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

Impact of seasonal blood pressure changes on visit-to-visit blood pressure variability and related cardiovascular outcomes

BACKGROUND

Visit-to-visit blood pressure (BP) variability associates with an increased risk of cardiovascular events. We investigated the role of seasonal BP modifications on the magnitude of BP variability and its impact on cardiovascular risk.

METHODS

In 25 390 patients included in the ONTARGET and TRANSCEND trials, the on-treatment systolic (S) BP values obtained by five visits during the first two years of the trials were grouped according to the month in which they were obtained. SBP differences between winter and summer months were calculated for BP variability quintiles (Qs), as quantified by the coefficient of variation (CV) of on-treatment mean SBP from the five visits. The relationship of BP variability with the risk of cardiovascular events and mortality was assessed by the Cox regression model.

RESULTS

SBP was approximately 4 mmHg lower in summer than in winter regardless of confounders. Winter/summer SBP differences contributed significantly to each SBP-CV quintile. Increase of SBP-CV from Q1 to Q5 was associated with a progressive increase in the adjusted hazard ratio (HR) of the primary endpoint of the trials, i.e. morbid and fatal cardiovascular events. This association was even stronger after removal of the effect of seasonality from the calculation of SBP-CV. A similar trend was observed for secondary endpoints.

CONCLUSIONS

Winter/summer SBP differences significantly contribute to visit-to-visit BP variability. However, this contribution does not participate in the adverse prognostic significance of visit-to-visit BP variations, which seems to be more evident after removal of the BP effects of seasonality from visit-to-visit BP variations.

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.

Effects of metabolic parameters' variability on cardiovascular outcomes in diabetic patients

BACKGROUND

Metabolic abnormalities such as dyslipidemia, glucose and high blood pressure are common in diabetic patients. Visit-to-visit variabilities in these measures have been reported as potential residual cardiovascular risk factors. However, the relationship between these variabilities and their effects on cardiovascular prognosis have not been studied.

METHODS

A total of 22,310 diabetic patients with ≥ 3 measurements of systolic blood pressure (SBP), blood glucose, total cholesterol (TC), and triglyceride (TG) levels during a minimum of three years at three tertiary general hospitals were selected. They were divided into high/low variability groups for each variable based on the coefficient of variation (CV) values. The primary outcome was the incidence of major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, and stroke.

RESULTS

All high CV groups had a higher incidence of MACE than those with low CV (6.0% vs. 2.5% for SBP-CV groups, 5.5% vs. 3.0% for TC-CV groups, 4.7% vs. 3.8% for TG-CV groups, 5.8% vs. 2.7% for glucose-CV groups). In multivariable Cox regression analysis,, high SBP-CV (HR 1.79 [95% CI 1.54-2.07], p < 0.01), high TC-CV (HR 1.54 [95% CI 1.34-1.77], p < 0.01), high TG-CV (HR 1.15 [95% CI 1.01-1.31], p = 0.040) and high glucose-CV (HR 1.61 [95% CI 1.40-1.86], p < 0.01) were independent predictors of MACE.

CONCLUSION

Variability of SBP, TC, TG and glucose are important residual risk factors for cardiovascular events in diabetic patients.

Feasibility and measurement stability of smartwatch-based cuffless blood pressure monitoring: A real-world prospective observational study

Cuffless wearable devices are currently being developed for long-term monitoring of blood pressure (BP) in patients with hypertension and in apparently healthy people. This study evaluated the feasibility and measurement stability of smartwatch-based cuffless BP monitoring in real-world conditions. Users of the first smartwatch-based cuffless BP monitor approved in Korea (Samsung Galaxy Watch) were invited to upload their data from using the device for 4 weeks post calibration. A total of 760 participants (mean age 43.7 ± 11.9, 80.3% men) provided 35,797 BP readings (average monitoring 22 ± 4 days [SD]; average readings 47 ± 42 per participant [median 36]). Each participant obtained 1.5 ± 1.3 readings/day and 19.7% of the participants obtained measurements every day. BP showed considerable variability, mainly depending on the day and time of the measurement. There was a trend towards higher BP levels on Mondays than on other days of the week and on workdays than in weekends. BP readings taken between 00:00 and 04:00 tended to be the lowest, whereas those between 12:00 and 16:00 the highest. The average pre-post calibration error for systolic BP (difference in 7-day BP before and after calibration), was 6.8 ± 5.6 mmHg, and was increased with higher systolic BP levels before calibration. Smartwatch-based cuffless BP monitoring is feasible for out-of-office monitoring in the real-world setting. The stability of BP measurement post calibration and the standardization and optimal time interval for recalibration need further investigation.

Visit-to-visit blood pressure variability and mortality and cardiovascular outcomes after acute myocardial infarction

The relationship between visit-to-visit blood pressure variability (BPV) and cardiovascular outcomes remains unclear. Our study assessed the prognostic implications of visit-to-visit BPV in patients after acute myocardial infarction (AMI). The present study enrolled 7,375 patients who underwent percutaneous coronary intervention for AMI and at least five measurements of blood pressure after hospital discharge. Visit-to-visit BPV was estimated as variability independent of mean. The primary endpoint was all-cause mortality. The secondary endpoints were major cardiovascular events (the composite of cardiovascular death, myocardial infarction, and ischemic stroke) and hospitalization for heart failure. During a median follow-up of 5.8 years, adjusted risks of all-cause mortality, major cardiovascular events, and hospitalization for heart failure continuously increased as systolic BPV and diastolic BPV increased. Patients in the highest quartile of systolic BPV (versus lowest) had increased risk of all-cause mortality (adjusted hazard ratio (aHR) 1.51 [95% confidence interval (CI) 1.23-1.85]), major cardiovascular events (aHR 1.31 [95% CI 1.1-1.55]), and hospitalization for heart failure (aHR 2.15 [95% CI 1.49-3.1]). Patients in the highest quartile of diastolic BPV was also associated with all-cause mortality (aHR 1.39 [95% CI 1.14-1.7]), major cardiovascular events (aHR 1.29 [95% CI 1.08-1.53]), and hospitalization for heart failure (aHR 2.01[95% CI 1.4-2.87]). Both systolic and diastolic BPV improved the predictive ability of the GRACE (Global Registry of Acute Coronary Events) risk score for both all-cause mortality and major cardiovascular events. Higher visit-to-visit BPV was associated with increased risks of mortality and cardiovascular events in patients after AMI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Novel insights into the association between seasonal variations, blood pressure, and blood pressure variability in patients with new-onset essential hypertension

Background

Blood pressure (BP) exhibits seasonal variations, with peaks reported in winter. However, the association between seasonal variations and blood pressure variability in patients with new-onset essential hypertension is not fully understood. This study evaluated the potential association of seasonal variations with new-onset essential hypertension.

Methods

This retrospective observational study recruited a total of 440 consecutive patients with new-onset essential hypertension who underwent 24-h ambulatory electrocardiograph (ECG) and BP measurement at our department between January 2019 and December 2019. Demographic and baseline clinical data including BP variability, heart rate variability, and blood tests were retrieved. Multivariate linear regression analysis was performed to identify factors independently associated with mean BP and BP variability.

Results

Among the 440 patients recruited, 93 cases were admitted in spring, 72 in summer, 151 in autumn, and 124 in winter. Univariate analysis revealed that systolic BP (SBP), diastolic BP (DBP), high-sensitivity C-reactive protein, SBP drop rate, DBP drop rate, 24-h standard deviation of SBP, 24-h standard deviation of DBP, 24-h SBP coefficient of variation, and 24-h DBP coefficient of variation were associated with patients admitted in winter (P < 0.05 for all). Multivariate linear regression analysis showed that winter was the influencing factor of 24-h standard deviation of SBP (B = 1.851, t = 3.719, P < 0.001), 24-h standard deviation of DBP (B = 1.176, t = 2.917, P = 0.004), 24-h SBP coefficient of variation (B = 0.015, t = 3.670, P < 0.001), and 24-h DBP coefficient of variation (B = 0.016, t = 2.849, P = 0.005) in hypertensive patients.

Conclusions

Seasonal variations are closely associated with BP variability in patients with new-onset essential hypertension. Our study provides insight into the underlying pathogenesis of new-onset essential hypertension.

Long-term variability and change trend of systolic blood pressure and risk of type 2 diabetes mellitus in middle-aged Japanese individuals: findings of the Aichi Workers' Cohort Study

Studies have reported that short-term blood pressure (BP) variability (BPV) is associated with type 2 diabetes mellitus (T2DM) incidence, but the association with long-term BPV remains unclear. The present study investigated the associations of long-term BPV as well as the time trend of BP changes over time with the incidence of T2DM. This study followed a cohort of 3017 Japanese individuals (2446 male, 571 female) aged 36-65 years from 2007 through March 31, 2019. The root-mean-square error (RMSE) and the slope of systolic BP (SBP) change regressed on year were calculated individually using SBP values obtained from 2003 to baseline (2007). A multivariable Cox proportional hazard model was applied to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for tertiles of SBP RMSE and continuous SBP slopes adjusted for age, sex, smoking status, regular exercise, sodium intake, family history of diabetes, sleep disorder, body mass index (BMI), SBP, and fasting blood glucose (FBG) at baseline, and BMI slope from 2003 to 2007. The highest RMSE tertile compared to the lowest was associated with a significantly higher incidence of T2DM after adjusting for covariates (HR: 1.79, 95% CI: 1.15, 2.78). The slope was also significantly associated with T2DM incidence until baseline SBP and FBG were adjusted (HR: 1.03, 95% CI: 0.99, 1.07). In conclusion, long-term SBP variability was significantly associated with an increased incidence of T2DM independent of baseline age, sex, BMI, SBP, FBG, lifestyle factors and BMI slope from 2003 until baseline.

Variability independent of mean blood pressure as a real-world measure of cardiovascular risk

Background

Individual-level blood pressure (BP) variability, independent of mean BP levels, has been associated with increased risk for cardiovascular events in cohort studies and clinical trials using standardized BP measurements. The extent to which BP variability relates to cardiovascular risk in the real-world clinical practice setting is unclear. We sought to determine if BP variability in clinical practice is associated with adverse cardiovascular outcomes using clinically generated data from the electronic health record (EHR).

Methods

We identified 42,482 patients followed continuously at a single academic medical center in Southern California between 2013 and 2019 and calculated their systolic and diastolic BP variability independent of the mean (VIM) over the first 3 years of the study period. We then performed multivariable Cox proportional hazards regression to examine the association between VIM and both composite and individual outcomes of interest (incident myocardial infarction, heart failure, stroke, and death).

Findings

Both systolic (HR, 95% CI 1.22, 1.17-1.28) and diastolic VIM (1.24, 1.19-1.30) were positively associated with the composite outcome, as well as all individual outcome measures. These findings were robust to stratification by age, sex and clinical comorbidities. In sensitivity analyses using a time-shifted follow-up period, VIM remained significantly associated with the composite outcome for both systolic (1.15, 1.11-1.20) and diastolic (1.18, 1.13-1.22) values.

Interpretation

VIM derived from clinically generated data remains associated with adverse cardiovascular outcomes and represents a risk marker beyond mean BP, including in important demographic and clinical subgroups. The demonstrated prognostic ability of VIM derived from non-standardized BP readings indicates the utility of this measure for risk stratification in a real-world practice setting, although residual confounding from unmeasured variables cannot be excluded.

Funding

This study was funded in part by National Institutes of Health grants R01-HL134168, R01-HL131532, R01-HL143227, R01-HL142983, U54-AG065141; R01-HL153382, K23-HL136853, K23-HL153888, and K99-HL157421; China Scholarship Council grant 201806260086; Academy of Finland (Grant no: 321351); Emil Aaltonen Foundation; Finnish Foundation for Cardiovascular Research.

Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association

Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.

Refining determinants of associations of visit-to-visit blood pressure variability with cardiovascular risk: results from the Action to Control Cardiovascular Risk in Diabetes Trial

OBJECTIVES

As there is uncertainty about the extent to which baseline blood pressure level or cardiovascular risk modifies the relationship between blood pressure variability (BPv) and cardiovascular disease, we comprehensively examined the role of BPv in cardiovascular disease risk in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial.

METHODS

Using data from ACCORD, we examined the relationship of BPv with development of the primary CVD outcome, major coronary heart disease (CHD), and total stroke using time-dependent Cox proportional hazards models.

RESULTS

BPv was associated with the primary CVD outcome and major CHD but not stroke. The positive association with the primary CVD outcome and major CHD was more pronounced in low and high strata of baseline SBP (<120 and >140 mmHg) and DBP (<70 and >80 mmHg). The effect of BPv on CVD and CHD was more pronounced in those with both prior CVD history and low blood pressure. Dips, not elevations, in blood pressure appeared to drive these associations. The relationships were generally not attenuated by adjustment for mean blood pressure, medication adherence, or baseline comorbidities. A sensitivity analysis using CVD events from the long-term posttrial follow-up (ACCORDION) was consistent with the results from ACCORD.

CONCLUSION

In ACCORD, the effect of BPv on adverse cardiovascular (but not cerebrovascular) outcomes is modified by baseline blood pressure and prior CVD. Recognizing these more nuanced relationships may help improve risk stratification and blood pressure management decisions as well as provide insight into potential underlying mechanisms.

Blood pressure visit-to-visit variability and outcomes in patients with heart failure with preserved ejection fraction

AIMS

Previous studies report that blood pressure (BP) variability is associated with increased risk of adverse outcomes in patients diagnosed with cardiovascular disease. However, studies have not fully explored this association in patients with heart failure with preserved ejection fraction (HFpEF). This study sought to explore the association between visit-to-visit variability (VVV) of BP and clinical outcomes in patients with HFpEF.

METHODS AND RESULTS

A total of 1988 patients (mean age of 67.73 ± 9.22, 51.7% female) from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial were included in this study. BP-VVV was determined by standard deviation (SD) of mean systolic BP (SBP-SD) from six measurements (baseline and months 1, 2, 4, 8, and 12) during the first 12 months after randomization. Mean on-treatment SBP during the first 12 months was 127.77 ± 10.42 mmHg, and the median of SBP-SD was 8.15 mmHg. A total of 192 (9.7%) patients met the primary outcome during the subsequent median follow-up of 35.16 months, including a composite of cardiovascular death, heart failure hospitalization, or aborted cardiac arrest. Multiple Cox regression analysis showed that SBP-SD was independently associated with the increased risk of the primary outcome after adjusting for age, gender, method of BP measurement, treatment, renal function and common co-morbidities, and the mean SBP during the first 12 months [hazard ratio (HR) for fourth vs. first quartile, 1.63; 95% confidence interval (CI), 1.07-2.49; P = 0.024]. Analysis showed that SBP-SD as continuous variable was associated with a 23% increase in the risk of primary outcome (HR 1.23, 95% CI 1.06-1.43; P = 0.006).

CONCLUSIONS

The findings of the current study show that high SBP-VVV in patients with HFpEF is associated with an increased risk of adverse outcomes independent of the mean on-treatment SBP.

Effectiveness of statin intensive therapy in type 2 diabetes mellitus with high visit-to-visit blood pressure variability

BACKGROUND

Intensive lipid-lowering therapy is recommended in type 2 diabetes mellitus (T2DM) patients with target organ damage. However, the evidence is insufficient to stratify the patients who will benefit from the intensive therapy among them. High visit-to-visit variability in systolic blood pressure (SBP) is associated with increased risk of cardiovascular events. We investigated the effectiveness of intensive versus standard statin therapy in the primary prevention of cardiovascular events among T2DM patients with retinopathy stratified by visit-to-visit SBP variability.

METHODS

The standard versus intensive statin therapy for hypercholesterolemic patients with diabetic retinopathy study was the first trial comparing statin intensive therapy targeting low-density lipoprotein cholesterol (LDL-C) <70 mg/dl and standard therapy targeting LDL-C ≥100 to <120 mg/dl in T2DM patients with retinopathy without known cardiovascular disease. Using this dataset, we divided the patients into two subpopulations based on standard deviation (SD) and average real variability (ARV) of clinic SBP within the initial 6 months.

RESULTS

In a total of 4899 patients, 240 composite cardiovascular events were observed during a median follow-up of 37.3 months. In multivariable-adjusted model comparing intensive versus standard therapy, the hazard ratios for composite cardiovascular events were 0.64 (95% CI 0.45-0.90) and 1.21 (95% CI 0.82-1.80) in patients with high and low SBP variability as defined by SD, respectively. Interaction between SBP variability and statin therapy was significant (P = 0.018). The analysis using ARV of SBP showed similar results.

CONCLUSION

Statin intensive therapy targeting LDL-C <70 mg/dl had benefits in primary prevention of cardiovascular events compared with standard therapy among T2DM patients with retinopathy having high, but not low, visit-to-visit SBP variability.

Impact of visit-to-visit blood pressure variability on hypertensive-mediated target organ damage and future cardiovascular events: the Campania salute network

BACKGROUND

Exaggerated variability of blood pressure (BP) poses additional stress on cardiovascular system independent of BP average value, increasing risk of target organ damage (HMOD) and cardiovascular events. We assessed the impact of visit-to-visit variability (VVV) of BP on development of cardiovascular events and HMOD.

METHODS

Standard deviation (SD) and coefficient of variability of mean SBP and DBP were calculated in 3555 patients from the Campania Salute Network registry, with available echocardiogram and more than six visits during follow-up. Values from the first visit were excluded. The impact of VVV of BP on cardiovascular events, and mediation of HMOD were assessed at final visit.

RESULTS

Mean number of visits was 11 ± 6 with mean interval between visits of 9.1 ± 3.7 months. Mean visit-to-visit SD during follow-up was 13 ± 5 for systolic and 8 ± 3 mmHg for DBP; coefficients of variability were 9.7 ± 3.5 and of 9.6 ± 3.2, respectively. In multivariable analysis, left ventricular mass at follow-up was correlated with systolic VVV of BP independently of significant effect of age, BMI, mean SBP during follow-up and initial left ventricular mass. Follow-up GFR was inversely associated with systolic and diastolic VVV, independently of significant effect of age, mean glucose and SBP during follow-up, and initial GFR. In Cox regression, high VVV of BP was also associated with increased risk of cardiovascular events (hazard ratio 1.49, 95% confidence interval 1.08-2.06, P = 0.015), independently of significant effect of HMOD.

CONCLUSION

VVV is associated with prevalent HMOD and development of cardiovascular events, independently of mean BP value during follow-up and HMOD.

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.

New Insights into the Role of Visit-to-Visit Glycemic Variability and Blood Pressure Variability in Cardiovascular Disease Risk

PURPOSE OF REVIEW

There is evidence from epidemiologic studies that variability in cardiovascular risk factors influences risk of cardiovascular disease. We review new studies and novel findings in the relationship between visit-to-visit glycemic variability and blood pressure variability and risk of adverse outcomes.

RECENT FINDINGS

Visit-to-visit glycemic variability is consistently linked to macrovascular disease. This relationship has been observed in both clinical trials and retrospective studies of electronic health records. Long-term blood pressure variability also predicts cardiovascular outcomes, and the association appears stronger in those with lower levels of systolic and diastolic function. As epidemiologic evidence increases in support of a role for metabolic risk factor variability in cardiovascular risk, there is a corresponding rise in interest in applying this information toward improving risk factor prediction and treatment. Future investigation of underlying mechanisms for these associations as well as implications for therapy is also warranted. The potential additive contribution of variability of multiple parameters also merits additional scrutiny. As our technology for capturing risk factor variability continues to improve, this will only enhance our understanding of its links with vascular disease and how to best utilize this information to reduce cardiovascular outcomes.

Effect of Variability in Blood Pressure, Glucose and Cholesterol Concentrations, and Body Weight on Emergency Hospitalization and 30-Day Mortality in the General Population

Background

Variability in blood pressure, glucose concentration, cholesterol concentration, or body weight is associated with a wide range of health outcomes. We hypothesized that high variability in metabolic parameters is associated with an increased risk of emergency hospitalization and mortality.

Methods and Results

Using a nationally representative database from the Korean National Health Insurance System, 8 049 228 individuals who underwent 3 or more health examinations during 2005 to 2010 were followed up until the end of 2016. Variability in fasting blood glucose and total cholesterol concentrations, systolic blood pressure, and body weight was measured using the variability independent of the mean (VIM). High variability was defined as the highest quartile of variability. Subjects were classified according to the number of high variability parameters. The end points of the study were emergency hospitalization and 30‐day mortality. There were 733 387 emergency hospitalizations (9.1%) during a median follow‐up of 5.6±1.2 years. For each metabolic parameter, an incrementally higher risk of emergency hospitalization was observed for higher VIM quartile groups than for the lowest quartile group. Compared with the group with low variability for all 4 parameters, the group with high variability for all 4 parameters had a significantly higher risk for emergency hospitalization (hazard ratio [HR], 1.58; 95% CI, 1.54–1.61) and 30‐day mortality (HR, 2.44; 95% CI, 1.62–3.69), after adjusting for possible confounding factors.

Conclusions

High variability in metabolic parameters was associated with increased risk of emergency hospitalization and short‐term mortality.

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.

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.

Cardiovascular Risk Factors: It's Time to Focus on Variability!

Atherosclerotic heart disease remains a leading cause of morbidity and mortality worldwide. While extensive research supports cardiovascular risk factor reduction in the form of achieving evidence-based blood pressure, lipid, glucose, and body weight targets as a means to improve cardiovascular outcomes, residual risk remains. Emerging data have demonstrated that the intraindividual variability of these risk factor targets potentially contribute to this residual risk. It may therefore be time to define risk factor by not only its magnitude and duration as done traditionally, but perhaps also by the variability of that particular risk factor over time.

Blood Pressure–Lowering Profiles and Clinical Effects of Angiotensin Receptor Blockers Versus Calcium Channel Blockers

Blood pressure–lowering drugs have different blood pressure–lowering profiles. We studied if differences in blood pressure mean and variability can explain the differences in risks of cardiovascular events and death among 15 245 high-risk hypertensive patients randomized to valsartan or amlodipine and followed for 4.2 years in the VALUE trial (Valsartan Antihypertensive Long-Term Use Evaluation). We selected patients with ≥3 visits and performed Cox regression analyses, defining mean blood pressure as a time-dependent covariate and visit-to-visit and within-visit blood pressure variability as the SD. Of 14 996 eligible patients, participants in the valsartan group had higher systolic mean blood pressure by 2.2 mm Hg, higher visit-to-visit systolic variability by 1.4 mm Hg, and higher within-visit systolic variability by 0.2 mm Hg ( P values <0.0001). The higher risks of myocardial infarction and stroke in the valsartan group was attenuated after adjustment for mean and variability of systolic blood pressure, from HR 1.19 (95% CI, 1.02–1.39) to 1.11 (0.96–1.30) and from HR 1.13 (0.96–1.33) to 1.00 (0.85–1.18), respectively. The lower risk of congestive heart failure in the valsartan group was accentuated after adjustment, from HR 0.86 (0.74–1.00) to 0.76 (0.65–0.89). A smaller effect was seen on risk of death, from 1.01 (0.92–1.12) to 0.94 (0.85–1.04). In conclusion, the higher risks of myocardial infarction and stroke in patients randomized to valsartan versus amlodipine were related to the drugs’ different blood pressure modulating profiles. The risk of congestive heart failure with valsartan was lower, independent of the less favorable blood pressure modulating profile.

Risk Factor Variability and Cardiovascular Outcome: JACC Review Topic of the Week

Until recently, intraindividual visit-to-visit variability of cardiovascular risk factors has been dismissed as random fluctuation. This simplistic concept was challenged by demonstrating that visit-to-visit blood pressure variability, independent of average blood pressure, was a powerful risk factor for stroke. Subsequently, variability of other cardiovascular risk factors such as cholesterol, glycemia, and body weight was documented to increase risk independent of their absolute values. Variability of these risk factors has been demonstrated to be a powerful predictor for all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia. With the notable exception of heart rate, cardiovascular risk factors must now be defined by 2 components: the magnitude and duration of sustained risk factor elevation and, equally important, the variability of the same risk factor over time.

Different contribution of SBP and DBP variability to vascular events in patients with stroke

Background

High blood pressure variability (BPV) is a novel risk factor for cardiovascular disease. However, the heterogeneity of systolic blood pressure variability (SBPV) and diastolic blood pressure variability (DBPV) for different vascular events remains unclear. This study aims to investigate whether SBPV or DBPV has different contribution to vascular events in patients with acute ischaemic stroke (IS) or transient ischaemic attack (TIA).

Methods

Data from the BOSS (blood pressure and clinical outcome in TIA or IS) study were examined for vascular events at 3-month and 1-year follow-up. BPV was defined as the SD and coefficient of variation (CV) of day-to-day measurements within 3 months after IS/TIA. Vascular events include cardiovascular events (myocardial infarction, unstable angina, cardiac death and congestive heart failure) and cerebrovascular events (ischaemic or haemorrhagic stroke). Logistic regression model was used to test the associations between BPV and vascular events.

Results

Of 2325 patients with IS or TIA, 103 (4.43 %) experienced a recurrent stroke and 64 (2.75 %) had cardiovascular events within 3 months. Day-to-day SBPV was only associated with stroke recurrence (BPV_SD: OR, 1.72, 95% CI 1.09 to 2.71; BPV_CV: 1.86, 95% CI 1.19 to 2.92), but not cardiovascular events (BPV_SD: 1.67, 95% CI 0.94 to 2.94; BPV_CV: 1.51, 95% CI 0.86 to 2.64). However, DBPV seems to be related to both stroke (BPV_SD: 1.60, 95% CI 1.02 to 2.49; BPV_CV: 1.53, 95% CI 0.99 to 2.37) and cardiovascular events (BPV_SD: 2.48, 95% CI 1.37 to 4.48; BPV_CV: 1.92, 95% CI 1.09 to 3.36). Similar results were found at 1 year.

Conclusions

For patients with IS/TIA, stroke recurrence was associated with both SBPV and DBPV; however, cardiovascular events seem to be only related to DBPV.

Preoperative outpatient blood pressure variability predicts postoperative mortality, readmission and morbidity after surgery

BACKGROUND

Outpatient blood pressure variability (BPV) predicts hospitalization and death in non-surgical patients independently of hypertension. We hypothesized that preoperative BPV predicts postoperative outcomes.

METHODS

We assessed 22,233 veterans undergoing CABG, colectomy, hip replacement, pancreatectomy, carotid endarterectomy or AV-fistula with ≥10 outpatient BP's over three preoperative years. Calculating BPV as SD of systolic or diastolic BP, we used logistic regression considering demographics, comorbidities, and pre-admission cardiovascular medications to estimate odds ratios for 90-day mortality or readmission, MI, CVA, renal failure, and wound infection, choosing the lowest 5%ile of systolic/diastolic BPV for reference.

RESULTS

Covariate-adjusted ORs for adverse outcomes increased as BPV increased. For instance, the highest 5%ile of systolic BPV had covariate-adjusted ORs of 2.96 and 1.78 for 90-day mortality and readmission. Systolic and diastolic BPV trended together but affected outcomes independently.

CONCLUSIONS

Preoperative BPV predicts postoperative outcomes. BPV should be considered in individualized risk assessment and subgroup risk stratification.

Low Systolic Blood Pressure and Mortality in Elderly Patients After Acute Myocardial Infarction

Background

Optimal blood pressure in elderly patients after acute myocardial infarction is still a matter of debate. In a prospective observational study, we aimed to identify optimal systolic blood pressure during the 48 first hours after admission for acute myocardial infarction and its prognostic value for cardiovascular mortality.

Methods and Results

From the Observatoire des Infarctus de Côte d'Or survey, all consecutive patients aged >75 years admitted for an acute myocardial infarction in a coronary care unit from 2012 to 2015 and discharged alive were included (n=814). Exclusion criteria were in‐hospital death, cardiogenic shock, and end‐stage renal disease. Average systolic blood pressure (aSBP) values over the first 48 hours after admission were recorded, and the population was dichotomized into 2 groups: low aSBP group (<125 mm Hg) and control group (aSBP ≥125 mm Hg). When compared with patients without cardiovascular death at 1‐year follow‐up, patients who died from a cardiovascular cause had higher rate of cardiovascular risks factors, including age, diabetes mellitus, comorbidities, and cardiovascular history. They had higher rates of low body mass index (<21 kg/m²) and more elevated Global Registry of Acute Coronary Events risk score. Patients with aSBP <125 mm Hg had a 2‐fold risk of 1‐year cardiovascular death (47 [12.0%] versus 28 [6.6%]; P=0.008). By multivariable logistic regression analysis, low aSBP (odds ratio [95% CI], 1.91 [1.07–3.41]) remained a strong and independent predictor of 1‐year cardiovascular mortality.

Conclusions

In our large population‐based study in elderly patients with acute myocardial infarction, low aSBP was an independent and powerful predictor of 1‐year cardiovascular mortality. Early aSBP measurement could help to improve risk stratification. Moreover, our results may suggest an optimal blood pressure target in elderly patients.

The link between elevated long-term resting heart rate and SBP variability for all-cause mortality

BACKGROUND

Resting heart rate (RHR) and SBP are important risk markers for all-cause mortality. However, the link between increased RHR and SBP for all causes of death remained unclear. We investigated the link between an increased visit-to-visit variation of RHR and SBP for risk of all-cause mortality in the general population.

METHODS

We examined long-term visit-to-visit variation of RHR and blood pressure among 46 751 residents of Tangshan city, China (mean age: 52.58 ± 11.64 years; 78% men). Cox proportional hazard model was used to estimate the hazard ratios and 95% confidence interval (CI) adjusting for clinical characteristics assessed at the last examination (2010-2011).

RESULTS

A total of 1667 deaths were recorded over 4.97 ± 0.69 years follow-up. A rise in 1 SD of heart rate (4 bpm) was associated with an increased risk of death among the participants in third and fourth quartile of SBP-SD in the subgroups of general population [hazard ratio (95% CI) = 1.10 (1.03-1.67) and 1.16 (1.03-1.30), respectively], men [hazard ratio (95% CI) = 1.10 (1.02-1.17) and 1.16 (1.03-1.30), respectively], and participants under 65 years of age [hazard ratio (95% CI) = 1.16 (1.02-1.33) and 1.20 (1.03-1.39), respectively]. Similarly, 1-SD increase of SBP (7 mmHg) was associated with an increased risk of death among the participants in the highest quartiles of RHR-SD in the subgroups of the general population, men, and under 65 years of age.

CONCLUSION

An elevated long-term SBP variability combined with an increased RHR variability or vice versa may amplify the risk of all-cause mortality in general population, as well as in men and middle-age group.

Visit-to-Visit Variability of Lipids Measurements and the Risk of Stroke and Stroke Types: A Prospective Cohort Study

BACKGROUND AND PURPOSE

Previous studies suggested increased visit-to-visit variability of total cholesterol (TC) is associated with stroke. This study aimed to investigate the associations of various lipids measurements variability and the risk of stroke and stroke type (ischemic and hemorrhagic stroke).

METHODS

Fifty-one thousand six hundred twenty participants in the Kailuan Study without history of myocardial infarction, stroke, and cancer who underwent three health examinations during 2006 to 2010 were followed for incident stroke. Variability in TC, triglycerides, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) measurements were measured using the coefficient of variation (CV), standard deviation (SD), variability independent of the mean (VIM), and average real variability (ARV).

RESULTS

During a median of 6.04 years of follow-up, 1,189 incident stroke (1,036 ischemic and 160 hemorrhagic stroke) occurred. In the multivariable-adjusted model, the hazard ratio (HR) comparing participants in the highest versus lowest quartile of CV of HDL-C were 1.21 (95% confidence interval [CI], 1.02 to 1.45; P for trend=0.013) for ischemic stroke. The highest quartile of CV of LDL-C was associated with 2.17-fold risk of hemorrhagic stroke (HR, 2.17; 95% CI, 1.25 to 3.75; P for trend=0.002) compared with the lowest quartile. We did not observe any significant association between TC and triglycerides variability with any of stroke. Consistent.

RESULTS

were obtained when calculating variability index using SD, VIM, or ARV.

CONCLUSIONS

These findings suggest the high visit-to-visit HDL-C and LDL-C variability were associated with an increased incidence of ischemic and hemorrhagic stroke, respectively.

[Mechanisms for the Development of Blood Pressure Variability and the Potential of Antihypertensive Drugs in Their Correction]

Blood pressure variability (BPV) is the fluctuations of blood pressure over a certain period of time under the influence of various factors. The issue of increased BPV is of particular clinical importance due to high predictive value of this parameter as a risk factor for fatal and non-fatal cardiovascular, cerebrovascular and renal events. It is proved that in the BPV increasing, the key role is played by impairments in arterial baroreflexes, which, in turn, are mediated by increased vascular stiffness, impact of angiotensin II and the sympathetic nervous system, endothelial dysfunction, nitric oxide deficiency and aging, including the vascular aging. Antihypertensive drugs that targeting largest amount of pathophysiological mechanisms in BPV increasing have a most advantages in correcting excessive pressure fluctuations. In this regard such drugs are perindopril and amlodipine, which can eliminate almost the entire spectrum of increased BPV causes and, therefore, optimally reduce the cardiovascular risk.

Lipoprotein-associated phospholipase A2: The story continues

Inflammation is thought to play an important role in the pathogenesis of vascular diseases. Lipoprotein-associated phospholipase A2 (Lp-PLA2) mediates vascular inflammation through the regulation of lipid metabolism in blood, thus, it has been extensively investigated to identify its role in vascular inflammation-related diseases, mainly atherosclerosis. Although darapladib, the most advanced Lp-PLA2 inhibitor, failed to meet the primary endpoints of two large phase III trials in atherosclerosis patients cotreated with standard medical care, the research on Lp-PLA2 has not been terminated. Novel pathogenic, epidemiologic, genetic, and crystallographic studies regarding Lp-PLA2 have been reported recently, while novel inhibitors were identified through a fragment-based lead discovery strategy. More strikingly, recent clinical and preclinical studies revealed that Lp-PLA2 inhibition showed promising therapeutic effects in diabetic macular edema and Alzheimer's disease. In this review, we not only summarized the knowledge of Lp-PLA2 established in the past decades but also emphasized new findings in recent years. We hope this review could be valuable for helping researchers acquire a much deeper insight into the nature of Lp-PLA2, identify more potent and selective Lp-PLA2 inhibitors, and discover the potential indications of Lp-PLA2 inhibitors.

Neurohumoral and ambulatory haemodynamic adaptations following isometric exercise training in unmedicated hypertensive patients

OBJECTIVE

Hypertension remains the leading modifiable risk factor for cardiovascular disease. Isometric exercise training (IET) has been shown to be a useful nonpharmacological intervention for reducing resting blood pressure (BP). This study aimed to measure alterations in office BP, ambulatory BP, cardiac autonomic modulation and inflammatory and vascular biomarkers following a programme of IET in unmedicated hypertensive patients.

METHODS

Twenty-four unmedicated stage 1 hypertensive patients (age 43.8 ± 7.3 years; height, 178.1 ± 7 cm; weight 89.7 ± 12.8 kg) were randomly assigned in a cross-over study design, to 4-weeks of home-based IET and control period, separated by a 3-week washout period. Office and ambulatory BP, cardiac autonomic modulation, and inflammatory and vascular biomarkers were recorded pre and post-IET and control periods.

RESULTS

Clinic and 24-h ambulatory BP significantly reduced following IET by 12.4/6.2 and 11.8/5.6 mmHg in SBP/DBP, respectively (P < 0.001 for both), compared with the control. The BP adaptations were associated with a significant (P = 0.018) reduction in the average real variability of 24-h ambulatory BP following IET, compared with control. Cardiac autonomic modulation improved by 11% (P < 0.001), baroreceptor reflex sensitivity improved by 47% (P < 0.001), and IL-6 and asymmetric dimethylarginine reduced by 10% (P = 0.022) and 19% (P = 0.023), respectively, which differed significantly to the control period.

CONCLUSION

This is the first evidence of durable BP reduction and wider cardiovascular disease risk benefits of IET in a relevant patient population. Our findings support the role of IET as a safe and viable therapeutic and preventive intervention in the treatment of hypertension.

Learning from Longitudinal Data in Electronic Health Record and Genetic Data to Improve Cardiovascular Event Prediction

Current approaches to predicting a cardiovascular disease (CVD) event rely on conventional risk factors and cross-sectional data. In this study, we applied machine learning and deep learning models to 10-year CVD event prediction by using longitudinal electronic health record (EHR) and genetic data. Our study cohort included 109, 490 individuals. In the first experiment, we extracted aggregated and longitudinal features from EHR. We applied logistic regression, random forests, gradient boosting trees, convolutional neural networks (CNN) and recurrent neural networks with long short-term memory (LSTM) units. In the second experiment, we applied a late-fusion approach to incorporate genetic features. We compared the performance with approaches currently utilized in routine clinical practice – American College of Cardiology and the American Heart Association (ACC/AHA) Pooled Cohort Risk Equation. Our results indicated that incorporating longitudinal feature lead to better event prediction. Combining genetic features through a late-fusion approach can further improve CVD prediction, underscoring the importance of integrating relevant genetic data whenever available.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cardiovascular Risk Factors and Markers

Cardiovascular risk is assessed for the prediction and appropriate management of patients using collections of identified risk markers obtained from clinical questionnaire information, concentrations of certain blood molecules (e.g., N-terminal proB-type natriuretic peptide fragment and soluble receptors of tumor-necrosis factor-α and interleukin-2), imaging data using various modalities, and electrocardiographic variables, in addition to traditional risk factors.