Short-Term Blood Pressure Variability Relates to the Presence of Subclinical Brain Small Vessel Disease in Primary Hypertension

Abstract

C urrent guidelines recommend the assessment of vascular risk factors, target organ damage, and blood pressure (BP) levels to guide the treatment on primary hypertension.1 Besides BP levels, other BP-related features, such as the nocturnal dipping 2 or more recently, visit-to-visit or long-term BP variability (BPV), have been independently associated with clinical cardiovascular outcomes in a recent systematic review and meta-analysis. 3 Also, the prognostic value of BPV measured with ambulatory BP monitoring (ABPM) for 24 hours (also value-to-value or short-term BPV) has been evaluated. Data on short-term BPV from 11 populations 4 suggest a positive association between measures of short-term BPV and cardiovascular death or any (fatal and nonfatal) event. Although the contribution of short-term BPV to the prediction of cardiovascular events was shown to be small (<1%), this is still a matter of debate because results from individual studies support significant contributions. 5,6 It has been also suggested that the prognostic significance of BPV on stroke risk is weaker for short-term than for longterm BPV in treated hypertension. 7 However, these data need further investigation taking into account not only between subject BPV but also within subject BPV.Moreover, several indices of short-term BPV have been related to the presence of subclinical damage in one or multiple organs, including the heart, kidney, and vessels, independently of BP levels. [8][9][10] About the brain, hypertension is a major risk factor for cerebral small vessel disease (CSVD), which is an Abstract-Blood pressure (BP) variability is associated with stroke risk, but less is known about subclinical cerebral small vessel disease (CSVD). We aimed to determine whether CSVD relates to short-term BP variability independently of BP levels and also, whether they improve CSVD discrimination beyond clinical variables and office BP levels. This was a cohort study on asymptomatic hypertensives who underwent brain magnetic resonance imaging and 24-hour ambulatory BP monitoring. Office and average 24-hour, daytime and nighttime BP levels, and several metrics of BP variability (SD, weighted SD, coefficient of variation, and average real variability [ARV]) were calculated. Definition of CSVD was based on the presence of lacunar infarcts and white matter hyperintensity grades. Multivariate analysis and integrated discrimination improvement were performed to assess whether BP variability and levels were independently associated with CSVD and improved its discrimination. Four hundred eighty-seven individuals participated (median age, 64; 47% women). CSVD was identified in 18.9%, related to age, male sex, diabetes mellitus, use of treatment, ambulatory BP monitoring-defined BP levels, and ARV of systolic BP at any period. The highest prevalence (33.7%) was found in subjects with both 24-hour BP levels and ARV elevated. BP levels at any period and ARV (24 hours and nocturnal) emerged as independent predictors of CSVD, and discrimination was incrementally improv...

24‐Hour Blood Pressure Variability Assessed by Average Real Variability: A Systematic Review and Meta‐Analysis

“…The study also found that lacunar infarction was significantly associated with cognitive impairment and that only ARV differed significantly between subjects with and without cognitive decline. Similarly, Filomena et al conducted a cohort study on asymptomatic hypertensive patients to evaluate the potential usefulness of BPV as a predictor of CSVD, compared with BP and other clinical factors . Only BPV, measured as ARV, was independently related to the presence of CSVD.…”

“…Although ARV has been shown to be a better predictor of risk than SD for most adverse outcomes, studies to date have not estimated ARV using real‐time monitoring, because no existing ABPM devices incorporate automatic quantification of ARV or other novel BPV indexes. The procedures for collection, computation, and storage of electronic BP recordings need to automatically provide accurate calculations of 24‐hour BPV.…”

Moderate-to-severe obstructive sleep apnea is associated with cerebral small vessel disease

“…A previous study showed that a fluctuation or variability in blood pressure was related to the presence of cerebral SVD [30]. Therefore, these fluctuations could cause shearing forces to the cerebral vasculature, and these shearing forces could injure arterioles leading to cerebral SVD.…”

Biochemical markers in vascular cognitive impairment associated with subcortical small vessel disease - A consensus report

“…Underlying vascular pathologies are arteriolosclerosis, lipohyalinosis, fibroid necrosis, oedema and damage to the blood-cerebrospinal fluid and blood–brain barriers (BCB/BBB), the latter resulting in chronic leakage of fluid and macromolecules in the white matter and inflammation (reviewed by Kalaria, 2016) [5]. Although SSVD pathogenesis remains poorly understood, it is an age-related condition, associated with a number of risk factors including systemic hypertension [6–9], chronic kidney disease [10, 11], smoking [12], metabolic syndrome [8, 13, 14], osteoporosis [15], chronic obstructive pulmonary disease [16] and sleep-apnoea syndrome [17]. The SSVD clinical manifestations are largely due to complete (lacunes) or incomplete (WML) infarction(s) and microbleeds resulting in cognitive, motor and mood disturbances and eventually functional disability [2], although same lesions might appear in cognitively intact persons during normal ageing.…”