Visit-to-visit blood pressure variability as a prognostic marker in patients with cardiovascular and cerebrovascular diseases--relationships and comparisons with vascular markers of atherosclerosis

Visit-to-Visit Systolic Blood Pressure Variability and Risk of Ischemic and Hemorrhagic Stroke

Background and Objectives: Systolic blood pressure (SBP) variability has been increasingly associated with cardiovascular outcomes, including stroke. This study aimed to evaluate the association between visit-to-visit SBP variability and the risk of ischemic and hemorrhagic stroke. Materials and Methods: A prospective cohort study was conducted on a set of 208 hypertensive patients over a period of three years, from August 2021 to September 2024, at the County Emergency Hospital "Pius Brinzeu", Timișoara. Patients included in the study were stroke-free. SBP variability was quantified as the standard deviation of SBP measurements obtained quarterly. Results: This study demonstrated that systolic blood pressure (SBP) variability serves as a robust predictor of stroke incidence, underscoring its important role in cerebrovascular risk. The study cohort had an average age of 65.3 ± 9.1 years, with 53.4% males and 46.6% females. Patients in the highest SBP variability group had a 1.21-fold increased risk (21%, p = 0.031) of ischemic stroke and a 1.73-fold increased risk (73%, p = 0.005) of hemorrhagic stroke compared to those in the lowest variability group, revealing that higher SBP variability is strongly associated with an increased risk of both ischemic and hemorrhagic strokes, with the relationship being particularly pronounced for hemorrhagic stroke. Patients exhibiting greater fluctuations in SBP experienced significantly earlier stroke events and reduced stroke-free survival. Moreover, mortality rates were notably higher among individuals with very high SBP variability, indicating its profound impact on long-term outcomes. Conclusions: Visit-to-visit SBP variability is a significant and independent predictor of both ischemic and hemorrhagic stroke, emphasizing the clinical importance of monitoring and managing blood pressure stability. Further research should explore interventions to mitigate SBP variability and its impact on cerebrovascular outcomes.

Blood pressure variability as a risk factor of recurrent paroxysmal atrial fibrillation after catheter ablation

Background

Blood pressure variability has been found to be a predictor of a stroke, heart failure, and ischemic heart disease that is independent of blood pressure control. This study used the variability independent of the mean (VIM) to evaluate the visit-to-visit blood pressure variability in patients previously undergoing catheter ablation (CA) of paroxysmal atrial fibrillation (PAF), and its relationship with AF recurrence was examined.

Method and Results

The subjects were 274 consecutive PAF patients who underwent CA at our hospital. Finally, 237 subjects were included in the analysis. The mean follow-up period was 29.6 months, during which 37 subjects had recurrences, and 200 did not. During the outpatient blood pressure examinations, the VIM of the systolic blood pressure (VIM SBP) was significantly higher in the recurrence group, suggesting that blood pressure variability is associated with recurrence. The Cox proportional hazards ratio of the VIM SBP was significantly higher in the recurrence (4.839) than no-recurrence group, even after an adjustment, suggesting that the extent of the variability was a risk factor of recurrence post-CA. In addition, the Cox proportional hazard ratio for recurrence was significantly lower in the patients taking dihydropyridine calcium channel blockers, suggesting that the risk of recurrence may differ depending on the type of antihypertensive drug.

Conclusions

Blood pressure variability may be a risk for AF recurrence after CA.

Long-term systolic blood pressure variability independent of mean blood pressure is associated with mortality and cardiovascular events: A systematic review and meta-analysis

The association between long-term systolic blood pressure variability (SBPV) and cardiovascular (CV) outcomes after being adjusted with mean blood pressure (BP) is questionable. This systematic review aims to evaluate the associations between mean BP adjusted long-term SBPV and CV outcomes. A systematic search was conducted on PubMed, Scopus, and Science Direct on January 4, 2023. A total of 9,944,254 subjects from 43 studies were included in this meta-analysis. Long-term SBPV increased the risk of all-cause mortality (HR 1.21 [95%CI 1.16-1.25], I2=100%), CV mortality (HR 1.10 [95%CI 1.07-11.4], I2 = 90%), MACE (HR 1.10 [1.07-1.13], I2 = 91%), cerebrovascular stroke (HR 1.22 [1.16-1.29], I2=100%), and myocardial infarction (HR 1.13 [95%CI (1.07-1.19)], I2=91%). European populations generally had higher risk compared to other continents. In conclusion, long-term SBPV is associated with all-cause mortality, CV mortality, MACE, MI, and stroke. Poor outcomes related to long-term SBPV seem more dominated by cerebrovascular than coronary events.

Visit-to-visit blood pressure variability and the risk of cardiovascular disease: a prospective cohort analysis

Large blood pressure (BP) variability contributed to subclinical brain disease thus may be implicated in the development of cardiovascular disease (CVD). This study included 64,810 CVD-free participants who attended the first two examinations from the Kailuan study to investigate the association of BP variation, considering its magnitude, direction, and time interval prior to CVD diagnosis, with the risk of CVD in Chinese population. Magnitude and directional BP variability was calculated as absolute BP difference or BP difference value divided by mean BP over 2 sequential visits, respectively. During a median follow-up of 10.91 years, a total of 4129 cases of CVD. A large SBP variability (the highest vs the lowest tertile) was associated with a higher risk of CVD (adjusted HR, 1.31; 95% CI, 1.22-1.41). The associations were stronger with longer time intervals, the hazard ratio (HR) with 95% confidence interval (CI) for CVD was 1.30 (95% CI, 1.20-1.39) at 1 years, 1.32 (1.18-1.40) at 3 years, and 1.34 (1.20-1.45) at 5 years. For directional SBP variability, rise in SBP was associated with an increased risk of CVD (HR, 6.17; 95% CI, 5.65-6.75), while fall in SBP was associated with a decreased risk of CVD (HR, 0.52; 95% CI, 0.46-0.59). Subgroup analysis showed the significant associations were only observed in men (Pint = 0.0010). Similar patterns were observed for DBP variability and CVD subtypes. The results indicated that a large SBP variation in rise direction was associated with an increased risk of incident CVD, especially in men.

The Effect of Blood Pressure Variability on Coronary Atherosclerosis Plaques

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

The association between blood pressure variability and hip or vertebral fracture risk: A population-based study

BACKGROUND

The present study evaluated the association between blood pressure variability and the risk of hip/vertebral fractures in middle aged and elderly patients.

METHODS

This was a retrospective observational study of patients attending family medicine outpatient clinics, recruited from 1st January 2000 to 31st December 2003 and were followed up until 31st December 2019. Standard deviation (SD), root mean square (RMS), coefficient of variation (CV) and a variability score (defined as the number of changes in blood pressure (diastolic and systolic) of 5 mm Hg or more) were used as measures of blood pressure variability. The primary outcome was a composite of new onset hip or vertebral fractures.

RESULTS

A total of 57,810 patients were included. Over a median follow-up of 5894 days (interquartile range: 3505-6487), 3285 patients (5.68%) developed new onset hip/vertebral fractures. The crude incidence rates were 4.95%, 5.31%, and 7.2% for diastolic blood pressure-CV and 5.0%, 5.28%, and 7.08% for systolic blood pressure-CV in the first, second, and third tertiles, respectively. Survival analysis demonstrated differences in hip/vertebral fracture amongst the tertiles of systolic and diastolic blood pressure variability (P < 0.0001).

CONCLUSIONS

Measures of blood pressure variability were significantly associated with incident hip/vertebral fractures. They can be incorporated into existing clinical scores to improve risk stratification.

Visit-to-visit office blood pressure variability combined with Framingham risk score to predict all-cause mortality: A post hoc analysis of the systolic blood pressure intervention trial

We aim to determine if visit‐to‐visit blood pressure variability (BPV) adds prognostic value for all‐cause mortality independently of the Framingham risk score (FRS) in the systolic blood pressure intervention trial (SPRINT). We defined BPV as variability independent of the mean (VIM) and the difference of maximum minus minimum (MMD) of the systolic blood pressure (SBP). Multivariable Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI). Based on FRS stratification, there were 1035, 2911, and 4050 participants in the low‐, intermediate‐, and high‐risk groups, respectively. During the trial, 230 deaths occurred since the 12th month with an average follow‐up of 2.5 years. In continuous analysis, 1‐SD increase of SBP VIM and MMD were significantly associated with all‐cause mortality (HR 1.18, 95% CI 1.05–1.32, p = .005; and HR 1.21, 95% CI 1.09–1.35, p < .001, respectively). In category analysis, the highest quintile of BPV compared with the lowest quintile had significantly higher risk of all‐cause mortality. Cross‐tabulation analysis showed that the 3rd tertile of SBP VIM in the high‐risk group had the highest HR of all‐cause mortality in total population (HR 4.99; 95% CI 1.57–15.90; p = .007), as well as in intensive‐therapy group (HR 7.48; 95% CI 1.01–55.45; p = .05) analyzed separately. Cross‐tabulation analysis of SBP MMD had the same pattern as VIM showed above. In conclusion, visit‐to‐visit BPV was an independent predictor of all‐cause mortality, when accounting for conventional risk factors or FRS. BPV combined with FRS conferred an increased risk for all‐cause mortality in the SPRINT trial.

Visit-to-Visit Blood Pressure Variability and Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

[Figure: see text].

Predictive value of visit-to-visit blood pressure variability for cardiovascular events in patients with coronary artery disease with and without diabetes mellitus

Background

High blood pressure is a major risk factor for cardiovascular disease. Visit-to-visit blood pressure variability (BPV) has recently been shown to predict cardiovascular outcomes. We investigated the predictive value of BPV for major adverse cardiovascular events (MACE) among patients with coronary artery disease (CAD), with and without type 2 diabetes mellitus (T2DM).

Methods

Patients with stable CAD were enrolled and monitored for new MACE. Visit-to-visit BPV was defined as the coefficient of variation (CV) of systolic and diastolic BP across clinic visits. Multivariable logistic regression analysis was performed to evaluate the association of BPV with MACE. Area under the receiver operating characteristic curve (AUC) was used to assess its predictive ability.

Results

Among 1140 Chinese patients with stable CAD, 192 (17%) experienced a new MACE. In multivariable analyses, the risk of MACE was significantly associated with CV of systolic BP (odds ratio [OR] for highest versus lowest quartile, 3.30; 95% CI 1.97–5.54), and diastolic BP (OR for highest versus lowest quartile, 2.39; 95% CI 1.39–4.11), after adjustment for variables of the risk factor model (age, gender, T2DM, hypertension, antihypertensive agents, number of BP measurements) and mean BP. The risk factor model had an AUC of 0.70 for prediction of MACE. Adding systolic/diastolic CV into the risk factor model with mean BP significantly increased the AUC to 0.73/0.72 (P = 0.002/0.007). In subgroup analyses, higher CV of systolic BP remained significantly associated with an increased risk for MACE in patients with and without T2DM, whereas the association of CV of diastolic BP with MACE was observed only in those without T2DM.

Conclusions

Visit-to-visit variability of systolic BP and of diastolic BP was an independent predictor of new MACE and provided incremental prognostic value beyond mean BP and conventional risk factors in patients with stable CAD. The association of BPV in CAD patients without T2DM with subsequent risk for MACE was stronger than in those with T2DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01280-z.

Within-visit SBP variability from childhood to adulthood and markers of cardiovascular end-organ damage in mid-life

BACKGROUND

Within-visit SBP variability is associated with age and SBP, but its long-term clinical significance is unknown. We examined the association between child, adult, and life-time within-visit SBP variability with markers of end-organ damage using data from a 31-year longitudinal study.

METHODS

Within-visit SBP variability was calculated as the standard deviation of three sitting SBP readings among up to 3010 participants aged 6-18 years (childhood) who were re-measured up to seven times to mid-adulthood. Markers of cardiovascular end-organ damage in adulthood were carotid intima--media thickness, brachial flow-mediated dilatation, carotid distensibility, pulse wave velocity, left ventricular mass index, carotid plaque, and coronary artery calcification.

RESULTS

The mean (standard deviation) cumulative within-visit SBP variability was 2.7 (1.5) mmHg in childhood, 3.9 (1.9) mmHg in adulthood and 3.7 (1.5) mmHg across the observed life-time. Childhood within-visit SBP variability was not correlated with its subsequent values measured from 3 to 31 years later. With adjustment for age, sex, cumulative SBP, BMI and serum lipids, neither child, adult, or life-time cumulative within-visit SBP variability associated with markers of cardiovascular end-organ damage. However, higher child, adult, and life-time cumulative SBP significantly associated with higher carotid intima--media thickness, higher pulse wave velocity, lower brachial flow-mediated dilatation, lower carotid distensibility in adulthood.

CONCLUSION

Within-visit SBP variability from childhood to adulthood does not provide additional predictive utility over SBP over the same period of the life course.

Visit-to-visit blood pressure variability and sleep architecture

Visit-to-visit blood pressure (BP) variability (BPV) is an independent risk factor of cardiovascular disease (CVD). Sleep architecture characterizes the distribution of different stages of sleep and may be important in CVD development. We examined the association between visit-to-visit BPV and sleep architecture using in-lab polysomnographic data from 3,565 patients referred to an academic sleep center. BPV was calculated using the intra-individual coefficient of variation of BP measures collected 12 months before the sleep study. We conducted multiple linear regression analyses to assess the association of systolic and diastolic BPV with sleep architecture-rapid eye movement (REM) and non-rapid eye movement (NREM) sleep duration. Our results show that systolic BPV was inversely associated with REM sleep duration (p = .058). When patients were divided into tertile groups based on their BPV, those in the third tertile (highest variability) spent 2.7 fewer minutes in REM sleep than those in the first tertile (lowest variability, p = .032), after adjusting for covariates. We did not find an association of systolic BPV with other measures of sleep architecture. Diastolic BPV was not associated with sleep architecture either. In summary, our study showed that greater systolic BPV was associated with lower REM sleep duration. Future investigation is warranted to clarify the directionality, mechanism, and therapeutic implications.

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.

Resveratrol Treatment Is Associated with Lipid Regulation and Inhibition of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in Rabbits Fed a High-Fat Diet

The effects of resveratrol on various conditions have been widely studied previously. This paper aimed to investigate the influence of resveratrol on atherosclerosis (AS). Twenty-four New Zealand male rabbits were randomly and equally assigned to the normal diet group (NDG), fat diet group (FDG), and fat diet with resveratrol group (80 mg/kg/d, RFG). Biochemical indicators from blood samples were analyzed at baseline and 3 months to investigate the effects of resveratrol on blood lipid, lipoprotein-associated phospholipase A2 (Lp-PLA2), liver, and renal function. The indicators including alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine (CREA), triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and Lp-PLA2. At 3 months, arteries were stained with hematoxylin and eosin to study the influence of resveratrol on the aortic intima, smooth muscle layer, and the intima/media ratio. Comparisons of weight, ALT, AST, CREA, TG, TC, HDL-C, LDL-C, and Lp-PLA2 among the three groups showed no significant difference at baseline. However, at the end of 3 months, significant differences were observed in AST, CREA, TC, HDL-C, LDL-C, and Lp-PLA2 between the three groups (P < 0.05). In pairwise comparison, CREA, TC, LDL-C, and Lp-PLA2 had significant differences between any two groups (P < 0.05). In addition, there were significant differences in the AST and HDL-C levels between RFG and NDG groups (P < 0.05). Meanwhile, the HDL-C levels were also significantly different between the FDG and NDG groups (P < 0.01). The histologic analysis also showed that the thickness of the aortic intima and the ratio of the intima and aortic tunica media (P < 0.05) significantly decreased in RFG compared to FDG. Resveratrol may have an antiatherosclerosis effect on a rabbit model of AS.

Prognostic importance of visit-to-visit blood pressure variability for micro- and macrovascular outcomes in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. We aimed to evaluate it in a prospective long-term follow-up study with 632 individuals with type 2 diabetes.

METHODS

BP-VVV parameters (systolic and diastolic standard deviations [SD] and variation coefficients) were measured during the first 24-months. Multivariate Cox analysis, adjusted for risk factors and mean BP levels, examined the associations between BP-VVV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications (total cardiovascular events [CVEs], major adverse CVEs [MACE] and cardiovascular and all-cause mortality). Improvement in risk discrimination was assessed by the C-statistic and integrated discrimination improvement (IDI) index.

RESULTS

Over a median follow-up of 11.3 years, 162 patients had a CVE (132 MACE), and 212 patients died (95 from cardiovascular diseases); 153 newly-developed or worsened diabetic retinopathy, 193 achieved the renal composite outcome (121 newly-developed microalbuminuria and 95 deteriorated renal function), and 171 newly-developed or worsened peripheral neuropathy. Systolic BP-VVV was an independent predictor of MACE (hazard ratio: 1.25, 95% CI 1.03-1.51 for a 1-SD increase in 24-month SD), but not of total CVEs, cardiovascular and all-cause mortality, and of any microvascular outcome. However, no BP-VVV parameter significantly improved cardiovascular risk discrimination (increase in C-statistic 0.001, relative IDI 0.9%).

CONCLUSIONS

Systolic BP-VVV was an independent predictor of MACE, but it did not improve cardiovascular risk stratification. The goal of anti-hypertensive treatment in patients with type 2 diabetes shall remain in controlling mean BP levels, not on decreasing their visit-to-visit variability.

Association between different methods of assessing blood pressure variability and incident cardiovascular disease, cardiovascular mortality and all-cause mortality: a systematic review

BACKGROUND

Blood pressure variability (BPV) is a possible risk factor for adverse cardiovascular outcomes and mortality. There is uncertainty as to whether BPV is related to differences in populations studied, measurement methods or both. We systematically reviewed the evidence for different methods to assess blood pressure variability (BPV) and their association with future cardiovascular events, cardiovascular mortality and all-cause mortality.

METHODS

Literature databases were searched to June 2019. Observational studies were eligible if they measured short-term BPV, defined as variability in blood pressure measurements acquired either over a 24-hour period or several days. Data were extracted on method of BPV and reported association (or not) on future cardiovascular events, cardiovascular mortality and all-cause mortality. Methodological quality was assessed using the CASP observational study tool and data narratively synthesised.

RESULTS

Sixty-one studies including 3,333,801 individuals were eligible. BPV has been assessed by various methods including ambulatory and home-based BP monitors assessing 24-hour, "day-by-day" and "week-to-week" variability. There was moderate quality evidence of an association between BPV and cardiovascular events (43 studies analysed) or all-cause mortality (26 studies analysed) irrespective of the measurement method in the short- to longer-term. There was moderate quality evidence reporting inconsistent findings on the potential association between cardiovascular mortality, irrespective of methods of BPV assessment (17 studies analysed).

CONCLUSION

An association between BPV, cardiovascular mortality and cardiovascular events and/or all-cause mortality were reported by the majority of studies irrespective of method of measurement. Direct comparisons between studies and reporting of pooled effect sizes were not possible.

Associations between systemic blood pressure parameters and intraplaque hemorrhage in symptomatic intracranial atherosclerosis: a high-resolution MRI-based study

The associations between blood pressure parameters and intracranial vulnerable plaques have not been fully elucidated. The purpose of this study was to investigate the associations between systemic blood pressure parameters, as well as their variability, and intraplaque hemorrhage (IPH) in stroke patients with intracranial atherosclerosis. We retrospectively analyzed the high-resolution MRI data set of intracranial atherosclerosis from a comprehensive stroke center. The atherosclerotic plaque burden and presence of IPH in each vessel were obtained from vessel wall imaging. Blood pressure parameters in the first week of admission were used. The systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and their variability (standard deviation [SD] and coefficient of variation [CV]) were compared between the IPH (+) and IPH (-) groups. Logistic regression analysis was used to demonstrate the correlations between different blood pressure parameters and IPH. The results indicated that SBP and PP were associated with multiple plaques and severe luminal stenosis after adjusting for confounders, with OR = 1.071, 95% CI: (1.044-1.098) and OR = 1.039, 95% CI: (1.019-1.060) for SBP and OR = 1.058, 95% CI: (1.027-1.089) and OR = 1.044, 95% CI: (1.019-1.070) for PP, respectively. SBP was associated with IPH after adjusting for cardiovascular risk factors, with OR = 1.021, 95% CI: (1.003-1.038), but not after correcting for plaque burden, with OR = 1.014, 95% CI: (0.996-1.032). No associations between blood pressure variability and atherosclerotic plaque burden or IPH were detected in this study. In conclusion, SBP is associated with IPH after adjusting for cardiovascular risk factors but not after further correction for atherosclerotic plaque burden. The association between blood pressure variability and intracranial atherosclerosis requires further study.

Visit-to-visit Blood Pressure Variability and Arterial Stiffness: Which Came First: The Chicken or the Egg?

Earlier studies have shown that visit-to-visit blood pressure (BP) variability (VVV) served as a significant independent risk factor of stroke, specifically, in the high-risk elderly of cardiovascular disease (CVD). Although the mechanism is not clearly understood, arterial remodeling such as carotid artery, coronary artery and large aortic artery would be a strong moderator in the relationship between VVV and CVD incidence. Recent studies have provided evidence that VVV predicted the progression of arterial stiffness. While the class of antihypertensive agents is suggested to be an important determinant of VVV, long-acting calcium channel blockers use (CCBs) is associated with the reduction of VVV, and thus, is suggested to decrease the arterial stiffness. Specifically, the relationship between VVV and coronary arterial remodeling has never been reviewed until now. This article summarizes the recent literature on these topics. In the elderly hypertensives, strict BP control using CCBs could play a pivotal role in suppressing arterial stiffening via VVV reduction.

Visit-to-visit Systolic Blood Pressure Variability and Stroke Risk: A Systematic Review and Meta-analysis

Visit-to-visit variability in systolic blood pressure (SBP) may have an important additional role in increasing the risk of vascular complications, including stroke. We conducted a meta-analysis to assess the relationship between visit-to-visit SBP variability (SBPV) and stroke risk. PubMed, EMBASE, and the Cochrane library databases were searched for cohort studies with data on visit-to-visit SBPV and stroke risk. Studies that reported adjusted relative risks (RRs) with 95% CIs of stroke associated with SBPV were included. Fourteen cohort studies met the inclusion criteria and were included in our meta-analysis. After adjustment for age, sex, and existing vascular risk factors, the analysis showed that the risk of stroke in patients with SBPV was significantly increased compared with patients with a small baseline SBPV [SD (RR=1.20, 95% CI=(1.07-1.35), P=0.0005), CV (RR=1.12, 95% CI=(1.00-1.26), P=0.008)]. In addition, follow-up variations of more than 5 years were associated with a higher risk of stroke than those of less than 5 years [RR=1.08, 95% CI=(1.04-1.11)]. Visit-to-visit SBPV was associated with an increased risk of stroke, especially in terms of the time of variation. Taken together, SBPV data may be useful as a preventative diagnostic method in the management of stroke.

Association of Acute Increases in Plasma Creatinine after Renin-Angiotensin Blockade with Subsequent Outcomes

BACKGROUND AND OBJECTIVES

Data from observational and interventional studies provide discordant results regarding the relationship between creatinine increase after renin-angiotensin system inhibition (RASi) and adverse outcomes. We compared health outcomes among patients with different categories of increase in creatinine upon initiation of RASi in a large population-based cohort.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a retrospective analysis of the Stockholm CREAtinine Measurements database, which contains complete information on diagnoses, medication dispensation claims, and laboratory test results for all Stockholm citizens accessing health care. Included were 31,951 adults initiating RASi during 2007-2011 with available pre- and postinitiation creatinine monitoring. Multivariable Cox regression was used to compare mortality, cardiovascular and ESKD events among individuals with different ranges of creatinine increases within 2 months after starting treatment.

RESULTS

In a median follow-up of 3.5 years, acute increases in creatinine were associated with mortality (3202 events) in a graded manner: compared with creatinine increases <10%, a 10%-19% increase showed an adjusted hazard ratio (HR) of 1.15 (95% confidence interval [95% CI], 1.05 to 1.27); HR 1.22 (95% CI, 1.07 to 1.40) for 20%-29%; HR 1.55 (95% CI, 1.36 to 1.77) for ≥30%. Similar graded associations were present for heart failure (2275 events, P<0.001) and ESKD (52 events; P<0.001), and, less consistently, myocardial infarction (842 events, P=0.25). Results were robust across subgroups, among continuing users, when patients with decreases in creatinine were excluded from the reference group, and after accounting for death as a competing risk.

CONCLUSIONS

Among real-world monitored adults, increases in creatinine (>10%) after initiation of RASi are associated with worse health outcomes. These results do not address the issue of discontinuation of RASi when plasma creatinine increases but do suggest that patients with increases in creatinine have higher subsequent risk of cardiovascular and kidney outcomes.

Visit-to-visit blood pressure variability and hip fracture risk in older persons

We investigated the association between blood pressure variability measured by the coefficient of variation (CV) of blood pressure and hip fracture in older persons with diabetes. After excluding patients with acute complications and comorbidities, a positive association with similar magnitude of strength was found between BP variability and hip fracture, compared with that in the original analysis.

INTRODUCTION

Hypertension is a risk factor of osteoporosis and hip fracture, but studies have yet to investigate whether blood pressure variability measured by the CV of blood pressure can predict hip fracture in older persons with diabetes.

METHODS

We conducted a retrospective cohort study on 21,160 patients who suffered from type 2 diabetes (age ≥ 50 years) and participated in the National Diabetes Care Management Program in Taiwan. The patients' 1-year variability in systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the baseline and subsequent hip fracture incidence for 8.2 years were analyzed.

RESULTS

There were 937 recorded incident hip fractures. SBP-CV and DBP-CV were classified based on their tertiles. After multivariate adjustment was conducted, SBP-CV found to be a predictor of hip fracture, and its hazard ratio was 1.18 (95% CI 1.00-1.40) for the third tertile compared with the first tertile.

CONCLUSIONS

Our study suggests SBP stability is a predictor for hip fracture incidence in older persons with type 2 diabetes.

Prognostic impact of systolic blood pressure variability in people with diabetes

Objective

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

Methods

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

Results

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

Conclusions

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

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

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

Visit-to-visit variability of systolic blood pressure predicts all-cause mortality in patients received percutaneous coronary intervention with drug-eluting stents

Blood pressure (BP) and its variability are associated with atherosclerotic disease and cardiovascular events. The prognostic implications of outpatient clinic visit-to-visit blood pressure variability (BPV) are unknown in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). A total of 1,463 patients undergoing PCI with DES were consecutively enrolled from January 2009 to December 2013. We analyzed the 1,234 patients, who measured clinic BP more than three times during the first year after PCI. The BPV is determined by standard deviation of systolic and diastolic BP, and coefficient of variation. Median follow-up duration was 905 days (interquartile range 529-1,310 days). All patients were divided into two groups according to the coefficient of variation of systolic BP (CVSBP); high CVSBP group (> 8.78, n = 617) and low CVSBP group (≤ 8.78, n = 617). High CVSBP group had significantly higher all-cause mortality (7.9% versus 3.1%, p < 0.001) and composite of all-cause mortality, myocardial infarction, and stroke (13.1% versus 6.2%, p < 0.001). In multivariate logistic regression analysis for prediction of all-cause mortality, and composite of all-cause mortality, myocardial infarction, and stroke after PCI with DES, hazard ratios of high CVSBP group were 2.441 (95% of confidence interval 1.042-5.718, p = 0.040), and 1.980 (95% of confidence interval 1.125-3.485, p = 0.018). The higher visit-to-visit BPV is associated higher mortality in patients undergoing PCI with DES. The clinic measured visit-to-visit BPV may serve as a predictor of all-cause mortality after PCI with DES.

Visit-to-visit blood pressure variability is a risk factor for all-cause mortality and cardiovascular disease: a systematic review and meta-analysis

OBJECTIVE

Clinical cohort studies have reported that visit-to-visit variability (VVV) of blood pressure (BP) is associated with cardiovascular disease (CVD) or mortality. However, the results were not consistent in all studies. The current study is, therefore, aimed to conduct a systematic review and meta-analysis to determine the association between VVV of BP and CVD and all-cause mortality.

METHOD

PubMed and EMBASE were searched through 18 May 2014, using the following terms: VVV, BP, CVD, coronary heart disease (CHD), myocardial ischemia, stroke, and mortality. Overall, 84 records were identified, and 23 publications were enrolled into the current study. Data were extracted from selected publications, and meta-analysis was performed using a random effect model.

RESULT

VVV of SBP was significantly associated with outcomes of all-cause mortality with the relative risk (RR) and 95% confidence interval (CI) 1.14 (1.09, 1.18), CVD incidence (RR = 1.12, 95% CI: 1.05, 1.09), CVD mortality (RR = 1.18, 95% CI: 1.09, 1.28), CHD incidence (RR = 1.12, 95% CI: 1.06, 1.19), and stroke incidence (RR = 1.34, 95% CI: 1.11, 1.61).

CONCLUSION

In summary, among the wide heterogenetic population, modest associations between VVV of SBP and all-cause mortality, CVD incidence, CVD mortality, CHD incidence, and stroke incidence were found. Findings of the current study suggested that standardized approaches of monitoring VVV in the high-risk population, including patients with cardiac infarction, diabetes, stroke, and patients with chronic kidney disease or in dialysis, are necessary in designing a prospective clinical study on the association of VVV and patients' prognosis.

Impact of Visit-to-Visit Variability in Systolic Blood Pressure on Cardiovascular Outcomes in Korean National Health Insurance Service-National Sample Cohort

BACKGROUND

Despite an association between visit-to-visit blood pressure (BP) variability (VV-BPV) and cardiovascular (CV) outcomes, many studies performed during the past 4 years have shown conflicting results. This study investigated the impact of VV-BPV on CV outcomes in the Korean National Health Insurance Service (NHIS) database-National Sample Cohort.

METHODS

From the 2002 Korean NHIS database (n = 47,851,928), sample subjects with 3 or more BP measurements (n = 51,811) were divided into 2 groups according to a 10 mm Hg cutoff in the SD of systolic BP (SD-SBP). The CV outcomes of these groups were compared by sensitivity analyses using various sampling methods.

RESULTS

Irrespective of sampling method, subjects with SD-SBPs ≥10 mm Hg had higher rates of CV events or death, nonfatal myocardial infarction (MI) or stroke, and total mortality, but were not associated with CV mortality. The hazard ratios for CV events or death, nonfatal MI or stroke, CV mortality, and total mortality were 1.43 (95% confidence interval [CI], 1.25-1.63, P < 0.01), 1.45 (95% CI, 1.27-1.65, P < 0.01), 1.32 (95% CI, 0.89-1.94, P = 0.17), and 1.18 (95% CI, 1.01-1.38, P = 0.04), respectively.

CONCLUSIONS

Increased VV-BPV was an independent risk factor for future CV outcomes, independent of mean BP status, even in normotensive subjects and in all subgroups, except females. Similar VV-BPV values in the sensitivity analyses suggest VV-BPV is a reproducible phenomenon, reflecting the various types of intrinsic physiologic properties.

China Stroke Primary Prevention Trial: Visit-to-Visit Systolic Blood Pressure Variability Is an Independent Predictor of Primary Stroke in Hypertensive Patients

BACKGROUND

The optimal range of blood pressure variability remains unclear. We aimed to stratify the degree of risk of stroke based on visit-to-visit systolic blood pressure (SBP) variability in a large Chinese hypertensive population in 32 communities.

METHODS AND RESULTS

We retrospectively analyzed the data of 20 702 hypertensive patients from the China Stroke Primary Prevention Trial. The participants were randomized into 2 treatment groups to receive either enalapril or enalapril plus folic acid. Their blood pressures were measured every 3 months. The outcome was the first stroke. Three parameters of SBP variability were calculated: standard deviation, coefficient of variation, and average real variability. The records of first 4, 6, 8, 10 and 12 visits at which SBP was measured were used to calculate SBP variability and to predict subsequent stroke risk in adjusted Cox regression models. After median follow-up of 4.5 years, 597 patients had experienced stroke. Visit-to-visit SBP variability was an independent predictor of subsequent stroke (eg, the hazard ratio for the highest quintile of average real variability [22.67-61.07 mm Hg] over 6 visits was 1.55, 95% CI 1.07-2.25, P=0.021), independent of mean SBP over the follow-up period. Its value was more predictive when more blood pressure records were used.

CONCLUSIONS

Visit-to-visit SBP variability is an independent predictor of primary stroke in Chinese hypertensive patients. This predictive value depends on the number of blood pressure measurements used to calculate variability but is independent of mean SBP.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00794885.

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

OBJECTIVE

 To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality.

DATA SOURCES

 Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

 Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation.

RESULTS

 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively).

CONCLUSIONS

 Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date.

SYSTEMATIC REVIEW REGISTRATION

 PROSPERO CRD42014015695.

Blood pressure (BP) assessment-from BP level to BP variability

The assessment of blood pressure (BP) can be challenging in children, especially in very young individuals, due to their variable body size and lack of cooperation. In the absence of data relating BP with cardiovascular outcomes in children, there is a need to convert absolute BP values (in mmHg) into age-, gender- and height appropriate BP percentiles or Z-scores in order to compare a patient's BP with the BP of healthy children of the same age, but also of children of different ages. Traditionally, the interpretation of BP has been based mainly on the assessment of the BP level obtained by office, home or 24-h BP monitoring. Recent studies suggest that it is not only BP level (i.e. average BP) but also BP variability that is clinically important for the development of target organ damage, including the progression of chronic kidney disease. In this review we describe current methods to evaluate of BP level, outline available methods for BP variability assessment and discuss the clinical consequences of BP variability, including its potential role in the management of hypertension.

Obstructive Sleep Apnea as Possible Causal Factor for Visit-to-Visit Blood Pressure Variability

BACKGROUND

Recent studies have shown that visit-to-visit blood pressure variability (BPV) is an independent risk factor for cardiovascular disease. However, it has not been clarified whether obstructive sleep apnea (OSA) is associated with visit-to-visit BPV.

METHODS AND RESULTS

The 56 subjects with OSA and 26 control subjects without OSA were examined. Office BP was measured on 5 separate consecutive occasions prior to a polysomnography examination. The visit-to-visit BPV was expressed as the standard deviation and the coefficient of variation of the 5 systolic BP measurements. In subjects with an apnea-hypopnea index (AHI) of more than 20 episodes per hour, the visit-to-visit BPV was also measured after the start of continuous positive airway pressure (CPAP) therapy. Overall, the AHI positively correlated with the standard deviation and the coefficient of variation of systolic BP. In a multivariate analysis, the plasma noradrenaline level and the AHI were independently and positively correlated with the standard deviation and the coefficient of variation of the systolic BP. Among the patients who underwent CPAP therapy, good adherence with CPAP therapy significantly reduced the visit-to-visit BPV.

CONCLUSIONS

OSA is associated with abnormal visit-to-visit BPV and sympathetic activation seems to be related in some way. (Circ J 2016; 80: 1787-1794).

Visit-to-Visit Variability of Systolic Blood Pressure and Cardiovascular Disease

Visit-to-visit variability of blood pressure (VVV of BP) is gaining interest as a prognostic marker for stroke, cardiovascular disease, and all-cause mortality. In this review, we discuss different metrics used to define VVV of BP, explore the potential sources of this phenomenon including patient characteristics and antihypertensive medication classes, and discuss recent evidence of its relation with cardiovascular outcomes. Current evidence relies on secondary analyses of clinical trials or on observational studies, none of which was designed to examine VVV of BP specifically. More research is required to develop standardized definitions of VVV of BP, to confirm the value of VVV as a prognostic indicator, and to ascertain whether efforts to reduce VVV of BP in addition to mean BP will improve outcomes.

Cerebral Small Vessel Disease and Arterial Stiffness: Tsunami Effect in the Brain?

BACKGROUND

Cerebral small vessel diseases, including silent lacunar infarcts, white matter hyperintensities, and microbleeds, pose a risk for cerebrovascular disease, cognitive impairment, and the geriatric syndrome via effects on arterial stiffness. However, the vascular, physiological, and metabolic roles of arterial stiffness in cerebral small vessel diseases remain unclear.

SUMMARY

Arterial stiffness can be assessed using various indicators such as the ankle-brachial index, pulse wave velocity, cardio-ankle vascular index, and augmentation index. Arterial stiffness is independently associated with all components of cerebral small vessel disease including silent lacunar infarcts, white matter hyperintensities, and microbleeds, although there are some methodological differences between the various surrogate markers. Evidence of arterial stiffness indicates microvessel arteriosclerosis presenting with vascular endothelial dysfunction. Further, vascular narrowing due to atherosclerosis and vascular stiffness due to lipohyalinosis can accelerate the pulse waves. This hemodynamic stress, pulsatile pressure, or blood pressure variability can cause a 'tsunami effect' towards the cerebral parenchyma and lead to cerebral small vessel disease. Previous studies have shown that silent lacunar infarcts and white matter hyperintensities are strongly associated with arterial stiffness. However, the association between microbleeds and arterial stiffness remains controversial, as there are two vessel mechanisms related to microbleeds: cerebral amyloid angiopathy and hypertensive small vessel disease.

KEY MESSAGES

Cerebral small vessel disease with associated arterial stiffness is a risk factor for silent cerebral lesions, stroke, and cognitive impairment. Improvement of the living environment, management of risk factors, and innovation and development of novel drugs that improve arterial stiffness may suppress the progression of cerebral small vessel disease, and may reduce the risk for stroke and dementia.

Medication adherence and visit-to-visit variability of systolic blood pressure in African Americans with chronic kidney disease in the AASK trial

Lower adherence to antihypertensive medications may increase visit-to-visit variability of blood pressure (VVV of BP), a risk factor for cardiovascular events and death. We used data from the African American Study of Kidney Disease and Hypertension (AASK) trial to examine whether lower medication adherence is associated with higher systolic VVV of BP in African Americans with hypertensive chronic kidney disease (CKD). Determinants of VVV of BP were also explored. AASK participants (n=988) were categorized by self-report or pill count as having perfect (100%), moderately high (75-99%), moderately low (50-74%) or low (<50%) proportion of study visits with high medication adherence over a 1-year follow-up period. We used multinomial logistic regression to examine determinants of medication adherence, and multivariable-adjusted linear regression to examine the association between medication adherence and systolic VVV of BP, defined as the coefficient of variation or the average real variability (ARV). Participants with lower self-reported adherence were generally younger and had a higher prevalence of comorbid conditions. Compared with perfect adherence, moderately high, moderately low and low adherence was associated with 0.65% (±0.31%), 0.99% (±0.31%) and 1.29% (±0.32%) higher systolic VVV of BP (defined as the coefficient of variation) in fully adjusted models. Results were qualitatively similar when using ARV or when using pill counts as the measure of adherence. Lower medication adherence is associated with higher systolic VVV of BP in African Americans with hypertensive CKD; efforts to improve medication adherence in this population may reduce systolic VVV of BP.

Mediterranean-style diet is associated with reduced blood pressure variability and subsequent stroke risk in patients with coronary artery disease

BACKGROUND AND PURPOSE

The Mediterranean-style diet is widely advocated for the prevention of cardiovascular diseases (CVD). Meanwhile, blood pressure variability (BPV) is a novel risk factor for CVD. It is unknown whether dietary pattern plays a role in modulating BPV.

METHODS

We prospectively followed-up 274 consecutive patients with stable coronary artery disease (CAD). The Mediterranean diet score (MDS) was derived for all individuals upon recruitment, blood pressure (BP) was measured during each subsequent clinic visit and the visit-to-visit BPV was calculated. The occurrence of major adverse cardiovascular events (MACEs) and all-cause mortality was monitored.

RESULTS

After a mean follow-up of 77±12 months, 16.1% of the study population developed MACEs. About 11.3% died from all causes. Patients who developed MACEs or all-cause mortality had a greater systolic BPV compared to those who did not develop an adverse event. Patients who developed a MACE had a lower MDS and further analysis revealed those who developed a stroke had a lower MDS compared with those who did not develop a stroke, but there were no significant differences in MDS between CAD patients with or without subsequent acute coronary syndrome, cardiovascular, or all-cause mortality. After adjusting for confounding variables, a high MDS was an independent predictor for low systolic BPV (B -0.74, 95% confidence interval -1.27 to -0.21, P < 0.01) and was noted to be protective against subsequent development of stroke (hazards ratio 0.48, 95% confidence interval 0.24 to 0.94, P = 0.03).

CONCLUSIONS

Among patients with CAD, a higher MDS is associated with a lower visit-to-visit BPV and with lower stroke risk.