Office Blood Pressure Variability Research Articles

VISIT-TO-VISIT 24 HOUR BLOOD PRESSURE VARIABILITY VS OFFICE BLOOD PRESSURE VARIABILITY UNDER ANTIHYPERTENSIVE DRUG TREATMENT

Objective: In any treated hypertensive patient office blood pressure (BP) values differ between visits and this variability (V) has an adverse prognostic impact. Almost no information is available on visit-to-visit 24-hour(h) BPV and the consistency of its therapeutic control. Design and method: In 1114 differently treated hypertensive patients of the ELSA and PHYLLIS trials we calculated 24-h BPV by the coefficient of variation of the mean BP from yearly measurements during a 3-4 year treatment period. Calculation was also made of yearly variation of the percentage of patients achieving 24-h BP control (<130/80mmHg). Calculations were extended to day and night BP. Data were compared with office visit-to visit BPV and yearly office BP control (<140/90mmHg) and variations . Results: Visit-to-visit 24-h BPV was 20% to 30% less than office BP variability, similarly for systolic and diastolic BP and consistently for different demographic, clinical and treatment conditions. BPV was considerably greater for the night than for the daytime (%, p < 0.01) . Yearly 24-h BP control was considerably less frequent and variable than yearly office BP control and was considerably than daytime BP control. In the whole study and subgroups there was a linear correlation between office and 24-h but the correlation coefficients were never >0.20, indicating that office BPV does not precisely correspond to it is impossible to precisely predict 24-h BPV from office in individual patients. Conclusions: 24-h BPV across visits is noticeably more stable than across visit office BPV, although with a greater variability of night BP. The correlation between office and 24-h BPV is significant but the low correlation coefficient makes office BPV hardly predictive of the 24-h BP stability across visits.

DETERMINANTS OF OFFICE BLOOD PRESSURE VARIABILITY AND INSTABILITY IN CHILDREN, ADOLESCENTS AND YOUNG ADULTS

Objective: To evaluate the determinants of office blood pressure (BP) variability and instability within a single visit in young individuals. Design and method: Apparently healthy individuals aged 6-25 years referred for elevated blood pressure (BP) were subjected to triplicate office BP measurements in a single visit and 24h ambulatory BP monitoring. BP variability and instability were assessed separately for systolic and diastolic BP using: (i) standard deviation (SD) (ii) coefficient of variation (CV) (iii) average real variability (ARV) (iv) maximum office BP (Max) (v) maximum-minimum office BP difference (MMD) (vi) ratio of difference between 1st-3rd measurement to the average office BP (Relative change). White-coat effect was defined as the difference between office and daytime ambulatory BP. Results: 320 individuals were analyzed (mean age 13.6±3.6 years, 66.8% males, BMI z-score 1.12±0.96, average office BP 122.6±16.6/72.6±10.7 mmHg, 24h ambulatory BP 119.3±11.5/67.8±6.8). Based on office and 24h ambulatory BP, 21.3% of the participants had white-coat hypertension, 8.1% masked and 16.6% sustained hypertension. Age was associated with SD (r = 0.23, p<0.001), CV (r = 0.11, p<0.05), Max (r = 0.54, p<0.001) and MMD (r = 0.23, p<0.001) of office systolic BP, and Max (r = 0.29, p<0.001) and ARV (r = 0.12, p<0.05) of diastolic. In multivariable log-linear regression models [(independent variables: age, sex, BMI z-score, heart rate, office BP, white-coat effect (> = 5/6 mmHg systolic/diastolic, 75th centile)], office BP was an independent determinant for indices of systolic BP variability and instability [SD (↓ = 0.01, p<0.001), ARV (↓ = 0.01, p<0.001), Max (↓ = 0.01, p<0.001), MMD (↓ = 0.01, p<0.001) and Relative change (↓ = 0.001, p<0.05)], and for CV (↓ = -0.06, p<0.001) and Max (↓ = 0.01, p<0.001) of diastolic. White-coat effect was a significant determinant for CV of office systolic BP (↓ = 0.15, p<0.05) and Relative change of office diastolic BP (↓ = 0.03, p<0.05). Conclusions: These results suggest that in healthy children, adolescents, and young adults the indices of office BP variability and instability within the first visit seem to be determined by the level of office BP and the magnitude of the white-coat effect.

Office blood pressure variability in non-hypertensive patients during a preventive examination

Background: Despite advantages of ambulatory and home blood pressure monitoring, office blood pressure measurement remains the principal method for the diagnosis and management of hypertension. There still seems to be too little evidence to date showing variation in blood pressure during a medical visit and the current recommendations are mainly based on expert’s opinions. The aim of this study was to evaluate the difference between the first two blood pressure measurements performed during a preventive examination and to verify whether the second measurement could influence clinical decisions in non-hypertensive patients. Material and methods: The study included 52 consecutive patients without history of hypertension or other cardiovascular diseases. Blood pressure and heart rate (HR) were measured twice, the first reading after 5 minutes rest and the second 1 minute later. Results: Significant differences were found between the first (fBPM) and second (sBPM) blood pressure measurements, both systolic blood pressure (SBP) 142.4 mm Hg [interquartile range (IQR): 130.8–152.0] vs. 138.1 mm Hg (IQR: 125.8–149.5), p < 0.001 and diastolic blood pressure (DBP) 85.8 mm Hg (IQR: 80.0–91.5) vs. 83.9 mm Hg (IQR: 77.0–90.3), p < 0.001, and heart rate (HR) 73.1/min (IQR: 64.8–80.0) vs. 71.8/min (IQR: 64.8–77.3), p < 0.001. In 63.5% of the participants, the difference between the measurements was over 5 mm Hg for SBP values and in 23.1% of the participants for DBP values. According to fBPM, 53.8% of the patients met the criteria for the diagnosis of hypertension and according to sBPM 48.1% (NS). Conclusion: We demonstrated substantial discrepancies between blood pressure values taken during the first and the second preventive medical check-up visit performed in the workplace. Preventive examination in the workspace is associated with similar number of false-positive results when hypertension status is evaluated as compared to regular office visits.

PS-C12-8: BLOOD PRESSURE VARIABILITY IN PREVIOUSLY UNTREATED HYPERTENSIVE PATIENTS RANDOMIZED TO NIFEDIPINE GITS OR RAMIPRIL. REVERENT STUDY

Blood pressure (BP) variability (BPV) independently predicts adverse outcomes, making it a potential target for treatment. Preliminary data indicate that dihydropyridine calcium channel blockers (CCB) may reduce BPV more than other antihypertensives. Aim of Reverent: (Reducing blood pressure Variability in Essential hypertension with Ramipril vErsus Nifedipine GITS) Trial was to compare changes in either short-, mid- and long-term BPV in patients treated with a CCB (nifedipine GITS) or an ACE inhibitor (ramipril) in a randomised fashion. Methods: Untreated (treatment-naïve or after treatment washout) patients with mild to moderate essential hypertension and elevated basal BPV, were randomized to open label treatment with nifedipine GITS 30 mg or ramipril 10 mg once daily. BPV after 10 weeks and 12 months of treatment was assessed based on home (primary endpoint; validated AND UA-651BLE monitor), 24-hour ambulatory (A&D TM 2430) and office (AND UA-651BLE) measurements and expressed as standard deviation [SD] of obtained readings. Results: 156 patients were included in the intention-to-treat analysis of the main study (10 weeks, primary analysis) and 138 of the extension study (12 months, exploratory analysis). No significant differences were observed between groups at baseline. Patient characteristics, BP and BPV values after 10 weeks of treatment are reported in the table. No significant differences between groups were observed in home and office BPV at the end of main study, also after adjusting for mean BP reduction. 24-hour weighted SD of systolic BP after 10 weeks of treatment was lower in the nifedipine GITS group (p = 0.032). Exploratory analysis also revealed lower office BPV after 12 months of treatment in nifedipine GITS group (7.15 ± 3.79 vs 9.00 ± 5.28 mmHg, p = 0.026). Conclusions: The study did not identify differences between nifedipine GITS and ramipril in reducing home BPV, while significant differences in favour of nifedipine GITS were observed in 24-hour BPV and in office BPV after 12 months. Clinical impact of these findings remains to be evaluated in outcome studies.

EFFECT OF NIFEDIPINE GITS OR RAMIPRIL ON BLOOD PRESSURE VARIABILITY IN PREVIOUSLY UNTREATED HYPERTENSIVE PATIENTS: RESULTS OF REVERENT RANDOMIZED TRIAL

Objective: Blood pressure (BP) variability (BPV) independently predicts adverse outcomes, making it a potential target for treatment. Preliminary data indicate that dihydropyridine calcium channel blockers (CCB) may reduce BPV more than other antihypertensives but data from ad hoc andomised trials are missing. Aim of REVERENT (Reducing blood pressure Variability in Essential hypertension with Ramipril andom Nifedipine GITS) Trial was to compare changes in short-, mid- and long-term BPV in patients treated with a CCB (nifedipine GITS) or an ACE inhibitor (ramipril). Design and method: Untreated (treatment-naïve or after treatment washout) patients with mild to moderate essential hypertension and elevated basal BPV (SD of home SBP> 7 mmHg and/or SD of daytime ambulatory SBP> 12 mmHg), were andomised to open label treatment with nifedipine GITS 30 mg or ramipril 10 mg once daily. BPV after 10 weeks and 12 months of treatment was assessed based on home (primary endpoint; validated A&D UA-651BLE monitor), 24-hour ambulatory (A&D TM 2430) and office (A&D UA-651BLE) measurements and expressed as standard deviation (SD) of obtained readings. Results: 156 patients were included in the intention-to-treat analysis of the main study (10 weeks, primary analysis) and 138 of the extension study (12 months, exploratory analysis). No significant differences were observed between groups at baseline. Patient characteristics, BP and BPV values after 10 weeks of treatment are reported in the table (Table). No significant differences between groups were observed in home and office BPV at the end of main study, also after adjusting for mean BP reduction. 24-hour weighted SD of systolic BP after 10 weeks of treatment was lower in the nifedipine GITS group (p = 0.032) (Table). Exploratory analysis also revealed lower office systolic BPV after 12 months of treatment in nifedipine GITS group (7.2 ± 3.8 vs 9.0 ± 5.3 mmHg, p = 0.026). Conclusions: The study did not identify differences between nifedipine GITS and ramipril in their effect on home BPV, while significant differences in favour of nifedipine GITS were observed in 24-hour and office systolic BPV after 12 months. Clinical impact of these findings remains to be evaluated in outcome studies.

Visit-to-visit office blood pressure variability combined with Framingham risk score to predict all-cause mortality: A post hoc analysis of the systolic blood pressure intervention trial.

We aim to determine if visit‐to‐visit blood pressure variability (BPV) adds prognostic value for all‐cause mortality independently of the Framingham risk score (FRS) in the systolic blood pressure intervention trial (SPRINT). We defined BPV as variability independent of the mean (VIM) and the difference of maximum minus minimum (MMD) of the systolic blood pressure (SBP). Multivariable Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI). Based on FRS stratification, there were 1035, 2911, and 4050 participants in the low‐, intermediate‐, and high‐risk groups, respectively. During the trial, 230 deaths occurred since the 12th month with an average follow‐up of 2.5 years. In continuous analysis, 1‐SD increase of SBP VIM and MMD were significantly associated with all‐cause mortality (HR 1.18, 95% CI 1.05–1.32, p = .005; and HR 1.21, 95% CI 1.09–1.35, p < .001, respectively). In category analysis, the highest quintile of BPV compared with the lowest quintile had significantly higher risk of all‐cause mortality. Cross‐tabulation analysis showed that the 3rd tertile of SBP VIM in the high‐risk group had the highest HR of all‐cause mortality in total population (HR 4.99; 95% CI 1.57–15.90; p = .007), as well as in intensive‐therapy group (HR 7.48; 95% CI 1.01–55.45; p = .05) analyzed separately. Cross‐tabulation analysis of SBP MMD had the same pattern as VIM showed above. In conclusion, visit‐to‐visit BPV was an independent predictor of all‐cause mortality, when accounting for conventional risk factors or FRS. BPV combined with FRS conferred an increased risk for all‐cause mortality in the SPRINT trial.

Visit-to-visit office blood pressure variability revisited in SPRINT.

Visit-to-visit office blood pressure variability revisited in SPRINT.

Long-Term Blood Pressure Variability and Risk of Cardiovascular Disease Events Among Community-Dwelling Elderly.

High office blood pressure variability (OBPV) in midlife increases the risk of cardiovascular disease (CVD), but the impact of OBPV in older adults without previous CVD is unknown. We conducted a post hoc analysis of ASPREE trial (Aspirin in Reducing Events in the Elderly) participants aged 70-years and older (65 for US minorities) without history of CVD events at baseline, to examine risk of incident CVD associated with long-term, visit-to-visit OBPV. CVD was a prespecified, adjudicated secondary end point in ASPREE. We estimated OBPV using within-individual SD of mean systolic BP from baseline and first 2 annual visits. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% CI for associations with CVD events. In 16 475 participants who survived to year 2 without events, those in the highest tertile of OBPV had increased risk of CVD events after adjustment for multiple covariates, when compared with participants in the lowest tertile (HR, 1.36 [95% CI, 1.08-1.70]; P=0.01). Similar increased risk was observed for ischemic stroke (HR, 1.56 [95% CI, 1.04-2.33]; P=0.03), heart failure hospitalization, or death (HR, 1.73 [95% CI, 1.07-2.79]; P=0.02), and all-cause mortality (HR, 1.27 [95% CI, 1.04-1.54]; P=0.02). Findings were consistent when stratifying participants by use of antihypertensive drugs, while sensitivity analyses suggested the increased risk was especially for individuals whose BP was uncontrolled during the OBPV estimation period. Our findings support increased OBPV as a risk factor for CVD events in healthy older adults with, or without hypertension, who have not had such events previously. Registration- URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01038583; URL: https://www.isrctn.com; Unique identifiers: ISRCTN83772183.

A PROPOSAL FOR A NEW HIGH RISK THRESHOLD ASSOCIATED WITH VISIT-TO-VISIT OFFICE BLOOD PRESSURE VARIABILITY AND ITS EFFECT ON ALL-CAUSE MORTALITY

Elevated visit-to-visit office blood pressure variability (VVOBPV) is a proposed mortality risk predictor. A post hoc analysis of the ALLHAT Trial proposed VVOBPV risk thresholds to be 14.4 mmHg; however, whether these apply to actual practice is unknown. We analyzed >10 years

EFFECT OF ANTIHYPERTENSIVE CLASS ON VISIT-TO-VISIT OFFICE BLOOD PRESSURE VARIABILITY AND ITS EFFECT ON ALL-CAUSE MORTALITY

Visit-to-visit office blood pressure variability (VVOBPV) is a proposed mortality risk predictor, but whether its association varies with the type of antihypertensive medication prescribed is unknown. VVOBPV was analyzed as a predictor of all-cause mortality in >10 years of electronic health record

Agreement between ambulatory, home, and office blood pressure variability.

Ambulatory, home, and office blood pressure (BP) variability are often treated as a single entity. Our aim was to assess the agreement between these three methods for measuring BP variability. Twenty-four-hour ambulatory BP monitoring, 28 home BP measurements, and eight office BP measurements were performed on 461 population-based or hypertensive participants. Five variability indices were calculated for all measurement methods: SD, coefficient of variation, maximum-minimum difference, variability independent of the mean, and average real variability. Pearson's correlation coefficients were calculated for indices measured with different methods. The agreement between different measurement methods on the diagnoses of extreme BP variability (participants in the highest decile of variability) was assessed with kappa (κ) coefficients. SBP/DBP variability was greater in daytime (coefficient of variation: 9.8 ± 2.9/11.9 ± 3.6) and night-time ambulatory measurements (coefficient of variation: 8.6 ± 3.4/12.1 ± 4.5) than in home (coefficient of variation: 4.4 ± 1.8/4.7 ± 1.9) and office (coefficient of variation: 4.6 ± 2.4/5.2 ± 2.6) measurements (P < 0.001/0.001 for all). Pearson's correlation coefficients for systolic/diastolic daytime or night-time ambulatory-home, ambulatory-office, and home-office variability indices ranged between 0.07-0.25/0.12-0.23, 0.13-0.26/0.03-0.22 and 0.13-0.24/0.10-0.19, respectively, indicating, at most, a weak positive (r < 0.3) relationship. The agreement between measurement methods on diagnoses of extreme SBP/DBP variability was only slight (κ < 0.2), with the κ coefficients for daytime and night-time ambulatory-home, ambulatory-office, and home-office agreement varying between-0.014-0.20/0.061-0.15, 0.037-0.18/0.082-0.15, and 0.082-0.13/0.045-0.15, respectively. Shorter-term and longer-term BP variability assessed by different methods of BP measurement seem to correlate only weakly with each other. Our study suggests that BP variability measured by different methods and timeframes may reflect different phenomena, not a single entity.

3D.09

Objective: Increased blood pressure (BP) variability is a possible independent risk factor for cardiovascular events. BP variability has been assessed with several methods of BP measurement in recent literature, although it is unclear whether these measurements of variability with varying timeframes reflect the same phenomenon. The aim of our study was to compare the agreement between ambulatory, home and office BP variability. Design and method: The study population consisted of 509 participants randomly drawn from the population register or recruited by general practitioners on the basis of newly diagnosed untreated hypertension. Ambulatory 24-h blood pressure monitoring, 28 home BP measurements (twice every morning and evening during 7 consecutive days) and 8 office BP measurements (duplicate measurements on 4 visits) were performed in all participants. 3 log-transformed variability indices (SD, standard deviation; CV, coefficient of variation and ARV, average real variability) were calculated for all measurement methods and Pearson's correlations between them were calculated. The agreement of different methods on the diagnoses of extreme BP variability (participants with variability above the highest decile) was also assessed with kappa coefficients. Results: Systolic/diastolic BP variability was greater in 24-h ambulatory (CV: 12.6 ± 2.8 /15.1 ± 3.4) than home (CV: 4.4 ± 1.8/4.7 ± 2.0, p < 0.001 versus ambulatory CV for both) and office (CV: 4.8 ± 2.6/5.3 ± 2.6, p < 0.001 versus ambulatory CV for both) measurements. Ambulatory daytime variability was greater than night-time variability (CV: 11.0 ± 2.8/13.1 ± 3.5 vs. 9.5 ± 3.8/12.8 ± 4.6, p < = 0.001 for both). Pearson's correlation coefficients for systolic/diastolic variability indices between different measurement methods were 0.08–0.34/0.03–0.26, indicating only negligible to weak positive relationship (Table). The agreement of ambulatory, home and office BP variability measures on diagnoses of extreme systolic/diastolic BP variability was only slight, with the kappa coefficients varying between 0.00–0.20/0.03–0.16. Extreme variability was diagnosed in only two persons with all three methods.Conclusions: Shorter-term and longer-term BP variability assessed with different methods of BP measurement seem to correlate only weakly with each other. Our study suggests that BP variability assessed by different methods and timeframes reflects various phenomena, not a single entity.

Long-term visit-to-visit office blood pressure variability increases the risk of adverse cardiovascular outcomes in patients with chronic kidney disease

Long-term visit-to-visit blood pressure (BP) variability predicts a high risk for cardiovascular events in patients with essential hypertension. Whether long-term visit-to-visit BP variability holds the same predictive power in predialysis patients with chronic kidney disease (CKD) is unknown. Here we tested the relationship between long-term visit-to-visit office BP variability and a composite end point (death and incident cardiovascular events) in a cohort of 1618 patients with stage 2-5 CKD. Visit-to-visit systolic BP variability was significantly and independently related to baseline office, maximal, and average systolic BPs, age, glucose, estimated glomerular filtration rate, and albumin, and to the number of visits during the follow-up. Both the standard deviation of systolic BP (hazard ratio: 1.11, 95% confidence interval: 1.01-1.20) and the coefficient of variation of systolic BP (hazard ratio: 1.15, 95% confidence interval: 1.02-1.29) were significant predictors of the combined end point independent of peak and average systolic BP, cardiovascular comorbidities, Framingham risk factors, and CKD-related risk factors. Antihypertensive treatment (β-blockers and sympatholytic drugs) significantly abrogated the excess risk associated with high systolic BP variability. Thus, large visit-to-visit systolic BP variability in patients with CKD predicts a higher risk of death and nonfatal cardiovascular events independent of underlying BP levels.

Office blood pressure variability as a predictor of acute myocardial infarction in elderly patients receiving antihypertensive therapy

Larger variability of office blood pressure (BP) was reportedly associated with a higher risk of stroke or mortality from all causes. In the present study, we focused on the relationship of variability of office BP and occurrence of acute myocardial infarction (MI). We registered 139 patients receiving antihypertensive therapy for more than 1 year who experienced first-ever episode of MI at the age of 60 years or over. At least two sex- and age-matched (+/- 5 years) control patients were registered for every MI patient. Average systolic and diastolic BP during the 12-month period prior to the occurrence of MI, or the time of registration in the case of control patients, was similar in both patient groups. The office BP variability was evaluated by calculating the variation coefficient (VC) of BP. VC of diastolic BP was significantly higher in the MI patients (10.0 +/- 4.0%) compared with the control patients (8.8 +/- 3.4%). VC of systolic BP was not different between the MI and the control patients. Multiple logistic analysis revealed the relationship of the VC for office diastolic BP to the occurrence of MI was significant after adjustment for BP level, age, gender, body mass index, serum total cholesterol concentrations, diabetes mellitus, and current smoking. In conclusion, larger long-term variability of office diastolic BP during antihypertensive therapy is a predictor of MI.

Office blood pressure variability as a predictor of brain infarction in elderly hypertensive patients.

Large 24-h blood pressure (BP) variability and an excessive drop in BP during nighttime are associated with a higher risk of cardiovascular events. Data are lacking regarding the prognostic significance of variability in BP measured during office visits. We analyzed the relationship between office BP variability and the risk of brain infarction in elderly patients receiving antihypertensive therapy. Patients who experienced their first-ever stroke at the age of 60 years or over were registered in the study. At least 2 sex- and age-matched control patients were registered for each case patient. Office BP at each clinic visit and known cardiovascular risk factors were recorded. The BP variability was defined as the variation coefficient (VC) of office BP. In this report, we analyze the data of brain infarction patients. The VC of both systolic and diastolic BPs was significantly higher in the brain infarction patients than in the control patients. Higher office BP variability was associated with a higher risk of brain infarction after adjustment for BP level and other confounding factors. Regarding diastolic BP, the association of brain infarction with the maximal value for the difference of office BPs taken at any consecutive two visits (Max-deltaBP) or the difference between the highest and lowest values of office BP (BP-range) recorded during a 1-year period prior to the event was also significant. In conclusion, a retrospective case-control study suggested that office BP variability was an independent predictor of brain infarction. Either the Max-deltaBP or the BP-range may be surrogate indices of diastolic BP variability.