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Kodani E, Inoue H, Atarashi H, Okumura K, Suzuki S, Yamashita T, Origasa H. Predictive ability of visit-to-visit blood pressure indices for adverse events in patients with non-valvular atrial fibrillation: Subanalysis of the J-RHYTHM Registry. IJC HEART & VASCULATURE 2023; 46:101216. [PMID: 37206091 PMCID: PMC10189411 DOI: 10.1016/j.ijcha.2023.101216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/26/2023] [Accepted: 04/27/2023] [Indexed: 05/21/2023]
Abstract
Background We previously reported that standard deviation (SD) of systolic blood pressure (SBP), an index of BP variability, and SBP-time in target range (TTR), an index of BP consistency, were significantly associated with adverse events in patients with non-valvular atrial fibrillation (NVAF). Thus, this study aimed to compare predictive ability for adverse events among visit-to-visit BP variability/consistency indices using data from the J-RHYTHM Registry. Methods Of 7406 outpatients with NVAF, 7226 (age, 69.7 ± 9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6 ± 5.0 times) during the 2-year follow-up period or until occurrence of an event, were included. As BP consistency for target SBP between 110 and 130 mmHg, SBP-TTR by the Rosendaal method and SBP-frequency in range (FIR) were calculated. Predictive ability was expressed by the area under receiver-operating-characteristic curve (AUC). AUCs of SBP-TTR and SBP-FIR for adverse events were compared with those of SBP-SD by the DeLong's test. Results SBP-SD, SBP-TTR, and SBP-FIR were 11.0 ± 4.2 mmHg, 49.5 ± 28.3%, and 52.3 ± 23.0%, respectively. AUCs of these indices for thromboembolism, major hemorrhage, and all-cause death were 0.62, 0.64, and 0.63 for SBP-SD; 0.56, 0.55, and 0.56 for SBP-TTR; and 0.55, 0.56, and 0.58 for SBP-FIR; respectively. AUCs of SBP-SD were significantly larger than those of SBP-TTR for major hemorrhage (P = 0.010) and all-cause death (P = 0.014), and SBP-FIR for major hemorrhage (P = 0.016). Conclusion Among visit-to-visit BP variability/consistency indices, predictive ability of SBP-SD for major hemorrhage and all-cause death was superior to that of SBP-TTR and SBP-FIR in patients with NVAF.
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Affiliation(s)
- Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
- Corresponding author at: Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan.
| | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
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2
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Auer J, Weber T. Blood pressure measurement for prediction of chronic pressure overload and cardiovascular events. Eur J Clin Invest 2023; 53:e13902. [PMID: 36349443 DOI: 10.1111/eci.13902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Johann Auer
- Department of Cardiology and Intensive Care, St Josef Hospital, Braunau, Austria.,Department of Cardiology and Intensive Care, Kepler University Hospital Linz, Linz, Austria.,Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Thomas Weber
- Department of Cardiology and Intensive Care, Klinikum Wels-Grieskirchen, Wels, Austria
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3
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Gmitrov J. Carotid Baroreceptor Magnetic Activation and Beat‐to‐Beat Blood Pressure Variability, Implications to Treat Abrupt Blood Pressure Elevation in Labile Hypertension. Bioelectromagnetics 2022; 43:413-425. [DOI: 10.1002/bem.22425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/20/2022] [Accepted: 09/10/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Juraj Gmitrov
- Diabetology Clinic Krompachy Hospital, Agel SK Inc. Krompachy Slovakia
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4
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Park CH, Kim HW, Joo YS, Park JT, Chang TI, Yoo TH, Park SK, Chae DW, Chung W, Kim YS, Oh KH, Kang SW, Han SH. Association Between Systolic Blood Pressure Variability and Major Adverse Cardiovascular Events in Korean Patients With Chronic Kidney Disease: Findings From KNOW-CKD. J Am Heart Assoc 2022; 11:e025513. [PMID: 35656977 PMCID: PMC9238732 DOI: 10.1161/jaha.122.025513] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Whether visit-to-visit systolic blood pressure (SBP) variability can predict major adverse cardiovascular events (MACE) in patients with chronic kidney disease is unclear. Methods and Results We investigated the relationship between SDs of visit-to-visit SBP variability during the first year of enrollment and MACE among 1575 participants from KNOW-CKD (Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease). Participants were categorized into 3 groups according to tertiles of visit-to-visit SBP variability (SD). The study end point was MACE, defined as a composite of nonfatal myocardial infarction, unstable angina, revascularization, nonfatal stroke, hospitalization for heart failure, or cardiac death. During 6748 patient-years of follow-up (median, 4.2 years), MACE occurred in 64 participants (4.1%). Compared with the lowest tertile of visit-to-visit SBP variability (SD), the hazard ratios (HRs) for the middle and the highest tertile were 1.64 (95% CI, 0.80-3.36) and 2.23 (95% CI, 1.12-4.44), respectively, in a multivariable cause-specific hazard model. In addition, the HR associated with each 5-mm Hg increase in visit-to-visit SBP variability (SD) was 1.21 (95% CI, 1.01-1.45). This association was consistent in sensitivity analyses with 2 additional definitions of SBP variability determined by the coefficient of variation and variation independent of the mean. The corresponding HRs for the middle and highest tertiles were 2.11 (95% CI, 1.03-4.35) and 2.28 (95% CI, 1.12-4.63), respectively, in the analysis with the coefficient of variation and 1.76 (95% CI, 0.87-3.57) and 2.04 (95% CI, 1.03-4.03), respectively, with the variation independent of the mean. Conclusions Higher visit-to-visit SBP variability is associated with an increased risk of MACE in patients with chronic kidney disease. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01630486.
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Affiliation(s)
- Cheol Ho Park
- Department of Internal Medicine College of MedicineInstitute of Kidney Disease ResearchYonsei University Seoul Republic of Korea
| | - Hyung Woo Kim
- Department of Internal Medicine College of MedicineInstitute of Kidney Disease ResearchYonsei University Seoul Republic of Korea
| | - Young Su Joo
- Department of Internal Medicine College of MedicineInstitute of Kidney Disease ResearchYonsei University Seoul Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine College of MedicineInstitute of Kidney Disease ResearchYonsei University Seoul Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine National Health Insurance Service Medical CenterIlsan Hospital Goyangshi Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine College of MedicineInstitute of Kidney Disease ResearchYonsei University Seoul Republic of Korea
| | - Sue Kyung Park
- Department of Preventive Medicine Seoul National University College of Medicine Seoul Republic of Korea
| | - Dong-Wan Chae
- Department of Internal Medicine Seoul National University Bundang Hospital Seongnamsi Gyeonggi-do Republic of Korea
| | - Wookyung Chung
- Department of Internal Medicine Gil Medical CenterGachon University Incheon Republic of Korea
| | - Yong-Soo Kim
- Department of Internal Medicine Seoul St Mary's HospitalCollege of MedicineThe Catholic University of Korea Seoul Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine Seoul National University HospitalKidney Research Institute Seoul Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine College of MedicineInstitute of Kidney Disease ResearchYonsei University Seoul Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine College of MedicineInstitute of Kidney Disease ResearchYonsei University Seoul Republic of Korea
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Stevens D, Lane DA, Harrison SL, Lip GYH, Kolamunnage-Dona R. Modelling of longitudinal data to predict cardiovascular disease risk: a methodological review. BMC Med Res Methodol 2021; 21:283. [PMID: 34922465 PMCID: PMC8684210 DOI: 10.1186/s12874-021-01472-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/15/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The identification of methodology for modelling cardiovascular disease (CVD) risk using longitudinal data and risk factor trajectories. METHODS We screened MEDLINE-Ovid from inception until 3 June 2020. MeSH and text search terms covered three areas: data type, modelling type and disease area including search terms such as "longitudinal", "trajector*" and "cardiovasc*" respectively. Studies were filtered to meet the following inclusion criteria: longitudinal individual patient data in adult patients with ≥3 time-points and a CVD or mortality outcome. Studies were screened and analyzed by one author. Any queries were discussed with the other authors. Comparisons were made between the methods identified looking at assumptions, flexibility and software availability. RESULTS From the initial 2601 studies returned by the searches 80 studies were included. Four statistical approaches were identified for modelling the longitudinal data: 3 (4%) studies compared time points with simple statistical tests, 40 (50%) used single-stage approaches, such as including single time points or summary measures in survival models, 29 (36%) used two-stage approaches including an estimated longitudinal parameter in survival models, and 8 (10%) used joint models which modelled the longitudinal and survival data together. The proportion of CVD risk prediction models created using longitudinal data using two-stage and joint models increased over time. CONCLUSIONS Single stage models are still heavily utilized by many CVD risk prediction studies for modelling longitudinal data. Future studies should fully utilize available longitudinal data when analyzing CVD risk by employing two-stage and joint approaches which can often better utilize the available data.
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Affiliation(s)
- David Stevens
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, UK.,Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, UK. .,Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, UK.,Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, L7 8TX, UK.,Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ruwanthi Kolamunnage-Dona
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
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Lai SW, Tsai KZ, Wang SH, Lin YK, Lin YP, Lin GM. Erythrocyte Indices and Long-term Blood Pressure Variability in Military Males. Cardiovasc Hematol Disord Drug Targets 2021; 21:217-224. [PMID: 34906064 DOI: 10.2174/1871529x21666211214154545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/24/2021] [Accepted: 10/21/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUNDS Severe microcytic anemia has been associated with BP changes. AIMS AND OBJECTIVES Whether the erythrocyte indices are associated with long-term BPV is unknown. This study aimed to investigate the association of hemoglobin levels and erythrocyte size with long-term blood pressure variability (BPV) in young males. METHODS This study included 1,112 healthy military males, averaging 32 years of age, in Taiwan. All participants took a measurement of systolic and diastolic BP (SBP and DBP) every two-year from 2012 to 2018 (2012-14, 2014-15, 2015-16, 2016-18). Lev-els of hemoglobin and mean corpuscular volume (MCV) of erythrocytes were obtained at the first visit. Long-term BPV was assessed by the standard deviation (SD) and aver-age real variability (ARV). Multivariate linear regression analysis with adjustment for the baseline BP levels and other covariates was used to elucidate the association. RESULTS Hemoglobin levels were borderline positively correlated with SD DBP (β and standard errors = 0.016 (0.009), P =0.06). In those with hemoglobin levels of 10.0-13.9 g/dL, hemoglobin was negatively correlated with SDSBP (β= -0.039 (0.018), P =0.03). In contrast, MCV levels were borderline positively correlated with SDSBP (β =0.085 (0.052), P =0.09). In those with MCV levels <80 fL, MCV was positively correlated with SDSBP and ARVSBP (β= 0.445 (0.210) and 0.286 (0.149), p = 0.03 and 0.05, re-spectively). CONCLUSION There were inconsistent patterns for the associations of erythrocyte indices with long-term BPV. We found a U-shaped relationship of hemoglobin levels with sys-tolic BPV, whereas there was a positive linear relationship of hemoglobin and MCV levels with diastolic BPV, respectively.
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Affiliation(s)
- Shiue-Wei Lai
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien City 970. Taiwan
| | - Kun-Zhe Tsai
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien City 970. Taiwan
| | - Shen-Huei Wang
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien City 970. Taiwan
| | - Yu-Kai Lin
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien City 970. Taiwan
| | - Yen-Po Lin
- Department of Critical Care Medicine, Taipei Tzu-Chi General Hospital, New Tai-pei City 231. Taiwan
| | - Gen-Min Lin
- Department of Medicine, Hualien Armed Forces General Hospital, Hualien City 970. Taiwan
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7
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Visit-to-visit variability of blood pressure and cardiovascular events among the working-age population in Japan: findings from the Japan Epidemiology Collaboration on Occupational Health Study. Hypertens Res 2021; 44:1017-1025. [PMID: 33990791 DOI: 10.1038/s41440-021-00654-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/25/2021] [Accepted: 03/02/2021] [Indexed: 02/03/2023]
Abstract
Increased visit-to-visit variability (VVV) of blood pressure, which is calculated based on several readings, has been suggested to be a significant predictor of cardiovascular events and mortality, independent of mean blood pressure. This study examined associations between the VVV of systolic blood pressure (SBP) measured annually and cardiovascular disease (CVD) events among 72,617 Japanese subjects. Data were obtained from the Japan Epidemiology Collaboration on Occupational Health Study, which is an ongoing epidemiological survey of workers in Japan. VVV was calculated as the coefficient of variation of SBP readings from 2008 to 2011; information on fatal and nonfatal CVD events was collected from registries of specific outcomes between April 2012 and March 2019. A Cox proportional hazards model was applied to investigate associations after adjusting for mean SBP between 2008 and 2011 and covariates. During the 7-year follow-up period, there were 63 CVD fatalities and 314 CVD events (combining fatal and nonfatal events). The results showed that a one-standard deviation increase in VVV was associated with a significant increase in the risk of CVD mortality (hazard ratio [HR] = 1.42; 95% confidence interval [CI] = 1.32-1.54); those in the highest tertile had a 3.20 times (95% CI = 1.26-8.17) higher risk of CVD mortality than those in the lowest tertile. We found less pronounced associations regarding CVD events (HR = 1.08, 95% CI = 1.02-1.15). In conclusion, VVV was significantly associated with CVD mortality in our Japanese working population.
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8
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Ceriello A, Prattichizzo F. Variability of risk factors and diabetes complications. Cardiovasc Diabetol 2021; 20:101. [PMID: 33962641 PMCID: PMC8106175 DOI: 10.1186/s12933-021-01289-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022] Open
Abstract
Several studies suggest that, together with glucose variability, the variability of other risk factors, as blood pressure, plasma lipids, heart rate, body weight, and serum uric acid, might play a role in the development of diabetes complications. Moreover, the variability of each risk factor, when contemporarily present, may have additive effects. However, the question is whether variability is causal or a marker. Evidence shows that the quality of care and the attainment of the target impact on the variability of all risk factors. On the other hand, for some of them causality may be considered. Although specific studies are still lacking, it should be useful checking the variability of a risk factor, together with its magnitude out of the normal range, in clinical practice. This can lead to an improvement of the quality of care, which, in turn, could further hesitate in an improvement of risk factors variability.
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Affiliation(s)
- Antonio Ceriello
- IRCCS MultiMedica, Via Gaudenzio Fantoli, 16/15, 20138, Milan, Italy.
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9
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Dasa O, Smith SM, Howard G, Cooper-DeHoff RM, Gong Y, Handberg E, Pepine CJ. Association of 1-Year Blood Pressure Variability With Long-term Mortality Among Adults With Coronary Artery Disease: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e218418. [PMID: 33914047 PMCID: PMC8085725 DOI: 10.1001/jamanetworkopen.2021.8418] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/11/2021] [Indexed: 12/11/2022] Open
Abstract
Importance Accumulating evidence indicates that higher blood pressure (BP) variability from one physician office visit to the next (hereafter referred to as visit-to-visit BP variability) is associated with poor outcomes. Short-term measurement (throughout 1 year) of visit-to-visit BP variability in high-risk older patients may help identify patients at increased risk of death. Objective To evaluate whether short-term visit-to-visit BP variability is associated with increased long-term mortality risk. Design, Setting, and Participants The US cohort of the International Verapamil SR-Trandolapril Study (INVEST), a randomized clinical trial of 16 688 patients aged 50 years or older with hypertension and coronary artery disease, was conducted between September 2, 1997, and December 15, 2000, with in-trial follow-up through February 14, 2003. The study evaluated a calcium antagonist (sustained-release verapamil plus trandolapril) vs β-blocker (atenolol plus hydrochlorothiazide) treatment strategy. Blood pressure measurement visits were scheduled every 6 weeks for the first 6 months and biannually thereafter. Statistical analysis was performed from September 2, 1997, to May 1, 2014. Exposures Visit-to-visit systolic BP (SBP) and diastolic BP variability during the first year of enrollment using 4 different BP variability measures: standard deviation, coefficient of variation, average real variability, and variability independent of the mean. Main Outcomes and Measures All-cause death, assessed via the US National Death Index, beginning after the exposure assessment period through May 1, 2014. Results For the present post hoc analysis, long-term mortality data were available on 16 688 patients (9001 women [54%]; mean [SD] age, 66.5 [9.9] years; 45% White patients, 16% Black patients, and 37% Hispanic patients). During a mean (SD) follow-up of 10.9 (4.2) years, 5058 patients (30%) died. All 4 variability measures for SBP were significantly associated with long-term mortality after adjustment for baseline demographic characteristics and comorbidities. After comparison of lowest vs highest variability measure quintiles, the magnitude of the association with death remained statistically significant even after adjustment for baseline demographic characteristics and comorbidities (average real variability: adjusted hazard ratio [aHR], 1.18; 95% CI, 1.08-1.30; standard deviation: aHR, 1.14; 95% CI, 1.04-1.24; coefficient of variation: aHR, 1.15; 95% CI, 1.06-1.26; variability independent of the mean: aHR, 1.15; 95% CI, 1.05-1.25). The signal was stronger in women compared with men. Associations of diastolic BP variability measures with death were weaker than for SBP and were not significant after adjustment. Conclusions and Relevance This study suggests that, in a large population of older patients with hypertension and coronary artery disease, short-term visit-to-visit SBP variability was associated with excess long-term mortality, especially for women. Efforts to identify and minimize visit-to-visit SBP variability may be important in reducing excess mortality later in life. Trial Registration ClinicalTrials.gov Identifier: NCT00133692.
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Affiliation(s)
- Osama Dasa
- Department of Internal Medicine and Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville
- Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville
| | - Steven M. Smith
- Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham
| | - Rhonda M. Cooper-DeHoff
- Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville
| | - Eileen Handberg
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville
| | - Carl J. Pepine
- Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville
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Ma Y, Tully PJ, Hofman A, Tzourio C. Blood Pressure Variability and Dementia: A State-of-the-Art Review. Am J Hypertens 2020; 33:1059-1066. [PMID: 32710605 DOI: 10.1093/ajh/hpaa119] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/30/2022] Open
Abstract
Accumulating evidence demonstrates that blood pressure variability (BPV) may contribute to target organ damage, causing coronary heart disease, stroke, and renal disease independent of the level of blood pressure (BP). Several lines of evidence have also linked increased BPV to a higher risk of cognitive decline and incident dementia. The estimated number of dementia cases worldwide is nearly 50 million, and this number continues to grow with increasing life expectancy. Because there is no effective treatment to modify the course of dementia, targeting modifiable vascular factors continues as a top priority for dementia prevention. A clear understanding of the role of BPV in dementia may shed light on the etiology, early prevention, and novel therapeutic targets of dementia, and has therefore gained substantial attention from researchers and clinicians. This review summarizes state-of-art evidence on the relationship between BPV and dementia, with a specific focus on the epidemiological evidence, the underlying mechanisms, and potential intervention strategies. We also discuss challenges and opportunities for future research to facilitate optimal BP management and the clinical translation of BPV for the risk assessment and prevention of dementia.
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Affiliation(s)
- Yuan Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Phillip J Tully
- School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Albert Hofman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Christophe Tzourio
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, CHU Bordeaux, Bordeaux, France
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11
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Kodani E, Inoue H, Atarashi H, Okumura K, Yamashita T, Otsuka T, Origasa H. Impact of Blood Pressure Visit-to-Visit Variability on Adverse Events in Patients With Nonvalvular Atrial Fibrillation: Subanalysis of the J-RHYTHM Registry. J Am Heart Assoc 2020; 10:e018585. [PMID: 33372541 PMCID: PMC7955501 DOI: 10.1161/jaha.120.018585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Blood pressure (BP) variability has reportedly been a risk factor for various clinical events. To clarify the influence of BP visit‐to‐visit variability on adverse events in patients with nonvalvular atrial fibrillation, a post hoc analysis of the J‐RHYTHM Registry was performed. Methods and Results Of 7406 outpatients with nonvalvular atrial fibrillation from 158 institutions, 7226 (age, 69.7±9.9 years; men, 70.7%), in whom BP was measured 4 times or more (14.6±5.0 times) during the 2‐year follow‐up period or until occurrence of an event, constituted the study group. SD and coefficient of variation of BP values were calculated as BP variability. Thromboembolism, major hemorrhage, and all‐cause death occurred in 110 (1.5%), 121 (1.7%), and 168 (2.3%) patients, respectively. When patients were divided into quartiles of systolic BP‐SD (<8.20, 8.20–10.49, 10.50–13.19, and ≥13.20 mm Hg), hazard ratios (HRs) for all adverse events were significantly high in the highest quartile compared with the lowest quartile (HR, 2.00, 95% CI, 1.15–3.49, P=0.015 for thromboembolism; HR, 2.60, 95% CI, 1.36–4.97, P=0.004 for major hemorrhage; and HR, 1.85, 95% CI, 1.11–3.07, P=0.018 for all‐cause death) after adjusting for components of the CHA2DS2‐VASc score, warfarin and antiplatelet use, atrial fibrillation type, BP measurement times, and others. These findings were consistent when BP‐coefficient of variation was used instead of BP‐SD. Conclusions Systolic BP visit‐to‐visit variability was significantly associated with all adverse events in patients with nonvalvular atrial fibrillation. Further studies are needed to clarify the causality between BP variability and adverse outcomes in patients with nonvalvular atrial fibrillation. Registration URL: https://www.umin.ac.jp/ctr/; Unique Identifier: UMIN000001569.
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Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology Nippon Medical School Tama-Nagayama Hospital Tokyo Japan
| | | | | | | | | | - Toshiaki Otsuka
- Department of Hygiene and Public Health Nippon Medical School Tokyo Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology University of Toyama Japan
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12
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Barton TJ, Low DA, Bakker EA, Janssen T, de Groot S, van der Woude L, Thijssen DHJ. Traditional Cardiovascular Risk Factors Strongly Underestimate the 5-Year Occurrence of Cardiovascular Morbidity and Mortality in Spinal Cord Injured Individuals. Arch Phys Med Rehabil 2020; 102:27-34. [PMID: 32861666 DOI: 10.1016/j.apmr.2020.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/26/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To explore whether traditional models of cardiovascular disease (CVD) risk prediction correctly predict CVD events across a median 5.7-year follow-up period in individuals with spinal cord injury (SCI) and whether adding SCI-related characteristics (ie, lesion level) to the prediction model can improve the prognostic value. DESIGN Retrospective analysis of patient records. SETTING Observation at the start of active rehabilitation of participants in a multicenter cohort study, "Restoration of (Wheelchair) Mobility in SCI Rehabilitation," in the Netherlands. PARTICIPANTS Patients with SCI (N=200) The patients were 74% men, aged 40±14 years, and with an American Spinal Injury Association (ASIA) impairment score of A through D. Forty percent had tetraplegia, and 69% were motor complete. INTERVENTIONS Risk profiling/not applicable. MAIN OUTCOME MEASURES Survival status and cardiovascular morbidity and mortality qwere obtained from medical records. Five-year Framingham Risk Scores (FRS) and the FRS ability to predict events assessed using receiver operating characteristic (ROC) curves with corresponding areas under the curve (AUC) and 95% confidence intervals (CI). Kaplan-Meier curves and the log-rank test were used to assess the difference in clinical outcome between participants with an FRS score lower or higher than the median FRS score for the cohort. SCI-related factors associated with CVD events, ASIA impairment, motor completeness, level of injury, and sports participation before injury were explored using univariate and multivariate Cox proportional hazard regression. RESULTS The median 5-year FRS was 1.36%. Across a median follow-up period of 5.7 years, 39 developed a CVD event, including 10 fatalities. Although the FRS markedly underestimated the true occurrence of CVD events, the Kaplan-Meier curves and the log-rank test showed that the risk ratio for individuals with an FRS score less than the median FRS (eg, low risk) versus a score greater than the median FRS (high risk) was 3.2 (95% CI, 1.6-6.5; P=.001). Moreover, ROC with corresponding AUCs suggests acceptable accuracy of the FRS to identify individuals with increased risk for future CVD events (ROC AUC of 0.71; 95% CI, 0.62-0.82). Adding ASIA impairment (0.74; 95% CI, 0.66-0.82), motor impairment (0.74; 95% CI, 0.66-0.83), level of injury (0.72; 95% CI, 0.63-0.81), or active engagement in sport before injury (0.72; 95% CI, 0.63-0.88) to the FRS did not improve the level of discrimination. CONCLUSIONS Our 5.7-year retrospective study reveals that cardiovascular risk factors and risk models markedly underestimate the true risk for CVD events in individuals with SCI. Nonetheless, these markers successfully distinguish between SCI individuals at high versus low risk for future CVD events. Our data may have future clinical implications, both related to (cutoff values of) CVD risk factors, but also for (earlier) prescription of (non)pharmacologic strategies against CVD in SCI individuals.
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Affiliation(s)
- Thomas J Barton
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - David A Low
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Esmee A Bakker
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom; Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Thomas Janssen
- Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands
| | - Sonja de Groot
- Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands; University of Groningen, University Medical Center Groningen, Center of Human Movement Sciences; Groningen, the Netherlands
| | - Lucas van der Woude
- University of Groningen, University Medical Center Groningen, Center of Human Movement Sciences; Groningen, the Netherlands
| | - Dick H J Thijssen
- Research Institute for Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom; Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, the Netherlands.
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Barnett MP, Bangalore S. Cardiovascular Risk Factors: It's Time to Focus on Variability! J Lipid Atheroscler 2020; 9:255-267. [PMID: 32821735 PMCID: PMC7379092 DOI: 10.12997/jla.2020.9.2.255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Mallory P Barnett
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | - Sripal Bangalore
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY, USA
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Blood pressure variability at midlife is associated with all-cause, coronary heart disease and stroke long term mortality. J Hypertens 2020; 38:1722-1728. [DOI: 10.1097/hjh.0000000000002447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Visit-to-visit blood pressure variability in patients with type 2 diabetes with and without previous history of cardiovascular disease. J Hypertens 2020; 38:1737-1744. [DOI: 10.1097/hjh.0000000000002443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Risk Factor Variability and Cardiovascular Outcome: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 73:2596-2603. [PMID: 31118154 DOI: 10.1016/j.jacc.2019.02.063] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/15/2019] [Accepted: 02/21/2019] [Indexed: 02/08/2023]
Abstract
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.
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Factors Associated with Visit-to-Visit Variability of Blood Pressure Measured as Part of Routine Clinical Care among Patients Attending Cardiology Outpatient Department of a Tertiary Care Centre in Northern Sri Lanka. Int J Hypertens 2019; 2019:6450281. [PMID: 31885898 PMCID: PMC6915156 DOI: 10.1155/2019/6450281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 11/18/2022] Open
Abstract
Visit-to-visit variability (VVV) is a relatively new concept in the hypertensive arena. Data regarding VVV are lacking in our region, and factors associated with VVV are rarely examined in previous studies. This study was conducted among 406 patients attended to the cardiology outpatient department of Teaching Hospital, Jaffna, Sri Lanka, in 2018 to assess the long-term variability of blood pressure (BP) by reviewing last six consecutive BP readings from the records retrospectively. Data regarding sociodemographic variables and behavioural factors such as medication adherence, physical activity, smoking, alcohol consumption, and relevant comorbidities were taken through an interviewer-administered questionnaire. Data were analysed by using SPSS version 25 and VVV of systolic blood pressure (SBP) matrix expressed as mean of SD and association were examined with various factors and VVV of SBP. SBP showed high VVV among the participants as expressed by mean of SD which was 13.06 ± 5.64. When comparing mean SD among the categories of different variables, female sex (P=0.023) and comorbidities such as diabetes mellitus (DM) (P=0.013), chronic kidney disease (CKD) (P=0.007), and risk of developing obstructive sleep apnoea (OSA) (P=0.04) showed significant variation. Medication adherence to prescribed hypertensive medication was a major issue even though significant association was not found with high VVV (P=0.536). The SD of SBP was then classified into high and low VVV groups by means of a cutoff point at the 50th percentile. Bivariate analysis by using Chi-squared test revealed comorbidities such as DM, CKD, and physical activity (P=0.044) were significantly associated with high VVV. Further multivariate regression analysis revealed that comorbidities such as DM and CKD have 1.561 times and 5.999 times more risk to show high variability, respectively. In conclusion, we recommend simple practical measures to achieve sustainable BP control among hypertensive patients with DM and CKD to minimize the VVV and improve their cardiovascular outcome.
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Yu ZB, Li D, Chen XY, Zheng PW, Lin HB, Tang ML, Jin MJ, Wang JB, Chen K. Association of Visit-to-Visit Variability of Blood Pressure with Cardiovascular Disease among Type 2 Diabetes Mellitus Patients: A Cohort Study. Diabetes Metab J 2019; 43:350-367. [PMID: 30877712 PMCID: PMC6581546 DOI: 10.4093/dmj.2018.0108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increasing evidence has shown that visit-to-visit variability (VVV) of blood pressure (BP) is associated with an increased risk of cardiovascular disease (CVD). The objective of this study was to evaluate the impact of VVV of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on the risk of CVD among patients with type 2 diabetes mellitus (T2DM) in China. METHODS We conducted a retrospective cohort study of 10,163 T2DM patients who were not previously diagnosed with CVD from January 2008 to December 2012 in Ningbo, China. The VVV of BP was calculated using five metrics, including standard deviation (SD), coefficient of variation (CV), variation independent of mean, average real variability, and successive variability (SV) of measurements, obtained over a 24-month measurement period. Hazard ratios and 95% confidence intervals (CIs) were estimated by Cox proportional hazards regression models for the associations of variability in BP with risk of CVD. RESULTS A total of 894 CVD events were observed during a median follow-up of 49.5 months. The hazard ratio in the highest quintile of SD of SBP was 1.24 (95% CI, 1.01 to 1.52) compared with patients in the lowest quintile. The association between higher VVV of DBP and risk of CVD was not consistent across different metrics and sensitivity analyses. CONCLUSION Higher VVV of SBP was associated with an increased risk of CVD, irrespective of the mean SBP level. Future studies are needed to confirm these findings.
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Affiliation(s)
- Zhe Bin Yu
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Die Li
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Xue Yu Chen
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Pei Wen Zheng
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Hong Bo Lin
- Center for Disease Control and Prevention of Yinzhou District, Ningbo, China
| | - Meng Ling Tang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Ming Juan Jin
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Jian Bing Wang
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
- Research Center for Air Pollution and Health, Zhejiang University, Hangzhou, China.
| | - Kun Chen
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
- Research Center for Air Pollution and Health, Zhejiang University, Hangzhou, China.
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Lee HT, Namgung J, Lim YH, Park HC, Park JK, Shin J. The relationship between visit-to-visit variability in blood pressure and incidence of metabolic syndrome: a general population-based cohort study in Korea. Clin Hypertens 2019; 25:11. [PMID: 31123598 PMCID: PMC6518773 DOI: 10.1186/s40885-019-0117-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/18/2019] [Indexed: 01/13/2023] Open
Abstract
Background Previous studies demonstrated that visit-to-visit variability of blood pressure (BP) has significant relationship with cardiovascular disease. Visit-to-visit variability in BP might have prognostic value for cardiovascular disease. The aim of this study is to evaluate the effect of visit-to-visit variability in BP on development of metabolic syndrome in general population without cardiovascular disease, diabetes mellitus, metabolic syndrome, and BP medication. Method We used data from the Korean Genome Epidemiology Study conducted by the Korean Centers for Disease Control and Prevention. All cohorts who were followed first 3 periods formed the basis of the study sample, which consisted of 7195 people. Of these samples, 3431 subjects who had cardiovascular disease, diabetes mellitus, or metabolic syndrome were excluded, and 312 subjects who were using antihypertensive medication in first 3 periods were excluded. Our final study sample consisted of 3452 cohorts. Results The mean age was 53.5 (8.25) years. The proportion of male was 50.2%. Average follow-up duration was 5.91 (0.17) years. In generalized estimating equation, the development of metabolic syndrome was associated with mean systolic BP (SBP) (Odd ratio (OR) 1.042, 95% confidence interval (CI) 1.035–1.048, p < 0.001), mean diastolic BP (DBP) (OR 1.058, 95% CI 1.049–1.069, p < 0.001), standard deviation (SD) of SBP (OR 1.036, 95% CI 1.017–1.055, p < 0.001), SD of DBP (OR 1.053, 95% CI 1.027–1.080, p < 0.001), and coefficient of variation (CV) of DBP (OR 1.025, 95% CI 1.005–1.046, p = 0.016) after adjusted for age, sex, and metabolic syndrome component. When mean SBP, mean DBP, SBP variability, and DBP variability were entered all together in the analysis model, SD of DBP (OR 1.033, 95% CI 1.003–1.063, p = 0.030) and CV of DBP (OR 1.027, 95% CI 1.004–1.051, p = 0.020) were significantly associated with the development of metabolic syndrome. Conclusion In general population without cardiovascular disease, diabetes mellitus, metabolic syndrome, and BP medication, SD of DBP and CV of DBP was associated with the development of metabolic syndrome. Visit-to-visit variability in DBP might be helpful for the prediction of future metabolic syndrome development.
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Affiliation(s)
- Hyung Tak Lee
- Departments of Internal Medicine, Gumdan Top General Hospital, Incheon, Republic of Korea
| | - June Namgung
- 2Division of Cardiology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Young-Hyo Lim
- 3Division of Cardiology, Departments of Internal Medicine, Hanyang University, College of Medicine, 222 Wangsimni-ro Sungdong-gu, 133-792 Seoul, Republic of Korea
| | - Hwan-Cheol Park
- 3Division of Cardiology, Departments of Internal Medicine, Hanyang University, College of Medicine, 222 Wangsimni-ro Sungdong-gu, 133-792 Seoul, Republic of Korea
| | - Jin-Kyu Park
- 3Division of Cardiology, Departments of Internal Medicine, Hanyang University, College of Medicine, 222 Wangsimni-ro Sungdong-gu, 133-792 Seoul, Republic of Korea
| | - Jinho Shin
- 3Division of Cardiology, Departments of Internal Medicine, Hanyang University, College of Medicine, 222 Wangsimni-ro Sungdong-gu, 133-792 Seoul, Republic of Korea
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Visit-to-visit systolic blood pressure variability in patients with ST-elevation myocardial infarction predicts long-term cardiovascular outcomes. J Hum Hypertens 2019; 33:259-266. [PMID: 30778130 PMCID: PMC6760754 DOI: 10.1038/s41371-019-0176-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 01/11/2019] [Accepted: 01/24/2019] [Indexed: 12/22/2022]
Abstract
Elevated visit-to-visit blood pressure variability (BPV), independent of mean BP, has been associated with cardiovascular events. However, its impact after ST-elevation myocardial infarction (STEMI) has not been established. This study aimed to investigate the prognostic impact of BPV on patients after STEMI. We analyzed the data and clinical outcomes of STEMI survivors who underwent successful primary coronary intervention from 2003 to 2009. BP was measured at discharge and at 1, 3, 6, 12, 24, and 36 months, and we calculated BPV as the intra-individual standard deviations (SDs) of systolic BP (SBP) across these measurements. We classified the patients as high and low-BPV group, and evaluated the outcomes: occurrence of major adverse cardiovascular events (MACEs), death, recurrent myocardial infarction, and target vessel revascularization within 60 months. We enrolled 343 patients, and mean follow-up duration was 68 ± 34 months (median: 76 months). Mean and median SBP SDs were 13.2 and 12.3 mmHg, and patients were divided into one of the two groups based on the median (high-BPV group = SD ≥ 12.3 mmHg; low-BPV group = SD < 12.3 mmHg). The MACE-free survival in the high-BPV group was significantly worse than that in low-BPV group (log-rank p = 0.035). For the high-BPV group, the risk of a MACE significantly increased by 57% (95% confidence interval: 1.03–2.39; p = 0.038). Visit-to-visit systolic BPV was associated with increased rates of adverse clinical outcomes in patients after STEMI. Careful assessment of BP and attempts to reduce BPV might be also important in STEMI survivors.
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Impact of obstructive sleep apnea on long-term blood pressure variability in Japanese men: a cross-sectional study of a work-site population. Hypertens Res 2018; 41:957-964. [DOI: 10.1038/s41440-018-0096-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/10/2018] [Accepted: 03/17/2018] [Indexed: 11/08/2022]
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Visit-to-visit blood pressure variability is a risk factor for all-cause mortality and cardiovascular disease: a systematic review and meta-analysis. J Hypertens 2017; 35:10-17. [PMID: 27906836 DOI: 10.1097/hjh.0000000000001159] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Abstract
OBJECTIVE Higher blood pressure variability (BPV), independent of mean blood pressure (BP), has been associated with adverse health outcomes. We investigated the association between visit-to-visit BPV and functional decline in older adults at high cardiovascular risk. METHODS In PROspective Study of Pravastatin in the Elderly at Risk, 4745 participants with mean age of 75.2 years and high cardiovascular risk were followed for a mean of 3.2 years. BP was measured in every 3 months during the first 18 months. BPV was defined as the intraindividual SD of measurements across these visits. Functional status in basic and instrumental activities of daily living was measured using the Barthel (ADL) and Lawton (IADL) scales, first at 18 months and then during follow-up until 48 months. Functional decline was calculated over this period. RESULTS BPV was not cross-sectionally associated with functional status at 18 months. Higher SBPV was associated with steeper functional decline, whereas DBPV was not. Each 10 mmHg higher SBPV was associated with a 0.064 (95% confidence interval 0.016-0.112, P = 0.009) annual decline in ADL score and with a 0.078 decline (95% confidence interval 0.020-0.136, P = 0.008) in IADL score. These associations were not modified by sex, hypertension or antihypertensives. These findings were independent of mean BP, cardiovascular risk factors and morbidities and cognition. CONCLUSION Higher visit-to-visit SBPV but not DBPV was associated with steeper functional decline in older adults at high cardiovascular risk. Higher SBPV is a novel risk factor for functional decline.
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Setia S, Subramaniam K, Tay JC, Teo BW. Hypertension and blood pressure variability management practices among physicians in Singapore. Vasc Health Risk Manag 2017; 13:275-285. [PMID: 28761353 PMCID: PMC5522821 DOI: 10.2147/vhrm.s138694] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose There are limited data on blood pressure variability (BPV) in Singapore. The absence of updated local guidelines might contribute to variations in diagnosis, treatment and control of hypertension and BPV between physicians. This study evaluated BPV awareness, hypertension management and associated training needs in physicians from Singapore. Materials and methods Physicians from Singapore were surveyed between September 8, 2016, and October 5, 2016. Those included were in public or private practice for ≥3 years, cared directly for patients ≥70% of the time and treated ≥30 patients for hypertension each month. The questionnaire covered 6 main categories: general blood pressure (BP) management, BPV awareness/diagnosis, home BP monitoring (HBPM), ambulatory BP monitoring (ABPM), BPV management and associated training needs. Results Responses from 60 physicians (30 general practitioners [GPs], 20 cardiologists, 10 nephrologists) were analyzed (77% male, 85% aged 31–60 years, mean 22 years of practice). Approximately 63% of physicians considered white-coat hypertension as part of BPV. The most common diagnostic tool was HBPM (overall 77%, GPs 63%, cardiologists 65%, nephrologists 70%), but ABPM was rated as the tool most valued by physicians (80% overall), especially specialists (97%). Withdrawn Singapore guidelines were still being used by 73% of GPs. Approximately 48% of physicians surveyed did not adhere to the BP cutoff recommended by most guidelines for diagnosing hypertension using HBPM (>135/85 mmHg). Hypertension treatment practices also varied from available guideline recommendations, although physicians did tend to use a lower BP target for patients with diabetes or kidney disease. There were a number of challenges to estimating BPV, the most common of which was patient refusal of ABPM/HBPM. The majority of physicians (82%) had no training on BPV, but stated that this would be useful. Conclusion There appear to be gaps in knowledge and guideline adherence relating to the assessment and management of BPV among physicians in Singapore.
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Affiliation(s)
- Sajita Setia
- Chief Medical Office, Medical Affairs, Pfizer Pte Ltd, Singapore
| | - Kannan Subramaniam
- Global Medical Affairs, Asia Pacific Region, Pfizer Australia, West Ryde, NSW, Australia
| | - Jam Chin Tay
- Department of General Medicine, Tan Tock Seng Hospital
| | - Boon Wee Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Parizadeh D, Ghahvehchian H, Asgari S, Momenan AA, Azizi F, Hadaegh F. The association between changes in blood pressure components and incident cardiovascular diseases. Blood Press 2017; 26:341-349. [PMID: 28708028 DOI: 10.1080/08037051.2017.1353882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the association of changes in blood pressure (BP) components between baseline examination (1999-2001) and a second visit (2002-2005) with incident cardiovascular diseases (CVD). METHODS In 3569 (2048 female) Iranian subjects ≥30 y, systolic BP, diastolic BP, mean arterial pressure (MAP) and pulse pressure (PP) were evaluated in two consecutive visits. Subjects were then followed for cardiovascular events. Multivariate sex-adjusted Cox Proportional-Hazards models were built for each BP component's change, and further adjusted for baseline BP values, traditional cardiovascular risk factors, and their changes. RESULTS During a median follow-up of 6.09 years after the second examination, 303 CVD cases occurred. A 1 SD increase in systolic BP, diastolic BP and MAP were significantly associated with 21%, 22%, and 95% increased CVD risk after adjustments for baseline values of BP components and other common risk factors (all p-values <0.05). Importantly, diastolic BP change resisted after further adjustment with systolic BP change (hazard ratio 1.21, CI 95% 1.05-1.39). PP change showed no significant association with CVD. CONCLUSIONS In a middle-aged population, three-year rises in systolic BP, diastolic BP, MAP, but not PP were associated with increased incident CVD. The significant association between diastolic BP change and CVD was shown independent of systolic BP change.
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Affiliation(s)
- Donna Parizadeh
- a Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Hosein Ghahvehchian
- a Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Samaneh Asgari
- a Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Amir Abbas Momenan
- a Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Fereidoun Azizi
- b Endocrine Research Center, Research Institute for Endocrine Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Farzad Hadaegh
- a Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences , Shahid Beheshti University of Medical Sciences , Tehran , Iran
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Cavarretta E, Frati G, Sciarretta S. Visit-to-Visit Systolic Blood Pressure Variability and Cardiovascular Outcomes: New Data From a Real-World Korean Population. Am J Hypertens 2017; 30:550-553. [PMID: 28379328 DOI: 10.1093/ajh/hpx055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/15/2017] [Indexed: 01/26/2023] Open
Affiliation(s)
- Elena Cavarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Department of AngioCardioNeurology, IRCCS NeuroMed, Pozzilli, Isernia, Italy
| | - Sebastiano Sciarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Department of AngioCardioNeurology, IRCCS NeuroMed, Pozzilli, Isernia, Italy
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Ayalon-Dangur I, Shochat T, Shiber S, Grossman A. Can Diastolic Blood Pressure Decrease in Emergency Department Setting be Anticipated? High Blood Press Cardiovasc Prev 2017; 24:387-392. [DOI: 10.1007/s40292-017-0210-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/13/2017] [Indexed: 11/28/2022] Open
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Wu C, Shlipak MG, Stawski RS, Peralta CA, Psaty BM, Harris TB, Satterfield S, Shiroma EJ, Newman AB, Odden MC. Visit-to-Visit Blood Pressure Variability and Mortality and Cardiovascular Outcomes Among Older Adults: The Health, Aging, and Body Composition Study. Am J Hypertens 2017; 30:151-158. [PMID: 27600581 DOI: 10.1093/ajh/hpw106] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/07/2016] [Accepted: 08/17/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Level of blood pressure (BP) is strongly associated with cardiovascular (CV) events and mortality. However, it is questionable whether mean BP can fully capture BP-related vascular risk. Increasing attention has been given to the value of visit-to-visit BP variability. METHODS We examined the association of visit-to-visit BP variability with mortality, incident myocardial infarction (MI), and incident stroke among 1,877 well-functioning elders in the Health, Aging, and Body Composition Study. We defined visit-to-visit diastolic BP (DBP) and systolic BP (SBP) variability as the root-mean-square error of person-specific linear regression of BP as a function of time. Alternatively, we counted the number of considerable BP increases and decreases (separately; 10mm Hg for DBP and 20mm Hg for SBP) between consecutive visits for each individual. RESULTS Over an average follow-up of 8.5 years, 623 deaths (207 from CV disease), 153 MIs, and 156 strokes occurred. The median visit-to-visit DBP and SBP variability was 4.96 mmHg and 8.53 mmHg, respectively. After multivariable adjustment, visit-to-visit DBP variability was related to higher all-cause (hazard ratio (HR) = 1.18 per 1 SD, 95% confidence interval (CI) = 1.01-1.37) and CV mortality (HR = 1.35, 95% CI = 1.05-1.73). Additionally, individuals having more considerable decreases of DBP (≥10mm Hg between 2 consecutive visits) had higher risk of all-cause (HR = 1.13, 95% CI = 0.99-1.28) and CV mortality (HR = 1.30, 95% CI = 1.05-1.61); considerable increases of SBP (≥20mm Hg) were associated with higher risk of all-cause (HR = 1.18, 95% CI = 1.03-1.36) and CV mortality (HR = 1.37, 95% CI = 1.08-1.74). CONCLUSIONS Visit-to-visit DBP variability and considerable changes in DBP and SBP were risk factors for mortality in the elderly.
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Affiliation(s)
- Chenkai Wu
- School of Biological and Population Health Sciences, Oregon State University, Corvallis, Oregon, USA;
| | - Michael G Shlipak
- Department of Medicine, University of California, San Francisco, California, USA
- Department of Medicine, Kidney Health Research Collaborative at the San Francisco VA Medical Center, San Francisco, California, USA
| | - Robert S Stawski
- School of Social and Human Health Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Carmen A Peralta
- Department of Medicine, University of California, San Francisco, California, USA
- Department of Medicine, Kidney Health Research Collaborative at the San Francisco VA Medical Center, San Francisco, California, USA
| | | | - Tamara B Harris
- Intramural Research Program, Laboratory of Epidemiology and Population Sciences, National Institute on Aging, Bethesda, Maryland, USA
| | - Suzanne Satterfield
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Eric J Shiroma
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne B Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michelle C Odden
- School of Biological and Population Health Sciences, Oregon State University, Corvallis, Oregon, USA
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Slepecky M, Kotianova A, Prasko J, Majercak I, Gyorgyova E, Kotian M, Zatkova M, Popelkova M, Ociskova M, Tonhajzerova I. Which psychological, psychophysiological, and anthropometric factors are connected with life events, depression, and quality of life in patients with cardiovascular disease. Neuropsychiatr Dis Treat 2017; 13:2093-2104. [PMID: 28831258 PMCID: PMC5552144 DOI: 10.2147/ndt.s141811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of the study was to determine psychological, psychophysiological, and anthropometric factors connected with life events, level of depression, and quality of life in people at risk for cardiovascular disease and healthy controls. METHODS This is a cross-sectional study involving arterial hypertension patients and healthy controls. There were several measurements including physical, anthropological, cardiovascular, and psychophysiological measurements and administration of questionnaires. RESULTS A total of 99 participants were recruited for this study, 54 healthy controls (mean age: 35.59±13.39 years) and 45 patients with cardiovascular disease (CVD) (mean age: 46.33±12.39 years). The healthy controls and the patients with CVD significantly differed in the mean total score of life events, level of depression, quality of life score, temperature, blood pressure (BP), pulse transit time, heart rate, high-frequency total power, heart rate variability total power, waist-to-height ratio (WHtR), body fat percentage, fat control, pulse wave velocity, and augmentation index. In healthy subjects, the total score of the life events was not correlated with any cardiovascular or anthropometric factor. A score of depression significantly correlated with the WHtR, augmentation index, body fat percentage, and fat control. The quality of life - visual scale correlated with the body temperature, BP, and percentage of body fat. In the group of the patients with CVD, the score of the life events did not correlate with any measured cardiovascular or anthropometric factor. The level of depression correlated with the augmentation index. The quality of life - visual scale significantly correlated with body temperature, WHtR, and fat control. CONCLUSION The patients with CVD reported higher scores of life events, worse quality of life, and a greater level of depressive symptoms than healthy controls. In healthy controls, a higher mean total score of life events significantly negatively correlated with high-frequency total power, and the degree of depression correlated with being overweight. In patients with CVD, a score of depression was linked to being overweight.
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Affiliation(s)
- Milos Slepecky
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra
| | - Antonia Kotianova
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra.,Psychagogia, Liptovsky Mikulas, Slovak Republic
| | - Jan Prasko
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra.,Department of Psychiatry, Faculty of Medicine and Dentistry, University Palacky Olomouc, University Hospital Olomouc, Olomouc, Czech Republic
| | - Ivan Majercak
- First Department of Internal Medicine, Faculty of Medicine, Pavol Josef Safarik University in Kosice.,Internal Medicine and Cardiology Private Practice, MUDr Ivan Majercak, Kosice
| | - Erika Gyorgyova
- Internal Medicine and Cardiology Private Practice, MUDr Ivan Majercak, Kosice
| | - Michal Kotian
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra.,Psychagogia, Liptovsky Mikulas, Slovak Republic
| | - Marta Zatkova
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra
| | - Marta Popelkova
- Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra
| | - Marie Ociskova
- Department of Psychiatry, Faculty of Medicine and Dentistry, University Palacky Olomouc, University Hospital Olomouc, Olomouc, Czech Republic
| | - Ingrid Tonhajzerova
- Department of Physiology and Biomedical Centre Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
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Stevens SL, Wood S, Koshiaris C, Law K, Glasziou P, Stevens RJ, McManus RJ. Blood pressure variability and cardiovascular disease: systematic review and meta-analysis. BMJ 2016; 354:i4098. [PMID: 27511067 PMCID: PMC4979357 DOI: 10.1136/bmj.i4098] [Citation(s) in RCA: 479] [Impact Index Per Article: 59.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Sarah L Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Sally Wood
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Kathryn Law
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Paul Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Richard J Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
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McMullan CJ, Forman JP. Finding a Signal in the Noise. Clin J Am Soc Nephrol 2016; 11:374-6. [PMID: 26912545 DOI: 10.2215/cjn.00880116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Ciaran J McMullan
- Renal Division, Department of Medicine, andChanning Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - John P Forman
- Renal Division, Department of Medicine, andChanning Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Meredith PA, Lloyd SM, Ford I, Elliott HL. Importance of sustained and "tight" blood pressure control in patients with high cardiovascular risk. Blood Press 2016; 25:74-82. [PMID: 26796355 DOI: 10.3109/08037051.2015.1127528] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A retrospective further analysis of the ACTION database evaluated the relationship between cardiovascular outcomes and the "quality" of the control of blood pressure (BP). The study population (n = 6287) comprised those patients with four BP measurements during year 1 subdivided according to the proportion of visits in which BP was controlled in relation to two BP targets: < 140/90mmHg and < 130/80 mmHg. Differences between the BP control groups for the major prespecified ACTION outcomes were investigated with Cox proportional hazards models. For all the prespecified cardiovascular endpoints the incidence declined as the proportion of visits with BP control increased. The greatest differences in outcomes between the different BP control groups were observed for the risk of stroke but were still apparent for all the other endpoints. For example, the risks for the primary outcome [hazard ratio (HR) 0.78; 95% confidence interval (CI) 0.67 to 0.90] were significantly less in the group with >_75% of visits with BP control than in the group with < 25% of visits with BP control. There were no significant treatment-related differences. Retrospective analyses are not definitive but these results highlight the importance of the attainment of BP control targets and the consistency of BP control during long-term follow-up.
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Affiliation(s)
- Peter A Meredith
- a Division of Cardiovascular and Medical Sciences , University of Glasgow , Western Infirmary , Glasgow , UK
| | - Suzanne M Lloyd
- b Robertson Centre for Biostatistics, University of Glasgow , Glasgow , UK
| | - Ian Ford
- b Robertson Centre for Biostatistics, University of Glasgow , Glasgow , UK
| | - Henry L Elliott
- c Institute of Pharmaceutical and Biomedical Sciences, University of Strathclyde , Glasgow , UK
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Higher visit-to-visit intra-dialytic blood pressure is associated with the progression of aortic valve stenosis in chronic hemodialysis patients. Heart Vessels 2015; 31:1491-6. [PMID: 26438530 DOI: 10.1007/s00380-015-0756-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 09/25/2015] [Indexed: 10/23/2022]
Abstract
Aortic valve stenosis (AS) is a frequent complication contributing to poor prognosis in chronic hemodialysis (CHD) patients. High blood pressure (BP) is known to be associated with AS progression in the general population. In CHD patients, however, BP varies during and between hemodialysis sessions with ultrafiltration volume or inter-dialytic weight gain; therefore it is difficult to characterize the BP status with a conventional single measurement. Our purpose was to clarify the BP variables affecting AS progression in CHD patients. We retrospectively enrolled 32 consecutive CHD patients with AS [aortic valve area (AVA), 1.3 ± 0.3 cm(2); mean age 69 ± 8 years] who had serial transthoracic echocardiographic studies at least 6 months apart (mean 23 ± 9 months). AS progression was evaluated using absolute reduction in AVA per year. Pre-dialytic and intra-dialytic (every hour during sessions) BPs throughout the 3 consecutive visits were used to determine each patient's BP status. We calculated the mean values of pre-dialytic and intra-dialytic BPs and their variability. In univariate analysis, mean visit-to-visit pre-dialytic and intra-dialytic BP were associated with AS progression, whereas all variables of BP variability were not. Multiple regression analysis indicated that only mean visit-to-visit intra-dialytic systolic and diastolic BP remained independently associated with AS progression after adjustment for age, sex, hypertension, hypercholesterolemia, diabetes mellitus, and serum parathyroid hormone (p < 0.05). Although BP regulation in CHD patients is complex and multifactorial, mean visit-to-visit intra-dialytic BP was independently associated with AS progression. Prospective studies are necessary before considering intra-dialytic BP as a potential target for therapy.
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Asayama K, Wei FF, Hara A, Hansen TW, Li Y, Staessen JA. Prognosis in Relation to Blood Pressure Variability. Hypertension 2015; 65:1170-9; discussion 1179. [DOI: 10.1161/hypertensionaha.115.04808] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kei Asayama
- From the Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (F.-F.W., A.H., J.A.S.); Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan (K.A.); Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.); the Steno Diabetes Center, Gentofte and
| | - Fang-Fei Wei
- From the Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (F.-F.W., A.H., J.A.S.); Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan (K.A.); Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.); the Steno Diabetes Center, Gentofte and
| | - Azusa Hara
- From the Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (F.-F.W., A.H., J.A.S.); Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan (K.A.); Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.); the Steno Diabetes Center, Gentofte and
| | - Tine W. Hansen
- From the Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (F.-F.W., A.H., J.A.S.); Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan (K.A.); Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.); the Steno Diabetes Center, Gentofte and
| | - Yan Li
- From the Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (F.-F.W., A.H., J.A.S.); Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan (K.A.); Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.); the Steno Diabetes Center, Gentofte and
| | - Jan A. Staessen
- From the Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (F.-F.W., A.H., J.A.S.); Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan (K.A.); Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan (K.A.); the Steno Diabetes Center, Gentofte and
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Taylor KS, Heneghan CJ, Stevens RJ, Adams EC, Nunan D, Ward A. Heterogeneity of prognostic studies of 24-hour blood pressure variability: systematic review and meta-analysis. PLoS One 2015; 10:e0126375. [PMID: 25984791 PMCID: PMC4435972 DOI: 10.1371/journal.pone.0126375] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/01/2015] [Indexed: 01/19/2023] Open
Abstract
In addition to mean blood pressure, blood pressure variability is hypothesized to have important prognostic value in evaluating cardiovascular risk. We aimed to assess the prognostic value of blood pressure variability within 24 hours. Using MEDLINE, EMBASE and Cochrane Library to April 2013, we conducted a systematic review of prospective studies of adults, with at least one year follow-up and any day, night or 24-hour blood pressure variability measure as a predictor of one or more of the following outcomes: all-cause mortality, cardiovascular mortality, all cardiovascular events, stroke and coronary heart disease. We examined how blood pressure variability is defined and how its prognostic use is reported. We analysed relative risks adjusted for covariates including the appropriate mean blood pressure and considered the potential for meta-analysis. Our analysis of methods included 24 studies and analysis of predictions included 16 studies. There were 36 different measures of blood pressure variability and 13 definitions of night- and day-time periods. Median follow-up was 5.5 years (interquartile range 4.2–7.0). Comparing measures of dispersion, coefficient of variation was less well researched than standard deviation. Night dipping based on percentage change was the most researched measure and the only measure for which data could be meaningfully pooled. Night dipping or lower night-time blood pressure was associated with lower risk of cardiovascular events. The interpretation and use in clinical practice of 24-hour blood pressure variability, as an important prognostic indicator of cardiovascular events, is hampered by insufficient evidence and divergent methodologies. We recommend greater standardisation of methods.
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Affiliation(s)
- Kathryn S. Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Carl J. Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard J. Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Emily C. Adams
- Oxford University Hospitals Trust, Oxford, United Kingdom
| | - David Nunan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alison Ward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Poortvliet RKE, Lloyd SM, Ford I, Sattar N, de Craen AJM, Wijsman LW, Mooijaart SP, Westendorp RGJ, Jukema JW, de Ruijter W, Gussekloo J, Stott DJ. Biological correlates of blood pressure variability in elderly at high risk of cardiovascular disease. Am J Hypertens 2015; 28:469-79. [PMID: 25298176 DOI: 10.1093/ajh/hpu181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Visit-to-visit variability in blood pressure is an independent predictor of cardiovascular disease. This study investigates biological correlates of intra-individual variability in blood pressure in older persons. METHODS Nested observational study within the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) among 3,794 male and female participants (range 70-82 years) with a history of, or risk factors for cardiovascular disease. Individual visit-to-visit variability in systolic and diastolic blood pressure and pulse pressure (expressed as 1 SD in mm Hg) was assessed using nine measurements over 2 years. Correlates of higher visit-to-visit variability were examined at baseline, including markers of inflammation, endothelial function, renal function and glucose homeostasis. RESULTS Over the first 2 years, the mean intra-individual variability (1 SD) was 14.4mm Hg for systolic blood pressure, 7.7mm Hg for diastolic blood pressure, and 12.6mm Hg for pulse pressure. After multivariate adjustment a higher level of interleukin-6 at baseline was consistently associated with higher intra-individual variability of blood pressure, including systolic, diastolic, and pulse pressure. Markers of endothelial function (Von Willebrand factor, tissue plasminogen activator), renal function (glomerular filtration rate) and glucose homeostasis (blood glucose, homeostatic model assessment index) were not or to a minor extent associated with blood pressure variability. CONCLUSION In an elderly population at risk of cardiovascular disease, inflammation (as evidenced by higher levels of interleukin-6) is associated with higher intra-individual variability in systolic, diastolic, and pulse pressure.
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Affiliation(s)
- Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands;
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Anton J M de Craen
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Liselotte W Wijsman
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands; Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands; Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands; Institute for Evidence-Based Medicine in Old Age, Leiden, The Netherlands
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter de Ruijter
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - David J Stott
- Academic Section of Geriatric Medicine, University of Glasgow-Faculty of Medicine, Glasgow Royal Infirmary, Glasgow, UK
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Gavriilaki E, Gkaliagkousi E, Douma S. Visit-To-Visit Blood Pressure Variability: More to Come. J Clin Hypertens (Greenwich) 2015; 17:116-7. [DOI: 10.1111/jch.12480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Eleni Gavriilaki
- 3rd Department of Internal Medicine; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Eugenia Gkaliagkousi
- 2nd Propedeutic Department of Internal Medicine; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Stella Douma
- 3rd Department of Internal Medicine; Aristotle University of Thessaloniki; Thessaloniki Greece
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The effects of weight loss and salt reduction on visit-to-visit blood pressure variability: results from a multicenter randomized controlled trial. J Hypertens 2014; 32:840-8. [PMID: 24366034 DOI: 10.1097/hjh.0000000000000080] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES As evidence suggests visit-to-visit variability (VVV) of blood pressure (BP) is associated with cardiovascular events and mortality, there is increasing interest in identifying interventions that reduce VVV of BP. We investigated the effects of weight loss and sodium reduction, alone or in combination, on VVV of BP in participants enrolled in phase II of the Trials of Hypertension Prevention. METHODS BP readings were taken at 6-month intervals for 36 months in 1820 participants with high-normal DBP who were randomized to weight loss, sodium reduction, combination (weight loss and sodium reduction), or usual care groups. VVV of BP was defined as the SD of BP across six follow-up visits. RESULTS VVV of SBP was not significantly different between participants randomized to the weight loss (7.2 ± 3.1 mmHg), sodium reduction (7.1 ± 3.0 mmHg), or combined (6.9 ± 2.9 mmHg) intervention groups vs. the usual care group (6.9 ± 2.9 mmHg). In a fully adjusted model, no difference (0.0 ± 0.2 mmHg) in VVV of SBP was present between individuals who successfully maintained their weight loss vs. individuals who did not lose weight during follow-up (P = 0.93). Also, those who maintained a reduced sodium intake throughout follow-up did not have lower VVV of SBP compared to those who did not reduce their sodium intake (0.1 ± 0.3 mmHg; P = 0.77). Results were similar for VVV of DBP. CONCLUSIONS These findings suggest that weight loss and sodium reduction may not be effective interventions for lowering VVV of BP in individuals with high-normal DBP.
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Yu JM, Kong QY, Schoenhagen P, Shen T, He YS, Wang JW, Zhao YP, Shi DN, Zhong BL. The prognostic value of long-term visit-to-visit blood pressure variability on stroke in real-world practice: a dynamic cohort study in a large representative sample of Chinese hypertensive population. Int J Cardiol 2014; 177:995-1000. [PMID: 25449513 DOI: 10.1016/j.ijcard.2014.09.149] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/25/2014] [Accepted: 09/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The prognostic significance of long-term visit-to-visit blood pressure variability (BPV) has not yet been validated in "real world" hypertensive patients. The aim of the current study is to explore the prognostic value of BPV on stroke in hypertensive patients. METHODS This was a dynamic prospective cohort study based on electronic medical records in Shanghai, China. Hypertensive patients (N=122,636) without history of stroke at baseline, were followed up from 2005 to 2011. The cohort comprised of 4522 stroke patients and 118,114 non-stroke patients during a mean follow-up duration of 48 months. BPV was measured by standard deviation (SD) and the coefficient of variation (CV) of blood pressure. RESULTS The visit-to-visit variability of both systolic blood pressure (SBP) and diastolic blood pressure (DBP) was independently associated with the occurrence of stroke [SD: the hazard ratios (95% confidence intervals) of SBP and DBP were 1.042 (1.021 to 1.064) and 1.052 (1.040 to 1.065); CV: the hazard ratios (95% confidence intervals) of SBP and DBP were 1.183 (1.010 to 1.356) and 1.151 (1.005 to 1.317), respectively]. The hazard ratio values increased along with an increase of the BPV levels of SBP and DBP. The increment effect remained significant after controlling the blood pressure control status of subjects. CONCLUSIONS Increased BPV of both SBP and DBP, independent of the average blood pressure, is a predictor of stroke among community hypertensive patients in real-world clinical practice. The risk of stroke increased along with increased BPV. Stabilizing BPV might be a therapeutic target in hypertension.
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Affiliation(s)
- Jin-ming Yu
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China.
| | - Qun-yu Kong
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| | - Paul Schoenhagen
- Cleveland Clinic, Imaging Institute and Heart & Vascular Institute, Cleveland, OH, USA
| | - Tian Shen
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| | - Yu-song He
- Medical Affairs of Great China Region of Novartis, Beijing, China
| | - Ji-wei Wang
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| | - Yan-ping Zhao
- Shanghai Minhang Center for Disease Control and Prevention, Shanghai, China
| | - Dan-ni Shi
- Medical Affairs of Great China Region of Novartis, Beijing, China
| | - Bao-liang Zhong
- Department of Science and Education, Affiliated Mental Health Center, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Hara A, Thijs L, Asayama K, Jacobs L, Wang JG, Staessen JA. Randomised double-blind comparison of placebo and active drugs for effects on risks associated with blood pressure variability in the Systolic Hypertension in Europe trial. PLoS One 2014; 9:e103169. [PMID: 25090617 PMCID: PMC4121168 DOI: 10.1371/journal.pone.0103169] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 06/23/2014] [Indexed: 12/23/2022] Open
Abstract
Background In the Systolic Hypertension in Europe trial (NCT02088450), we investigated whether systolic blood pressure variability determines prognosis over and beyond level. Methods Using a computerised random function and a double-blind design, we randomly allocated 4695 patients (≥60 years) with isolated systolic hypertension (160–219/<95 mm Hg) to active treatment or matching placebo. Active treatment consisted of nitrendipine (10–40 mg/day) with possible addition of enalapril (5–20 mg/day) and/or hydrochlorothiazide (12.5–25.0 mg/day). We assessed whether on-treatment systolic blood pressure level (SBP), visit-to-visit variability independent of the mean (VIM) or within-visit variability (WVV) predicted total (n = 286) or cardiovascular (n = 150) mortality or cardiovascular (n = 347), cerebrovascular (n = 133) or cardiac (n = 217) endpoints. Findings At 2 years, mean between-group differences were 10.5 mm Hg (p<0.0001) for SBP, 0.29 units (p = 0.20) for VIM, and 0.07 mm Hg (p = 0.47) for WVV. Active treatment reduced (p≤0.048) cardiovascular (−28%), cerebrovascular (−40%) and cardiac (−24%) endpoints. In analyses dichotomised by the median, patients with low vs. high VIM had similar event rates (p≥0.14). Low vs. high WVV was not associated with event rates (p≥0.095), except for total and cardiovascular mortality on active treatment, which were higher with low WVV (p≤0.0003). In multivariable-adjusted Cox models, SBP predicted all endpoints (p≤0.0043), whereas VIM did not predict any (p≥0.058). Except for an inverse association with total mortality (p = 0.042), WVV was not predictive (p≥0.15). Sensitivity analyses, from which we excluded blood pressure readings within 6 months after randomisation, 6 months prior to an event or both were confirmatory. Conclusions The double-blind placebo-controlled Syst-Eur trial demonstrated that blood-pressure lowering treatment reduces cardiovascular complications by decreasing level but not variability of SBP. Higher blood pressure level, but not higher variability, predicted risk. Trial Registration ClinicalTrials.gov NCT02088450
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Affiliation(s)
- Azusa Hara
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium
| | - Kei Asayama
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Lotte Jacobs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium
| | - Ji-Guang Wang
- Center for Epidemiological Studies and Clinical Trials, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jan A. Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands
- * E-mail:
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Diaz KM, Tanner RM, Falzon L, Levitan EB, Reynolds K, Shimbo D, Muntner P. Visit-to-visit variability of blood pressure and cardiovascular disease and all-cause mortality: a systematic review and meta-analysis. Hypertension 2014; 64:965-82. [PMID: 25069669 DOI: 10.1161/hypertensionaha.114.03903] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Visit-to-visit variability of blood pressure (BP) has been associated with cardiovascular disease (CVD) and mortality in some but not all studies. We conducted a systematic review and meta-analysis to examine the association between visit-to-visit variability of BP and CVD and all-cause mortality. Medical databases were searched through June 4, 2014, for studies meeting the following eligibility criteria: adult participants; BP measurements at ≥3 visits; follow-up for CVD, coronary heart disease, stroke, or mortality outcomes; events confirmed via database, death certificate, or event ascertainment committee; and adjustment for confounders. Data were extracted by 2 reviewers and pooled using a random-effects model. Overall, 8870 abstracts were identified of which 37 studies, representing 41 separate cohorts, met inclusion criteria. Across studies, visit-to-visit variability of systolic BP and diastolic BP showed significant associations with outcomes in 181 of 312 (58.0%) and 61 of 188 (32.4%) analyses, respectively. Few studies provided sufficient data for pooling risk estimates. For each 5 mm Hg higher SD of systolic BP, the pooled hazard ratio for stroke across 7 cohorts was 1.17 (95% confidence interval [CI], 1.07-1.28), for coronary heart disease across 4 cohorts was 1.27 (95% CI, 1.07-1.51), for CVD across 5 cohorts was 1.12 (95% CI, 0.98-1.28), for CVD mortality across 5 cohorts was 1.22 (95% CI, 1.09-1.35), and for all-cause mortality across 4 cohorts was 1.20 (95% CI, 1.05-1.36). In summary, modest associations between visit-to-visit variability of BP and CVD and all-cause mortality are present in published studies. However, these findings are limited by the small amount of data available for meta-analysis.
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Affiliation(s)
- Keith M Diaz
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.).
| | - Rikki M Tanner
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Louise Falzon
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Emily B Levitan
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Kristi Reynolds
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Daichi Shimbo
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Paul Muntner
- From the Department of Medicine, Columbia University Medical Center, New York, NY (K.M.D., L.F., D.S.); Department of Epidemiology, University of Alabama at Birmingham (R.M.T., E.B.L., P.M.); and Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
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Gao S, Hendrie HC, Wang C, Stump TE, Stewart JC, Kesterson J, Clark DO, Callahan CM. Redefined blood pressure variability measure and its association with mortality in elderly primary care patients. Hypertension 2014; 64:45-52. [PMID: 24799611 DOI: 10.1161/hypertensionaha.114.03576] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Visit-to-visit blood pressure (BP) variability has received considerable attention recently. The objective of our study is to define a variability measure that is independent of change over time and determine the association between longitudinal summary measures of BP measurements and mortality risk. Data for the study came from a prospective cohort of 2906 adults, aged ≥60 years, in an urban primary care system with ≤15 years of follow-up. Dates of death for deceased participants were retrieved from the National Death Index. Systolic and diastolic BP measurements from outpatient clinic visits were extracted from the Regenstrief Medical Record System. For each patient, the intercept, regression slope, and root mean square error for visit-to-visit variability were derived using linear regression models and used as independent variables in Cox proportional hazards models for both all-cause mortality and mortality attributable to coronary heart disease or stroke. Rate of change was associated with mortality risk in a U-shaped relationship and that participants with little or no change in BP had the lowest mortality risk. BP variability was not an independent predictor of mortality risk. By separating change over time from visit-to-visit variability in studies with relatively long follow-up, we demonstrated in this elderly primary care patient population that BP changes over time, not variability, were associated with greater mortality risk. Future research is needed to confirm our findings in other populations.
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Affiliation(s)
- Sujuan Gao
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.).
| | - Hugh C Hendrie
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.)
| | - Chenkun Wang
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.)
| | - Timothy E Stump
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.)
| | - Jesse C Stewart
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.)
| | - Joe Kesterson
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.)
| | - Daniel O Clark
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.)
| | - Christopher M Callahan
- From the Departments of Biostatistics (S.G., C.W., T.E.S.), Psychiatry (H.C.H.), and Medicine (C.M.C.), Indiana University School of Medicine, Indianapolis; Department of Biostatistics, Richard M. Fairbank School of Public Health, Indiana University, Indianapolis (S.G., C.W.); Regenstrief Institute Inc, Indianapolis, IN (H.C.H., J.K., D.O.C., C.M.C.); Indiana University Center for Aging Research, Indianapolis (S.G., H.C.H., D.O.C., C.M.C.); and Department of Psychology, Indiana University-Purdue University Indianapolis (J.C.S.)
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Visit-to-visit blood pressure variability in the elderly: Associations with cognitive impairment and carotid artery remodeling. Atherosclerosis 2014; 233:19-26. [DOI: 10.1016/j.atherosclerosis.2013.11.071] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 11/23/2013] [Accepted: 11/26/2013] [Indexed: 11/18/2022]
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Nagai M, Kario K. Visit-to-visit blood pressure variability, silent cerebral injury, and risk of stroke. Am J Hypertens 2013; 26:1369-76. [PMID: 24080990 DOI: 10.1093/ajh/hpt167] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Apart from the well-known role of hypertension in cerebrovascular disease, visit-to-visit blood pressure (BP) variability is emerging as an independent risk factor for stroke. Although the underlying mechanism is not fully understood, artery remodeling is thought to be closely involved in the relationship between visit-to-visit BP variability and stroke. This review article summarizes the recent literature on these topics. Silent cerebral injury is considered to serve as a common pathophysiology in the relationship of visit-to-visit BP variability with cognitive impairment and stroke. Here we review visit-to-visit BP variability, some comparisons of the effects of antihypertensive agents on visit-to-visit BP variability, and an issue regarding the impact of these agents on stroke.
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Affiliation(s)
- Michiaki Nagai
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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45
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Suchy-Dicey AM, Wallace ER, Mitchell SVE, Aguilar M, Gottesman RF, Rice K, Kronmal R, Psaty BM, Longstreth WT. Blood pressure variability and the risk of all-cause mortality, incident myocardial infarction, and incident stroke in the cardiovascular health study. Am J Hypertens 2013; 26:1210-7. [PMID: 23744496 DOI: 10.1093/ajh/hpt092] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recent reports have linked variability in visit-to-visit systolic blood pressure (SBP) to risk of mortality and stroke, independent of the effect of mean SBP level. This study aimed to evaluate whether variability in SBP is associated with all-cause mortality, incident myocardial infarction (MI), and incident stroke, independent of mean SBP or trends in SBP levels over time. METHODS The Cardiovascular Health Study is a longitudinal cohort study of vascular risk factors and disease in the elderly. Participants who attended their first 5 annual clinic visits and experienced no event before the 5th visit were eligible (n = 3,852). Primary analyses were restricted to participants not using antihypertensive medications throughout the first 5 clinic visits (n = 1,642). Intraindividual SBP variables were defined using each participant's 5-visit blood pressure measures. Cox proportional hazards models estimated adjusted hazard ratios (HRs) per SD increase in intraindividual SBP variability, adjusted for intraindividual SBP mean and change over time. RESULTS Over a mean follow-up of 9.9 years, there were 844 deaths, 203 MIs, and 195 strokes. Intraindividual SBP variability was significantly associated with increased risk of mortality (HR = 1.13; 95% confidence interval (CI) = 1.05-1.21) and of incident MI (HR = 1.20; 95%CI = 1.06-1.36), independent of the effect from adjustment factors. Intraindividual SBP variability was not associated with risk of stroke (HR = 1.03; 95% CI = 0.89-1.21). CONCLUSIONS Long-term visit-to-visit SBP variability was independently associated with a higher risk of subsequent mortality and MI but not stroke. More research is needed to determine the relationship of BP variability with cardiovascular risk and the clinical implications.
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46
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van Gestel AJR, Clarenbach CF, Stöwhas AC, Rossi VA, Sievi NA, Camen G, Kohler M. The speed of blood pressure fluctuations in patients with chronic obstructive pulmonary disease. Heart Lung Circ 2013; 23:280-6. [PMID: 24080024 DOI: 10.1016/j.hlc.2013.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 08/07/2013] [Accepted: 08/08/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) has been associated with increased risk for cardiovascular disease but mechanisms underlying this association are incompletely understood. The speed of beat-to-beat changes in systolic blood pressure (vSBP) was found to be pronounced in patients with elevated cardiovascular risk. Although increased vSBP may thus be a contributing mechanism to cardiovascular morbidity, no data exist on vSBP in patients with COPD. Therefore, the purpose of this study was to evaluate whether there is an association between severity of COPD and vSBP. METHODS Resting beat-to-beat blood pressure was recorded during 5 min. vSBP was assessed by calculating the slopes of oscillatory fluctuations in SBP for different inter-beat intervals (IBI). Univariate and multivariate analyses were performed to evaluate the association between forced expiratory volume in 1 s (FEV1) and vSBP. RESULTS This study comprised 60 patients with COPD (24 females) with a mean [SD] FEV1 of 45.4 [22.7] %predicted and 34 healthy controls. Short-term fluctuations in SBP were more pronounced in patients with COPD compared to healthy controls. There was a significant inverse correlation between FEV1 and vSBP (r=-0.41, p=0.001). Even after adjustment for covariates in multivariate analysis, FEV1 was found to be independently associated with vSBP. CONCLUSIONS Patients with COPD are characterised by steeper blood pressure changes than healthy controls. The speed of fluctuations in SBP is associated with the severity of airflow limitation. Increased vSBP may be a mechanism underpinning the association between COPD and cardiovascular disease.
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Affiliation(s)
- Arnoldus J R van Gestel
- Pulmonary Division, University Hospital of Zurich, Zurich, Switzerland; Department of Health, Zurich University of Applied Sciences, Winterthur, Switzerland.
| | | | | | - Valentina A Rossi
- Pulmonary Division, University Hospital of Zurich, Zurich, Switzerland.
| | - Noriane A Sievi
- Pulmonary Division, University Hospital of Zurich, Zurich, Switzerland.
| | - Giovanni Camen
- Pulmonary Division, University Hospital of Zurich, Zurich, Switzerland.
| | - Malcolm Kohler
- Pulmonary Division, University Hospital of Zurich, Zurich, Switzerland; Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland.
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Hastie CE, Jeemon P, Coleman H, McCallum L, Patel R, Dawson J, Sloan W, Meredith P, Jones GC, Muir S, Walters M, Dominiczak AF, Morrison D, McInnes GT, Padmanabhan S. Long-term and ultra long-term blood pressure variability during follow-up and mortality in 14,522 patients with hypertension. Hypertension 2013; 62:698-705. [PMID: 23959561 DOI: 10.1161/hypertensionaha.113.01343] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Recent evidence indicates that long-term visit-to-visit blood pressure variability (BPV) may be an independent cardiovascular risk predictor. The implication of this variability in hypertension clinical practice is unclear. BPV as average real variability (ARV) was calculated in 14,522 treated patients with hypertension in 4 time frames: year 1 (Y1), years 2 to 5 (Y2-5), years 5 to 10 (Y5-10), and years >10 (Y10+) from first clinic visit. Cox proportional hazards models for cause-specific mortality were used in each time frame separately for long-term BPV, across time frames based on ultra long-term BPV, and within each time frame stratified by mean BP. ARV in systolic blood pressure (SBP), termed ARV(SBP), was higher in Y1 (21.3±11.9 mm Hg) in contrast to Y2-5 (17.7±9.9 mm Hg), Y5-10 (17.4±9.6 mm Hg), and Y10+ (16.8±8.5 mm Hg). In all time frames, ARV(SBP) was higher in women (P<0.01) and in older age (P<0.001), chronic kidney disease (P<0.01), and prevalent cardiovascular disease (P<0.01). Higher long-term and ultra long-term BPV values were associated with increased mortality (all-cause, cardiovascular, and noncardiovascular mortality; P for trend, <0.001). This relationship was also evident in subgroups with mean SBP<140 mm Hg in all time frames. Monitoring BPV in clinical practice may facilitate risk reduction strategies by identifying treated hypertensive individuals at high risk, especially those with BP within the normal range.
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Affiliation(s)
- Claire E Hastie
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, United Kingdom.
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Parati G, Ochoa JE, Salvi P, Lombardi C, Bilo G. Prognostic value of blood pressure variability and average blood pressure levels in patients with hypertension and diabetes. Diabetes Care 2013; 36 Suppl 2:S312-24. [PMID: 23882065 PMCID: PMC3920798 DOI: 10.2337/dcs13-2043] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Gianfranco Parati
- Cardiovascular Medicine, University of Milano-Bicocca, Milan, Italy.
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Shimbo D, Shea S, McClelland RL, Viera AJ, Mann D, Newman J, Lima J, Polak JF, Psaty BM, Muntner P. Associations of aortic distensibility and arterial elasticity with long-term visit-to-visit blood pressure variability: the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Hypertens 2013; 26:896-902. [PMID: 23537891 DOI: 10.1093/ajh/hpt040] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Although higher visit-to-visit variability (VVV) of blood pressure (BP) is associated with increased cardiovascular disease risk, the physiological basis for VVV of BP is incompletely understood. METHODS We examined the associations of aortic distensibility (assessed by magnetic resonance imaging) and artery elasticity indices (determined by radial artery pulse contour analysis) with VVV of BP in 2,640 and 4,560 participants, respectively, from the Multi-Ethnic Study of Atherosclerosis. Arterial measures were obtained at exam 1. BP readings were taken at exam 1 and at 3 follow-up visits at 18-month intervals (exams 2, 3, and 4). VVV was defined as the SD about each participant's mean systolic BP (SBP) across visits. RESULTS The mean SDs of SBP were inversely associated with aortic distensibility: 7.7, 9.9, 10.9, and 13.2mm Hg for quartiles 4, 3, 2, and 1 of aortic distensibility, respectively (P trend < 0.001). This association remained significant after adjustment for demographics, cardiovascular risk factors, mean SBP, and antihypertensive medication use (P trend < 0.01). In a fully adjusted model, lower quartiles of large artery and small artery elasticity (LAE and SAE) indices were also associated with higher mean SD of SBP (P trend = 0.02 for LAE; P trend < 0.001 for SAE). CONCLUSIONS In this multiethnic cohort, functional alterations of central and peripheral arteries were associated with greater long-term VVV of SBP.
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Affiliation(s)
- Daichi Shimbo
- Department of Medicine, Columbia University Medical Center, New York, New York, USA.
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Quantifying the speed of fluctuations in systolic blood pressure. Hypertens Res 2013; 36:1039-44. [PMID: 23784510 DOI: 10.1038/hr.2013.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 03/21/2013] [Accepted: 04/14/2013] [Indexed: 11/08/2022]
Abstract
Increased blood pressure variability (BPV), even in the absence of hypertension, has been identified as an important independent cardiovascular risk factor (CVRF). However, the role of the speed of changes in systolic blood pressure (SBP; vSBP) on cardiovascular risk needs to be investigated. The objective of this study was to investigate whether subjects with a high cardiovascular risk profile have an increased degree and speed of changes in SBP compared with subjects with low or no risk. Resting beat-to-beat blood pressure (BP) was recorded for 5 min. Standard BPV measures in both time and frequency domains were conducted. The s.d. of SBP (s.d.-SBP) values was used to quantify the degree of BPV. vSBP was assessed by calculating the slopes of oscillatory fluctuations in SBP for different interbeat intervals (IBI). Subjects were allocated to one of four groups according to the number of CVRFs (0, 1, 2, ≥ 3 CVRF). Of 122 subjects, 19.7% had 0 CVRF, 27.0% had 1, 32.0% had 2 and 21.3% had ≥ 3 CVRFs. There was an increase in vSBP across the four risk groups. The vSBP in patients without CVRF was 3.12 (1.09), 1 CVRF 3.23 (1.07), 2 CVRF 4.16 (2.26) and ≥ 3 CVRF 4.22 (1.66; P = 0.015). The s.d.-SBP was not significantly different between the cardiovascular risk groups. The speed of fluctuations in SBP rather than the degree of BPV is pronounced in patients with elevated cardiovascular risk. Increased speed of BP fluctuations may thus be a contributing mechanism to cardiovascular morbidity.
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