Abstract
BackgroundThe prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. We aimed to evaluate it in a prospective long-term follow-up study with 632 individuals with type 2 diabetes.MethodsBP-VVV parameters (systolic and diastolic standard deviations [SD] and variation coefficients) were measured during the first 24-months. Multivariate Cox analysis, adjusted for risk factors and mean BP levels, examined the associations between BP-VVV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications (total cardiovascular events [CVEs], major adverse CVEs [MACE] and cardiovascular and all-cause mortality). Improvement in risk discrimination was assessed by the C-statistic and integrated discrimination improvement (IDI) index.ResultsOver a median follow-up of 11.3 years, 162 patients had a CVE (132 MACE), and 212 patients died (95 from cardiovascular diseases); 153 newly-developed or worsened diabetic retinopathy, 193 achieved the renal composite outcome (121 newly-developed microalbuminuria and 95 deteriorated renal function), and 171 newly-developed or worsened peripheral neuropathy. Systolic BP-VVV was an independent predictor of MACE (hazard ratio: 1.25, 95% CI 1.03–1.51 for a 1-SD increase in 24-month SD), but not of total CVEs, cardiovascular and all-cause mortality, and of any microvascular outcome. However, no BP-VVV parameter significantly improved cardiovascular risk discrimination (increase in C-statistic 0.001, relative IDI 0.9%).ConclusionsSystolic BP-VVV was an independent predictor of MACE, but it did not improve cardiovascular risk stratification. The goal of anti-hypertensive treatment in patients with type 2 diabetes shall remain in controlling mean BP levels, not on decreasing their visit-to-visit variability.
Highlights
The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled
Previous studies have shown that Visit-to-visit blood pressure variability (BP-VVV) is reproducible [12] and that long-term BPVVV has been associated with cardiovascular outcomes and mortality in most [1,2,3,4,5,6,7,8] but not in all of them [9,10,11]
We evaluated whether any BP-VVV parameter was capable of improving risk discrimination for any of these adverse outcomes
Summary
The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. A recent meta-analysis observed a wide heterogeneity among the included studies, which precluded precise effects estimations, but showed only modest associations between systolic BP-VVV and all-cause and cardiovascular mortality and cardiovascular disease incidence [13]. A recent meta-analysis [28] suggested that the systolic BP-VVV might be a risk marker for adverse micro- and macrovascular outcomes and all-cause mortality in individuals with type 2 diabetes Their results were clearly inconclusive because of few studies included, with very high heterogeneity among them; and probable publication bias for some outcomes, evident for cardiovascular disease [28]. Only few previous studies [21, 24, 25] addressed, by specific statistical approaches, whether any BP-VVV parameter, beyond of being a predictive marker of any adverse outcome, was capable of improving risk discrimination for this outcome, which is an essential step before a potential risk marker could be recommended for clinical use
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