Changes In Blood Pressure Variability Research Articles

P217 MAY MEASUREMENT MONTH 2019: BLOOD PRESSURE VARIABILITY IN RELATION TO AGE AND SEX

Background and Objective: Within-visit blood pressure variability (BPV) is predictive of cardiovascular events independent of mean blood pressure (BP) levels and may serve as marker of cardiovascular aging. This study aimed to explore changes in BPV by age, and sex in May Measurement Month (MMM) 2019 survey participants. Methods: Adults (≥18 years) were surveyed opportunistically from 92 countries and up to three standardized seated BP readings were recorded. This analysis included all participants who were not taking BP-lowering medication and with complete data on age, sex, and three valid BP recordings. Three indices of BPV were compared: the standard deviation (SD), coefficient of variation (CV), and variation independent of the mean (VIM). A linear regression model was created for each index. Models were adjusted for mean BP, age, sex, and an interaction between age and sex. Age and mean BP were each included as natural cubic splines with 11 and 5 knots, respectively, to allow for flexibility with modelling relationships. Results: Data from 842,356 participants were included. The mean age was 42.9 (SD 15.9) years and 51.5% were female. Patterns of BPV from 18-90 years and by sex were consistent across BPV indices. Systolic BPV was higher in female than male participants between the ages of 30 and 80. In female participants, systolic BPV declined with age from 18-25, after which systolic BPV increased with age. In male participants, systolic BPV declined with age from 18-45, after which systolic BPV increased with age. Diastolic BPV was highest at the youngest and oldest ages, and lowest between 45 and 55 in both sexes. Conclusions: There was a highly consistent pattern amongst three commonly used indices of BPV in their relationships with age and sex. The BPV of screened adults was lower in males than females and varied non-linearly with age, with markedly higher BPV at younger and older ages, with distinct patterns of variation observed between systolic and diastolic BPV.

Changes in Blood Pressure Variability in Children with Postural Tachycardia Syndrome.

(1) Objective: In this research, we explored the difference in blood pressure variability (BPV) between children with postural tachycardia syndrome (POTS) and healthy children. Furthermore, we tried to investigate the effect of BPV on POTS and its relationship with prognosis of POTS. (2) Methods: 47 children with POTS (11.2 ± 1.8 years, 23 males) were enrolled in the POTS group and 30 healthy children (10.9 ± 1.9 years, 15 males) were matched for the control group. All participants completed 24 h ambulatory blood pressure monitoring (24hABPM). Thirty-three children with POTS were followed up for 52.0 (30.5, 90.5) days and were divided into a response group and a non-response group after evaluation. (3) Results: The 24 h diastolic blood pressure standard deviation (24hDSD), daytime diastolic blood pressure standard deviation (DDSD), nighttime systolic blood pressure standard deviation (NSSD), daytime diastolic blood pressure variation coefficient (DDCV) and nighttime systolic blood pressure variation coefficient (NSCV) in the control group were lower than those in the POTS group (p < 0.05). Percentage of females, age and height were lower in the response group than in the non-response group in children with POTS (p < 0.05). Univariate analysis showed that 24hDSD, DDSD, NSSD, DDCV and NSCV were potential risk factors for POTS, and sex and height were potential risk factors for poor prognosis of POTS. After adjusting for covariates, the risk of POTS increased by 48%, 53% and 49% when DDSD, NSSD and NSCV increased by 1 mmHg, 1 mmHg and 1%, respectively. The risk of poor prognosis in females was 12.99 times higher than that in males. (4) Conclusions: The results suggest that children with POTS may have an abnormal circadian rhythm in blood pressure and increased BPV. DDSD, NSSD and NSCV are independent risk factors for POTS, and being female is an independent risk factor for poor prognosis of POTS.

BLOOD PRESSURE VARIABILITY AND CIRCADIAN PATTERN AFTER RENAL DENERVATION - CROATIAN REAL-LIFE STUDY

Objective: Recent trials confirmed the lowering effect of renal denervation (RDN) on blood pressure (BP). We aimed to analyze the impact of RDN on BP variability and circadian rhythm. Design and method: Out of 31 truly resistant patients whose secondary forms of hypertension were ruled out and were enrolled into the Croatian Spyral RDN registry, 18 (10 m, 8 w, average age 49.3) were eligible for analyses. Office BP, ABPM, central BP, and PWV were measured with Omron M6, Mobilograph, and Sphygmocor devices. Sympathetic/parasympathetic activity was measured with ANX-3.0 ANSAR device. All RDN procedures (Spyral Medtronic) were done by one physician (average number of ablation spots was 41/procedure). Patients were examined the day before and that day, 1,3,6, and 12 months after the RDN. The response was a drop of office systolic BP by 10 mmHg or more 6 months after RDN. There were no differences in the RDN procedure between responders and non-responders. Results: Office and ABPM values dropped the day after RDN and remained significantly lower at the end of the follow-up (6.5/-5.5 and -16.2/9 mmHg, respectively). We failed to find changes in BP variability (SD) after RDN. However, a significant decrease in morning BP surge was observed immediately the day after RDN (-12.4) and was even lower at the end of the follow-up (-18.8 mmHg). Substantial number of patients who had an abnormal nocturnal BP pattern became dippers. Central systolic BP and PWV decreased (-6.3 mmHg and -0.72 m/s, respectively). LFa/RFa decreased the day after RDN and reminded lower during the follow-up period. After RDN morning BP surge remained stable and normal in responders; however, in non-responders, it decreased immediately after RDN (-21.2) and remained lower during the follow-up till the last visit (-33.3). Conclusions: Significant improvements in circadian rhythm and several parameters of central hemodynamics were observed after RDN indicating that RDN might be considered as a pathway to the complete, so-called perfect 24-hour BP control. Observed beneficial effects run in parallel with the observed decrease in sympathetic activity. Importantly, even in non-responders, RDN had a beneficial effect on morning BP surge.

Reduction in blood pressure following acute dietary nitrate ingestion is correlated with increased red blood cell S-nitrosothiol concentrations

Dietary nitrate (NO3−) supplementation can enhance nitric oxide (NO) bioavailability and lower blood pressure (BP) in humans. The nitrite concentration ([NO2−]) in the plasma is the most commonly used biomarker of increased NO availability. However, it is unknown to what extent changes in other NO congeners, such as S-nitrosothiols (RSNOs), and in other blood components, such as red blood cells (RBC), also contribute to the BP lowering effects of dietary NO3−. We investigated the correlations between changes in NO biomarkers in different blood compartments and changes in BP variables following acute NO3− ingestion. Resting BP was measured and blood samples were collected at baseline, and at 1, 2, 3, 4 and 24 h following acute beetroot juice (∼12.8 mmol NO3−, ∼11 mg NO3−/kg) ingestion in 20 healthy volunteers. Spearman rank correlation coefficients were determined between the peak individual increases in NO biomarkers (NO3−, NO2−, RSNOs) in plasma, RBC and whole blood, and corresponding decreases in resting BP variables. No significant correlation was observed between increased plasma [NO2−] and reduced BP, but increased RBC [NO2−] was correlated with decreased systolic BP (rs = −0.50, P = 0.03). Notably, increased RBC [RSNOs] was significantly correlated with decreases in systolic (rs = −0.68, P = 0.001), diastolic (rs = −0.59, P = 0.008) and mean arterial pressure (rs = −0.64, P = 0.003). Fisher's z transformation indicated no difference in the strength of the correlations between increases in RBC [NO2−] or [RSNOs] and decreased systolic blood pressure. In conclusion, increased RBC [RSNOs] may be an important mediator of the reduction in resting BP observed following dietary NO3− supplementation.

TU-187. Blood pressure variability changes are more pronounced in secondary progressive Multiple Sclerosis

TU-187. Blood pressure variability changes are more pronounced in secondary progressive Multiple Sclerosis

Effects of Concurrent Aerobic Plus Resistance Training on Blood Pressure Variability and Blood Pressure Values in Patients with Hypertension and Coronary Artery Disease: Gender-Related Differences.

The purpose of this study was to compare changes in blood pressure variability (BPV) and blood pressure (BP) values occurring in response to concurrent training (CT) between the two genders. A total of 35 males and 20 women aged 55–80 years, with hypertension and coronary artery disease, were included. They underwent a 12-week CT program. The aerobic component of CT was performed according to the rate of perceived exertion while the intensity of the resistance component was set at 60% of 1 repetition maximum for the first 4 weeks and then increased to 80%. BP and BPV were evaluated at baseline and at the end of the CT program through 24 h ambulatory blood pressure monitoring. After 12-weeks, 24 h and daytime systolic BPV decreased in both men and women without significant between-groups differences. Twenty-four-hour daytime and nighttime diastolic BPV decreased in both genders with a significantly greater decrease in women compared to men. Twenty-four-hour daytime systolic and 24 h diastolic BP decreased in men while they were unchanged in women. In conclusion, CT induced similar reductions of systolic BPV in men and women and a greater decrease in diastolic BPV in women. Conversely, CT decreased BP values in males but not in females. CT appears to be an effective intervention for reducing BPV in both genders.

The Effect of Unilateral Nephrectomy on Arterial Blood Pressure Variability in Spontaneously Hypertensive Rats

&#x0D; &#x0D; &#x0D; The aim of the current study was to investigate the effects of unilateral nephrectomy (ULN) on fast oscillation of arterial blood pressure in spontaneously hypertensive rats (SHR). Experiments were carried out on conscious normotensive Wistar rats and SHR divided in groups with intact kidneys: W, n = 10; SHR, n = 9 and with unilateral nephrectomy: WN, n = 10; SHRN, n = 10. ULN was performed under general anaesthesia (Nembutal 35 mg/kg b.w. i.p.), eight days before the experiments. Blood pressure variability was investigated by means of spectral analysis of systolic (SAP) diastolic (DAP) and mean (MAP) arterial blood pressure, estimated in directly registered arterial blood pressure wave. In SAP, DAP and MAP spectrograms, derived by Lab View software equipment, the spectral power (P) in low (LF, 20–195 mHz), mid (MF, 195–605 mHz) and high frequency (HF, 605—3000 mHz) bands was calculated. PLF in SAP spectrograms increased after ULN both in Wistar rats and SHR. ULN led to decrease of PMF in SAP, DAP and MAP spectrograms only in SHR. The ULN provokes changes in blood pressure variability in different manner in the normotensive and the spontaneously hypertensive rats. In addition to humorally-mediated low-frequency oscillations, ULN in SHR also af- fected the spectral characteristics of the arterial pressure in which sympathetic nervous activity operates.&#x0D; &#x0D; &#x0D;

Association between Short-Term Blood Pressure Variability and Intracranial Atherosclerotic Plaque Vulnerability: A High-Resolution Magnetic Resonance Imaging Study.

Aim: short-term blood pressure variability (BPV) as a risk factor of atherosclerosis and cardiovascular events has been investigated. However, its association with atherosclerotic plaque vulnerability remains unknown. The objective of this study was to determine the association between short-term BPV and intracranial atherosclerotic plaque vulnerability. Methods: this is a cross-sectional analysis of 267 ischemic stroke patients with symptomatic intracranial atherosclerosis (mean age, 65±12 years old; 60.3% male), which were prospectively recruited in a comprehensive stroke center. Systolic and diastolic BP SD, CV, and BP variability ratio (BPVR) from 24 hours, daytime, and nighttime were calculated from 24-h ambulatory blood pressure monitoring, intracranial atherosclerotic plaque burden and vulnerability were evaluated by high-resolution magnetic resonance vessel wall imaging. Logistic regression analysis was used to locate the correlation between short-term BPV and plaque vulnerability. Results: a total of 36.3% subjects presented with intraplaque hemorrhage (IPH) in this study. Multivariate logistic regression suggested that nighttime diastolic BP CV and 24-h BPVR were associated with intracranial IPH independently after adjusted for cardiovascular risk factors, odds ratio (OR) and 95% confidence interval (CI) for per SD BPV changes were 1.418 (1.051, 1.914) and 0.731 (0.548, 0.976), respectively, and this association also independent of atherosclerosis burden and 24-h mean systolic BP level. Further subgroup analysis by age and hypertension history demonstrated that the statistical correlation could only establish in the elder, and subjects with hypertension. Conclusion: nighttime diastolic BP CV and 24-h BPVR were associated with intracranial IPH independently, especially in the elderly and subjects with hypertension.

Blood Pressure Variability and Baroreflex Sensitivity in Premature Newborns-An Effect of Postconceptional and Gestational Age.

Introduction: Cardiovascular system is the vitally important system in the dynamical adaptation process of the newborns to the extrauterine environment. To reliably detect immaturity in the given organ system, it is crucial to study the development of the organ functions in relation to maturation process.Objectives: The objective was to determine the changes in the spontaneous short-term blood pressure variability (BPV) and baroreflex sensitivity (BRS) reflecting various aspects of cardiovascular control during the process of maturation in preterm babies and to separate effects of gestational age and postnatal age.Methods: Thirty-three prematurely born infants without any signs of cardio-respiratory disorders (gestational age: 31.8, range: 27–36 weeks; birth weight: 1,704, range: 820–2,730 grams) were enrolled. Continuous peripheral blood pressure signal was obtained by non-invasive volume-clamp photoplethysmography method during supine rest. The recordings of 250 continuous beat-to-beat blood pressure values were processed by spectral analysis of BPV (assessed measures: total power, low frequency and high frequency powers of systolic BPV) and BRS calculation. For each infant we also assessed systolic, diastolic and mean blood pressures, heart rate and respiratory rate.Results: With the postconceptional age, BPV measures decreased (for total power: Spearman correlation coefficient rs = −0.345, P = 0.049; for low frequency power: rs = −0.365, P = 0.037; for high frequency power rs = −0.349; P = 0.046); and BRS increased significantly (rs = 0.448, P = 0.009). The further analysis demonstrated that these effects were more attributable to gestational age than to postnatal age. BRS correlated negatively with BPV magnitude (rs = −0.479 to −0.592, P = 0.001–0.005). Mean blood pressure and diastolic blood pressure increased during maturation (rs = 0.517 and 0.537, P = 0.002 and 0.001, respectively) while heart rate and respiratory rate decreased (rs = −0.366 and −0.516, P = 0.036 and 0.002, respectively).Conclusion: We conclude that maturation process is accompanied by an increased involvement of baroreflex buffering of spontaneous short-term blood pressure oscillations. Gestational age plays a dominant role not only in BPV changes but also in BRS, mean blood pressure, diastolic blood pressure and heart rate changes.

EFFECT OF NIFEDIPINE GITS VERSUS RAMIPRIL ON HOME BLOOD PRESSURE VARIABILITY: PRELIMINARY RESULTS OF REVERENT RANDOMIZED TRIAL

Objective: Blood pressure (BP) variability (BPV) was shown to independently predict adverse outcomes, making it a potential target for treatment. Preliminary data indicated a possible larger reduction of BPV with dihydropyridine calcium channel blockers (CCB). However, it is not clear whether different antihypertensive drug classes can differently affect BPV. Aim of REVERENT (Reducing blood pressure Variability in Essential hypertension with Ramipril vErsus Nifedipine GITS) Trial was to compare BPV changes after a period of treatment with a CCB (nifedipine GITS) or an ACEI (ramipril). Design and method: Patients with essential hypertension either treatment naïve or after washout from previous treatment were included. Participants were randomized according to a PROBE design to nifedipine GITS 30 mg or ramipril 10 mg in a single morning dose. We report preliminary data on day-to-day BPV (expressed as standard deviation; SD of all readings) estimated from home measurements (7 days; duplicate morning and evening measurements per day; AND UA-651BLE) at baseline and after 10 weeks of treatment. Results: 153 patients successfully completed the study (table). Patient characteristics, home BP and BPV values at baseline and after 10-week treatment in all participants and separately in naïve (N = 121) and previously treated patients (N = 32) are reported (table). We observed no significant differences between treatment groups in the change (baseline to 10-week) of home BPV except for treatment naïve hypertensive patients in whom a small but significant difference in systolic BPV change was observed. Conclusions: These data, overall, did not show clear differences between nifedipine GITS and ramipril in reducing home BPV, except for treatment-naïve individuals in whom a small but significant difference in favour of the CCB was observed. The relevance of treatment induced BPV changes requires documentation in outcome studies.

How to Choose the Optimal Single-Pill Combination of the First-Line Antihypertensive Drugs? The Benefits of Amlodipine and Telmisartan Combination

In patients with arterial hypertension (AH), an extremely important measure of the effectiveness of antihypertensive drugs (AHD) is not only a direct decrease in blood pressure (BP), but also its stable control throughout the 24 hours, preventing excessive morning surge and increased BP variability, which in turn are recognized cardiovascular risk factors. Currently, in the vast majority of hypertensive patients, the main antihypertensive therapy approach is using single-pill combinations (SPC) of AHD. Among the first-line combinations for a wide range of patients with AH and no special clinical conditions is amlodipine/telmisartan SPC. Distinctive features of these drugs, on the one hand, are unique pharmacological properties, consisting in an ultra-long antihypertensive effects, superior to other AHD in their classes; and on the other hand, there is an large body of evidence from numerous clinical trials confirming their high antihypertensive and target-organ protective potential as well as excellent capabilities in cardiovascular risk reduction. To assess the AHD effectiveness extent, several parameters have been proposed, of which the most rational and useful is the smoothness index, calculated using the ambulatory blood pressure monitoring data. Smoothness index describes both the degree of BP reduction and its distribution during the monitoring period. This index inversely associates with the changes in BP variability, and has predictive value in relation to the hypertension-mediated organ damage regression during different antihypertensive regimens. Amlodipine/telmisartan SPC has also been studied in many trials, including comparative ones with other AHD. In these works its direct powerful antihypertensive effect and a pronounced beneficial impact on the smoothness index have been proved, demonstrating stable BP control throughout the 24 hours (especially in the most dangerous morning hours), and also a decrease in BP variability. Therefore, amlodipine/telmisartan SPC can effectively reduce cardiovascular risk and improve prognosis in patients with AH.

BMAL1 in Renal Distal Segments Does Not Contribute to Variations in Beat‐to‐Beat Blood Pressure but a Low Potassium Diet Increases Blood Pressure Variability

IntroductionBlood pressure (BP) regulation is a dynamic process. Beat‐to‐beat fluctuations in BP can be studied by frequency domain analysis to determine variability. Measurements of BP and the heart rate variability have been used as an indication of cardiovascular health and autonomic nervous system (ANS) activity. The circadian clock, which is comprised of four core transcriptional factors, including BMAL1, regulates a variety of physiological and autonomic functions in the body such as BP and heart rate. Previously, we generated renal distal segment specific BMAL1 male knockout mice (dsBMAL1 KO) that exhibit lower BP compared to control mice (CNTL).GoalThe goal of this study was to determine if BMAL1 knockout within the distal segments of the kidney affects BP variability before or after dietary potassium depletion.MethodsMale 14–18‐week‐old mice were implanted with telemeter devices. Following recovery, basal mean arterial pressure and heart rate were measured. Data was collected at 1000 Hz for 2 minutes every hour during the active period (ZT 12–20) and inactive (ZT 0–8) period. Following basal measures, mice were given low potassium diet for 5 days. Data are from the active period of the 5th day (ZT 12–16). Fourier analysis was performed via Kubios software using pre‐determined high‐frequency (HF) and low‐frequency (LF) scaling established for mice. Data were analyzed by 2‐way ANOVA to test for time and genotype effects at baseline, and for genotype and treatment to assess effect of dietary potassium depletion. N=7 CNTL and 8 renal dsBMAL1 KO.ResultsAs expected, mean heart rate was higher during the active period vs. inactive (CNTL: 613 ± 12.7 vs. 508 ± 13.7 bpm; dsBMAL1 KO: 661 ± 17.0 vs. 538 ± 11.7 bpm; PTIME&lt;0.0001), furthermore, dsBMAL1 KO exhibited faster heart rates than CNTL (PGENOTYPE&lt;0.05). Power spectral analysis of mean arterial pressure indicated that there was greater variability during the inactive period vs. active in HF bands (PTIME&lt;0.0001) but no genotype differences were found. Additionally, spectral analysis did not demonstrate any significant differences in the ratio of LF/HF regardless of active period or genotype (PTIME=0.4; PGENOTYPE=0.3). Nighttime (ZT 12–16) HF BP variability was higher following potassium depletion compared to baseline (CNTL: 8.25 ± 0.199 vs. 8.97 ± 0.079 mmHg2/Hz; dsBMAL1 KO: 8.63 ± 0.170 vs. 9.07 ± 0.279 mmHg2/Hz; PTREATMENT&lt;0.01).ConclusionsBMAL1 in renal distal segments does not contribute to variations in beat‐to‐beat BP. Renal dsBMAL1 KO exhibit a faster heart rate independent of variability. Potassium depletion increases BP variability in this experimental setting. Using this analysis software, changes in BP variability reflected changes in heart rate with faster heart rates correlating with less BP variability.Support or Funding InformationNIH/NIDDK 1R01DK109570‐01A1 (PI: Gumz), Gatorade Trust through the UF Department of Medicine, 19POST34450134 AHA Postdoc Fellowship, North Florida/South Georgia Veterans Health Systems

Change in Blood Pressure Variability Among Treated Elderly Hypertensive Patients and Its Association With Mortality.

BackgroundInformation is scarce regarding effects of antihypertensive medication on blood pressure variability (BPV) and associated clinical outcomes. We examined whether antihypertensive treatment changes BPV over time and whether such change (decline or increase) has any association with long‐term mortality in an elderly hypertensive population.Methods and ResultsWe used data from a subset of participants in the Second Australian National Blood Pressure study (n=496) aged ≥65 years who had 24‐hour ambulatory blood pressure recordings at study entry (baseline) and then after a median of 2 years while on treatment (follow‐up). Weighted day‐night systolic BPV was calculated for both baseline and follow‐up as a weighted mean of daytime and nighttime blood pressure standard deviations. The annual rate of change in BPV over time was calculated from these BPV estimates. Furthermore, we classified both BPV estimates as high and low based on the baseline median BPV value and then classified BPV changes into stable: low BPV, stable: high BPV, decline: high to low, and increase: low to high. We observed an annual decline (mean±SD: −0.37±1.95; 95% CI, −0.54 to −0.19; P<0.001) in weighted day‐night systolic BPV between baseline and follow‐up. Having constant stable: high BPV was associated with an increase in all‐cause mortality (hazard ratio: 3.03; 95% CI, 1.67–5.52) and cardiovascular mortality (hazard ratio: 3.70; 95% CI, 1.62–8.47) in relation to the stable: low BPV group over a median 8.6 years after the follow‐up ambulatory blood pressure monitoring. Similarly, higher risk was observed in the decline: high to low group.ConclusionsOur results demonstrate that in elderly hypertensive patients, average BPV declined over 2 years of follow‐up after initiation of antihypertensive therapy, and having higher BPV (regardless of any change) was associated with increased long‐term mortality.

Blood Pressure Variability and Autonomic Dysfunction.

This review considers the relationship between abnormal blood pressure (BP) variability and autonomic dysfunction through an attempt to answer questions about its clinical relevance and pertinence to diabetes and cardiovascular autonomic neuropathy (CAN) and which therapeutic measures can lessen its cardiovascular impact. Office, ambulatory, and home BP monitoring identify posture-related, circadian, short-term, and long-term BP variabilities. Abnormal BP variability is a risk marker for organ damage, mortality, and cardiovascular events. Moreover, BP variability changes are common in diabetes and associated with CAN and possibly exacerbated by comorbidities like nephropathy, obstructive sleep apnoea syndrome, and chronic pain. The prognostic role of nondipping and reverse dipping is well documented in diabetes. Some findings suggest the possibility of restoring dipping with the dosage time of antihypertensive agents. Diabetes is a favorable scenario for altered BP variability, which might mediate the harmful effects of CAN. Preliminary data suggest the protective effect of targeting BP variability. However, further longitudinal outcome studies are needed. In the meantime, BP variability measures and practical expedients in antihypertensive treatment should be implemented in diabetes.

A7625 Change in blood pressure variability among elderly treated hypertensive population and its association with mortality

Objectives: Higher blood pressure variability (BPV) is associated with increased cardiovascular and all-cause mortality. We aimed to explore whether BPV changed overtime in response to treatment and whether such change (decline/increase) has any association with long-term mortality amongst an elderly hypertensive population. Methods: We used data from a subset of Second Australian National Blood Pressure study participants (n = 496) aged ≥65 years who had 24 hours ambulatory BP (ABP) recording at study entry (baseline) and then after a median 2-yrs while on-treatment (follow-up). Weighted 24hr systolic BPV was calculated for both baseline and follow-up as a weighted mean of daytime and nighttime BP records standard deviations (SD). The annual rate of change in BPV over-time was calculated from these BPV estimates. Further, we classified both BPV estimates into ‘high’ and ‘low’ based on the baseline median BPV value; and then classified BPV changes into ‘No-change: low’, ‘no-change: high’, ‘decline: high to low’ and ‘increase: low to high’. Association of BPV changes with mortality outcome was assessed over a median 8.5 years after the follow-up ABPM. Results: We observed a decline in average weighted 24hr systolic BPV (mmHg) between baseline (11.8 ± 2.9) and follow-up (11.2 ± 3.2) among the study cohort. The observed BPV annual decline rate (mean ± SD) was –0.78 ± 1.95 (range –7.36 to 9.87). Having a ‘high’ BPV at baseline was associated after adjustment with an increase in all-cause and cardiovascular mortality irrespective of any change in BPV (Table 1). For those with ‘low’ BPV at baseline was not associated with an increase in mortality. Conclusion: In Elderly hypertensives having BPV above baseline median was associated with increased long-term mortality irrespective of any change in BPV.

Blood pressure response to renal denervation is correlated with baseline blood pressure variability: a patient-level meta-analysis.

Sympathetic tone is one of the main determinants of blood pressure (BP) variability and treatment-resistant hypertension. The aim of our study was to assess changes in BP variability after renal denervation (RDN). In addition, on an exploratory basis, we investigated whether baseline BP variability predicted the BP changes after RDN. We analyzed 24-h BP recordings obtained at baseline and 6 months after RDN in 167 treatment-resistant hypertension patients (40% women; age, 56.7 years; mean 24-h BP, 152/90 mmHg) recruited at 11 expert centers. BP variability was assessed by weighted SD [SD over time weighted for the time interval between consecutive readings (SDiw)], average real variability (ARV), coefficient of variation, and variability independent of the mean (VIM). Mean office and 24-h BP fell by 15.4/6.6 and 5.5/3.7 mmHg, respectively (P < 0.001). In multivariable-adjusted analyses, systolic/diastolic SDiw and VIM for 24-h SBP/DBP decreased by 1.18/0.63 mmHg (P ≤ 0.01) and 0.86/0.42 mmHg (P ≤ 0.05), respectively, whereas no significant changes in ARV or coefficient of variation occurred. Furthermore, baseline SDiw (P = 0.0006), ARV (P = 0.01), and VIM (P = 0.04) predicted the decrease in 24-h DBP but not 24-h SBP after RDN. RDN was associated with a decrease in BP variability independent of the BP level, suggesting that responders may derive benefits from the reduction in BP variability as well. Furthermore, baseline DBP variability estimates significantly correlated with mean DBP decrease after RDN. If confirmed in younger patients with less arterial damage, in the absence of the confounding effect of drugs and drug adherence, baseline BP variability may prove a good predictor of BP response to RDN.

Change in blood pressure variability in patients with acute ischemic stroke and its effect on early neurologic outcome.

BackgroundHow short-term blood pressure variability (BPV) is affected in the acute stage of ischemic stroke and whether BPV is associated with early neurologic outcomes remains unclear.MethodsPatients who admitted for ischemic stroke within 24 h of symptom onset were consecutively identified between January 2010 and January 2015. BP profiles measured in real-time were summarized into short-term, 24-h time intervals, based on standard deviation (SD) and mean of systolic BP (SBPSD) during the first 3 days. The primary outcome was daily assessment of early neurological deterioration (END). The associations between short-term SBPSD values and the secular trend for primary outcome were examined.ResultsA total of 2,545 subjects (mean age, 67.1 ± 13.5 years old and median baseline National Institutes of Health Stroke Scale score, 3) arrived at the hospital an average of 6.1 ± 6.6 h after symptom onset. SBPSD values at day 1 (SD#D1), SD#D2, and SD#D3 were 14.4 ± 5.0, 12.5 ± 4.5, and 12.2 ± 4.6 mmHg, respectively. Multivariable analyses showed that SD#D2 was independently associated with onset of END at day 2 (adjusted odds ratio, 1.08; 95% confidence interval, 1.03–1.13), and SD#D3 was independently associated with END#D3 (1.07, 1.01–1.14), with adjustments for predetermined covariates, SBPmean, and interactions with daily SBPSD.ConclusionShort-term BPV changed and stabilized from the first day of ischemic stroke. Daily high BPV may be associated with neurological deterioration independent of BPV on the previous day.

Blood pressure lowering efficacy of renin inhibitors for primary hypertension.

Hypertension is a chronic condition associated with an increased risk of mortality and morbidity. Renin is the enzyme responsible for converting angiotensinogen to angiotensin I, which is then converted to angiotensin II. Renin inhibitors are a new class of drugs that decrease blood pressure (BP) by preventing the formation of both angiotensin I and angiotensin II. To quantify the dose-related BP lowering efficacy of renin inhibitors compared to placebo in the treatment of primary hypertension.To determine the change in BP variability, pulse pressure, and heart rate and to evaluate adverse events (mortality, non-fatal serious adverse events, total adverse events, withdrawal due to adverse effects and specific adverse events such as dry cough, diarrhoea and angioedema). The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to February 2017: the Cochrane Hypertension Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 2), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. There was no restriction by language or publication status. We also searched the European Medicines Agency (EMA) for clinical study reports, the Novartis Clinical Study Results Database, bibliographic citations from retrieved references, and contacted authors of relevant papers regarding further published and unpublished work. We included randomized, double-blinded, placebo-controlled studies evaluating BP lowering efficacy of fixed-dose monotherapy with renin inhibitor compared with placebo for a minimum duration of three to 12 weeks in adult patients with primary hypertension. This systematic review is a comprehensive update which includes four additional studies and extensive detail from nine clinical study reports (CSRs) of previously included studies obtained from EMA. The remaining three CSRs are not available.Two review authors independently assessed study eligibility and extracted data. In all cases where there was a difference between the CSR and the published report, data from the CSR was used. Dichotomous outcomes were reported as risk ratio (RR) with 95% confidence intervals (CIs) and continuous outcomes as mean difference (MD) with 95% CIs. 12 studies (mean duration of eight weeks) in 7439 mostly Caucasian patients (mean age 54 years) with mild-to-moderate uncomplicated hypertension were eligible for inclusion in the review. Aliskiren was the only renin inhibitor evaluated. All included studies were assessed to have high likelihood of attrition, reporting and funding bias.Aliskiren has a dose-related systolic/diastolic blood pressure (SBP/DBP) lowering effect as compared with placebo MD with 95% CI: aliskiren 75 mg (MD -2.97, 95% CI -4.76 to -1.18)/(MD -2.05, 95% CI -3.13 to -0.96) mm Hg (moderate-quality evidence), aliskiren 150 mg (MD -5.95, 95% CI -6.85 to -5.06)/ (MD -3.16, 95% CI -3.74 to -2.58) mm Hg (moderate-quality evidence), aliskiren 300 mg (MD -7.88, 95% CI -8.94 to -6.82)/ (MD -4.49, 95% CI -5.17 to -3.82) mm Hg (moderate-quality evidence), aliskiren 600 mg (MD -11.35, 95% CI -14.43 to -8.27)/ (MD -5.86, 95% CI -7.73 to -3.99) mm Hg (low-quality evidence). There was a dose-dependent decrease in blood pressure for aliskiren 75 mg, 150 mg and 300 mg. The blood pressure lowering effect of aliskiren 600 mg was not different from 300 mg (MD -0.61, 95% CI -2.78 to 1.56)/(MD -0.68, 95% CI -2.03 to 0.67). Aliskiren had no effect on blood pressure variability. Due to very limited information available regarding change in heart rate and pulse pressure, it was not possible to meta-analyze these outcomes.Mortality and non-fatal serious adverse events were not increased. This review found that in studies of eight week duration aliskiren may not increase withdrawal due to adverse events (low-quality evidence). Diarrhoea was increased in a dose-dependent manner (RR 7.00, 95% CI 2.48 to 19.72) with aliskiren 600 mg (low-quality evidence). The most frequent adverse events reported were headache, nasopharyngitis, diarrhoea, dizziness and fatigue. Compared to placebo, aliskiren lowered BP and this effect is dose-dependent. This magnitude of BP lowering effect is similar to that for angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). There is no difference in mortality, nonfatal serious adverse events or withdrawal due to adverse effects with short term aliskiren monotherapy. Diarrhoea was considerably increased with aliskiren 600 mg.

Early Hemodynamic Changes during Head-Up Tilt Table Testing Can Predict a Neurocardiogenic Response in an African-American Patient Population

Background: Head-up tilt table testing (HUTT) is time-consuming and associated with increased patient morbidity. Hemodynamic changes that occur during the early phase of HUTT may be predictive of neurocardiogenic syncope. Methods: A retrospective chart review was performed in 119 consecutive African Americans ( 57 ± 19) who underwent HUTT for evaluation of syncope of unknown etiology. Positive responses were defined as the development of symptoms linked with a systolic blood pressure (BP) <90 mm Hg, heart rate <50 b.p.m. or sinus arrest >3 s. Hemodynamic variables during the passive phase of HUTT were analyzed and results were then classified as a function of various predictors. Results: Sixty-two subjects (52%) had positive HUTT, and 57 (48%) had negative HUTT. Early changes in BP variables from baseline significantly predicted HUTT responses (p < 0.05). There was also a significant interaction between age and BP. An algorithm based on age and BP was developed which had positive and negative predictive values of 67.7 and 93%, respectively, with an accuracy of 79.8%. Conclusion: A novel algorithm utilizing the patients' age and changes in both systolic and diastolic BP during the early phase of HUTT enables the prediction of HUTT results without the use of vasoactive stimulation, allowing for rapid diagnosis, decreased patient morbidity and reduction in costs.

Role of Alpha 2-Adrenoceptors in Hemodynamic Instability in Rats under Cooling Challenge: Investigation by Spectral Analysis

Cooling causes hemodynamic instability manifested as changes in blood pressure variability and heart rate variability (BPV, HRV). We previously observed that increased sympathomyogenic responses to cooling indexed as very-low-frequency BPV (VLF BPV ) and low-frequency BPV (LF BPV ) were dependent on the evoked pressor effect in rats. As a follow-up, the present study was designed to explore whether the alpha 2-adrenoceptor (α2-ADR) is involved in such responses. Hemodynamic changes were telemectrically monitored throughout the experiments. Vehicle or yohimbine (YOH, 2.5 or 5.0 mg/kg) was administered with a latency (5 min, 30 min) before a cooling impact (CI, 4±2 o C). Plasma nitric oxide (NO) was measured in the presence and absence of the added hexamethonium. Spectral powers of high-frequency (HF, 0.6-3.0 Hz), low-frequency (LF, 0.2-0.6 Hz), and very-low-frequency (VLF, 0.02-0.2 Hz) BPV versus HRV were assessed. Our results generally showed 1) control cooling-induced pressor was significantly attenuated after YOH pretreatments, 2) Compared to control vehicle prior to CI initiation, YOH produced tachycardia and increased most frequency powers but reduced normalized HF HRV power (nHF HRV ), 3) In contrast, compared with control vehicle throughout the CI trial, YOH produced less pressor, more tachycardia, and increased nHF HRV but attenuated most other frequency powers. Furthermore, the dicrotic notch was undetectable and NO was increased in CI after YOH pretreatment; however, the increase in NO was diminished after hexamethonium addition. These findings substantialized the sympathomyogenic role for α2-ADR during the cooling-induced hemodynamic instability.