Visit-to-Visit Blood Pressure Variability, Coronary Atheroma Progression, and Clinical Outcomes

Abstract

Visit-to-visit blood pressure variability (BPV) is associated with cardiovascular events, but mechanisms and therapeutic implications underlying this association are not well understood. OBJECTIVE To examine the association of intraindividual BPV, coronary atheroma progression, and clinical outcomes using serial intravascular ultrasonography. DESIGN, SETTING, AND PARTICIPANTS Post hoc patient-level analysis of 7 randomized clinical trials conducted from 2004 to 2016 involving 3912 patients in multicenter, international, clinic-based primary and tertiary care centers. Adult patients with coronary artery disease who underwent serial intravascular ultrasonography in the setting of a range of medical therapies were included. Data were analyzed between November 2017 and March 2019. EXPOSURES Visit-to-visit BPV measured using intraindividual standard deviation over 3, 6, 12, 18, and 24 months. MAIN OUTCOMES AND MEASURES Percent atheroma volume (PAV) progression and major adverse cardiovascular events (defined as death, myocardial infarction, stroke, urgent revascularization for acute coronary syndrome, and hospitalization for unstable angina). RESULTS Of 3912 patients, the mean (SD) age was 58 (9) years, 1093 (28%) were women, and 3633 (93%) were white. Continuous change in PAV was significantly associated with systolic BPV (β, .049; 95% CI, 0.021-0.078; P = .001), diastolic BPV (β, .031; 95% CI, 0.002-0.059; P = .03), and pulse pressure variability (β, .036; 95% CI, 0.006-0.067; P = .02), without a signal for differential effect greater than or less than a mean BP of 140/90 mm Hg. The PAV progression as a binary outcome was significantly associated with systolic BPV (odds ratio, 1.09; 95% CI, 1.01-1.17; P = .02) but not diastolic BPV (odds ratio, 1.04; 95% CI, 0.97-1.11; P = .30) or pulse pressure variability (odds ratio, 1.03; 95% CI, 0.96-1.10; P = .47). Survival curves revealed a significant stepwise association between cumulative major adverse cardiovascular events and increasing quartiles of systolic BPV (Kaplan-Meier estimates for quartiles 1-4: 6.1% vs 8.5% vs 10.1% vs 12.0%, respectively; log-rank P <.001). These distinct stepwise associations were not seen with diastolic BPV or pulse pressure variability. CONCLUSIONS AND RELEVANCE Greater BPV, particularly systolic BPV, is significantly associated with coronary atheroma progression and adverse clinical outcomes. These data suggest maintaining stable blood pressure levels may be important to further improve outcomes in patients with coronary disease.

Visit‐to‐visit blood pressure variability and sleep architecture

“…4 Contrary to previous notions about visitto-visit BPV as a random phenomenon, it is highly reproducible in clinical practice and has been known to have prognostic values for a wide range of health outcomes (eg, coronary heart disease, stroke, and all-cause mortality). [5][6][7] Previous work revealed that visit-to-visit variability in systolic BP improved 8-year predictions of major CVDrelated health outcomes beyond those obtained from traditional risk factors. 8 Sleep also plays an essential role in cardiovascular health.…”

The Challenges of Episodic Office-based Blood Pressure Measurement for the Management of Hypertension

“…Multiple previous studies have demonstrated VVV, and its prognostic significance, using clinical trial data and data from longitudinal cohort studies. 7,9,11,14,15 For example, by conducting secondary analysis of the data from the ALLHAT trial, Muntner et al showed large variation in the degree of VVV across all measurements among study participants and that higher VVV of SBP was associated with increased risk of cardiovascular disease and mortality. 11 .…”

Cardiovascular Risk Factors: It's Time to Focus on Variability!

“…Several hypotheses exist to explain the association between BP variability and increased cardiovascular risk. As a biologic basis, coronary atheroma progression as measured by serial intravascular ultrasonography was significantly associated with higher BP variability in a study by Clark et al 31 Other proposed mechanisms include increased wall stress, baroreceptor dysfunction, and endothelial dysfunction in those with variable BPs. Lastly, BP variability may also be a marker for medication non-compliance and may suggest that patients spend a greater proportion of time above their guideline-recommended BP goal.…”