Blood Pressure Variability

Abstract

HomeHypertensionVol. 56, No. 2Blood Pressure Variability Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBBlood Pressure VariabilityClarity for Clinical Practice Eamon Dolan and Eoin O'Brien Eamon DolanEamon Dolan From the Hypertension Unit (E.D.), Connolly Hospital, Dublin, Ireland; Department of Molecular Pharmacology (E.O.), Conway Institute, University College Dublin, Belfield, Dublin, Ireland. Search for more papers by this author and Eoin O'BrienEoin O'Brien From the Hypertension Unit (E.D.), Connolly Hospital, Dublin, Ireland; Department of Molecular Pharmacology (E.O.), Conway Institute, University College Dublin, Belfield, Dublin, Ireland. Search for more papers by this author Originally published6 Jul 2010https://doi.org/10.1161/HYPERTENSIONAHA.110.154708Hypertension. 2010;56:179–181Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 6, 2010: Previous Version 1 A series of articles1–4 published recently in The Lancet and Lancet Neurology raise an interesting issue that has implications for both the clinical management of hypertension and future research in hypertension, particularly in the development and use of different classes of blood pressure (BP)–lowering drugs. These studies, which were led by Peter Rothwell at the John Radcliffe Hospital in Oxford, United Kingdom, suggest that, whereas there is undoubted and well-proven benefit in the current practice of reducing mean BP to prevent cardiovascular events, there may be additional benefit in also reducing BP variability (BPV), especially to prevent stroke. The studies suggest, moreover, that different classes of drugs are superior to others in reducing BPV (calcium channel blockers being best and the β-blocker atenolol being worst). However, these articles, by virtue of their sheer volume (≈50 pages of printed text and many pages of supplementary web appendix data), could overwhelm all but the most stoic readers, and misinterpretation of the data could lead to confusion and have an adverse effect on clinical practice. It is important, therefore, to assess the scientific reality and determine how attention to BPV might benefit patients with hypertension.A Summary of the StudiesIn the first analysis, systolic BPV between visits and maximum BP reached in 4 cohorts of patients with previous transient ischemic attacks were strong predictors for subsequent stroke.1 In treated hypertensive patients in the Anglo-Scandinavian Cardiac Outcome Trial-Blood Pressure Lowering Arm systolic BPV between visits was also a strong predictor of stroke and coronary events independent of mean clinic or ambulatory BP measurement (ABPM). BPV on ABPM was a weaker predictor overall but was related to visit-to-visit variability. Traditional measures of variability, such as SD and coefficient of variation (CV), were used in these analyses, but one of the problems encountered in the prognostic modeling of BPV and mean BP together is that the 2 variables are correlated, and it can be problematic to adjust usual measures of variability in a multivariate model. Therefore, a new measure of variability uncorrelated with mean BP was derived; named variation independent of mean (VIM), this measure is a transformation of SD uncorrelated with mean BP and is a statistical tool, rather than a clinical measure. VIM is calculated by fitting a curve through a plot of SD systolic BP (SBP; y axis) against mean SBP (x axis) with the parameter x estimated from the curve [VIM=(SD/meanX)]. In the first analysis, VIM was consistent with other measures of BPV, suggesting that variability affects outcome independent of mean BP.In the second analysis, visit-to-visit variability was evaluated in 2 large trials, the Anglo-Scandinavian Cardiac Outcome Trial-Blood Pressure Lowering Arm and the Medical Research Council Trial to determine whether the class of drug used might reduce BPV and by so doing reduce the occurrence of stroke.2 In the Anglo-Scandinavian Cardiac Outcome Trial-Blood Pressure Lowering Arm, patients treated with amlodipine and perindopril had lower BPV both on clinic BP and ABPM than patients on atenolol and a thiazide diuretic.3 Importantly, the marked changes in BPV between the 2 treatment groups were seen very early in this study, and in contrast to previous analyses of these data5 the addition of BPV indices explained a large proportion of the treatment benefit in patients treated with the amlodipine-perindopril combination. In the Medical Research Council Trial, systolic BPV was increased in the patients treated with atenolol compared with patients in the diuretic and placebo groups. From these analyses, it would appear that the opposite effects of calcium-channel blockers and β-blockers on BPV account for the disparity in observed effects on the risk of stroke. These results would suggest, therefore, that the most effective approach to preventing stroke is to use BP-lowering drugs that reduce both mean BP and BPV and to avoid drugs that increase BPV even if they reduce mean BP.In the third analysis (a meta-analysis of 389 trials), systolic BPV was reduced by calcium channel blockers and thiazide diuretics and increased by β-blockers, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers.4 However, this result was derived from observed differences in SD in the treatment groups of these studies, and the effect of different drug classes on BPV should be interpreted with caution, at least until BPV has been evaluated in larger cohorts of hypertensive patients on treatment with different drug regimens, such as in the Blood Pressure Lowering Treatment Trialists’ Collaboration.6Collectively these 3 studies provide evidence to suggest that BPV, whether measured on clinic visits or on ABPM, is predictive for stroke and other cardiovascular events and that calcium channel blockers, and to a lesser extent thiazide diuretics, are superior to other drugs in reducing BPV and preventing stroke and other vascular events and that the older β-blocker atenolol, which increases BPV, should probably only be used as a first-line drug if there are other compelling clinical indications, such as ischemic heart disease. It should be stressed that there is no evidence one way or the other that the newer generation of β-blockers affects BPV.These studies do not call into question the lowering of mean BP as recommended in all of the guidelines, but they do draw attention to BPV, which was identified as being associated with an adverse outcome by Parati and his colleagues over 20 years ago, and his group has continued to highlight the importance of BPV in hypertension.7,8 The findings are also in agreement with the Ohasama Study showing that medium-term BPV was an independent predictor of stroke after adjustment for mean BP,9 and a recent study in which subjects with greater BPV and higher mean BP had a greater risk of cerebrovascular disease than those with lower mean BP and nonfluctuating BP.10 However, in a large population cohort (8938 subjects), although short-term reading-to-reading BPV with ABPM was an independent risk factor, the level of the 24-hour ABPM was the primary BP-related risk factor in need of correction in clinical practice.11What Are the Implications for Clinical Practice and Research?The body of research led by Rothwell is clearly important and should focus the minds of clinical scientists, the pharmaceutical industry, those interested in BP measurement, and doctors who care for patients with hypertension on the need to study the mechanisms of BPV, to devise methods for its accurate detection, and to determine how best to reduce it. As can be seen in Figures 1 and 2, the reduction in ABPM variability in the Anglo-Scandinavian Cardiac Outcomes Trial ABPM Study almost mirrors visit-to-visit variability, and it may be possible by concentrating on the many measures of variability already available within a single ABPM to identify an index of variability that would be equivalent to visit-to-visit variability. Work has already been done using ABPM to gauge the smoothness of BP control and the influence of the duration of action of BP-lowering medication.12 Trials are now needed to determine whether drugs and combinations of drugs that reduce both mean BP and BPV will have a beneficial effect on outcome. It is likely that the duration of action and time of administration of drugs will be important considerations in reducing BPV. Download figureDownload PowerPointFigure 1. Within-visit variability of SBP in Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm.2 Bars are 95% CI. Within-visit variability (CV) of SBP in Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm. A, All patients. B, Patients on treatment. C, Patients not on antihypertensive drugs at baseline.Download figureDownload PowerPointFigure 2. Variability in daytime SBP on ABPM by randomized treatment allocation in ASCOT-BPLA.2 Daytime SD SBP (A) and CV SBP (B) from annual ABPM recordings during follow-up in Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm. Bars are 95% CI.So much for the future; what are the implications for today’s doctors treating patients with hypertension? Detecting BPV appears straightforward in retrospective studies, but this is not readily done in practice. Improved methods of collecting and storing data electronically so as to detect trends in BP in the office and home and the increased use of ABPM are methods that should be more widely available, but clearly research into such methodologies will take time. However, there are more positive solutions at hand on the therapeutic front.The recent introduction of what we have termed the “flexipill” to distinguish it from its more primitive predecessor the “polypill” is a welcome therapeutic innovation.13 Polypills have been available for many years in different guises. The first polypill was introduced in 1967 for the Veterans” Administration Study; SER-AP-ES was a combination of reserpine, Apresoline, and a thiazide diuretic.14 This was followed by combination pills composed of thiazide diuretics with potassium or with potassium-sparing diuretics and then by combination pills of β-blockers with thiazide diuretics and, more recently, by angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers combined with thiazide diuretics. However, these early polypills had the major disadvantage of being fixed-dose combinations, making up-titration and tailoring of treatment to the individual patient impossible. The pharmaceutical industry has now recognized the need for flexible-dose combinations within 1 tablet allowing a prescribing physician to increase the dosage of the component parts in a single tablet according to BP response. In this regard, we now have flexipill combinations of angiotensin-receptor blockers and angiotensin-converting enzyme inhibitors with calcium channel blockers, angiotensin-receptor blockers and angiotensin-converting enzyme inhibitors with thiazide diuretics, and β-blockers and renin inhibitors with thiazide diuretics. Quite apart from the advantages of being able to prescribe low doses of 2 drugs in 1 tablet, thereby minimizing the adverse effects that might occur with higher doses of the individual components and the beneficial effects that this should have on compliance, the flexipill provides a means of not only lowering mean BP but of also reducing BPV by using medication with a contrasting mode of actions. So the concluding message for doctors managing patients with hypertension is that we acknowledge the exhortations of the guidelines that to achieve BP control requires more than one BP-lowering drug in most patients but that we may now consider availing of advantages offered in the flexipills, among which is the opportunity to lower both mean BP and BPV. Measures of VariabilitySD indicates standard deviation; CV, coefficient of variation; VIM, variation independent of the mean; BP, blood pressure; ASV, average successive variability.• SD=square root [sum of (individual reading–sample mean)2/number of readings].• CV=SD/mean.• VIM=SD/meanx; which is essentially similar to CV except that the mean BP denominator is raised to a certain power, x, that removes any correlation with mean BP. The derivation of x is explained in the text.• ASV=average absolute difference between successive values.Clinical Messages From BPV AnalysesABPM indicates ambulatory blood pressure measurement; BP, blood pressure; BPV, blood pressure variability.• Lowering mean BP remains the therapeutic goal of BP management.• Prognostic information in the medium-term fluctuations of BP is not captured using mean BP alone.• ABPM may indicate BPV and should be used more widely in clinical practice.• Most patients need more than one drug for BP control, and consideration should be given to using combination drugs that lower both mean BP and BPV.• Greater use of electronic recordings of BP allows for the calculation of BPV.• Further prospective work is needed to elucidate whether altering BPV will improve outcome.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Eoin O'Brien, Department of Molecular Pharmacology, Conway Institute, University College Dublin, Belfield, Dublin, Ireland. E-mail [email protected] References 1 Rothwell PM, Howard SC, Dolan E, O'Brien E, Dobson JE, Dahlöf B, Sever PS, Poulter NR. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010; 375: 895–905.CrossrefMedlineGoogle Scholar2 Rothwell PM, Howard SC, Dolan E, O'Brien E, Dobson JE, Dahlöf B, Poulter NR, Sever PS, on behalf of the ASCOT-BPLA and MRC Trial Investigators. Effects of β blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke. Lancet Neurol. 2010; 9: 469–480.CrossrefMedlineGoogle Scholar3 Rothwell PM. Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension. Lancet. 2010; 375: 938–948.CrossrefMedlineGoogle Scholar4 Webb AJS, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis. Lancet. 2010; 375: 906–915.CrossrefMedlineGoogle Scholar5 Poulter NR, Wedel H, Dahlöf B, Sever PS, Beevers DG, Caulfield M, Kjeldsen SE, Kristinsson A, McInnes GT, Mehlsen J, Nieminen M, O'Brien E, Östergren J, Pocock S, for the ASCOT investigators. Role of BP and other variables in the differential cardiovascular event rates noted in the Anglo-Scandinavian Cardiac Outcomes Trial-BP Lowering Arm (ASCOT-BPLA). Lancet. 2005; 366: 907–913.CrossrefMedlineGoogle Scholar6 Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different blood pressure lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus. Arch Intern Med. 2005; 165: 1410–1419.CrossrefMedlineGoogle Scholar7 Parati G, Pomidossi G, Albini F, Malaspina D, Mancia G. Relationship of 24-hour blood pressure mean and variability to severity of target damage in hypertension. Hypertension. 1987; 5: 93–98.CrossrefGoogle Scholar8 Schillaci G, Parati G. Determinants of blood pressure variability in youth: at the roots of hypertension. J Hypertens. 2010; 28: 660–664.CrossrefMedlineGoogle Scholar9 Kikuya M, Ohkubo T, Metoki H, Asayama K, Hara A, Obara T, Inoue R, Hoshi H, Hashimoto J, Totsune K, Satoh H, Imai Y. Day-by-day variability of blood pressure and heart rate at home as a novel predictor of prognosis: the Ohasama Study. Hypertension. 2008; 52: 1045–1050.LinkGoogle Scholar10 Brickman AM, Reitz C, Luchsinger JA, Manly JJ, Schupf N, Muraskin J, DeCarli C, Brown TR, Mayeux R. Long-term blood pressure fluctuation and cerebrovascular disease in an elderly cohort. Arch Neurol. 2010; 67: 564–569.CrossrefMedlineGoogle Scholar11 Hansen TW, Thijs L, Li Y, Boggia J, Kikuya M, Björklund-Bodegård K, Richart T, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Imai Y, Wang J, Ibsen H, O'Brien E, Staessen JA, on behalf of the International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes (IDACO) investigators. Prognostic value of reading-to-reading blood pressure variability over 24 hours in 8938 subjects from 11 populations. Hypertension. 2010; 55: 1049–1057.LinkGoogle Scholar12 Parati G, Omboni S, Rizzoni D, Agabiti-Rosei E, Mancia G. The smoothness index: a new, reproducible and clinically relevant measure of the homogeneity of the blood pressure reduction with treatment for hypertension. J Hypertens. 1998; 16: 1685–1691.CrossrefMedlineGoogle Scholar13 O'Brien E. Clinical developments in hypertension management. Irish Medical Times. 2010: 44 (suppl 13); viii.Google Scholar14 Black HR. Triple fixed-dose combination therapy: back to the past. Hypertension. 2009; 54: 19–22.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByLi W, Huang Z, Fang W, Wang X, Cai Z, Chen G, Wu W, Chen Z, Wu S and Chen Y (2022) Remnant Cholesterol Variability and Incident Ischemic Stroke in the General Population, Stroke, 53:6, (1934-1941), Online publication date: 1-Jun-2022. Zhang X, Xu L, Zhou P, Song D, Wu J and Jia L (2021) Intradialytic BP variability is associated with cardiovascular mortality and hospitalization in HD patients, Therapeutic Apheresis and Dialysis, 10.1111/1744-9987.13745, 26:3, (624-631), Online publication date: 1-Jun-2022. Xiao H, Li H, Dong L, Song X, Wu Y, Wei H, Shang W, Tian M and Dong J (2021) Correlation between home systolic blood pressure variability and cognitive impairment in maintenance hemodialysis patients, Seminars in Dialysis, 10.1111/sdi.13017, 35:2, (129-137), Online publication date: 1-Mar-2022. He C, Liu C, Yang J, Tan H, Ding X, Gao X, Yang Y, Shen Y, Xiang H, Ke J, Yuan F, Chen R, Cheng R, Lv H, Li P, Zhang L and Huang L (2022) Prognostic significance of day‐by‐day in‐hospital blood pressure variability in COVID‐19 patients with hypertension, The Journal of Clinical Hypertension, 10.1111/jch.14437, 24:3, (224-233), Online publication date: 1-Mar-2022. Haverkamp R, Melis R, Claassen J, de Heus R and O’Caoimh R Day-To-Day Home Blood Pressure Variability and All-Cause Mortality in a Memory Clinic Population, Journal of Alzheimer's Disease, 10.3233/JAD-215002, 85:3, (1219-1231) Park J, Shin E, Lee J, Lee S, Lee H, Choi S, Choe E, Choi S and Park H (2022) Genetic Determinants of Visit-to-Visit Lipid Variability: Genome-Wide Association Study in Statin-Naïve Korean Population, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2022.811657, 9 Suzuki D, Hoshide S and Kario K (2022) Day-by-Day Home Blood Pressure Monitoring as a Biomarker in Diabetes Biomarkers in Diabetes, 10.1007/978-3-030-81303-1_36-1, (1-24), . Kim Y, Lim J, Oh M, Yu K, Lee J, Park J, Kim Y, Rha J, Hwang Y, Heo S, Ahn S, Lee J and Kwon S (2021) Blood pressure variability is related to faster cognitive decline in ischemic stroke patients: PICASSO subanalysis, Scientific Reports, 10.1038/s41598-021-83945-z, 11:1, Online publication date: 1-Dec-2021. Wang M, Wang C, Zhao M, Li Y, Yao S, Wu S and Xue H (2021) Uric Acid Variability and All-Cause Mortality: A Prospective Cohort Study in Northern China, The journal of nutrition, health & aging, 10.1007/s12603-021-1706-3, 25:10, (1235-1240), Online publication date: 1-Dec-2021. Inoue Y, Kuwahara K, Hu H, Yamamoto S, Nakagawa T, Honda T, Eguchi M, Kochi T, Okazaki H, Miyamoto T, Shimizu M, Ogasawara T, Sasaki N, Uehara A, Yamamoto M, Tomita K, Hori A, Nagahama S, Kabe I, Mizoue T, Dohi S, Nakagawa T, Yamamoto S, Honda T, Shirasaka T, Mizuta I, Shimizu M, Gonmori N, Kitahara K, Yokoya T, Nishiura C, Imai T, Nishihara A, Fukasawa K, Yamamoto K, Kuroda R, Kato N, Kawashima M, Kinugawa C, Totsuzaki T, Masuda M, Sakamoto N, Ohsaki Y, Tomizawa A, Nagahama S, Ohtsu M, Endo M, Nakashima H, Tatemichi M, Fukai K, Kawashima M, Kunugita N, Sone T, Ohkubo T, Mizoue T, Inoue Y, Miki T, Fukunaga A, Yamamoto S, Konishi M, Katayama N and Osawa R (2021) 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, Hypertension Research, 10.1038/s41440-021-00654-w, 44:8, (1017-1025), Online publication date: 1-Aug-2021. Wei F, Zhou Y, Thijs L, Xue R, Dong B, He X, Liang W, Wu Y, Jiang J, Tan W, He J, Staessen J, Dong Y, Zhao J and Liu C (2021) Visit-to-Visit Blood Pressure Variability and Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction, Hypertension, 77:5, (1549-1558), Online publication date: 1-May-2021. Bakkar N, El-Yazbi A, Zouein F and Fares S (2021) Beat-to-beat blood pressure variability: an early predictor of disease and cardiovascular risk, Journal of Hypertension, 10.1097/HJH.0000000000002733, 39:5, (830-845), Online publication date: 1-May-2021. Huang Y, Liu L, Liu X, Lo K, Tang S, Feng Y and Zhang B (2021) The association of blood lipid parameters variability with ischemic stroke in hypertensive patients, Nutrition, Metabolism and Cardiovascular Diseases, 10.1016/j.numecd.2021.02.004, 31:5, (1521-1532), Online publication date: 1-May-2021. Monnier L, Colette C and Owens D (2021) Glucose variability and diabetes complications: Risk factor or biomarker? Can we disentangle the “Gordian Knot”?, Diabetes & Metabolism, 10.1016/j.diabet.2021.101225, 47:3, (101225), Online publication date: 1-May-2021. Okada H, Hamaguchi M, Habu M, Kurogi K, Murata H, Ito M and Fukui M (2021) Association between variability in body mass index and development of type 2 diabetes: Panasonic cohort study, BMJ Open Diabetes Research & Care, 10.1136/bmjdrc-2021-002123, 9:1, (e002123), Online publication date: 1-Apr-2021. 费 美 (2021) Research Progress of Blood Pressure Variation in Elderly Patients with Hypertension, Advances in Clinical Medicine, 10.12677/ACM.2021.115351, 11:05, (2436-2441), . Tseng P, Chen Y, Wang C, Chiu K, Peng Y, Hsu S, Chen K, Yang C and Lee O (2020) Prediction of the development of acute kidney injury following cardiac surgery by machine learning, Critical Care, 10.1186/s13054-020-03179-9, 24:1, Online publication date: 1-Dec-2020. Lee D, Han K, Park S, Yu J, Seo J, Kim N, Yoo H, Kim S, Choi K, Baik S, Park Y and Kim N (2020) Glucose variability and the risks of stroke, myocardial infarction, and all-cause mortality in individuals with diabetes: retrospective cohort study, Cardiovascular Diabetology, 10.1186/s12933-020-01134-0, 19:1, Online publication date: 1-Dec-2020. Del Pinto R, Pietropaoli D, Dobre M and Ferri C (2020) Prognostic importance of long-term SBP variability in high-risk hypertension, Journal of Hypertension, 10.1097/HJH.0000000000002552, 38:11, (2237-2244), Online publication date: 1-Nov-2020. Hong S, Lee J, Kim J, Lee Y, Roh E, Yu J, Kim N, Yoo H, Seo J, Kim S, Kim N, Baik S and Choi K (2020) Gamma-glutamyl transferase variability and the risk of hospitalisation for heart failure, Heart, 10.1136/heartjnl-2019-316271, 106:14, (1080-1086), Online publication date: 1-Jul-2020. Ahmed T, Shams-Eddin H, Fathy M, El-Naggar H and Kishk Y (2020) Subclinical left ventricular systolic dysfunction by two-dimensional speckle-tracking echocardiography and its relation to ambulatory arterial stiffness index in hypertensive patients, Journal of Hypertension, 10.1097/HJH.0000000000002330, 38:5, (864-873), Online publication date: 1-May-2020. Hong S, Noh E, Kim J, Hwang S, Kim J, Lee Y, Roh E, Choi K, Baik S, Cho G and Yoo H (2020)(2020) Fasting Plasma Glucose Variability and Gastric Cancer Risk in Individuals Without Diabetes Mellitus: A Nationwide Population-Based Cohort Study, Clinical and Translational Gastroenterology, 10.14309/ctg.0000000000000221, 11:9, (e00221) Lee E, Yang Y, Kim H, Cho J, Yoon K, Chung W, Lee S and Chang K (2018) Effect of visit-to-visit LDL-, HDL-, and non-HDL-cholesterol variability on mortality and cardiovascular outcomes after percutaneous coronary intervention, Atherosclerosis, 10.1016/j.atherosclerosis.2018.10.012, 279, (1-9), Online publication date: 1-Dec-2018. Kusunoki H, Iwashima Y, Kawano Y, Hayashi S, Kishida M, Horio T, Shinmura K and Yoshihara F (2018) Circadian hemodynamic characteristics in hypertensive patients with primary aldosteronism, Journal of Hypertension, 10.1097/HJH.0000000000001800, 36:11, (2260-2268), Online publication date: 1-Nov-2018. Zhou T, Henry R, Stehouwer C, van Sloten T, Reesink K and Kroon A (2018) Blood Pressure Variability, Arterial Stiffness, and Arterial Remodeling, Hypertension, 72:4, (1002-1010), Online publication date: 1-Oct-2018. Tan Z, Meng H, Dong D, Zhao Y, Xu A and Kou Y (2018) Blood pressure variability estimated by ARV is a predictor of poor short-term outcomes in a prospective cohort of minor ischemic stroke, PLOS ONE, 10.1371/journal.pone.0202317, 13:8, (e0202317) Kaihara T, Imaizumi Y, Eguchi K and Kario K (2018) Maximum home blood pressure readings are associated with left atrial diameter in essential hypertensives, Journal of Human Hypertension, 10.1038/s41371-018-0060-3, 32:6, (432-439), Online publication date: 1-Jun-2018. Zhang Y, Wang H, Xu K, Wang P, Li X, Zhao J and Tang Y (2018) Ambulatory blood pressure variability within the first 24 hours after admission and outcomes of acute ischemic stroke, Journal of the American Society of Hypertension, 10.1016/j.jash.2017.12.012, 12:3, (195-203), Online publication date: 1-Mar-2018. Rivera A, Estañol B, Robles-Cabrera A, Toledo-Roy J, Fossion R and Frank A (2018) Looking for Biomarkers in Physiological Time Series Quantitative Models for Microscopic to Macroscopic Biological Macromolecules and Tissues, 10.1007/978-3-319-73975-5_6, (111-131), . Mena L, Felix V, Melgarejo J and Maestre G (2017) 24‐Hour Blood Pressure Variability Assessed by Average Real Variability: A Systematic Review and Meta‐Analysis, Journal of the American Heart Association, 6:10, Online publication date: 11-Oct-2017. Xu C, Xiong H, Gao Z, Liu X, Zhang H, Zhang Y, Du X, Wu W, Liu G and Li S (2017) Beat-to-Beat Blood Pressure and Two-dimensional (axial and radial) Motion of the Carotid Artery Wall: Physiological Evaluation of Arterial Stiffness, Scientific Reports, 10.1038/srep42254, 7:1, Online publication date: 1-Sep-2017. Lundholm M, Rooney M, Maas M, Attarian H and Prabhakaran S (2017) Wake-Up Stroke Is Associated With Greater Nocturnal Mean Arterial Pressure Variability, Stroke, 48:6, (1668-1670), Online publication date: 1-Jun-2017. Wu D, Xu L, Abbott D, Hau W, Ren L, Zhang H and Wong K (2017) Analysis of beat-to-beat blood pressure variability response to the cold pressor test in the offspring of hypertensive and normotensive parents, Hypertension Research, 10.1038/hr.2017.4, 40:6, (581-589), Online publication date: 1-Jun-2017. Takao T, Suka M, Yanagisawa H, Matsuyama Y and Iwamoto Y (2017) Predictive ability of visit-to-visit variability in HbA1c and systolic blood pressure for the development of microalbuminuria and retinopathy in people with type 2 diabetes, Diabetes Research and Clinical Practice, 10.1016/j.diabres.2017.03.027, 128, (15-23), Online publication date: 1-Jun-2017. Ng G, Boey E, Frampton C, Richards A, Yeo T and Lee C (2016) Obstructive sleep apnea is associated with visit-to-visit variability in low-density lipoprotein-cholesterol in patients with coronary artery disease, Sleep and Breathing, 10.1007/s11325-016-1394-0, 21:2, (271-278), Online publication date: 1-May-2017. Zawadzki M, Small A and Gerin W (2017) Ambulatory blood pressure variability, Blood Pressure Monitoring, 10.1097/MBP.0000000000000230, 22:2, (53-58), Online publication date: 1-Apr-2017. Iwashima Y, Fukuda T, Kusunoki H, Hayashi S, Kishida M, Yoshihara F, Nakamura S, Kamide K, Horio T and Kawano Y (2016) Effects of Percutaneous Transluminal Renal Angioplasty on Office and Home Blood Pressure and Home Blood Pressure Variability in Hypertensive Patients With Renal Artery Stenosis, Hypertension, 69:1, (109-117), Online publication date: 1-Jan-2017. Xu L, Lei H, Qiu J, Ma J, Zhao H, Deng Y, Lin W and Huang W (2015) Correlation between beat-to-beat blood pressure variability and arterial stiffness in healthy adults in the cold pressor test, Australasian Physical & Engineering Sciences in Medicine, 10.1007/s13246-015-0378-x, 39:4, (977-985), Online publication date: 1-Dec-2016. Wittke E, Fuchs S, Moreira L, Foppa M, Fuchs F and Gus M (2015) Blood pressure variability in controlled and uncontrolled blood pressure and its association with left ventricular hypertrophy and diastolic function, Journal of Human Hypertension, 10.1038/jhh.2015.106, 30:8, (483-487), Online publication date: 1-Aug-2016. Madden J, O'Flynn A, Fitzgerald A and Kearney P (2015) Correlation between short-term blood pressure variability and left-ventricular mass index: a meta-analysis, Hypertension Research, 10.1038/hr.2015.126, 39:3, (171-177), Online publication date: 1-Mar-2016. Costa A, Costa P, de Lima C, Pádua L, Campos L and Baltatu O (2016) ICU Blood Pressure Variability May Predict Nadir of Respiratory Depression After Coronary Artery Bypass Surgery, Frontiers in Neuroscience, 10.3389/fnins.2015.00506, 9 Whaley-Connell A and Sowers J (2015) Metabolic Control of Blood Pressure Variability in Humans, The Journal of Clinical Hypertension, 10.1111/jch.12686, 18:1, (25-26), Online publication date: 1-Jan-2016. Marcus Y, Segev E, Shefer G, Sack J, Tal B, Yaron M, Carmeli E, Shefer L, Margaliot M, Limor R, Gilad S, Sofer Y and Stern N (2015) Multidisciplinary Treatment of the Metabolic Syndrome Lowers Blood Pressure Variability Independent of Blood Pressure Control, The Journal of Clinical Hypertension, 10.1111/jch.12685, 18:1, (19-24), Online publication date: 1-Jan-2016. Pannier B, Thomas F, Hanon O, Czernichow S, Lemogne C, Simon T, Simon J and Danchin N (2015) Individual 6-year systolic blood pressure change and impact on cardiovascular mortality in a French general population, Journal of Human Hypertension, 10.1038/jhh.2015.44, 30:1, (18-23), Online publication date: 1-Jan-2016. Boey E, Gay G, Poh K, Yeo T, Tan H and Lee C (2016) Visit-to-visit variability in LDL- and HDL-cholesterol is associated with adverse events after ST-segment elevation myocardial infarction: A 5-year follow-up study, Atherosclerosis, 10.1016/j.atherosclerosis.2015.10.110, 244, (86-92), Online publication date: 1-Jan-2016. Fukuda K, Kai H, Kamouchi M, Hata J, Ago T, Nakane H, Imaizumi T, Kitazono T, Ishitsuka T, Fujimoto S, Ibayashi S, Kusuda K, Arakawa S, Irie K, Fujii K, Okada Y, Yasaka M, Nagao T, Ooboshi H, Omae T, Toyoda K, Sugimori H, Kuroda J, Wakisaka Y, Matsuo R and Fukushima Y (2015) Day-by-Day Blood Pressure Variability and Functional Outcome After Acute Ischemic Stroke, Stroke, 46:7, (1832-1839), Online publication date: 1-Jul-2015. Farquhar C (2015) Taking America's blood pressure: a public health response to pandemic hypertension, Public Health, 10.1016/j.puhe.2015.02.030, 129:7, (1000-1002), Online publication date: 1-Jul-2015. McMullan C, Yano Y, Bakris G, Kario K, Phillips R and Forman J (2015) Racial impact of diurnal variations in blood pressure on cardiovascular events in chronic kidney disease, Journal of the American Society of Hypertension, 10.1016/j.jash.2015.02.005, 9:4, (299-306), Online publication date: 1-Apr-2015. O’Brien E (2014) If I Had Resistant Hypertension, Hypertension, 64:5, (e3-e6), Online publication date: 1-Nov-2014. Ganesan M, Pal P, Gupta A and Sathyaprabha T (2014) Treadmill gait training improves baroreflex sensitivity in Parkinson’s disease, Clinical Autonomic Research, 10.1007/s10286-014-0236-z, 24:3, (111-118), Online publication date: 1-Jun-2014. Wei F, Li Y, Zhang L, Xu T, Ding F, Wang J and Staessen J (2014) Beat-to-Beat, Reading-to-Reading, and Day-to-Day Blood Pressure Variability in Relation to Organ Damage in Untreated Chinese, Hypertension, 63:4, (790-796), Online publication date: 1-Apr-2014. Diaz K, Muntner P, Levitan E, Brown M, Babbitt D and Shimbo D (2014) The effects of weight loss and salt reduction on visit-to-visit blood pressure variability, Journal of Hypertension, 10.1097/HJH.0000000000000080, 32:4, (840-848), Online publication date: 1-Apr-2014. Romero M (2013) Home blood pressure variability: a new target to monitor in chronic kidney disease patients with low eGFR?, Hypertension Research, 10.1038/hr.2013.53, 36:8, (673-675), Online publication date: 1-Aug-2013. Turner J (2013) Patient and Physician Adherence in Hypertension Management, The Journal of Clinical Hypertension, 10.1111/jch.12105, 15:7, (447-452), Online publication date: 1-Jul-2013. Muntner P, Levitan E, Joyce C, Holt E, Mann D, Oparil S and Krousel-Wood M (2012) Association Between Antihypertensive Medication Adherence and Visit-to-Visit Variability of Blood Pressure, The Journal of Clinical Hypertension, 10.1111/jch.12037, 15:2, (112-117), Online publication date: 1-Feb-2013. O’Brien E and Turner J (2012) Assessing Blood Pressure Responses to Noncardiovascular Drugs: The Beneficial Role of Ambulatory Blood Pressure Monitoring, The Journal of Clinical Hypertension, 10.1111/jch.12023, 15:1, (55-62), Online publication date: 1-Jan-2013. Cahan A, Ben-Dov I and Bursztyn M (2012) Association of Heart Rate With Blood Pressure Variability: Implications for Blood Pressure Measurement, American Journal of Hypertension, 10.1038/ajh.2011.230, 25:3, (313-318), Online publication date: 1-Mar-2012. Ahmed M, Guichard J and Calhoun D (2011) Resistant Hypertension, Current Cardiovascular Risk Reports, 10.1007/s12170-011-0177-1, 5:4, (307-313), Online publication date: 1-Aug-2011. Kanaoka T, Tamura K, Moriya T, Tanaka K, Konno Y, Kondoh S, Toyoda M, Umezono T, Fujikawa T, Ohsawa M, Dejima T, Maeda A, Wakui H, Haku S, Yanagi M, Mitsuhashi H, Ozawa M, Okano Y, Ogawa N, Yamakawa T, Mizushima S, Suzuki D and Umemura S (2011) Effects of Multiple Factorial Intervention on Ambulatory BP Profile and Renal Function in Hypertensive Type 2 Diabetic Patients with Overt Nephropathy – A Pilot Study, Clinical and Experimental Hypertension, 10.3109/10641963.2011.583971, 33:4, (255-263), Online publication date: 1-Jul-2011. O’Brien E (2011) Why ABPM Should Be Mandatory in All Trials of Blood Pressure-Lowering Drugs, Drug Information Journal, 10.1177/009286151104500303, 45:3, (233-239), Online publication date: 1-May-2011. O’Brien E (2011) Twenty-four-hour ambulatory blood pressure measurement in clinical practice and research: a critical review of a technique in need of implementation, Journal of Internal Medicine, 10.1111/j.1365-2796.2011.02356.x, 269:5, (478-495), Online publication date: 1-May-2011. Elliott W (2011) Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension, Yearbook of Cardiology, 10.1016/j.ycar.2011.01.078, 2011, (4-5), Online publication date: 1-Jan-2011. Elliott W (2011) Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis, Yearbook of Cardiology, 10.1016/j.ycar.2011.01.077, 2011, (8-10), Online publication date: 1-Jan-2011. Elliott W (2011) Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension, Yearbook of Cardiology, 10.1016/j.ycar.2011.01.063, 2011, (6-8), Online publication date: 1-Jan-2011. Elliott W (2011) Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension, Yearbook of Medicine, 10.1016/S0084-3873(11)00286-0, 2011, (375-377), Online publication date: 1-Jan-2011. Waeber B, Mourad J and O’Brien E (2010) Nighttime Blood Pressure: A Target for Therapy?, Current Hypertension Reports, 10.1007/s11906-010-0152-0, 12:6, (474-479), Online publication date: 1-Dec-2010. Ben-Dov I and Bursztyn M (2010) Increased Intervisit Blood Pressure Variability and β-Blockade: Measurement Imprecision Related to Bradycardia?, Hypertension, 56:5, (e48-e48), Online publication date: 1-Nov-2010.Webb D (2010) DORADO: Opportunity Postponed, Hypertension, 56:5, (806-807), Online publication date: 1-Nov-2010. August 2010Vol 56, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/HYPERTENSIONAHA.110.154708PMID: 20606104 Originally publishedJuly 6, 2010 PDF download Advertisement SubjectsClinical StudiesEpidemiologyHypertension