Reduce Blood Pressure Variability Research Articles

Blood pressure management after endovascular thrombectomy: Insights of recent randomized controlled trials.

The ideal blood pressure (BP) target in patients who undergo endovascular thrombectomy (EVT) with successful reperfusion is uncertain. Observational studies show that elevated BP during this period is associated with a higher risk of intracranial hemorrhage (ICH) and worse clinical outcomes. Several randomized controlled trials (RCTs) have explored whether intensive BP lowering improves clinical outcomes in these patients. This review aims to summarize the recent RCTs that compare intensive and conventional BP management strategies following EVT and discuss the innovative directions to improve. The recently published RCTs failed to demonstrate the benefit of intensive BP control on the functional outcome and decreasing the risk of ICH. The complex mechanism in cerebral blood flow regulation and the inappropriate BP range chosen in RCTs may be the reasons behind the inconsistent results between observational studies and RCTs. Individualized BP management, reducing BP variability, and multi-stage BP management should be paid more attention in future exploration. Intensive BP target did not improve clinical outcomes after successful EVT as compared with a conventional BP target. Further research is required to identify the optimal BP management strategy after reperfusion.

Use of vasopressors to manage spinal anesthesia-induced hypotension during cesarean delivery.

Cesarean sections are commonly performed under spinal anesthesia, which can lead to hypotension, adversely affecting maternal and fetal outcomes. Hypotension following spinal anesthesia is generally defined as a blood pressure of 80-90% below the baseline value. Various strategies have been implemented to reduce the incidence of spinal anesthesia-induced hypotension. The administration of vasopressors is a crucial method for preventing and treating hypotension. In the past decade, phenylephrine, a primarily alpha-adrenergic agonist, has been the preferred vasopressor for cesarean sections. Recently, norepinephrine, a potent alpha-agonist with modest beta-agonist activity, has gained popularity owing to its advantages over phenylephrine. Vasopressors can be administered via a bolus or continuous infusion. Although administering boluses alone is simpler in a clinical setting, continuous prophylactic infusion initiated immediately after spinal anesthesia is more effective in reducing the incidence of hypotension. Tailoring the infusion dose based on the patient's body weight and adjusting the rate in response to blood pressure changes, in addition to using a prophylactic or rescue bolus, helps reduce blood pressure variability during cesarean sections under spinal anesthesia until neonatal delivery.

Ambulatory blood pressure after 12 weeks of quadruple combination of quarter doses of blood pressure medication vs. standard medication.

A combination of four ultra-low-dose blood pressure (BP) medications lowered office BP more effectively than initial monotherapy in the QUARTET trial. The effects on average ambulatory BP changes at 12 weeks have not yet been reported in detail. Adults with hypertension who were untreated or on monotherapy were eligible for participation. Overall, 591 participants were randomized to either the quadpill (irbesartan 37.5 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg) or monotherapy control (irbesartan 150 mg). The difference in 24-h, daytime, and night-time systolic and diastolic ambulatory BP at 12 weeks along further metrics were predefined secondary outcomes. Of 576 participants, 289 were randomized to the quadpill group and 287 to the monotherapy group. At 12 weeks, mean 24-h ambulatory SBP and DBP were 7.7 [95% confidence interval (95% CI) 9.6-5.8] and 5.3 (95% CI: 6.5-4.1) mmHg lower in the quadpill vs. monotherapy group ( P < 0.001 for both). Similar reductions in the quadpill group were observed for daytime (8.1/5.7 mmHg lower) and night-time (6.3/4.0 mmHg lower) BP at 12 weeks (all P < 0.001) compared to monotherapy. The rate of BP control (24-h average BP < 130/80 mmHg) at 12 weeks was higher in the quadpill group (77 vs. 50%; P < 0.001). The reduction in BP load was also more pronounced with the quadpill. A quadruple quarter-dose combination compared with monotherapy resulted in greater ambulatory BP lowering across the entire 24-h period with higher ambulatory BP control rates and reduced BP variability at 12 weeks. These findings further substantiate the efficacy of an ultra-low-dose quadpill-based BP lowering strategy.

Amlodipine in the current management of hypertension.

Hypertension is the leading cause of death worldwide, affecting 1.4 billion people. Treatment options include the widely used calcium channel blockers, among which amlodipine, a dihydropyridine, has unique characteristics that distinguish it from other drugs within this class. This review aims to provide an updated overview of the evidence supporting the use of amlodipine over the past 30years and highlights its cardiovascular benefits in current hypertension management. Amlodipine has low renal clearance (7mL/min/mg) and long half-life (35-50h) and duration of action, which allows it to sustain its anti-hypertensive effect for more than 24h following a single dose. Additionally, blood pressure (BP) control is maintained even when a dose has been missed, providing continuous protection in case of incidental noncompliance. It has proven to reduce BP variability and successfully lower BP. Amlodipine also controls BP in patients with a systolic/diastolic BP of 130/80 mm Hg or higher, diabetes, or chronic kidney disease without worsening glycemic or kidney function. Additionally, amlodipine is a wise choice for older adults due to its ability to control BP and protect against stroke and myocardial infarction. Side effects of amlodipine include edema, palpitations, dizziness, and flushing, which are more common with the higher dose of 10mg. Amlodipine is cost effective and predicted to be cost saving when compared with usual care.

Review of 20-year results of ASCOT Legacy

The article presents the results of a 20-year follow-up of patients in the ASCOT Legacy study, indicating that antihypertensive and lipid-lowering therapy reduces mortality in patients with hypertension and high cardiovascular risk in the long term. In the group of patients treated with amlodipine compared with the β-blocker atenolol, there was a decrease in mean systolic and diastolic blood pressure (BP), as well as a long-term improve in the form of a decrease in the prevalence of cardiovascular events and mortality due to stroke. An important feature of therapy based on amlodipine was the reduction in BP variability. The article reflects the results of major studies that determine the possibility and effectiveness of early prescription of combined antihypertensive and lipid-lowering therapy.

Amlodipine limits microglia activation and cognitive dysfunction in aged hypertensive mice.

SBP and blood pressure variability are independent risk factors for cerebral small vessel disease, a leading cause for stroke and dementia. Calcium-channel blockers are known to reduce blood pressure variability and may thus offer benefit against dementia. Beyond this effect, the impact of calcium-channel blockers on hypertension-induced neuroinflammation, and especially, microglial phenotype remains unknown. We aimed to study the ability of amlopidine to alleviate microglia inflammation, and slow down cognitive dysfunction in aged hypertensive mice. Hypertensive BPH/2J and normotensive BPN/3J mice were studied until 12 months of age. Hypertensive mice were untreated or received amlodipine (10 mg/kg per day). Blood pressure parameters were measured by telemetry and tail cuff plethysmography. Mice underwent repeated series of cognitive tasks. Brain immunohistochemistry was performed to study blood-brain barrier dysfunction and microglial pro-inflammatory phenotype (CD68 + Iba1 + cells; morphological analysis). Amlodipine normalized SBP over the entire life span and decreased blood pressure variability. BPH/2J mice exhibited impaired short-term memory that was prevented by amlodipine at 12 months (discrimination index 0.41 ± 0.25 in amlodipine-treated vs. 0.14 ± 0.15 in untreated BPH/2J mice, P = 0.02). Amlopidine treatment of BPH/2J did not prevent blood-brain barrier leakage, a measure of cerebral small vessel disease, but limited its size. Microglia's inflammatory phenotype in BPH/2J, characterized by an increased number of Iba1 + CD68 + cells, increased soma size and shortened processes, was partly reduced by amlodipine. Amlodipine attenuated the short-term memory impairment in aged hypertensive mice. Beyond its blood pressure lowering capacity, amlodipine may be cerebroprotective by modulating neuroinflammation.

Activation of the Vascular Smooth Muscle GLP-1/NCX1 Pathway Regulates Cytoplasmic Ca2+ Homeostasis and Improves Blood Pressure Variability in Hypertension

Background: Hypertension is the most common cardiovascular disease, and its main harmful effect is chronic damage to target organs. In some patients with well-controlled blood pressure, target organ damage still occurs. GLP-1 agonists have significant cardiovascular benefits, but their antihypertensive effect is limited. The cardiovascular protective effect of GLP-1 is worth studying. Methods: The ambulatory blood pressure of spontaneously hypertensive rats (SHRs) was detected by ambulatory blood pressure monitoring, and the characteristics of blood pressure and the effect of subcutaneous intervention with a GLP-1R agonist on blood pressure were observed. To explore the mechanism of the cardiovascular benefit of GLP-1R agonists in SHRs, we evaluated the effects of GLP-1R agonists on vasomotor function and calcium homeostasis in vascular smooth muscle cells (VSMCs) in vitro. Results: Although the blood pressure of SHRs was significantly higher than that of WKY rats, the blood pressure variability of SHRs was also significantly higher than that of the control group. The GLP-1R agonist significantly reduced blood pressure variability in SHRs, but the antihypertensive effect was not obvious. GLP-1R agonists can significantly improve the cytoplasmic calcium overload of VSMCs in SHRs by upregulating the expression of NCX1, improving the systolic and diastolic functions of arterioles, and reducing blood pressure variability. Conclusions: Taken together, these results provide evidence that GLP-1R agonists improved VSMC cytoplasmic Ca2+ homeostasis through upregulated NCX1 expression in SHRs, which plays a key role in blood pressure stability and broad cardiovascular benefits.

Short- to long-term blood pressure variability: Current evidence and new evaluations.

Increased blood pressure (BP) variability and the BP surge have been reported to be associated with increased cardiovascular risk independently of BP levels and can also be a trigger of cardiovascular events. There are multiple types of BP variation: beat-to-beat variations related to breathing and the autonomic nervous system, diurnal BP variation and nocturnal dipping related to sleep and physical activity over a 24-hr period, day-to-day BP variability with anomalous readings within a several-day period, visit-to-visit BP variability between outpatient visits, and seasonal variations. BP variability is also associated with the progression to hypertension from prehypertension and the progression of chronic kidney disease and cognitive impairments. Our research group proposed the "resonance hypothesis of blood pressure surge" as a new etiological hypothesis of BP variability and surges; i.e., the concept that when the time phases of surges and hypertension-inducing environmental influences coincide, resonance occurs and is amplified into a larger "dynamic surge" that triggers the onset of cardiovascular disease. New devices to assess BP variability as well as new therapeutic interventions to reduce BP variability are being developed. Although there are still issues to be addressed (including measurement accuracy), cuffless devices and information and communication technology (ICT)-based BP monitoring devices have been developed and validated. These new devices will be useful for the individualized optimal management of BP. However, evidence regarding the usefulness of therapeutic interventions to control BP variability is still lacking.

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&amp;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.

S-01-3: SMART WELLNESS HOUSING AND BLOOD PRESSURE CONTROL

Objective: Mortality due to cardiovascular diseases (CVDs) rises sharply in winter, a phenomenon known as excess winter mortality. It is partially explained by cold exposure induced hypertension. Nevertheless, existing countermeasures for the prevention of hypertension and CVDs place emphasis only on improving lifestyle habits. Improving life environment has attracted attention recently because people spend 60–70% of their time at home. Therefore, we aimed to quantitatively evaluate the relationship between housing thermal environment and blood pressure (BP) in a real-world setting. Design and method: We conducted a nationwide prospective intervention study named the Smart Wellness Housing survey in Japan, as a nonrandomized controlled trial. The intervention was the thermal insulation retrofitting of homes. Participants were recruited by construction companies throughout all 47 prefectures of Japan. Home BP and indoor temperature were measured for 2 weeks before and after the intervention in winter (November-March) of FY 2014 to 2019. Results: Cross-sectional analyses before intervention involving about 2900 participants (1840 households) showed that systolic blood pressure (SBP) in the morning had significantly higher sensitivity to changes in indoor temperature (8.2 mmHg increase/10°C decrease) than that in the evening (6.5 mmHg increase/10°C decrease) in participants aged 57 years (mean age in this survey). Interaction terms between age/women and indoor temperature were significant, indicating that SBP in older residents and women was vulnerable to indoor temperature change. The association between BP variability and indoor temperature instability was also analyzed using the morning-evening (ME) difference as an index of diurnal variability and the standard deviation (SD) of 2-week data as an index of day-by-day variability. The analyses showed that the ME difference in indoor temperature was closely correlated with the ME difference in SBP (0.85 mmHg/°C). The SD of indoor temperature was also associated with the SD of SBP (0.61 mmHg/°C). In the comparison of before and after intervention, insulation retrofitting significantly reduced morning SBP by 3.1 mmHg. In addition, there was heterogeneity in the effect of insulation retrofitting on morning SBP in hypertensive patients compared with normotensive occupants (-7.7 versus -2.2 mmHg). Conclusions: Hypertension might be not only lifestyle diseases but also life-environment diseases. Residents should keep the indoor temperature high to reduce BP level and keep it stable to reduce BP variability through strategies such as installing high thermal insulation. We expect that these results will be useful to prevent excess winter mortality due to CVDs.

Blood Pressure Variability After Cerebrovascular Events: A Possible New Therapeutic Target: A Narrative Review.

Blood pressure variability, the variation of blood pressure during a certain period, results from the interaction of hemodynamic, neuronal, humoral, behavioral, and environmental factors. Cerebral autoregulation is impaired in acute cerebrovascular disease. Hence, increased blood pressure variability (BPV) may provoke or exacerbate secondary brain injury. In fact, available data showed that increased blood pressure variability is associated with worse outcomes after acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Consequently, BPV may represent a usual modifiable therapeutic target. This concept is particularly attractive because reduction of BPV can be feasible in regions with lower resources and can be applicable to patients with various forms of acute stroke. Prospective studies are needed to further clarify the relationship between BPV and secondary brain damage and the determinants of BPV in different clinical populations. Ultimately, cerebrovascular disease-specific randomized controlled trials aimed at reducing BPV, irrespective of the absolute blood pressure values, are needed to determine whether reduction of BPV can improve outcomes in patients with acute cerebrovascular disease.

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&gt; 7 mmHg and/or SD of daytime ambulatory SBP&gt; 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&amp;D UA-651BLE monitor), 24-hour ambulatory (A&amp;D TM 2430) and office (A&amp;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.

Two case reports: clinical experience with fixed combinations of indapamide/perindopril and amlodipine/perindopril in patients with arterial hypertension during the COVID-19 pandemic

The article, using the example of two clinical cases, discusses the severity of the course of COVID-19 depending on the presence of cardiovascular diseases and the effectiveness of their treatment. Randomized clinical trials and meta-analyses of the coronavirus infection indicate a greater likelihood of developing severe forms of COVID-19 in patients with high and very high cardiovascular risk, in older age groups, with comorbid pathology, especially with arterial hypertension (AH), coronary heart disease (CHD), chronic heart failure (CHF), diabetes mellitus (DM). Considering effectiveness, safety and influence on the prognosis, an adequately selected therapy for concomitant diseases can reduce the number of adverse outcomes of the coronavirus infection. A key role in the development and progression of cardiovascular pathology is played by the renin-angiotensin-aldosterone system (RAAS), so RAAS blockers remain the first-line medicine in the treatment of cardiac patients. The experts of the European Society of Cardiology, the American College of Cardiology and the Russian Society of Cardiology confirm the importance of continuing therapy with this class of medicine in patients having already received RAAS blockers according to such indications as AH, CHD and CHF during COVID-19 and emphasize the danger of their cancellation in high-risk patients. Most patients need to take several groups of medicine which affect complementary pathogenetic mechanisms. It is shown that the reason for the lack of achieving blood pressure control in clinical practice is monotherapy or non-optimally combined therapy of free acceptable but not rational combinations of antihypertensive medicine. Optimization of the therapeutic regimen using fixed combinations of indapamide/perindopril and amlodipine/perindopril has made it possible to achieve an effective reduction in blood pressure according to routine measurement and ambulatory blood pressure monitoring, to reduce blood pressure variability, to increase patients’ adherence to the treatment. The use of such medicine is becoming the most relevant during the COVID-19 pandemic.

Blood Pressure Goals in Acute Stroke.

Antihypertensive treatment is highly effective in both primary and secondary prevention of stroke. However, current guideline recommendations on the blood pressure goals in acute stroke are clinically empirical and generally conservative. Antihypertensive treatment is only recommended for severe hypertension. Several recent observational studies showed that the relationship between blood pressure and unfavorable clinical outcomes was probably positive in acute hemorrhagic stroke but J- or U-shaped in acute ischemic stroke with undetermined nadir blood pressure. The results of randomized controlled trials are promising for blood pressure management in hemorrhagic stroke but less so in ischemic stroke. A systolic blood pressure goal of 140 mm Hg is probably appropriate for acute hemorrhagic stroke. The blood pressure goal in acute ischemic stroke, however, is uncertain, and probably depends on the time window of treatment and the use of revascularization therapy. Further research is required to investigate the potential benefit of antihypertensive treatment in acute stroke, especially with regard to the possible reduction of blood pressure variability and more intensive blood pressure lowering in the acute and subacute phases of a stroke, respectively.

Prognostic significance of day-by-day in-hospital blood pressure variability in COVID-19 patients with hypertension.

Hypertension is the most common comorbidity in patients with coronavirus disease 2019 (COVID‐19) and increases in‐hospital mortality. Day‐by‐day blood pressure (BP) variability (BPV) is associated with clinical outcomes in hypertensive patients. However, little information is available on the association of BPV with the outcomes of COVID‐19 patients with hypertension. This study aimed to demonstrate whether day‐by‐day in‐hospital BPV had prognostic significance in these patients. The authors included 702 COVID‐19 patients with hypertension from Huoshenshan Hospital (Wuhan, China), who underwent valid in‐hospital BP measurements on at least seven consecutive days. Day‐by‐day BPV was assessed by standard deviation (SD), coefficient of variation (CV), and variation independent of mean (VIM). Overall, patients with severe COVID‐19 and non‐survivors had higher BPV than moderate cases and survivors, respectively. Additionally, higher BPV was correlated with greater age and higher levels of C‐reactive protein, procalcitonin, high‐sensitive cardiac troponin I, and B‐type natriuretic peptide. In multivariable Cox regression, SD of systolic BP (SBP) was predictive of mortality [hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.05–1.30] as well as acute respiratory distress syndrome (ARDS) (HR 1.09, 95% CI 1.01–1.16). Similar trends were observed for CV and VIM of SBP, but not indices of diastolic BP variability. The authors demonstrated that day‐by‐day in‐hospital SBP variability can independently predict mortality and ARDS in COVID‐19 patients with hypertension. And high BPV might be correlated with severe inflammation and myocardial injury. Further studies are needed to clarify whether early reduction of BPV will improve the prognosis of these patients.

Long-term predialysis blood pressure variability and outcomes in hemodialysis patients.

Blood pressure variability (BPV) is significantly associated with cardiovascular diseases (CVD) and mortality in hemodialysis patients. However, the relationship between blood pressure and CVD in hemodialysis patients is complex and affected by many factors. The present study aimed to assess the association of long‐term predialysis BPV with all‐cause mortality and major adverse cardiovascular events (MACE). One thousand seven hundred twenty‐seven patients receiving maintenance hemodialysis were recruited in nine hemodialysis centers. Predialysis BPV was assessed over 1‐year intervals. Outcomes included all‐cause mortality and MACE during follow‐up periods. The mean age of the final cohort was 59 years, of which 57% were males. Greater predialysis systolic BPV was associated with an increased risk of all‐cause mortality (adjusted hazard ratio, 1.101; 95% confidence intervals 1.064–1.140) and MACE (adjusted hazard ratio, 1.091; 95% confidence intervals 1.059–1.125). Results were similar when systolic BPV was stratified by baseline systolic blood pressure. In conclusion, greater predialysis BPV among hemodialysis patients was associated with all‐cause mortality and MACE. Strategies to reduce blood pressure variability might be beneficial for hemodialysis patients.

Blood Pressure Variability: Mechanisms, Measurement, Subtypes, and Clinical Implications

The complex topic of short- and long-term blood pressure (BP) variability confounds the diagnosis, classification, and management of hypertension. True pathophysiologic BP variation (systematic and non-systematic deviations between- and within-individuals) is related to heart rate, respiration, complex responses of the sympathetic nervous system, vascular reactivity, and arterial stiffness. Measurement errors (systematic biases and random error) further compound the analysis. Most studies use serial clinic BP values, 24-hour ambulatory BP recordings, or home BP values with standard statistical indicators (standard deviation, variance, or coefficient of variation) or absolute real variability (mean difference of successive values). Clinical impact in retrospective secondary analyses includes a modest increase in cardiovascular disease (CVD) risk (equivalent to a few mmHg in mean systolic BP) yet questions remain whether adjustment for mean BP is needed. BP variability is reduced to a small degree by calcium antagonists and increased by ACE inhibitors, beta-blockers, and alpha-blockers but no interventional trial has addressed the question of whether reducing BP variability confers CVD risk protection. BP variability is not specifically discussed in practice guidelines but it is tacitly acknowledged by recommendations to repeat BP measurements, standardize technique, and confirm the hypertension diagnosis by home or ambulatory BP measurements to account for the “white coat effect.” There is no formal consensus on how to quantitate or manage BP variability despite a real-world need for better diagnostic and therapeutic guidance. Practitioners should thus focus on control of (mean) BP using combinations of agents that improve CVD outcomes. Future consensus guidance should directly address BP variability and should include educational materials for physicians, patient-contact staff, and patients.

ВАРИАБЕЛЬНОСТЬ АРТЕРИАЛЬНОГО ДАВЛЕНИЯ ПРИ КОМОРБИДНОСТИ АРТЕРИАЛЬНОЙ ГИПЕРТОНИИ И ФИБРИЛЛЯЦИИ ПРЕДСЕРДИЙ

Background. Arterial hypertension plays a decisive role in the development of atrial fibrillation, being the most important risk factor. Purpose. Analyze the literature on modern concepts of the relationship between blood pressure variability and atrial fibrillation. Material and methods. We analyzed 53 literature sources. Results. Information about the modern mechanisms of atrial fibrillation formation in arterial hypertension has been obtained. Approaches to the choice of antihypertensive therapy in patients with arterial hypertension and atrial fibrillation have been described. Conclusions. Based on the studies presented in the literature, it was found that blood pressure variability has an additional contribution to cardiovascular risk. Reducing blood pressure variability can be added as one of the important strategies in the treatment of arterial hypertension and atrial fibrillation.

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.

THE EFFECT OF THYROID HORMONE NORMALIZATION ON AMBULATORY BLOOD PRESSURE MONITORING IN HYPOTHYROID PATIENTS

Objective: It is well known that thyroid hormones regulate cardiovascular function. Thyroid disease is extremely common with a prevalence of 9–15% in the general population. The aim of our study was to assess the effects of thyroid hormones on the changes of blood pressure and pulse wave in a cohort of hypothyroid patients. Design and method: a total of 24 patients with severe hypothyroidism were enrolled in this study. Follow-up data are available for 11 patients, after normalization of their thyroid hormone profile. At baseline and after normalization of thyroid hormone profile, patients underwent an ABPM and an arterial tonometry. Data were analyzed with the statistical software R (version 3.0.3). In particular, patients were compared by Wilcoxon test for paired data, as they didn’t have normal gaussian distributions. Results: hypothyroid patients presented with overt thyroid disease (TSH 58,66 ± 47,50). Our preliminary data show that after euthyroidism restoration (TSH 2,21 ± 1,21), there weren’t any variations in global systolic and diastolic blood pressure, meanwhile their variability was reduced. In particular, this was observed for global sistolic variability (p value 0.05) and there was a decrease with borderline significance of global diastolic variability (p value 0.06). We did not observe any difference in terms of mean arterial pressure, PWV, and the other pulse wave analysis parameters Conclusions: our preliminary data suggest that euthyroidism restoration with levothyroxine can significantly reduce blood pressure variability in hypothyroid patients. This confirms the importance of thyroid hormones for blood pressure control.