Blood pressure variability and risk of heart failure in ACCORD and the VADT

Abstract

Objective: Although blood pressure variability is increasingly appreciated as a risk factor for cardiovascular disease, its relationship with heart failure is less clear. We examined the relationship between blood pressure variability and risk of heart failure (HF) in two cohorts of type 2 diabetes participating in trials of glucose and/or other risk factor management. <p> </p> <p>Research Design and Methods: Data were drawn from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial and the Veterans Affairs Diabetes Trial (VADT). Coefficient of variation (CV) and average real variability (ARV) were calculated for systolic (SBP) and diastolic blood pressure (DBP) along with maximum and cumulative mean SBP and DBP during both trials. </p> <p> </p> <p>Results: In ACCORD, CV and ARV of SBP and DBP were associated with increased risk of HF, even after adjusting for other risk factors and mean blood pressure (e.g., CV-SBP: HR=1.15, <i>p</i> = 0.01; CV-DBP: HR=1.18, <i>p</i> = 0.003). In the VADT, DBP variability was associated with increased risk of HF (ARV-DBP: HR=1.16, <i>p</i> = 0.001; CV-DBP: HR=1.09, <i>p</i> = 0.04). Further, in ACCORD, those with progressively lower baseline blood pressure demonstrated a stepwise increase in risk of HF with higher CV-SBP, ARV-SBP, and CV-DBP. Effects of blood pressure variability were related to dips, not elevations, in blood pressure.</p> <p> </p> <p>Conclusions: Blood pressure variability is associated with HF risk in individuals with type 2 diabetes, possibly a consequence of periods of ischemia during diastole. These results may have implications for optimizing blood pressure treatment strategies in those with type 2 diabetes.</p>

Blood pressure variability and the development of hypertensive organ damage in the general population

“…Recent studies demonstrated that cardiovascular events, as well as TOD, are associated with the degree of BPV independent of blood pressure levels, 2–10 which seems to be incompatible with the present results, though some investigators have not observed such an association 27–29 . However, most studies investigating the clinical significance of BPV have targeted various patient populations.…”

Baseline blood pressure modifies the role of blood pressure variability in mortality: Results from the ACCORD trial

“…Moreover, we provide an assessment of this association across a wide spectrum of baseline blood pressure, leading to the identification of stronger relationships with mortality in those with high or low blood pressure, and in particular with cardiovascular death. These data support the notion that the nonlinear influences of BPv on risk of cardiovascular outcomes reported by us 7,12 and others may extend to fatal endpoints.…”

“…3 In patients with established coronary heart disease from the STABIL-ITY trial, a robust risk of the major adverse cardiovascular event outcome (P = 0.008) due to BPv was noted in those with low levels of diastolic function (<67 mmHg). 5 Our own prior analyses using the ACCORD trial revealed several interesting findings: heart failure risk due to BPv increased only in lower categories of baseline blood pressure, 12 while for coronary heart disease and the primary CVD outcome, BPv indicated risk exclusively in both high and low strata of blood pressure. 7 The present analysis highlights for the first time the relevance of ambient blood pressure when considering the potential impact of BPv on mortality in a purely diabetes cohort.…”

“…20 Our findings on BPv and mortality in ACCORD participants at the high end of baseline blood pressure are consistent with their findings. Moreover, because interactions between low baseline blood pressure and BPv were found for diastolic heart failure and coronary events, 3,7,12 we hypothesized previously that coronary hypoperfusion due to transient declines in blood pressure 12 may lead to these adverse outcomes. Our present findings that in those with lower DBP, only the association between BPv and cardiovascular mortality (and not with noncardiovascular mortality) was increased support this concept.…”

Joint effect of visit-to-visit variability in LDL-cholesterol, HDL-cholesterol and HbA1c on cardiovascular and total mortality in patients with diabetes

“…Recently, emerging evidence suggested that the longterm variability of many risk factors, including blood pressure [3,5], lipids [6,7], and glycosylated hemoglobin (HbA1c) [8,9], were associated with adverse cardiovascular outcomes and mortality. These effects remained significant after adjusting for the mean levels of the parameters, suggesting that not only managing the absolute value but also reducing the fluctuation should be targeted to improve health outcomes.…”