Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension.
ABSTRACT The mechanisms by which hypertension causes vascular events are unclear. Guidelines for diagnosis and treatment focus only on underlying mean blood pressure. We aimed to reliably establish the prognostic significance of visit-to-visit variability in blood pressure, maximum blood pressure reached, untreated episodic hypertension, and residual variability in treated patients.
We determined the risk of stroke in relation to visit-to-visit variability in blood pressure (expressed as standard deviation [SD] and parameters independent of mean blood pressure) and maximum blood pressure in patients with previous transient ischaemic attack (TIA; UK-TIA trial and three validation cohorts) and in patients with treated hypertension (Anglo-Scandinavian Cardiac Outcomes Trial Blood Pressure Lowering Arm [ASCOT-BPLA]). In ASCOT-BPLA, 24-h ambulatory blood-pressure monitoring (ABPM) was also studied.
In each TIA cohort, visit-to-visit variability in systolic blood pressure (SBP) was a strong predictor of subsequent stroke (eg, top-decile hazard ratio [HR] for SD SBP over seven visits in UK-TIA trial: 6.22, 95% CI 4.16-9.29, p<0.0001), independent of mean SBP, but dependent on precision of measurement (top-decile HR over ten visits: 12.08, 7.40-19.72, p<0.0001). Maximum SBP reached was also a strong predictor of stroke (HR for top-decile over seven visits: 15.01, 6.56-34.38, p<0.0001, after adjustment for mean SBP). In ASCOT-BPLA, residual visit-to-visit variability in SBP on treatment was also a strong predictor of stroke and coronary events (eg, top-decile HR for stroke: 3.25, 2.32-4.54, p<0.0001), independent of mean SBP in clinic or on ABPM. Variability on ABPM was a weaker predictor, but all measures of variability were most predictive in younger patients and at lower (<median) values of mean SBP in every cohort.
Visit-to-visit variability in SBP and maximum SBP are strong predictors of stroke, independent of mean SBP. Increased residual variability in SBP in patients with treated hypertension is associated with a high risk of vascular events.
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ABSTRACT: The link between vascular disease and cognitive impairment is a matter of an ongoing debate, and different cardiovascular conditions have been found to be predictors of the clinical development and progression of cognitive dysfunction. To compare the influence of visit-to visit blood pressure (BP) variability on the rate of cognitive decline in Alzheimer's disease (AD) and frontotemporal dementia (FTD). The patients affected by AD and FTD consecutively admitted to our center from January 2007 to September 2012 were evaluated every three months for a one-year period. The BP mean and coefficient of variation as index of variability were obtained for both systolic and diastolic values. Progression of cognitive decline was investigated using the Mini-Mental State Examination administered at entry and at the end of the follow-up. Two-hundred and forty-eight AD and eighty-one FTD patients were enrolled. Systolic and diastolic BP mean and variability were comparable between the two groups. Systolic BP variability (BPV) was associated with the rate of cognitive impairment in AD (B = 0.367, beta = 0.739, R2 = 0.594, adjusted R2 = 0.567; p < 0.001), but not in FTD patients; no relationship emerged between any other BP index and cognitive decline. The relationship between BPV and cognitive function is still not completely understood, and it may play different roles according to the types and stages of dementia. Fluctuations in systolic BP may contribute to the cognitive decline in AD patients and may represent a neglected therapeutic target.Journal of Alzheimer's disease: JAD 01/2015; 45(2):387-94. DOI:10.3233/JAD-142532 · 3.61 Impact Factor
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ABSTRACT: Elevated systolic blood pressure (SBP) and high resting heart rate (HR) are associated with cardiovascular endpoints. Although the association between atrial fibrillation (AF) and SBP is well established, the relation between AF and HR remains unclear. In patients from the ONTARGET and TRANSCEND trials trial with high cardiovascular disease risk (n = 27,064), new-onset AF was evaluated in relation to mean SBP, visit to visit variation in SBP (SBP-CV; i.e. SD/mean x 100%), mean HR and visit to visit variation in HR (HR-CV). Low mean HR (P < 0.0001) and high SBP (P = 0.0021) were associated with incident AF. High SBP-CV (P = 0.031) and HR-CV (p < 0.0001) were also associated with incident AF. After adjustment for confounders, SBP and SBP-CV were no longer significantly associated with AF. The detrimental effect of low HR was particularly evident in subjects who were not receiving treatment with beta-blockers (P = 0.014 for interaction between beta-blocker use and mean HR). In addition to low HR, high HR-CV and high SBP had additive effects on incident AF. Low mean HR (<60 beats/min) is independently associated with incident AF and low HR-CV and high SBP further increase the incidence of new-onset AF in patients at high risk of cardiovascular disease. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.Journal of Internal Medicine 04/2015; DOI:10.1111/joim.12373 · 5.79 Impact Factor
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ABSTRACT: Stroke patients are at high risk for recurrence or new occurrence of other cardiovascular events or cardiovascular mortality. It is estimated that a high percentage of non-cardioembolic ischemic stroke can be prevented by a suitable modification of lifestyle (diet and exercise), reducing blood pressure (BP) with antihypertensive medication, platelet aggregation inhibitors, statins and high intake reducing consumption of. Unfortunately the degree of control of the different risk factors in secondary prevention of stroke is low. The clinical practice guidelines show clear recommendations with corresponding levels of evidence, but only if implemented in a general way they will get a better primary and secondary stroke prevention. Copyright © 2014 Sociedad Española de Arteriosclerosis. Published by Elsevier España. All rights reserved.