. To investigate whether TRPC6 was a causative factor of BPV increase in SAD rats, TRPC6 activator and inhibitor with three progressively increasing doses were intraperitoneally injected to the SAD rats. We found that SAD rats presented significant augmentation of systolic and diastolic BPV with no change of BP level and heart rate. The mRNA and protein expression levels of TRPC6 in myocardial and thoracic aortic tissue in SAD rats were substantially increased, but there was no obvious change in TRPC3 expression. The systolic and diastolic BPV increase were dose-dependently exacerbated after TRPC6 activation with GSK1702934A but were dose-dependently attenuated after TRPC6 inhibition with SAR7334. In Conclusion, the TRPC6 (but not TRPC3) expressions in myocardial and thoracic aortic tissue were substantially increased in SAD rats, and TRPC6 probably played an important role in the development of BPV elevation.

Effect of Visit-to-Visit Blood Pressure Variability on Cognitive and Functional Decline in Mild to Moderate Alzheimer's Disease

BACKGROUND

Visit-to-visit blood pressure (BP) variability (VVV) is increasingly recognized as a marker of cardiovascular risk. Although implicated in cognitive decline, few studies are currently available assessing its effects on established dementia.

OBJECTIVE

To investigate if VVV is associated with one-year rate of decline in measures of cognition and function in patients with mild to moderate Alzheimer's disease (AD) in the Doxycycline And Rifampicin for Alzheimer's Disease study.

METHODS

Patients were included if ≥3 BP readings were available (n = 392). VVV was defined using different approaches including the coefficient of variation (CV) in BP readings between visits. Outcomes included rates of decline in the Standardized Alzheimer's Disease Assessment Scale-Cognitive Subscale (SADAS-cog), Standardized MMSE, Clinical Dementia Rating Scale, the Quick Mild Cognitive Impairment screen and the Lawton-Brody activities of daily living (ADL) scale.

RESULTS

Half of the patients (196/392) had a ≥4-point decline in the SADAS-cog over one-year. Using this cut-off, there were no statistically significant associations between any measures of VVV, for systolic or diastolic BP, with and without adjustment for potential confounders including treatment allocation, history of hypertension and use of anti-hypertensive and cognitive enhancing medications. Multiple regression models examining the association between systolic BP CV by quartile and decline over one-year likewise showed no clinically significant effects, apart from a U-shaped pattern of ADL decline of borderline clinical significance.∥Conclusions: This observational study does not support recent research showing that VVV predicts cognitive decline in AD. Further studies are needed to clarify its effects on ADL in AD.

Comparison of Blood Pressure Variability Between Losartan and Amlodipine in Essential Hypertension (COMPAS-BPV)

BACKGROUND

Antihypertensive therapy using renin-angiotensin system blockers and calcium channel blockers to target blood pressure variability (BPV) has not yet been established. We aimed to compare the ability of losartan and amlodipine to lower BPV and systolic blood pressure (SBP) in essential hypertensive patients.

METHODS

Patients were randomly assigned either losartan 50 mg or amlodipine 5 mg. Medications were uptitrated and hydrochlorothiazide was added according to protocol for 6 months. The primary endpoint was the office visit-to-visit SD of SBP. The secondary endpoints included average real variability (ARV), office SBP, and home SBP.

RESULTS

The losartan group (n = 71) and amlodipine group (n = 73) finished the scheduled visits between April 2013 and May 2017. The office visit-to-visit SD of SBP was comparable between the losartan and amlodipine groups (11.0 ± 4.2 vs. 10.5 ± 3.8, P = 0.468). The office visit-to-visit ARV of SBP was significantly elevated in the losartan group (10.6 ± 4.3 vs. 9.1 ± 3.4, P = 0.02). The absolute SBP decrement from baseline to 6 months was similar between groups, although the office mean SBP at 6 months was higher in the losartan group (132.3 ± 12.9 vs. 127.5 ± 9.0 mm Hg, P = 0.011). In home blood pressure analysis, evening day-to-day BPV indexes (SD and ARV) were significantly higher in the losartan group at 6 months.

CONCLUSIONS

The lowering effect of the office visit-to-visit SD of SBP was similar between losartan and amlodipine. However, the losartan group showed a higher office visit-to-visit ARV of SBP and evening day-to-day home BPV indexes. Therefore, amlodipine may be better to lower BPV in essential hypertensive patients.

Blood Pressure Variability and Outcomes in End-Stage Renal Disease Patients on Dialysis: A Systematic Review and Meta-Analysis

Objective: Previous studies have suggested that blood pressure variability (BPV) is associated with an increased risk of mortality and cardiovascular events in patients on dialysis. However, the results are inconsistent. A comprehensive literature review was conducted to analyze the association between BPV and outcomes in patients on dialysis. Methods: Articles in Embase, Medline, and Web of Science from the date of inception through January 1, 2020, were identified. The outcomes were all-cause and cardiovascular mortality and cardiovascular events. The risk of bias was assessed using the Newcastle-Ottawa scale tool. Random effects models were used to pool the overall effect sizes. Two reviewers extracted the data independently. Meta-regression and subgroup analyses were performed to explore potential heterogeneity. Results: Fifteen eligible studies were included, and all enrolled hemodialysis recipients only. The overall risk of bias for the included studies was low. A 1-SD increase in systolic BPV was associated with higher risks of all-cause mortality (HR = 1.18; 95% CI 1.11–1.26, I2 = 53.8%), cardiovascular mortality (HR = 1.23; 95% CI 1.10–1.37, I2 = 57.2%), and cardiovascular events (HR = 1.27; 95% CI 1.07–1.51, I2 = 69.3%). Likewise, a 1-SD increase in diastolic BPV was associated with higher HR for all-cause and cardiovascular mortality (HR = 1.14; 95% CI 1.05–1.23, I2 = 0.0%, and HR = 1.14; 95% CI 0.94–1.38, I2 = 0.0%, respectively). Conclusions: A greater BPV is associated with higher risks of cardiovascular and mortality outcomes in patients on hemodialysis. Further research is required to determine whether BPV may be useful either as a marker enabling individualized treatment of cardiovascular risk or as a treatment target in its own right.

Blood pressure control in type 2 diabetes mellitus with arterial hypertension. The important ancillary role of SGLT2-inhibitors and GLP1-receptor agonists

Type 2 diabetes mellitus and arterial hypertension are major cardiovascular risks factors which shares metabolic and haemodynamic abnormalities as well as pathophysiological mechanisms. The simultaneous presence of diabetes and arterial hypertension increases the risk of left ventricular hypertrophy, congestive heart failure, and stroke, as compared to either condition alone. A number of guidelines recommend lifestyle measures such as salt restriction, weight reduction and ideal body weight mainteinance, regular physical activity and smoking cessation, together with moderation of alcohol consumption and high intake of vegetables and fruits, as the basis for reduction of blood pressure and prevention of CV diseases. Despite the availability of multiple drugs effective for hypertension, BP targets are reached in only 50 % of patients, with even fewer individuals with T2DM-achieving goals. It is established that new emerging classes of type 2 diabetes mellitus treatment, SGLT2 inhibitors and GLP1-receptor agonists, are efficacious on glucose control, and safe in reducing HbA1c significantly, without increasing hypoglycemic episodes. Furthermore, in recent years, many CVOT trials have demonstrated, using GLP1-RA or SGLT2-inihibitors compared to placebo (in combination with the usual diabetes medications) important benefits on reducing MACE (cardio-cerebral vascular events) in the diabetic population. In this hypothesis-driven review, we have examined the anti-hypertensive effects of these novel molecules of the two different classes, in the diabetic population, and suggest that they could have an interesting ancillary role in controlling blood pressure in type 2 diabetic patients.