Absolute Blood Pressure Levels Research Articles

S-24-2: IMPACT OF FEBUXOSTAT ON VISIT-TO-VISIT BLOOD PRESSURE VARIABILITY: INSIGHTS FROM THE RANDOMIZED PRIZE STUDY

Objective: Although uric acid lowering therapies, including xanthine oxidase (XO) inhibition, may reduce the absolute level of blood pressure (BP), the effect of XO inhibition on BP variability is largely unknown. The objective of the present analysis was to evaluate the impact of febuxostat, an XO inhibitor, on BP variability in a randomized trial setting. Design and method: This was a sub-analysis of the PRIZE study, a randomized trial to evaluate the potential effect of febuxostat on carotid intima-media thickness progression. Patients with hyperuricemia and carotid plaques were randomly assigned to the febuxostat or control group. During a 24-month period, office BP and pulse rate (PR) were measured 3 times or more. BP and PR variabilities were assessed with standard deviation (SD) and coefficient of variation (CV). The effect of febuxostat on BP and PR variabilities were adjusted with age, sex, and baseline BP or PR, expressed with 95% confidence intervals. Results: A total of 472 patients with hyperuricemia and carotid plaques were included into the present analysis. Overall, the median serum uric acid level was 7.6 [7.1, 8.2] mg/dl at baseline, and a history of hypertension was found in 419 (88.8%) patients. Baseline characteristics were well balanced between the febuxostat group (n = 236) and control group (n = 236). During the 24-month follow-up period, the febuxostat group had a significantly lower adjusted mean systolic BP (128.4 [126.8 to 130.0] vs. 130.7 [129.1 to 132.2] mm Hg, p = 0.04) and CV of systolic BP (7.4 [6.7 to 8.0] vs. 8.2 [7.6 to 8.8], p = 0.04) than the control group. Adjusted SD of PR was also lower in the febuxostat group than their counterpart (5.95 [4.93 to 6.97] vs. 7.33 [6.32 to 8.33], p = 0.04). Conclusions: XO inhibition with febuxostat was associated with reduced visit-to-visit BP variability as well as reduced PR variability, illustrating the potential therapeutic effect of febuxostat in patients with hyperuricemia and carotid plaques.

Impact of febuxostat on visit-to-visit blood pressure variability: insights from the randomised PRIZE Study

ObjectivesAlthough uric acid lowering therapies, including xanthine oxidase (XO) inhibition, may reduce the absolute level of blood pressure (BP), the effect of XO inhibition on BP variability is largely unknown....

Abstract 044: Stimulation Of Intrarenal Angiotensinogen Expression And The Development Of Hypertension And Kidney Injury In Angiotensin II-infused Hepatic Angiotensinogen Knockout Mice

Regulation of systemic and local angiotensinogen (AGT) levels is a key determinant of tissue angiotensin II (Ang II) levels and inappropriate AGT augmentation promotes the development of hypertension and tissue injury. Kidney and urinary AGT levels are increased in Ang II-mediated hypertension. Recent studies have demonstrated that circulating hepatocyte-derived AGT (hAGT) enters kidneys sustaining kidney and urinary AGT levels. However, roles of hAGT in blood pressure elevation and kidney injury in Ang II-mediated hypertension have not been delineated. This study tested if hAGT contributes to the development of the pathophysiological events in Ang II-infused mice. A low dose of Ang II (400 ng/kg/min) was infused to male wild type (WT) and hAGT gene knockout (KO) mice (N=9 and 13) for 4 weeks. The control group in each genotype received vehicle (Veh) infusion (N=5 and 6). Western blot confirmed non-detectable levels of hAGT in KO mice. hAGT KO markedly decreased plasma AGT levels (WT+Veh:12.2±0.6 vs. hAGT KO+Veh: 0.8±0.1 μg/ml). Ang II infusion did not elevate plasma AGT levels in either WT and hAGT KO mice. Although hAGT KO mice exhibited a lower baseline of systolic blood pressure (SBP) than WT mice, Ang II-mediated increases in SBP was not attenuated in hAGT KO mice (ΔSBP in WT+Ang II: 30.1±4.4 vs. hAGT KO+Ang II: 26.0±4.2 mmHg). Kidney AGT mRNA levels were increased by Ang II infusion to the same extent in both WT and hAGT mice (WT+Ang II: 1.30±0.04 vs. hAGT KO+Ang II: 1.34±0.06, ratio to control). Likewise, Ang II infusion increased IL-6 mRNA to the same magnitude in both WT and hAGT KO mice. Urinary AGT was sustained in hAGT KO+Veh mice (66±9%) compared to WT+Veh mice. Ang II infusion did not alter urinary AGT levels in both groups. Glomerular mesangial expansion and fibrosis by Ang II infusion were not observed. Ang II infusion developed tubulointerstitial fibrosis in renal cortex and medulla. hAGT KO prevented the fibrosis only in the medulla. These outcomes demonstrate that elevation of SBP, augmentation of intrarenal AGT and IL-6 expression, and the development of renal cortical fibrosis in Ang II-mediated hypertension do not require hAGT. In contrast, hAGT contributes to renal medullary fibrosis which may be due to the lower absolute levels of blood pressure.

Blood Pressure Trajectories Across the Life Course.

High blood pressure (BP) is a strong modifiable risk factor for cardiovascular disease (CVD). Longitudinal BP patterns themselves may reflect the burden of risk and vascular damage due to prolonged cumulative exposure to high BP levels. Current studies have begun to characterize BP patterns as a trajectory over an individual's lifetime. These BP trajectories take into account the absolute BP levels as well as the slope of BP changes throughout the lifetime thus incorporating longitudinal BP patterns into a single metric. Methodologic issues that need to be considered when examining BP trajectories include individual-level vs. population-level group-based modeling, use of distinct but complementary BP metrics (systolic, diastolic, mean arterial, mid, and pulse pressure), and potential for measurement errors related to varied settings, devices, and number of readings utilized. There appear to be very specific developmental periods during which divergent BP trajectories may emerge, specifically adolescence, the pregnancy period, and older adulthood. Lifetime BP trajectories are impacted by both individual-level and community-level factors and have been associated with incident hypertension, multimorbidity (CVD, renal disease, cognitive impairment), and overall life expectancy. Key unanswered questions remain around the additive predictive value of BP trajectories, intergenerational contributions to BP patterns (in utero BP exposure), and potential genetic drivers of BP patterns. The next phase in understanding BP trajectories needs to focus on how best to incorporate this knowledge into clinical care to reduce the burden of hypertensive-related outcomes and improve health equity.

Abstract P041: Proximal Tubule-specific Deletion Of Angiotensin Ii Type 1a Receptors In The Kidney Lowers Basal Blood Pressure And Attenuates Angiotensin Ii-induced Hypertension By Increasing Glomerular Filtration And The Pressure-natriuresis Response

The present study tested the hypothesis that intratubular angiotensin II (Ang II) and AT 1a receptors in the proximal tubules of the kidney plays an important role in basal blood pressure control and in the development of Ang II-induced hypertension. Mutant mice with proximal tubule-specific deletion of AT 1a receptors in the kidney, PT- Agtr1a -/- , were generated to test the hypothesis. Eight groups (n=7-12 per group) of adult male wild-type (WT) and PT- Agtr1a -/- mice were infused with or without Ang II for 2 weeks (1.5 mg/kg, i.p.). Basal systolic, diastolic, and mean arterial pressures were ~13 ± 3 mmHg lower in PT- Agtr1a -/- than WT mice ( P <0.01). Basal glomerular filtration rate (GFR), as measured using transdermal FITC-sinistrin, was significantly higher in PT- Agtr1a -/- mice (WT: 160.4 ± 7.0 μl/min vs. PT- Agtr1a -/- : 186.0 ± 6.0 μl/min, P <0.05). Basal 24 h urinary Na + excretion (U Na V) was significantly higher in PT- Agtr1a -/- than WT mice ( P <0.01). In response to Ang II infusion, both WT and PT- Agtr1a -/- mice developed hypertension, and the magnitude of the pressor response to Ang II was similar in WT (Δ43 ± 3 mmHg, P <0.01) and PT- Agtr1a -/- mice (Δ39 ± 5 mmHg, P <0.01). However, the absolute blood pressure level was still 16 ± 3 mmHg lower in PT- Agtr1a -/- mice ( P <0.01). Ang II significantly decreased GFR to 132.2 ± 7.0 μl/min in WT mice ( P <0.01), and to 129.4 ± 18.6 μl/min in PT- Agtr1a -/- mice ( P <0.01), respectively. In WT mice, U Na V increased from 139.3 ± 22.3 μmol/24 h in the control group to 196.4 ± 29.6 μmol/24 h in the Ang II-infused group ( P <0.01). In PT- Agtr1a -/- mice, U Na V increased from 172.0 ± 10.2 μmol/24 h in the control group to 264.7 ± 35.4 μmol/24 h in the Ang II-infused group ( P <0.01). The pressor response to Ang II was attenuated, while the natriuretic response was augmented by losartan in WT and PT- Agtr1a -/- mice ( P <0.01). Finally, proximal tubule-specific deletion of AT 1a receptors significantly augmented the pressure-natriuresis response and natriuretic responses to acute saline infusion ( P <0.01) or a 2% high salt diet ( P <0.01). We concluded that deletion of AT 1a receptors selectively in the proximal tubules lowers basal blood pressure and attenuates Ang II-induced hypertension by increasing GFR and promoting the natriuretic response in PT- Agtr1a -/- mice.

Stress-Induced Blood Pressure Elevation Self-Measured by a Wearable Watch-Type Device.

BACKGROUNDPsychological stress contributes to blood pressure (BP) variability, which is a significant and independent risk factor for cardiovascular events. We compared the effectiveness of a recently developed wearable watch-type BP monitoring (WBPM) device and an ambulatory BP monitoring (ABPM) device for detecting ambulatory stress-induced BP elevation in 50 outpatients with 1 or more cardiovascular risk factors.METHODSThe WBPM and ABPM were both worn on the subject’s nondominant arm. ABPM was measured automatically at 30-minute intervals, and each ABPM measurement was followed by a self-measured WBPM measurement. We also collected self-reported information about situational conditions, including the emotional state of subjects at the time of each BP measurement. We analyzed 642 paired BP readings for which the self-reported emotional state in the corresponding diary entry was happy, calm, anxious, or tense.RESULTSIn a mixed-effect analysis, there were significant differences between the BP values measured during negative (anxious, tense) and positive (happy, calm) emotions in both the WBPM (systolic BP [SBP]: 9.3 ± 2.1 mm Hg, P < 0.001; diastolic BP [DBP]: 8.4 ± 1.4 mm Hg, P < 0.001) and ABPM (SBP: 10.7 ± 2.1 mm Hg, P < 0.001; DBP: 5.6 ± 1.4 mm Hg, P < 0.001). The absolute BP levels induced by emotional stress self-measured by the WBPM were similar to those automeasured by the ABPM (SBP, WBPM: 141.1 ± 2.7 mm Hg; ABPM: 140.3 ± 2.7 mm Hg; P = 0.724). The subject’s location at the BP measurement was also significantly associated with BP elevation.CONCLUSIONSThe self-measurement by the WBPM could detect BP variability induced by multiple factors, including emotional stress, under ambulatory conditions as accurately as ABPM.

Estimation of Absolute Blood Pressure Using Video Images Captured at Different Heights from the Heart.

The risk of cardiovascular diseases is related to the absolute level of blood pressure as well as its fluctuation while sleeping or during daily activities. To assess the risk, a simpler method to monitor daily blood pressure is desirable. In recent years, there has been a focus on developing a method to obtain pulse waves from video images of the human body. This is a promising technique to acquire biometric information without contact. In this study, we propose a new method to estimate the absolute level of blood pressure by using two video images of human hands captured at different heights from the heart. We focus on the amplitude difference of pulse waves obtained from the video images and derive an equation to estimate blood pressure based on the relationship between the internal pressure and the cross-sectional area of the blood vessel. The accuracy of the estimation was evaluated using data obtained from 5 healthy subjects performing cycling exercises that change their blood pressure. The average value of the root mean square error between the real value and the estimated value was 25.7 mmHg, while that of correlation coefficient was 0.66. There were large individual differences, particularly in the estimation of the absolute value of blood pressure. This result suggests the need for individual correction of the compliance curve, which represents the relationship between the internal pressure and the cross-sectional area of the blood vessel.

Blood pressure variability and hemorrhagic transformation in patients with successful recanalization after endovascular recanalization therapy: A retrospective observational study.

Although blood pressure (BP) variability has been regarded as a risk factor for hemorrhagic transformation (HTF) after intravenous thrombolysis, its effect on HTF after endovascular recanalization therapy (ERT) remains to be elucidated. We aimed to study the relationship between BP variability and symptomatic intracerebral hemorrhage (sICH) after successful recanalization with ERT. A total of 211 patients with acute ischemic stroke and successful recanalization (thrombolysis in cerebral infarction 2b or 3) after ERT were included between January 2013 and May 2017. The BP data following ERT was obtained over the first 24 hours using parameters including mean, maximum, minimum, difference between maximum and minimum, standard deviation, coefficient of variation, successive variations, and time rate (TR) of BP variation for systolic BP (SBP) and diastolic BP. sICH was defined as parenchymal hemorrhage type 2 with neurological deterioration of 4 points of more on the National Institute of Health Stroke Scale. Among the included patients, 20 (9.5%) developed sICH after successful ERT. The parameters linked with BP fluctuation over time were significantly related to sICH. After adjusting for confounders, the TR of SBP (per 0.1 mmHg/min increase) variation was independently associated with sICH (odds ratio = 1.71, 95% confidence interval = 1.013-2.886). Time-related BP variability in the first 24 hours following successful ERT was more correlated with sICH than other absolute BP levels. This suggests that maintaining a stable BP may be an important factor in preventing sICH after successful ERT. Ann Neurol 2019;85:574-581.

Letter re: Ischemic Lesions, blood pressure dysregulation, and poor outcomes in intracerebral hemorrhage.

We appreciated the article by Kidwell et al.1 that showed higher first-recorded blood pressure (BP) and greater delta mean arterial pressure are associated with the development of diffusion-weighted imaging (DWI) lesions in acute intracerebral hemorrhage (ICH). The most desirable BP target and optimal antihypertensive strategy in ICH are controversial.2 The relationship between BP and outcome is more complex than simply linear, and mechanisms other than BP reduction play a role. There is accruing evidence that not only absolute BP levels but their variation over time affect ICH prognosis.3 Besides increasing the risk of hematoma enlargement, BP fluctuations could favor remote ischemia by working synergistically with preexistent burden of cerebral small angiopathy, namely leukoaraiosis and microbleeds, and influence the stroke outcome. Both systolic and diastolic BP dysregulation deserve more comprehensive assessment through the proper measures of variability, such as standard and residual deviation, variation coefficient, average real variability, and variation independent of the mean.4 In addition, time to MRI differed among DWI+ and DWI− patient subgroups, which could represent a meaningful bias: it would be appropriate to include this variable among the controlling factors of the multivariable predictive model for DWI lesions development.

24-Hour Blood Pressure Variability Assessed by Average Real Variability: A Systematic Review and Meta-Analysis.

BackgroundAlthough 24‐hour blood pressure (BP) variability (BPV) is predictive of cardiovascular outcomes independent of absolute BP levels, it is not regularly assessed in clinical practice. One possible limitation to routine BPV assessment is the lack of standardized methods for accurately estimating 24‐hour BPV. We conducted a systematic review to assess the predictive power of reported BPV indexes to address appropriate quantification of 24‐hour BPV, including the average real variability (ARV) index.Methods and ResultsStudies chosen for review were those that presented data for 24‐hour BPV in adults from meta‐analysis, longitudinal or cross‐sectional design, and examined BPV in terms of the following issues: (1) methods used to calculate and evaluate ARV; (2) assessment of 24‐hour BPV determined using noninvasive ambulatory BP monitoring; (3) multivariate analysis adjusted for covariates, including some measure of BP; (4) association of 24‐hour BPV with subclinical organ damage; and (5) the predictive value of 24‐hour BPV on target organ damage and rate of cardiovascular events. Of the 19 assessed studies, 17 reported significant associations between high ARV and the presence and progression of subclinical organ damage, as well as the incidence of hard end points, such as cardiovascular events. In all these cases, ARV remained a significant independent predictor (P<0.05) after adjustment for BP and other clinical factors. In addition, increased ARV in systolic BP was associated with risk of all cardiovascular events (hazard ratio, 1.18; 95% confidence interval, 1.09–1.27). Only 2 cross‐sectional studies did not find that high ARV was a significant risk factor.ConclusionsCurrent evidence suggests that ARV index adds significant prognostic information to 24‐hour ambulatory BP monitoring and is a useful approach for studying the clinical value of BPV.

Comparison of Different Automated Office Blood Pressure Measurement Devices: Evidence of Nonequivalence and Clinical Implications

BackgroundAutomated office blood pressure (AOBP) measuring devices are increasingly recommended as preferred blood pressure (BP) diagnostic tools, but it is unclear how they compare and how clinical environments impact their performance. MethodsThis prospective randomized factorial parallel 4-group study compared BP estimates by BpTRU (VSM MedTech, Vancouver, BC, Canada) and Omron HEM 907 (Omron Healthcare, Kyoto, Japan) devices in closed vs open areas. Patients diagnosed with hypertension were recruited during office visits. After baseline open-room AOBP measurement with the BpTRU, patients had a second BP measurement with either the BpTRU or HEM 907 in either open or closed areas. Absolute BP levels and differences between the first and second measurements were compared. Diagnostic performance was also assessed. ResultsTwo hundred fifty-eight patients were studied. Their mean age was 66.2 ± 12.0 years, and 62% were men. The mean of first AOBP estimates was 127.4/73.3 mm Hg. Analyses of subsequent measurements revealed no influence of open or closed areas on BP means and diagnostic performance. Conversely, the Omron HEM 907 exceeded BpTRU systolic BP measurements by 4.6 mm Hg (< 0.01) in closed areas and by 3.9 mm Hg (< 0.01) in open areas. The discrepancy between devices was amplified at lower BP levels. ConclusionsAlthough different areas did not influence BP estimates, the Omron HEM 907 significantly exceeded BpTRU measurements on average and especially at lower BP levels. These differences should be considered when interchanging devices and could have clinical decision impacts in a population of patients treated for hypertension. Our results support the constant use of only 1 device type in a given clinic.

Cardiovascular Profile of Propranolol after Multiple Dosing in Infantile Hemangioma

Propranolol is becoming the treatment of choice for complicated infantile hemangioma. We report here data on peripheral blood flow, O₂-saturation, electrocardiographic PR-interval, left ventricular function, blood pressure and heart rate that were assessed before and during treatment for ≥4 weeks with propranolol 2 mg/kg of body weight daily in 67 infants <12 months of age in normal sinus rhythm and with structurally normal hearts. Management with propranolol was well tolerated in all and did not modify peripheral blood flow, O₂-saturation, electrocardiographic PR-interval and left ventricular fractional shortening or ejection fraction. Absolute blood pressure levels were similar without and with propranolol. However, age-adjusted centile levels for both systolic and diastolic levels were significantly lower while on propranolol. The heart rate was significantly lower both when expressed as absolute value and when expressed as age-adjusted centile on treatment with propranolol. In conclusion, propranolol 2 mg/kg of body weight daily causes a statistically though not clinically relevant decrease in blood pressure and heart rate in cardially healthy infants affected by infantile hemangioma. Temporary discontinuation during acute febrile illnesses and during diarrheal diseases should be considered to prevent excessive hypotension.

Low-dose hydrocortisone replacement is associated with improved arterial stiffness index and blood pressure dynamics in severely adrenocorticotrophin-deficient hypopituitary male patients.

Increased cardiovascular and cerebrovascular morbidity and mortality in hypopituitary subjects may be linked to inappropriate glucocorticoid exposure; however, the pathophysiology remains unclear. We aimed to examine the effect of three commonly prescribed hydrocortisone (HC) regimens on vascular risk factors. An open crossover study randomising ten hypopituitary men with severe adrenocorticotrophic hormone deficiency to three HC dose regimens: dose A (20mg mane and 10mg tarde), dose B (10mg mane and 10mg tarde) and dose C (10mg mane and 5mg tarde). Following 6 weeks on each regimen, participants underwent 24-h serum cortisol sampling, 24-h ambulatory blood pressure (BP) measurements, calculation of the Ambulatory Arterial Stiffness Index (AASI), oral glucose tolerance testing and fasting serum osteoprotegerin (OPG) sampling. There were no differences in 24-h BP between dose regimens and controls; however, low-dose HC replacement (dose C) was associated with the lowest AASI, indicating a less stiff arterial tree (P<0.05) compared with the other dose regimens. Loss of the physiologic nocturnal BP dip was more common in higher HC replacement regimens, although only significant for dose B compared with dose C (P=0.03). Twenty per cent of patients had abnormal glucose tolerance, but this was unrelated to dose regimen. OPG correlated strongly with 24-h BP in those on dose A only (r=0.65, P=0.04). Currently prescribed HC replacement doses do not result in significant differences in absolute BP levels or improvements in insulin sensitivity. However, lower HC doses may result in lower arterial stiffness and a more physiological nocturnal BP dip. Long-term studies are required to confirm these findings and evaluate their impact on vascular morbidity in this patient group.

Night-time blood pressure and target organ damage: a comparative analysis of absolute blood pressure and dipping status.

The prognostic significance of abnormal circadian blood pressure (BP) patterns is well established. Research to date has focused on both nocturnal dipping and absolute night-time BP levels; however, which of these variables should be the primary target for therapy remains unclear. The aim of this study is to determine whether dipping status or absolute night-time BP levels have a stronger association with subclinical target organ damage (TOD). The Mitchelstown Cohort was established to examine cardiovascular health in an adult population sample recruited from primary care. Night-time BP was categorized by dipping status. Subclinical TOD was defined as Cornell Product left ventricular hypertrophy (LVH) voltage criteria on ECG and urine albumin : creatinine ratio (ACR) at least 1.1 mg/mmol. Multivariable logistic regression analysis was used to assess the association between night-time BP and TOD. Of 2047 participants, 1207 (response rate 59%), underwent 24-h ambulatory BP monitoring. We excluded 161 studies due to incomplete data. Of 1046 participants, 178 (17%) had evidence of TOD. Each 10-mmHg rise in night-time SBP increased the odds of TOD. Odds ratio (OR) ACR at least 1.1 mg/mmol 1.5 [95% confidence interval (95% CI) 1.2-1.8] and OR LVH 1.4 (95% CI 1.1-1.8). Absolute BP level rather than dipping status may be a superior early marker of risk associated with night-time BP. Interventional studies are required to determine whether there is a benefit in specifically targeting absolute night-time BP levels to prevent clinically important outcomes.

Response to Body Position and Quality of Sleep Interfere With Day-Night Blood Pressure Dip

We thank Bakx and coworkers1 for their interest in our study. They are right in stating that sleeping on the right or left lateral side can result in different blood pressure (BP) values, with BP differences averaging 15 mm Hg.2 Thus, the absolute nighttime BP levels, the day-night BP dip, and the early morning surge in BP should be corrected for the left or right lateral position. Unfortunately, tracking such information for all BP measurements taken in lying position during night, or even during day, is problematic from a technical point …

Reproducibility of Blood Pressure Response to the Cold Pressor Test: The GenSalt Study

An elevated blood pressure (BP) response to the cold pressor test (CPT) is associated with increased risk of hypertension and cardiovascular disease. However, it is still unclear whether BP response to the CPT is a stable and reproducible trait over time. Using the same study protocol, the authors repeated the CPT 4.5 years after initial administration among 568 Han Chinese in rural northern China (2003-2005 and 2008-2009). BP was measured using a standard mercury sphygmomanometer prior to and 0, 1, 2, and 4 minutes after the participants immersed their hand in ice water (3°C-5°C) for 1 minute. Absolute BP levels and BP responses during the CPT in the initial and repeated administrations were highly correlated. For example, the correlation coefficients were 0.67, 0.73, 0.71, and 0.72 for absolute systolic BP levels at 0, 1, 2, and 4 minutes after ice-water immersion (all P 's < 0.0001). The correlation coefficients for systolic BP response were 0.41 at 0 minutes, 0.37 at 1 minute, 0.42 for maximum response, and 0.39 for the area under the curve during CPT (all P 's < 0.0001). These data indicate that BP response to the CPT is a long-term reproducible and stable characteristic in the general population.

Blood Pressure Variability, Cardiovascular Risk, and Risk for Renal Disease Progression

The adverse cardiovascular consequences of high blood pressure (BP) not only depend on absolute BP values, but also on BP variability (BPV). Evidence has been provided that independently of mean BP levels, BP variations in the short- and long-term are associated with the development, progression and severity of cardiac, vascular and renal organ damage, and with an increased risk of CV events and mortality. Alterations in BPV have also been shown to be predictive of the development and progression of renal damage, which is of relevance if considering that impaired renal function in a hypertensive patient constitutes a very potent predictor of future CV events and mortality even in treated subjects. This review will address whether antihypertensive treatment should target alterations in BPV, in addition to reducing absolute BP levels, in order to achieve the highest CV and renal protection in hypertensive and renal patients.

Hypertensive crisis

Hypertensive crisis

The Significance of Blood Pressure Variability for the Development of Hemorrhagic Transformation in Acute Ischemic Stroke

Elevated blood pressure (BP) is commonly observed in acute ischemic stroke and is known to be associated with hemorrhagic transformation (HT). However, the effect of BP variability on the development of HT is not known well. A consecutive series of patients with acute ischemic stroke, who were hospitalized within 24 hours of onset and showed no HT on initial gradient echo MRI, were enrolled in this study. BP measurements during the first 72 hours were obtained, and BP variability of each patient was described using various summary parameters: SD, maximum (max), minimum (min), difference between max and min (max-min), average squared difference between successive measurements (sv), and maximum sv (svmax). Of 792 patients meeting the eligibility criteria, 70 (8.8%) developed HT. Among BP variability parameters categorized into quartiles, SBP(max), SBP(min), SBP(max-min), SBP(svmax), DBP(SD), DBP(max), DBP(min), DBP(max-min), and DBP(svmax) were significantly associated with HT independent of mean SBP, age, interval from onset to arrival, initial stroke severity, diabetes mellitus, stroke subtype, thrombolysis, initial glucose, and total cholesterol (P<0.05 on likelihood ratio test of trend). The analyses about the interaction between thrombolysis and variability parameters showed that the effects of BP variability on the development of HT did not differ by whether patients received thrombolysis or not. Our study suggests that we may consider not only the absolute level of BP but also its variability to prevent hemorrhagic transformation.

Comparison of intradialytic blood pressure variability between conventional thrice‐weekly hemodialysis and short daily hemodialysis

Intradialytic blood pressure (BP) variability may be associated with increased mortality. We examined the effect of short daily hemodialysis (SDHD) on intradialytic BP variability relative to conventional thrice-weekly HD (CHD). This is a retrospective cohort study. Subjects were those converted from CHD to SDHD (n=12). All intradialytic BPs were collected on the last month of CHD, and on month 6 of SDHD. Absolute predialysis BP level and intradialytic BP variability were defined as the intercept and average residual terms, respectively, from a mixed-effects linear regression model of time on BP. Dialysis modality was a predictor variable (CHD vs. SDHD). Outcome variables were intradialytic BP variability and hypotension (BP<90/55 mmHg at any time during HD). In addition to a predictor and outcomes, the demographics, estimated dry weight, and ultrafiltration ratio were examined. The median (range) age of the patients was 48 (34-77); all had hypertension, and 4 (33%) had diabetes. By a mixed effects linear regression model, the intradialytic systolic BP variability was 13.2 (quartile range 9.5-14.0) mmHg and 10.0 (8.3-10.9) mmHg for CHD and SDHD, respectively (P<0.006). Intradialytic diastolic BP variability was also significantly reduced (7.7 [6.4-9.2] vs. 6.1 [5.5-6.6] mmHg, P=0.005). Relative to CHD, less hypotension was observed during treatment on SDHD: the odds ratio (95% confidence interval) was 0.36 (0.16-0.81; P=0.008). In this retrospective study, SDHD was associated with less intradialytic BP variability and with fewer episodes of hypotension during treatments. Further studies are necessary to generalize these findings.