Visit-to-visit Blood Pressure Variability Research Articles

PS-BPC04-6: INCREASED VISIT-TO-VISIT BLOOD PRESSURE VARIABILITY IS ASSOCIATED WITH LEFT ATRIUM ENLARGEMENT AND HIGH RDW-CV IN HYPERTENSIVE PATIENTS

Objective: Visit-to-visit blood pressure variability (BPV) has been shown to be associated with incidence of atrial fibrillation and poor prognosis of heart failure with preserved ejection fraction (HFpEF). However, it is unknown why BPV induces AF or worsening of HFpEF. Objectives of this study are to investigate whether visit-to visit BPV affected cardiac remodeling and to explore the factors that associate with visit-to visit BPV. Methods: Out-patient with hypertension who received blood tests and echocardiography twice at an about 1-year interval in our hospital from 2014 to 2016 were included. Exclusion criteria were the number of blood pressure measurement less than 3, hospital admission between 2 tests, significant valvular heart disease, atrial fibrillation, hypertrophic cardiomyopathy, and hemodialysis. Visit-to visit BPV was evaluated with coefficient of variation of systolic blood pressure (SBP-CV) between 2 tests. Data were obtained from electronic health record of the hospital. Logarithmic transformations were used for values of red cell distribution width (RDW-CV) and left atrial volume index (LAVI) because they skewed to the left. Changing rate (Δ) of test value was calculated as follows: (2nd test value-1st test value)/[1st test value × test interval (years)]. This is a retrospective observational study and approved by the Institutional Ethics Committee. Results: One hundred and thirty-eight patients were included (median of age was 69, male 71%). In univariate analysis, SBP-CV was significantly correlated with age (P = 0.002), DBP-CV (P < 0.001), ΔlogLAVI (P = 0.001), logRDW-CV (P = 0.002), A wave (P = 0.011), and laxative use (P = 0.032). Multivariate analysis revealed that SBP-CV was significantly correlated with ΔlogLAVI (P = 0.009) and logRDW-CV (P = 0.022) Conclusions: Increase in visit-to-visit systolic BPV was associated with enlargement of left atrium and high red cell distribution width in patients with hypertension. Increased BPV was shown to be associated with impaired left ventricular (LV) diastolic dysfunction in cross sectional study. We found the association of increased visit-to visit BPV and enlargement of left atrium, the most sensitive marker of LV diastolic dysfunction, in longitudinal study for the first time. Experimental study using rats that received sinoaortic denervation showed that exaggerated BPV induced LV fibrosis and hypertrophy. BPV may cause LV diastolic dysfunction via LV fibrosis in patients with hypertension. We also found that SBP-CV was significantly correlated with RDW-CV. RDW-CV has been thought to be a marker of chronic inflammation. Chronic inflammation may causally relate to increased BPV.

Within-visit and between-visit intra-individual blood pressure variability in an unselected adult population from rural China.

To assess the association between the variability of blood pressure (BP) readings within an initial clinic visit, the variability within subsequent visits and the variability between visits over 1 week in a general population. This study included 1401 adult residents, who were not taking antihypertensive drugs, having BP measurements at three visits over 1 week. The difference between maximal and minimal BP readings (ΔBP), ΔBP/BPm (the mean BP value in a visit), the standard deviation (SD) and coefficient of variation (coefficient of variation = SD × 100/mean) of three BP values in each visit were used to estimate the within-visit BP variability (BPV). The SD and coefficient of variation of all nine BP readings over the three visits were calculated as SD9 or CV9 to reflect the overall BPV during the study visits. The SD and coefficient of variation on the mean BP values (BPm) of three visits were computed as SD-3 or CV-3, whereas the difference between maximal and minimal BP in three visits was computed as ΔBP-3 to estimate visit-to-visit BPV. The average BP or HR was the mean values of nine BP or HR readings over three visits. The systolic and diastolic mean BP (SBP and DBP) decreased from the first to the third visit. The ΔBP, SD and coefficient of variation for both SBP and DBP at the first visit were positively and significantly correlated with the corresponding variables computed at the second and third visits, as well as with overall BPV (ΔBP9, SD9 and CV9). A positive correlation was also found between overall BPV and visit-to visit BPV (SD-3, CV-3 and ΔBP9). Multivariate analysis showed: no association between average SBP and systolic coefficient of variation or ΔBP/BPm but a negative association between average DBP and coefficient of variation or ΔBP/BPm for DBP at the first visit, DBP-3 and DBP9. Age was positively correlated with coefficient of variation or ΔBP/BPm for SBP at the first visit, SBP-3 and SBP9, and correlated with coefficient of variation and ΔBP/BPm for DBP only at the first visit. In a general population, within-visit BPV at an initial visit is associated with within-visit BPV at subsequent visits and with visit-to-visit BPV over three visits within 1 week.

School-based surveillance on visit-to-visit blood pressure variability and high blood pressure in children and adolescents

BackgroundThe predictive importance of visit-to-visit blood pressure variability (VVV) for high blood pressure (HBP) in a pediatric population has been largely unsettled. We aimed to evaluate it based on Health Promotion Program for Children and Adolescents (HPPCA), a school-based surveillance conducted from 2012 to 2018 in Suzhou, China.MethodsA total of 330,618 participants had BP measurement in 2018 and ≥ 3 BP records during 2012–2017, were recruited from HPPCA. Absolute BP values (in mmHg) were converted into age-, sex- and height- normalized z-scores. VVV was expressed as standard deviation (SD), coefficient of variation (CV) or average real variability (ARV) of BP z-scores during 2012–2017. Logistic regression models were used to assess the associations between VVV and HBP in 2018.ResultsIn 2018, 42,554 (12.87%) subjects were defined as HBP. VVV, except for SBP-CV and DBP-CV, was significantly higher in the HBP group than normotensives group. After adjusting for covariates including mean BP values from 2012 to 2017, SBP-SD, SBP-ARV, DBP-SD and DBP-ARV, increased the risk of HBP by 5.70 [95% confidence interval (95% CI) 5.54–5.87], 4.10 (95% CI 4.01–4.20), 4.70 (95% CI 4.50–4.90) and 3.39 (95% CI 3.28–3.50) times, respectively. Notably, SBP-SD significantly improved risk discrimination of HBP based on other risk variables (c-statistics, net reclassification index and integrated discrimination improvement significantly increased).ConclusionsHigher SD or ARV of BP, was independently related with higher probability of HBP in Chinese pediatric population. SBP-SD could be potentially helpful for detecting HBP. Future researches investigating the predictive value of VVV are warrant.

Abstract 13571: Association Between Pre-kidney Transplantation Medial Arterial Calcification Andpost-transplant Visit-to-visit Blood Pressure Variability: A Propensity Score Matching Analysis

Introduction: Arterial calcification is associated with vascular stiffness, which manifests with visit-to-visit blood pressure variability (VVBPV). Although media arterial calcification (MAC) is significantly associated with poor cardiovascular outcomes in kidney patients, the association in kidney transplant (KT) patients is unknown. Hypothesis: We hypothesize that MAC is associated with VVBPV in long-tern post-KT. Methods: Since MAC, which is detected from mammogram (MG) and determined by linear calcified breast arteries, is exclusively medial, female KT patients with ≥1 MG during pre-KT period were included in this study. VVBPV was examined by average successive variability (ASV), which is the average absolute difference between successive BP measured at 4, 12, 24, 36, and 48 weeks post-KT. After balancing patients with and without MAC by using propensity score matching based on age, diabetes, and obesity status, the association between MAC and systolic and diastolic VVBPV (VVSBPV and VVDBPV) at 48 weeks post-KT was tested by multiple linear regression (Figure1A&1B). Results: Of 51 patients, mean age±SD is 54±12 years, 21 had diabetes, and 21 were obese. Mean duration of follow-up was 47±9 years. Among 20 patients with MAC, mean VVSBPV was 20±14 mmHg; whereas, VVSBPV in non-MG group was 14±8 mmHg (mean difference -6± 3.0, p 0.06, 95%CI -12.03, 0.15). Mean VVDBPV in MG and non-MG groups were 12±5 and 11±5.6 mmHg, respectively (mean difference -1±1.6, p 0.41, 95%CI -4.44, 1.86). Laboratory-related bone and mineral metabolism were not different between both groups. On average, MG group had 8 mmHg higher VVSBPV compared to non-MG group (Coef. 3.62, p 0.02, 95%CI 1.16, 15.34). The MG group remained having higher VVDBPV but the magnitude of the association decreased and no statistical significance (Coef. 0.58, p 0.83, 95%CI -4.58, 5.73). Conclusions: Similar to non-transplant patients, KT recipients with pre-KT MAC had significant higher VVSBPV at the late post-KT.

Visit-to-visit blood pressure variability and risk of adverse birth outcomes in pregnancies in East China.

To investigate the potential associations between visit-to-visit blood pressure variability (VVV) and adverse birth outcomes in pregnancies, 48,209 pregnant women without proteinuria or chronic hypertension before 20 weeks of gestation who delivered live singletons between January 2014 and November 2019 in Taizhou or Taicang cities were recruited. VVV was estimated as the standard deviation and coefficient of variation of blood pressure [i.e., systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP)] measured from 20 weeks of gestation onwards. Pregnant women were classified into four groups according to the corresponding quartiles for each VVV index. It was found that VVV was significantly higher in women with small for gestational age (SGA) or low birth weight (LBW) infants than in their counterparts. Graded associations between VVV categories and poor birth outcomes were observed. In particular, when comparing the women with the highest to the lowest quartiles of standard deviation and coefficient variation of DBP, the odds ratios (95% confidence interval) for SGA was 1.15 (1.06-1.26) and 1.14 (1.05-1.25), respectively. Interestingly, the addition of DBP-VVV to established risk factors improved risk prediction of SGA; DBP-VVV demonstrated modestly superior predictive performance to VVV obtained from SBP or MAP. Similar results were found even among normotensive pregnancies. Our findings indicated that VVV during pregnancy, especially DBP-VVV, was independently associated with poor birth outcomes of pregnancies in East China. The inclusion of DBP-VVV with established risk factors may help in identifying pregnancies at high risk of SGA. Validations are needed.

Abstract P037: Association Between Early Post-kidney Transplant Visit-to-Visit Systolic Blood Pressure Variability And Late Post-Transplant Systolic Blood Pressure

Background: Visit-to-visit blood pressure variability (VVBPV) results from regional or systemic circulatory factors such as stiffness or neuro-hormonal factors. Association between VVBPV and long-term post-kidney transplant (KT) blood pressure (BP) is unknown. Method: VVBPV was measured by average successive variability (ASV), which is the average absolute difference between successive BP measured at 4, 12, and 24 weeks post-KT. Association between the VVBPV and BP at 48 weeks post-KT was examined by multiple linear regression. Results: Of all 105 KT recipients, mean age±SD was 54±12 years and 64 patients (61%) was female. Mean ASV of SBP and DBP were 16±12 mmHg (range 1-58) and 11±6.3 mmHg (range 1-29.5), respectively. Mean SBP at 24 and 48 weeks post-KT were 135±19 and 133±16 mmHg, respectively. Similar to SBP, mean DBP at 24 weeks post-KT was higher than DBP at 48 weeks (DBP 24 vs 48 weeks 80±12 vs 77±11 mmHg). Every 10-mmHg increase in ASV of SBP predicts 3.4 mmHg increase in SBP at 48 weeks post-KT (p 0.01; 95%CI 0.83, 6.14; Figure 1A). However, an increase in 10 mmHg of ASV of DBP predicts a decrease in DBP of 0.12 mmHg (p 0.12, 95%CI -0.28, 0.04; Figure 1B). After adjusted for age, gender, donor type (deceased vs living), induction immunosuppressive medications, pre-KT weight-spline interaction term at 70 kg, every 10 mmHg increase in ASV of SBP was significantly associated with 2.7 mmHg increase in SBP at 48 weeks post-KT (p 0.04, 95%CI 0.15, 5.29); whereas, 10 mmHg increase in ASV of DBP predicts a decrease in DBP of 2.13 mmHg with no statistical significance (p 0.16, 95% -5.14, 0.88) Conclusion: Higher VVSBPV during early post-KT predicts a higher SBP, but not DBP, at late post-KT period.

Higher visit-to-visit blood pressure variability and N-terminal pro-brain natriuretic peptide elevation: influence of left ventricular hypertrophy and left ventricular diastolic function

The issue of whether visit-to-visit blood pressure variability (VVV) is associated with higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) has been controversial, and the underlying mechanism is not well understood. We hypothesized that (1) VVV is associated with the NT-proBNP level, and (2) this association is mediated by left ventricular (LV) hypertrophy and LV diastolic dysfunction. A total of 72 hypertensive patients were examined. Clinic blood pressure was measured at each visit for 12 months (1×/month or every 2 months), and echocardiography was performed during this period. VVV is expressed as the SD, coefficient of variation (CV), and delta (Δ; the difference between the maximum and the minimum) in SBP and in DBP. We investigated the association between VVV and NT-proBNP and whether the LV mass index (LVMI) and the mitral early diastolic inflow velocity (E) to mitral annular early-diastolic peak velocity (e') ratio (E/e') influence this association. The loge NT-proBNP values were significantly correlated with the CV of SBP (r = 0.42), ΔSBP (r = 0.41), the CV of DBP (r = 0.32), and ΔDBP (r = 0.28). The CV and Δ in SBP or those in DBP were not significantly correlated with LVMI or E/e'. A multiple linear regression analysis revealed that higher CV of SBP and ΔSBP were significantly associated with loge NT-proBNP. Higher VVV was significantly associated with higher NT-proBNP independently of LV hypertrophy and diastolic function.

Biological Pathways of Long-Term Visit-to-Visit Blood Pressure Variability in the American Population: Cardiovascular Health Study and Women’s Health Initiatives

Studies reported a positive relationship between visit-to-visit blood pressure variability (VVBPV) and cardiovascular morbidity and mortality independently of the mean arterial blood pressure across clinical visits. The literature is scarce on the genes and biological mechanisms that regulate long-term VVBPV. We sought to identify biological pathways that regulate visit-to-visit blood pressure variability. We used phenotypic and genotype data from the Women’s Health Initiatives and Cardiovascular Health Studies. We defined VVBPV of systolic and diastolic blood pressure phenotypes as the standard deviation about the participant’s regression line with systolic and diastolic blood pressure regressed separately across visits. We imputed missing genotypes and then conducted a genome-wide association analysis to identify genomic variants related to the VVBPV and detect biological pathways. For systolic VVBPV, we identified a neurological pathway, the GABAergic pathway (P values = 1.1E − 2), and a vascular pathway, the RAP1 signaling pathway (P values = 5.8E − 2). For diastolic VVBPV, the hippo signaling (P values = 4.1E − 2), CDO myogenesis (P values = 7.0E − 2), and O-glycosylation of TSR domain-containing protein pathways (P values = 9.0E − 2) were the significant pathways. Future studies are warranted to validate these results. Further understanding of the roles of the genes regulating the identified pathways will help researchers to improve future pharmacological interventions to treat VVBPV in clinical practice.

Visit-to-visit blood pressure variability is associated with gestational hypertension and pre-eclampsia.

Visit-to-visit blood pressure variability (VVV) was an independent risk factor for cardiovascular events. In pregnant women whose hemodynamic changes are unique, the role of VVV in hypertensive disorders is still obscure. Therefore, we aimed to investigate the association of VVV with gestational hypertension (GH) and pre-eclampsia (PE). 14,702 pregnant women were recruited at around 13 weeks of their gestation. VVV during the second, third trimester and the whole pregnancy, were estimated as standard deviation (SD) or coefficient of variation (CV) of systolic blood pressure (SBP) or diastolic blood pressure (DBP). The associations between VVV, GH and PE were assessed by multivariate logistic regression models. 878 and 131 women developed GH and PE, respectively. VVV was significantly higher in GH and PE subjects than normotensive controls, regardless of whichever metric was calculated. In maximally adjusted models, odds ratio (95% confidence interval) of SBP-CV during the whole pregnancy was 1.62 (1.56-1.68) for GH, 1.14 (1.06-1.21) for PE, and 1.51 (1.47-1.56) for either GH or PE. The cooperation of SBP-CV to other risk factors could help in discriminating pregnant women at high risk of GH and PE. VVV during pregnancy, especially SBP-CV, was independently associated with GH and PE. These results suggested that VVV could provide additional information to identify pregnant women at high risk of GH or PE. Further studies exploring prospective association between VVV, GH and PE are warranted.

Characteristics of visit-to-visit blood pressure variability in hemodialysis patients.

Visit-to-visit blood pressure variability (VVBPV) is an independent risk factor for cardiovascular morbidity and mortality in the general population. Hemodialysis (HD) patients have a poor prognosis due to an increased prevalence of cardiovascular disease. Intradialytic hypotension is associated with excess mortality, but whether VVBPV influences mortality is still unclear in HD patients. The present study aimed to investigate the characteristics of VVBPV in these patients. A total of 324 maintenance HD patients, who could be followed for 60 months, were recruited. We used variation independent of the mean (VIM) in pre-dialysis systolic blood pressure (pre-VIM-SBP) as an index of VVBPV. We investigated (1) the reproducibility of pre-VIM-SBP, (2) the relationship between pre-VIM-SBP and background factors, and (3) the association between pre-VIM-SBP and mortality. Pre-VIM-SBP showed significant reproducibility [intraclass correlation, 0.45 (P < 0.001)]. Higher pre-VIM-SBP was associated with less physical activity and worse left ventricular diastolic function. Higher pre-VIM-SBP was associated with a higher rate of cardiovascular deaths independent of other factors. These data suggest that VVBPV in HD patients is reproducible and associated with various background factors. VVBPV is independently correlated with cardiovascular mortality (hazard ratio: 1.166, 95% confidence interval: 1.030-1.320, P = 0.015). Further studies are necessary to confirm the mechanism of increased VVBPV and to clarify whether reducing VVBPV will improve the prognosis for HD patients.

Differences in visit-to-visit blood pressure variability between normotensive and hypertensive pregnant women.

We evaluated the relationship between blood pressure variability (BPV) and the development of hypertension during pregnancy. A total of 4163 pregnant women with normal blood pressure (BP) before 20 weeks of gestation were included in this study. The visit-to-visit blood pressure variability (VVV) was evaluated using the standard deviation (SD) of the systolic BP taken three times during pregnancy at approximately 10, 20, and 30 weeks of gestation. The VVV gradually decreased during pregnancy in normotensive subjects (SD: 7.2 ± 4.2 mmHg, 6.8 ± 3.9 mmHg, and 6.3 ± 3.6 mmHg at 10, 20, and 30 weeks, respectively). However, the VVV of hypertensive subjects did not decrease (SD: 8.2 ± 5.7 mmHg, 7.6 ± 5.0 mmHg, and 8.3 ± 5.3 mmHg at 10, 20, and 30 weeks, respectively) and was significantly greater than the VVV of normotensive subjects (p < 0.001). The VVV was significantly higher in patients who developed hypertension, and there was no decrease in VVV during pregnancy. Pregnancy complications were significantly increased in women with higher VVV at 10 and 30 weeks. Therefore, increased VVV during pregnancy may be a predictor of poor pregnancy outcomes.

Diastolic blood pressure variability in 24 hour-ABPM and outcomes of chronic kidney disease .

Blood pressure variability (BPV) has been associated with increased morbidity and mortality. There are a few studies that reported worse outcomes of chronic kidney disease (CKD) with greater visit-to-visit BPV (VVV), but data with ambulatory blood pressure monitoring (ABPM) is scarce. Ambulatory hypertensive CKD (stage 2 - 4) patients (&gt;18 years old) with complete 24hours of ABPM study (SpaceLabs), who were followed up between January 2012 and December 2016, were retrospectively analyzed for the baseline characteristics and outcomes of CKD. Coefficient of variation (CV) in diastolic blood pressure (DBP) was used as an index of BPV. Data of 191 patients (mean age 59.7±12.4 years, 54.9% males, 42.1% diabetic, mean eGFR-EPI (Chronic Kidney Disease Epidemiology Collaboration) 51.7±22.0 mL/min/1.73m2, mean follow-up 26.2±10.4 months) were available for the analysis. On multivariate linear regression analysis, greater DBP-CV was associated with slower decline in eGFR-EPI per year (B -0.648, p=0.000). Likewise, the hazard ratio (HR) for dialysis inception (occurred in 9.4%) was found significantly lower with increasing DBP-CV in unadjusted and fully adjusted Cox models (HR 0.730, 95% CI 0.618-0.861, p=0.000, and HR 0.678, 95% CI 0.526-0.874, p=0.003, respectively). These findings suggest that DBP variability in 24-hour ABPM may be a good prognostic factor for the outcomes of CKD. Further studies are needed to determine the impact of 24-hour ABPM BPV on CKD progression and its differences from VVV. .

Treating Visit-to-Visit Blood Pressure Variability to Improve Prognosis: Is Amlodipine the Drug of Choice?

Blood pressure (BP) levels are linearly associated with cardiovascular risk, and hypertension is the most common modifiable risk factor for cardiovascular disease.1 Moreover, antihypertensive treatment-induced BP lowering has been associated with reduction in all outcomes (stroke, heart failure, coronary events, cardiovascular, and all-cause mortality).2 Apart from the established knowledge regarding the importance of hypertension and its effective treatment, during the last years, there has been an increasing interest in the possibility that BP variability (BPV) might carry an additional contribution to cardiovascular risk, on top of the impact of mean BP levels. BP fluctuates constantly and its variability not only may have diagnostic implications regarding the accurate assessment of hypertension but also seems to exert additional stress on the cardiovascular system over and above average BP levels.3 Different components of BPV have been identified, characterized by BP fluctuations between hours, days, or months/years, respectively, termed as short-, mid-, and long-term components.3 All these types of BPV have been shown to carry an independent prognostic value in terms of cardiovascular events and all-cause and cardiovascular mortality.4–10 Three interesting articles have been recently published in this journal regarding long-term visit-to-visit BPV (VVV). Tedla et al11 showed that an increased VVV among 1122 untreated individuals was predictive of arterial stiffness progression after 10 years of follow-up. The 2 remaining papers reported data on the prognostic value of systolic VVV coming from 2 major trials: the observational extension of the ADVANCE trial (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation)12 and the SPRINT (Systolic Blood Pressure Intervention Trial).13 However, it seems that at the present time, despite the accumulating evidence on the clinical relevance of VVV, the latter still remains a research tool failing to provide clinical application in …

Visit-to-Visit Blood Pressure Variability andAlzheimer's Disease: Links and Risks.

While hypertension has been shown to be a risk factor for vascular dementia, several studies have also demonstrated that hypertension also increases the risk of Alzheimer's disease (AD). Although the relationship between visit-to-visit blood pressure variability (VVV) and cognitive impairment, including AD, have been provided, the mechanisms remain poorly understood. This review paper focuses on the relationship of VVV with AD and summarizes the pathophysiology underlying that relationship, which appears to be mediated by arterial stiffness.

Abstract 06: Long-term Blood Pressure Variability Throughout Young Adulthood and Mid-life Cerebrovascular Structure and Function: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Introduction: In addition to average blood pressure (BP) values, BP variability has been suggested to be associated with lower cognitive function. It is unclear how long-term BP variability throughout young adulthood is associated with cerebrovascular structure (e.g., hippocampus) and function in midlife. Methods: Using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, which recruited healthy young adults ages 18 to 30 years (mean age 25 years) in 1985-1986, we assessed average BP over visits and visit-to visit BP variability (average real variability [ARV], defined as the absolute differences of BP between successive BP measurements) during 25-year follow-up (8 visits). Normal brain volume, abnormal brain volume, brain integrity assessed by fractional anisotropy, and cerebral blood flow were calculated by 3-Tesla MRI at the Year 25 follow-up (n=557, 52.2 % women, and 34.5 % African Americans). Results: For the 557 participants, mean ARV of SBP was 7.8±3.1 mm Hg. Higher ARV of SBP was associated with lower normal total brain volume, gray matter, and hippocampus after adjustment for covariates including intracranial volume and average BP during follow-up (Table). Higher average SBP during follow-up was associated with higher abnormal brain volume and lower integrity in the whole brain and the white matter, and lower blood flow in the hippocampus. Conclusions: Long-term visit-to-visit BP variability for 25 years beginning in young adulthood was associated with midlife cerebrovascular structural and functional alterations, independent of average BP during follow-up. Focusing not only on BP values alone but also on visit-to-visit BPV may be important to identify younger adults who may be at risk for developing lower cognitive function later.

Increased visit-to-visit blood pressure variability is associated with worse cardiovascular outcomes in low ejection fraction heart failure patients: Insights from the HEAAL study

BackgroundRecent data have highlighted shortcomings of the usual blood pressure (BP) hypothesis in several populations, and emphasized the importance of visit-to-visit variability of BP in predicting cardiovascular events. Herein, we aimed at assessing the association between visit-to-visit BP variability and outcomes in chronic heart failure (CHF) patients enrolled in the Heart failure Endpoint evaluation of Angiotensin II Antagonist Losartan (HEAAL). Methods and resultsThe HEAAL study randomized 3834 patients with HF and reduced ejection fraction administered 150mg or 50mg losartan daily in a double blind, randomized, controlled trial. The patients were followed up for up to 6.8years after randomization, and BP was measured at 3 time points in the first year and at semi-annual visits in the years thereafter. Three measures of visit-to-visit BP variability were computed for each subject: the standard deviation, the coefficient of variation and the average absolute visit-to-visit variation. Cox proportional hazard models were used to investigate the relationship between variations in systolic blood pressure, baseline covariates and the time to death or heart failure hospitalization (i.e. primary outcome). In multivariate analyses stratified on baseline BP, the patients with higher visit-to visit BP variability exhibited poorer outcomes (average absolute difference in SBP in mmHg:hazard ratio: 1.023 [95% CI (1.013, 1.034), P<0.0001]), independent from high dose losartan (still beneficial). ConclusionsFor the first time, visit-to-visit BP variability was found elevated in CHF patients with reduced ejection fraction, and associated with poorer cardiovascular outcomes. Such assessments should be prioritized for testing prevention strategies in CHF. Clinical trial registrationThis study is registered with the ClinicalTrials.gov, number NCT00090259.

Abstract 22: Visit-to-Visit Variability in Blood Pressure is Related to Late-Life Cognitive Decline

Introduction: Recent studies suggest higher visit-to-visit variability of blood pressure (BP) is associated with worse cognitive function, but evidence based on longitudinal cognitive testing has not been reported. Hypothesis: We assessed the hypothesis that higher visit-to-visit variability in BP, but not mean BP, would be associated with faster decline in cognitive function among community-dwelling older adults. Methods: This prospective cohort study comprised 1213 adults who had two or more waves of BP measurements as part of the China Health and Nutrition Survey from 1991, up to their first cognitive tests, and completed a cognitive screening test at two or more waves in 1997, 2000 or 2004. Mean (SD) age at first cognitive test was 64 (6) y. Outcomes were repeated measures of global cognitive scores (baseline mean ± SD: 19 ± 6 points), standardized composite cognitive and verbal memory scores (standardized units [SU]). Visit-to visit BP variability was expressed as the standard deviation [SD] or as the variation independent of mean (SD/mean^x, with x derived from curve fitting) in BP measures obtained at a mean interval of 3.6 years. Multivariable-adjusted linear mixed-effects models were used to determine the association of changes in cognitive scores with visit-to visit BP variability. Results: Higher visit-to-visit variability in systolic BP, but not mean systolic BP, was associated with a faster decline of cognitive function (adjusted mean difference [95% CI] for high vs. low tertile of SD in variability (Figure): global score -0.23 points/y [-0.41 to -0.04], composite scores -0.029 SU/y [-0.056 to -0.002] and verbal memory -0.044 SU/y [-0.075 to -0.012]). Higher visit-to-visit variability in diastolic BP was associated with a faster decline of global cognitive function only among adults 55-64 years, independent of mean diastolic BP. Conclusion: Higher long-term BP visit-to-visit variability predicted a faster rate of cognitive decline among older adults.

Increased visit-to visit blood pressure variability: a new predictor of total cardiovascular risk in romanian adult hypertensive population?

Increased visit-to visit blood pressure variability: a new predictor of total cardiovascular risk in romanian adult hypertensive population?

Visit-to-visit systolic blood pressure variability and outcomes in hemodialysis

Visit-to-visit blood pressure variation (VTV-BPV) is an independent risk factor for cardiovascular events and death in the general population. We sought to determine the association of VTV-BPV with outcomes in patients on hemodialysis, using data from a National Institutes of Health-sponsored randomized trial (the HEMO Study). We used the coefficient of variation (CV) and the average real variability (ARV) in systolic blood pressure (SBP) as metrics of VTV-BPV. 1844 of 1846 randomized subjects had at least three visits with SBP measurements and were included in the analysis. Median follow-up was 2.5 years (interquartile range [IQR] 1.3 to 4.3 years), during which time there were 869 deaths from any cause and 408 (adjudicated) cardiovascular deaths. The mean pre-dialysis SBP CV was 9.9% ± 4.6%. In unadjusted models, we found a 31% higher risk of death from any cause per 10% increase in VTV-BPV. This association was attenuated after multivariable adjustment but remained statistically significant. Similarly, we found a 28% higher risk of cardiovascular death per 10% increase in VTV-BPV, which was attenuated and no longer statistically significant in fully adjusted models. The associations among VTV-BPV, death and cardiovascular death were modified by baseline SBP. In a diverse, well-dialyzed cohort of patients on maintenance hemodialysis, VTV-BPV, assessed using metrics of variability in pre-dialysis SBP, was associated with a higher risk of all-cause mortality and a trend towards higher risk of cardiovascular mortality, particularly in patients with a lower baseline SBP.