Abstract-Day-by-day blood pressure and heart rate variability defined as within-subject SDs of home measurements can be calculated from long-term self-measurement. We investigated the prognostic value of day-by-day variability in 2455 Ohasama, Japan, residents (baseline age: 35 to 96 years; 60.4% women). Home blood pressure and heart rate were measured once every morning for 26 days (median). A total of 462 deaths occurred over a median of 11.9 years, composing 168 cardiovascular deaths (stroke: nϭ83; cardiac: nϭ85) and 294 noncardiovascular deaths. Using Cox regression, we computed hazard ratios while adjusting for baseline characteristics, including blood pressure and heart rate level, sex, age, obesity, current smoking and drinking habits, history of cardiovascular disease, diabetes mellitus, hyperlipidemia, and treatment with antihypertensive drugs. An increase in systolic blood pressure variability of ϩ1 between-subject SD was associated with increased hazard ratios for cardiovascular (1.27; Pϭ0.002) and stroke mortality (1.41; Pϭ0.0009) but not for cardiac mortality (1.13; Pϭ0.26). Conversely, heart rate variability was associated with cardiovascular (1.24; Pϭ0.002) and cardiac mortality (1.30; Pϭ0.003) but not stroke mortality (1.17; Pϭ0.12). Similar findings were observed for diastolic blood pressure variability. Additional adjustment of heart rate variability for systolic blood pressure variability and vice versa produced confirmatory results. Coefficient of variation, defined as within-subject SD divided by level of blood pressure or heart rate, displayed similar prognostic value. In conclusion, day-by-day blood pressure variability and heart rate variability by self-measurement at home make up a simple method of providing useful clinical information for assessing cardiovascular risk. Key Words: epidemiology Ⅲ cerebrovascular disease/stroke Ⅲ population science Ⅲ risk factors Ⅲ blood pressure measurement/monitoring H ome blood pressure measurement is reportedly more reliable than conventional blood pressure measurement, because this approach avoids both observer and regression dilution biases and eliminates the white coat effect. 1 Home blood pressure measurement offers more prognostic significance than office blood pressure 2 and is more indicative of target organ damage. 3 The clinical significance of home blood pressure measurement is primarily produced by multiple measurements of blood pressure. 2 These multiple measurements also provide information on day-by-day blood pressure variability under relatively controlled conditions. 4 Previous studies of ambulatory blood pressure monitoring have highlighted that circadian variation 5 and short-term blood pressure variability 6 can predict cardiovascular events above and beyond traditional risk factors. However, no studies have investigated associations between home blood pressure variability and cardiovascular events. We hypothesized that day-by-day blood pressure variability derived from self-measurement at home would provide further insights into pro...
Background and Purpose-Ambulatory arterial stiffness index (AASI) and pulse pressure (PP) are indexes of arterial stiffness and can be computed from 24-hour blood pressure recordings. We investigated the prognostic value of AASI and PP in relation to fatal outcomes. Methods-In 1542 Ohasama residents (baseline age, 40 to 93 years; 63.4% women), we applied Cox regression to relate mortality to AASI and PP while adjusting for sex, age, BMI, 24-hour MAP, smoking and drinking habits, diabetes mellitus, and a history of cardiovascular disease. Results-During 13.3 years (median), 126 cardiovascular and 63 stroke deaths occurred. The sex-and age-standardized incidence rates of cardiovascular and stroke mortality across quartiles were U-shaped for AASI and J-shaped for PP. Across quartiles, the multivariate-adjusted hazard ratios for cardiovascular and stroke death significantly deviated from those in the whole population in a U-shaped fashion for AASI, whereas for PP, none of the HRs departed from the overall risk. The hazard ratios for cardiovascular mortality across ascending AASI quartiles were 1.40 (Pϭ0.04), 0.82 (Pϭ0.25), 0.64 (Pϭ0.01), and 1.35 (Pϭ0.03). Additional adjustment of AASI for PP and sensitivity analyses by sex, excluding patients on antihypertensive treatment or with a history of cardiovascular disease, or censoring deaths occurring within 2 years of enrollment, produced confirmatory results. Conclusions-In a Japanese population, AASI predicted cardiovascular and stroke mortality over and beyond PP and other risk factors, whereas in adjusted analyses, PP did not carry any prognostic information.
Hypertension guidelines recommend blood pressure self-measurement at home (HBP), but no previous trial has assessed cardiovascular outcomes in hypertensive patients treated according to HBP. The multicenter Hypertension Objective Treatment Based on Measurement by Electrical Devices of Blood Pressure (HOMED-BP;-2010 trial involved 3518 patients (50% women; mean age 59.6 years) with an untreated systolic/diastolic HBP of 135-179/85-119 mm Hg. In a 2 Â 3 design, patients were randomized to usual control (125-134/80-84 mm Hg (UC)) vs. tight control (o125/o80 mm Hg (TC)) of HBP and to initiation of drug treatment with angiotensin converting enzyme inhibitors, angiotensin receptor blockers or calcium channel blockers. During follow-up, a computer algorithm automatically generated treatment recommendations based on HBP. At the last follow-up (median 5.3 years), TC patients used more antihypertensive drugs than UC patients (1.82 vs. 1.74 defined daily doses, P ¼ 0.045) and had a greater HBP reduction (21.3/13.1 mm Hg vs. 22.7/13.9 mm Hg, P ¼ 0.018/0.020), but they less frequently achieved the lower HBP targets (37.4 vs. 63.5%, Po0.0001). The primary end point, cardiovascular death plus stroke and myocardial infarction, occurred in 25 UC and 26 TC patients (hazard ratio, 1.02; 95% confidence interval, 0.59-1.77; P ¼ 0.94). Rates were similar (PX0.13) in the three drug groups. In all patients combined, the risk of the primary end point independently increased by 41% (6-89%; P ¼ 0.019) and 47% (15-87%; P ¼ 0.0020) for a 1-s.d. increase in baseline (12.5 mm Hg) and follow-up (13.2 mm Hg) systolic HBP. The 5-year risk was minimal (p1%) if on-treatment systolic HBP was 131.6 mm Hg or less. HOMED-BP proved the feasibility of adjusting antihypertensive drug treatment based on HBP and suggests that a systolic HBP level of 130 mm Hg should be an achievable and safe target.
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