Visit-to-visit blood pressure variability in patients after acute coronary syndrome

Objective. The aim of the study was to assess the possible association of visit-to-visit blood pressure (BP) variability and the risk of adverse outcomes in hypertensive (HTN) patients after acute coronary syndrome.

Design and methods. We analyzed data of 1,456 patients (mean age 65,6 ± 12,2 years, 875 (60,1 %) men) discharged from the hospital after acute coronary syndrome and followed up for 1 year in 4 vascular centers in Moscow, Astrakhan, Kazan and Krasnodar in 2014–2017. BP, heart rate, and adverse events were recorded on the day of discharge and on days 25, 90, 180 and 360 after discharge. The visit-to-visit BP variability was assessed by the VIM coefficient (variation independent of mean).

Results. The systolic BP variability was 7,81 ± 0,226 mm Hg, diastolic BP variability was 9,89 ± 0,577 mm Hg during follow-up. In total, 110 deaths from any cause, 63 coronary deaths, 130 repeated non-fatal coronary events, 33 ischemic strokes were recorded. A decrease in BP variability was associated with the dihydropyridine calcium antagonists (10,21 ± 6,45 and 7,99 ± 4,70 mm Hg, p = 0,024) and thiazide diuretics (10,34 ± 6,59 and 7,63 ± 9,63 mm Hg, p = 0,049). Multivariate analysis showed that high long-term variability of BP is a more significant factor associated with the overall mortality rate than the initial severity of HTN and even the fact of achieving target BP. The risk of ischemic stroke in patients with HTN was associated with factors such as atrial fibrillation, heart failure, a history of stroke, and high visit-to-visit BP variability.

Conclusions. Visit-to-visit BP variability is an important characteristic of BP control and is associated with the risk of death from any causes and stroke in patients with coronary heart disease.

1. Rothwell PM, Howard SC, Dolan E, O’Brien E, Dobson JE, Dahlöf B et al. Effects of beta blockers and calcium-channel blockers on within-individual variability in blood pressure and risk of stroke. Lancet Neurol. 2010;9(5):469–480. doi:10.1016/S1474-4422(10)70066-1

2. Rakugi H, Ogihara T, Saruta T, Kawai T, Saito I, Teramukai S et al. Preferable effects of olmesartan/calcium channel blocker to olmesartan/diuretic on blood pressure variability in very elderly hypertension: COLM study subanalysis. J Hypertens. 2015;33(10):2165–2172. doi:10.1097/HJH.0000000000000668

3. Muntner P, Whittle J, Lynch AI, Colantonio LD, Simpson LM, Einhorn PT et al. Visit-to-visit variability of blood pressure and coronary heart disease, stroke, heart failure, and mortality: A Cohort Study. Ann Intern Med. 2015;163(5):329–338. doi:10.7326/M14-2803

4. Hata J, Arima H, Rothwell PM, Woodward M, Zoungas S, Anderson C et al. Effects of visit-to-visit variability in systolic blood pressure on macrovascular and microvascular complications in patients with type 2 diabetes mellitus: the ADVANCE trial. Circula- tion. 2013;128(12):1325–1334. doi:10.1161/CIRCULATIONAHA.113.002717

5. Wan EYF, Yu EYT, Chin WY, Fong DYT, Choi EPH, Lam CLK. Association of visit-to-visit variability of systolic blood pressure with cardiovascular disease, chronic kidney disease and mortality in patients with hypertension. J Hypertens. 2020;38(5):943–953. doi:10.1097/HJH.0000000000002347

6. Vidal-Petiot E, Stebbins A, Chiswell K, Ardissino D, Aylward PE, Cannon CP et al. Visit-to-visit variability of blood pressure and cardiovascular outcomes in patients with stable coronary heart disease. Insights from the STABILITY trial. Eur Heart J. 2017;38(37):2813–2822. doi:10.1093/eurheartj/ehx250

7. Clark D, Nicholls SJ, St John J, Elshazly MB, Ahmed HM, Khraishah H et al. Visit-to-visit blood pressure variability, coronary atheroma progression, and clinical outcomes. JAMA Cardiol. 2019;4(5):437–443. doi:10.1001/jamacardio.2019.0751

8. Gondo K, Miura S, Suematsu Y, Shiga Y, Kuwano T, Sugihara M et al. Association between visit-to-visit variability in blood pressure and cardiovascular events in hypertensive patients after successful percutaneous coronary intervention. J Clin Med Res. 2015;7(7):545–550. doi:10.14740/jocmr2173w

9. Soh MS, Park JS, Seo KW, Yang HM, Lim HS, Choi BJ et al. Visit-to-visit systolic blood pressure variability in patients with ST-elevation myocardial infarction predicts long-term cardiovascular outcomes. J Hum Hypertens. 2019;33(4):259–266. doi:10.1038/s41371-019-0176-0

10. Hoshide S. Clinical implication of visit-to-visit blood pressure variability. Hypertens Res. 2018;41(12):993–999. doi:10.1038/s41440-018-0107-4

11. Li SN, Luo Y, Li GL, Huang HF, Chen PA, Liu Z. The association of insulin resistance, blood pressure variability and severity of acute coronary syndrome. Zhonghua Nei Ke Za Zhi. 2012;51(8):609–612.

12. Hassan AKM, Abd-El Rahman H, Mohsen K, Dimitry SR. Impact of in-hospital blood pressure variability on cardiovascular outcomes in patients with acute coronary syndrome. J Clin Hypertens (Greenwich). 2017;19(12):1252–1259. doi:10.1111/jch.13107

13. Tully PJ, Debette S, Dartigues JF, Helmer C, Artero S, Tzourio C. Antihypertensive drug use, blood pressure variability, and incident stroke risk in older adults: Three-City Cohort Study. Stroke. 2016;47(5):1194–1200. doi:10.1161/STROKEAHA.115.012321

14. Kim BJ, Kwon SU, Wajsbrot D, Koo J, Park JM, Jeffers BW. Relationship of inter-individual blood pressure variability and the risk for recurrent stroke. J Am Heart Assoc. 2018;7(24):e009480. doi:10.1161/JAHA.118.009480

15. Wang H, Li M, Xie SH, Oyang YT, Yin M, Bao B et al. Visit-to-visit systolic blood pressure variability and stroke risk: a systematic review and meta-analysis. Curr Med Sci. 2019;39(5):741–747. doi:10.1007/s11596-019-2100-9

16. Lee SR, Choi YJ, Choi EK, Han KD, Lee E, Cha MJ et al. Blood pressure variability and incidence of new-onset atrial fibrillation: A Nationwide Population-Based Study. Hypertension. 2020;75(2):309–315. doi:10.1161/HYPERTENSIONAHA.119.13708