Blood Pressure Variability and Cardiovascular Risk in Treated Hypertensive Patients

Pierdomenico, Sante D.; Lapenna, Domenico; Tommaso, Roberta Di; Carlo, Silvio Di; Esposito, Anna L.; Mascio, Rocco Di; Ballone, Enzo; Cuccurullo, Franco; Mezzetti, Andrea

doi:10.1016/j.amjhyper.2006.03.009

Cited by 56 publications

(35 citation statements)

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“…Possible limitations of previous studies were a lack of statistical power, 2-5 selection of specific groups of patients, [5][6][7] categorization of variability by arbitrary cutoff points, 2,4,[7][8][9] and sole reliance on fatal end points. 10,11 Moreover, various parameters can capture short-term blood pressure variability over 24 hours, but most studies only considered the SD of systolic 4,6,12 or diastolic blood pressure or both.…”

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Prognostic Value of Reading-to-Reading Blood Pressure Variability Over 24 Hours in 8938 Subjects From 11 Populations

et al. 2010

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Abstract-In previous studies, of which several were underpowered, the relation between cardiovascular outcome and blood pressure (BP) variability was inconsistent. We followed health outcomes in 8938 subjects (mean age: 53.0 years; 46.8% women) randomly recruited from 11 populations. At baseline, we assessed BP variability from the SD and average real variability in 24-hour ambulatory BP recordings. We computed standardized hazard ratios (HRs) while stratifying by cohort and adjusting for 24-hour BP and other risk factors. Over 11.3 years (median), 1242 deaths (487 cardiovascular) occurred, and 1049, 577, 421, and 457 participants experienced a fatal or nonfatal cardiovascular, cardiac, or coronary event or a stroke.Higher diastolic average real variability in 24-hour ambulatory BP recordings predicted (PՅ0.03) total (HR: 1.14) and cardiovascular (HR: 1.21) mortality and all types of fatal combined with nonfatal end points (HR: Ն1.07) with the exception of cardiac and coronary events (HR: Յ1.02; PՆ0.58). Higher systolic average real variability in 24-hour ambulatory BP recordings predicted (PϽ0.05) total (HR: 1.11) and cardiovascular (HR: 1.16) mortality and all fatal combined with nonfatal end points (HR: Ն1.07), with the exception of cardiac and coronary events (HR: Յ1.03; PՆ0.54). SD predicted only total and cardiovascular mortality. While accounting for the 24-hour BP level, average real variability in 24-hour ambulatory BP recordings added Ͻ1% to the prediction of a cardiovascular event. Sensitivity analyses considering ethnicity, sex, age, previous cardiovascular disease, antihypertensive treatment, number of BP readings per recording, or the night:day BP ratio were confirmatory. In conclusion, in a large population cohort, which provided sufficient statistical power, BP variability assessed from 24-hour ambulatory recordings did not contribute much to risk stratification over and beyond 24-hour BP. (Hypertension. 2010;55:1049-1057.)Key Words: blood pressure variability Ⅲ ambulatory blood pressure Ⅲ population science Ⅲ risk factors Ⅲ epidemiology A mbulatory blood pressure monitoring not only provides information on the blood pressure level but on the diurnal changes in blood pressure as well. Blood pressure variability includes both short-term and circadian components, which can be estimated by the SD of the blood pressure values over a defined period of the day or by the night:day blood pressure ratio, respectively. We recently reported in Ͼ7000 subjects recruited from 6 populations on the prognos- Although the aforementioned analyses shed light on the association between outcome and long-term blood pressure variability, the predictive value of short-term reading-toreading blood pressure variability remains uncertain. Possible limitations of previous studies were a lack of statistical power, 2-5 selection of specific groups of patients, 5-7 categorization of variability by arbitrary cutoff points, 2,4,7-9 and sole reliance on fatal end points. 10,11 Moreover, various parameters can capture short-term b...

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Prognostic Value of Reading-to-Reading Blood Pressure Variability Over 24 Hours in 8938 Subjects From 11 Populations

et al. 2010

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“…Possible limitations of previous studies were lack of statistical power, 38-41 selection of specific groups of patients, [41][42][43] categorization of variability by arbitrary cut-off points, 38,40,[43][44][45] and sole reliance on fatal end points. 46,47 Moreover, various parameters can capture short-term BP variability over 24 h, but most studies only considered the s.d.…”

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confidence: 99%

Blood pressure variability in relation to outcome in the International Database of Ambulatory blood pressure in relation to Cardiovascular Outcome

et al. 2010

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Ambulatory blood pressure (BP) monitoring provides information not only on the BP level but also on the diurnal changes in BP.In the present review, we summarized the main findings of the International Database on Ambulatory BP in relation to Cardiovascular Outcome (IDACO) with regard to risk stratification based on BP variability. The predictive accuracy of daytime and nighttime BP and the night-to-day BP ratio depended on the disease outcome under study and treatment status, and differed for fatal outcomes compared with the composite of fatal and nonfatal diseases. An exaggerated morning surge, exceeding the 90th percentile of the population, is an independent risk factor for mortality and cardiovascular and cardiac events. Conversely, a sleep-trough or preawakening morning surge in systolic BP below 20 mm Hg is probably not associated with an increased risk of death or cardiovascular events. BP variability as captured by the average of the daytime and nighttime s.d. weighted for the duration of the daytime and nighttime interval (s.d. dn ) and the average real variability (ARV 24 ) predicted the outcome, but improved the prediction of the composite of all cardiovascular events by only 0.1%. In conclusion, the IDACO observations support the concept that BP variability adds to risk stratification, but above all highlight that 24-h ambulatory BP level remains the main predictor to be considered in clinical practice. Hypertension Research (2010) 33, 757-766; doi:10.1038/hr.2010.110; published online 8 July 2010Keywords: blood pressure; cardiovascular outcome; diurnal blood pressure variability; morning surge INTRODUCTION Ambulatory monitoring allows the registration of blood pressure (BP) throughout the day in patients engaged in their usual activities. Ambulatory BP recordings have high reproducibility, are not subject to digit preference, and avoid the transient rise of a patient's BP in response to a medical environment, the so-called white-coat effect. 1,2 Collaborative meta-analyses of individual patient data constitute a powerful research tool to clarify the role of cardiovascular risk factors in relation to total and cause-specific mortality and morbidity, over and beyond the prognostic information generated by single-cohort studies. 3,4 The international database on ambulatory BP monitoring 5 illustrated to what extent a meta-analysis of individual patient data can contribute to our understanding of the distribution 5,6 and the diurnal profile 5,7 of ambulatory BP across ethnically diverse populations. This database, constructed in 1993This database, constructed in -1994 however, lacked a

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“…However, the predictive value of BPV concerning cardiovascular and all-cause mortality has long been a matter of debate. [3][4][5][6][7][8][9] More recently, nighttime BPV was considered to be a more pronounced risk factor than daytime BPV. 10,11 Finally, Rothwell 12 showed that visit-to-visit BPV was an independent and strong predictor of cardiovascular events, such as stroke and coronary heart disease, and calcium channel blockers and nonloop diuretics were the most effective antihypertensive agents in reducing BPV and in preventing stroke.…”

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Effect of Antihypertensive Agents on Blood Pressure Variability

Zhang

Agnoletti²,

Safar³

et al. 2011

Hypertension

140

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Abstract-To investigate the effect of different antihypertensive agents on blood pressure (BP) variability (BPV) and the underlying mechanism, we analyzed the ambulatory BP monitoring data of 577 patients before and after 3-month antihypertensive treatment, in the Natrilix SR Versus Candesartan and Amlodipine in the Reduction of Systolic Blood Pressure in Hypertensive Patients (X-CELLENT) Study, a multicenter, multinational, randomized, double-blind, placebo-controlled study with 4 parallel treatment arms (placebo, candesartan, indapamide sustained release, and amlodipine). Within-subject mean and SD of 24-hour BP, weighted by time interval between consecutive readings, were calculated in 3 time frames (daytime, nighttime, and 24 hours) to evaluate BP and BPV. The mean 24-hour heart rate (HR) and HR variability were calculated with the same algorithms. We found that the 3 antihypertensive drugs had a similar BP-lowering effect (PϽ0.001 for all), but amlodipine (PϽ0.007) and indapamide sustained release (PϽ0.04) were the only agents associated with a significantly decreased BPV after 3-month treatment. On the other hand, the major determinants of BPV at baseline were age, mean BP, and the corresponding HR variability. However, the reduction in BPV by amlodipine was significantly associated with the reduction in BP (PϽ0.006) and the reduction in HR variability (PϽ0.02), whereas the corresponding reduction by indapamide sustained release was only associated with the reduction in HR variability at night (Pϭ0.004). In summary, 3-month amlodipine or indapamide sustained release treatment was associated with a significant reduction in BPV, and the mechanism of those reductions was possibly attributable to lowering BP or ameliorating the autonomic nervous system regulation or both. The combination of the 2 agents might help to optimize such properties. (Hypertension. 2011;58:155-160.)Key Words: ambulatory blood pressure monitoring Ⅲ calcium channel blocker Ⅲ diuretics Ⅲ blood pressure variability Ⅲ heart rate variability F or many decades, the main goal of antihypertensive treatment was to lower blood pressure (BP) to a defined level. Recently, several investigators have shown that BP variability (BPV) is another critical cardiovascular risk factor, which should also be emphasized in the treatment of hypertension. Mancia et al 1 were the first to report a close association of BPV, assessed by 24-hour ambulatory BP monitoring (ABPM), with target-organ damage in hypertensive patients. Carotid artery damage 1 and increased left ventricular mass index 2 were, therefore, investigated in the first instance. However, the predictive value of BPV concerning cardiovascular and all-cause mortality has long been a matter of debate. 3-9 More recently, nighttime BPV was considered to be a more pronounced risk factor than daytime BPV. 10,11 Finally, Rothwell 12 showed that visit-to-visit BPV was an independent and strong predictor of cardiovascular events, such as stroke and coronary heart disease, and calcium channel blockers and no...

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Blood Pressure Variability and Cardiovascular Risk in Treated Hypertensive Patients

Cited by 56 publications

References 34 publications

Prognostic Value of Reading-to-Reading Blood Pressure Variability Over 24 Hours in 8938 Subjects From 11 Populations

Prognostic Value of Reading-to-Reading Blood Pressure Variability Over 24 Hours in 8938 Subjects From 11 Populations

Blood pressure variability in relation to outcome in the International Database of Ambulatory blood pressure in relation to Cardiovascular Outcome

Effect of Antihypertensive Agents on Blood Pressure Variability

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