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. 2016 Sep 27;68(13):1375-1386.
doi: 10.1016/j.jacc.2016.06.054.

Association of Systolic Blood Pressure Variability With Mortality, Coronary Heart Disease, Stroke, and Renal Disease

Elvira O Gosmanova  1 , Margit K Mikkelsen  2 , Miklos Z Molnar  3 , Jun L Lu  3 , Lenar T Yessayan  4 , Kamyar Kalantar-Zadeh  5 , Csaba P Kovesdy  6
Affiliations

Association of Systolic Blood Pressure Variability With Mortality, Coronary Heart Disease, Stroke, and Renal Disease

Elvira O Gosmanova et al. J Am Coll Cardiol. .

Abstract

Background: Intraindividual blood pressure (BP) fluctuates dynamically over time. Previous studies suggested an adverse link between greater visit-to-visit variability in systolic blood pressure (SBP) and various outcomes. However, these studies have significant limitations, such as a small size, inclusion of selected populations, and restricted outcomes.

Objectives: This study investigated the association of increased visit-to-visit variability and all-cause mortality, cardiovascular events, and end-stage renal disease (ESRD) in a large cohort of U.S. veterans.

Methods: From among 3,285,684 U.S. veterans with and without hypertension and normal estimated glomerular filtration rates (eGFR) during 2005 and 2006, we identified 2,865,157 patients who had 8 or more outpatient BP measurements. Systolic blood pressure variability (SBPV) was measured using the SD of all SBP values (normally distributed) in 1 individual. Associations of SD quartiles (<10.3, 10.3 to 12.7, 12.7 to 15.6, and ≥15.6 mm Hg) with all-cause mortality, incident coronary heart disease (CHD), stroke, and ESRD was examined using Cox models adjusted for sociodemographic characteristics, baseline eGFR, comorbidities, body mass index, SBP, diastolic BP, and antihypertensive medication use.

Results: Several sociodemographic variables (older age, male sex, African-American race, divorced or widowed status) and clinical characteristics (lower baseline eGFR, higher SBP and diastolic BP), and comorbidities (presence of diabetes, hypertension, cardiovascular disease, and lung disease) were all associated with higher intraindividual SBPV. The multivariable adjusted hazard ratios and 95% confidence intervals for SD quartiles 2 through 4 (compared with the first quartile) associated with all-cause mortality, CHD, stroke, and ESRD were incrementally higher.

Conclusions: Higher SBPV in individuals with and without hypertension was associated with increased risks of all-cause mortality, CHD, stroke, and ESRD. Further studies are needed to determine interventions that can lower SBPV and their impact on adverse health outcomes.

Keywords: hypertension; outcomes; visit-to-visit variability.

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Conflict of interest statement

None of the authors have relevant conflicts of interest.

Figures

Figure 1
Figure 1. Kaplan-Meier curves of various clinical outcomes associated with different SD quartiles of mean SBP
Increasing systolic blood pressure (SBP) variability, as measured in SD quartiles, was associated with corresponding increase in all-cause mortality in (A) unadjusted and (B) all adjusted models. Composition of the models is outlined in the Statistical Analysis section.
Figure 2
Figure 2. Hazard ratios and 95% confidence intervals of outcome of interest associated with different SD quartiles of mean SBP in unadjusted and various adjusted analyses
Increasing SBP variability, as measured in SD quartiles, was associated with corresponding increase in incident coronary heart disease (CHD) in (A) unadjusted and (B) all adjusted models. Composition of the models is outlined in the Statistical Analysis section. Abbreviations as in Figure 1.
Figure 3
Figure 3. Adjusted Hazard ratios and 95% confidence intervals of outcomes of interest associated with different SD quartiles of mean SBP in various subgroups
Increasing SBP variability, as measured in SD quartiles, was associated with corresponding increase in incident ischemic stroke in (A) unadjusted and (B) all adjusted models. Composition of the models is outlined in the Statistical Analysis section. Abbreviations as in Figure 1.
Figure 4
Figure 4. Central Illustration. Systolic Blood Pressure Variability: Clinical Outcomes
A variety of intrinsic and extrinsic factors influence visit-to-visit systolic blood pressure variability (SBPV), which was measured using SDs of normally distributed SBP values. As SD quartiles rose, so too did risk of all-cause mortality, incident coronary heart disease (CHD), stroke, and end-stage renal disease (ESRD). CI = confidence interval.
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