Increasing SBP variability is associated with an increased risk of developing incident diabetic foot ulcers

Correlations Among Visit-to-Visit Blood Pressure Variability and Treatment With Antihypertensive Medication With Long-Term Adverse Outcomes in a Large Veteran Cohort

BACKGROUND

Blood pressure variability (BPV) is associated with adverse events (AEs) independently of hypertension. It has been suggested that calcium channel blockers (CCBs) may reduce BPV, and thus be particularly valuable in hypertensives with high BPV. We sought to investigate how CCB affect BPV progression and whether long-term adverse effects of BPV differ after CCB treatment than after treatment with other antihypertensives.

METHODS

We retrospectively analyzed 25,268 US veterans who had been followed for 3 years without hypertensive therapy, started on a single class of antihypertensive agents (thiazides, CCBs, ACE inhibitors, or beta blockers [BBs]), treated for 6 years, and then followed for 3 additional years. BPV was calculated as SD of systolic or diastolic blood pressures from at least 10 measurements over each 3-year period. A combined AE endpoint included hospitalization, coronary artery bypass grafting, carotid endarterectomy, angioplasty, amputation, arteriovenous fistula creation, and mortality was assessed in years 9-12.

RESULTS

Post-medication high BPV and BB or thiazide use were associated with increased AE risk. Medication type also affected mean post-medication BPV. The effects of medications except for BBs on AE and mortality was independent of the patient BPV.

CONCLUSIONS

The possible deleterious effects of thiazides should be considered within the context of the study population, who were mostly male and received only a single class of hypertensives. While CCB may ameliorate BPV over time, this study does not support choosing CCB over other agents specifically to lessen BPV-associated risk.

Impact of in-hospital blood pressure variability on clinical outcomes in patients with symptomatic peripheral arterial disease

Various types of blood pressure (BP) variability have been recognized as risk factors for future cardiovascular events. However, the prognostic impact of in-hospital BP variability in patients with symptomatic peripheral arterial disease (PAD) has not yet been thoroughly investigated. A total of 386 patients with PAD who underwent endovascular therapy in two hospitals were retrospectively included. BP variability was assessed by the coefficient of variation (CV) of systolic BP measured during hospitalization by trained nurses. The primary endpoint was a composite of major adverse cardiovascular events (cardiovascular death, acute coronary syndrome, stroke, and hospitalization for heart failure) and major adverse limb events (major amputation, acute limb ischemia, and surgical limb revascularization). The mean systolic BP and the CV of systolic BP during hospitalization were 130.8 ± 15.7 mmHg and 11.2 ± 4.1%, respectively. During the median follow-up period of 22 months, 80 patients (21%) reached the primary endpoint. Receiver operating characteristic curve analysis showed that the CV of systolic BP significantly predicted major adverse cardiovascular and limb events (area under the curve 0.60, best cutoff value 9.8, P = 0.01). Using the best cutoff value, patients with high BP variability (n = 242) had a higher risk of clinical events than those with low BP variability (n = 144) (26% vs. 12%, P < 0.001). Multivariable analysis indicated that the CV of systolic BP, age, hemodialysis, and atrial fibrillation were associated with the primary endpoint. In conclusion, greater in-hospital systolic BP variability was associated with major adverse cardiovascular and limb events in patients with symptomatic PAD undergoing endovascular therapy.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Retrospective cohort study of the relationship between systolic blood pressure variability and multiple sclerosis disability

OBJECTIVE

To examine the relationship between visit-to-visit systolic blood pressure (SBP) variability and patient-reported outcome measure of disability in multiple sclerosis (MS) patients.

DESIGN

A retrospective cohort study of individuals with MS who completed a patient-determined disease steps (PDDS) scale between 2011 and 2015 at an MS specialty clinic.

PARTICIPANTS

Individuals with MS for whom both a completed PDDS scale and ≥3 SBP measures within the prior 12 months of the survey were available.

MAIN OUTCOME MEASURE

Participants were grouped into three classes of disability (no or mild (PDDS 0-1), moderate (2-3), severe (4-7)). SBP variability was calculated as within-subject SD using all SBP measures taken during the past 12 months. SBP variability was analysed by Tertile groups.

RESULTS

Ninety-two subjects were included in this analysis. Mean PDDS score was 2.22±1.89. Compared with subjects in Tertile 1 (lowest variability), the odds of being in a higher disability group was 3.5 times higher (OR=3.48; 95% CI: 1.08 to 11.25; p=0.037) in Tertile 2 and 5.2 times higher (OR=5.19; 95% CI: 1.53 to 17.61; p=0.008) in Tertile 3 (highest variability), independent of mean SBP, age, sex, race/ethnicity, body mass index and comorbidities (p for trend=0.008). Mean PDDS scores were 1.52±1.18 in Tertile 1, 2.73±1.02 in Tertile 2 and 2.42±0.89 in Tertile 3 after adjusting for the same covariates.

CONCLUSIONS

Our results show a significant gradient relationship between SBP variability and MS-related disability. More research is needed to determine the underlying pathophysiological relationship between SBP variability and MS disability progression.