{"id":1133,"date":"2016-10-04T19:43:41","date_gmt":"2016-10-04T19:43:41","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1133"},"modified":"2017-08-21T10:47:48","modified_gmt":"2017-08-21T10:47:48","slug":"primary-care-corner-with-geoffrey-modest-md-blood-pressure-variability-increases-cardiovasc-disease","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/04\/primary-care-corner-with-geoffrey-modest-md-blood-pressure-variability-increases-cardiovasc-disease\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Blood Pressure Variability Increases Cardiovasc Disease"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>There has been concern about the adverse effects of blood pressure variability on\u00a0cardiovascular outcomes. A\u00a0prior blog (see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/08\/10\/primary-care-corner-with-geoffrey-modest-md-blood-pressure-variability-and-heart-disease\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/08\/10\/primary-care-corner-with-geoffrey-modest-md-blood-pressure-variability-and-heart-disease\/<\/a> ) reviewed the ALLHAT trial, which found\u00a0that visit-to-visit blood pressure variability was associated with increased CV events and commented on a 2010 issue of the Lancet that found that\u00a0hour-to-hour BP variability in individuals was associated with more strokes, and, to\u00a0a lesser degree, coronary events\u00a0(see\u00a0Rothwell PM.\u00a0Lancet 2010;375:895). BMJ just had a systematic\u00a0review and meta-analysis confirming the association\u00a0(see\u00a0doi.org\/10.1136\/bmj.i4098).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>41 papers representing 19 observational cohort studies and 17 clinical trial cohorts. 24 papers studied long-term variability (monitoring\u00a0blood pressure in clinics), 4 studies mid-term variability (home monitoring) and 15 short-term (ambulatory blood pressure monitoring).<\/li>\n<li>Range of studies: 457 to 122,636 participants; follow-up ranged from 2514 to 490,544 person-years; mean age ranged from 48.5 to 77 yo<\/li>\n<li>Increased long term variability in systolic blood pressure was associated with:\n<ul>\n<li>All-cause mortality: 15% increase,\u00a0HR\u00a01.15 (1.09 to 1.22)<\/li>\n<li>Cardiovascular disease mortality: 18% increase,\u00a0HR\u00a01.18 (1.09 to 1.28)<\/li>\n<li>Cardiovascular disease events: 18% increase, HR\u00a01.18 (1.07 to 1.30)<\/li>\n<li>Coronary heart disease: 10% increase, HR\u00a01.10 (1.04 to 1.16)<\/li>\n<li>Stroke: 15% increase, HR\u00a01.15 (1.04 to 1.27)<\/li>\n<\/ul>\n<\/li>\n<li>Increased mid-term\u00a0variability (home BP)\u00a0in daytime systolic blood pressure was\u00a0associated with all-cause mortality [HR\u00a01.15 (1.06 to 1.26)].<\/li>\n<li>Increased short term variability (ambulatory BP)\u00a0in daytime systolic blood pressure was\u00a0also associated with all-cause mortality\u00a0[HR\u00a01.10\u00a0(1.04 to\u00a01.16)]. The conclusions are a bit limited, since 2 studies dominated the meta-analysis.<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>As with meta-analyses, they combine different studies with differing methodologies, limiting their conclusions. For example, there is not necessarily any consistency across studies in terms of how the BP was measured, what size cuffs were used, whether using\u00a0manual or automated devices, etc.)<\/li>\n<li>They did not include studies on nocturnal dipping (that&#8217;s the normal variation, with lower blood pressure at night on ambulatory monitoring; non-dippers seem to have higher mortality). They did exclude patients on dialysis, since blood pressure variability is basically intrinsic to hemodialysis patients.<\/li>\n<li>As a perspective, the 15+% difference in cardiovascular events found still pales in comparison to overall effect of\u00a0lowering\u00a0the mean blood pressure. I.e., the primary goal is to decrease the mean blood pressure. That being said, the difference from blood pressure variability in the above meta-analysis did\u00a0control\u00a0for the mean blood pressure, revealing an increased risk over the mean BP<\/li>\n<li>Blood pressure variability during the day is normal, typically\u00a0up to\u00a0the 18\/12 mmHg range. This variability is enhanced in those with arterial stiffness (and the above meta-analysis was skewed to older hypertensive\u00a0patients), which may put these patients at higher CV risk.<\/li>\n<li>This all supports the conclusions that:\n<ul>\n<li>We should be doing more\u00a0ambulatory or home\u00a0BP monitoring:\u00a0several analyses have found that\u00a0ambulatory or home blood pressure monitoring is superior to\u00a0office blood pressure at predicting cardiovascular events, perhaps\u00a0since ambulatory or home measurements are more likely to pick up BP variability.<\/li>\n<li>There are likely advantages to using BP meds that produce a more sustained, less variable blood pressure over 24 hours:\u00a0amlodipine seems to be the best, ACE-I\u00a0are intermediate (and there are arguments that the increased stroke rate in several studies of ACE-I may be related to the higher blood pressure in the early mornings), and HCTZ up to 25 mg is the worst\u00a0(for example, see Webb AJS. Lancet 2010; 375: 906). B-blockers are also in the intermediate category.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Many prior blogs have assessed these last 2 conclusions, at\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/hypertension\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/category\/hypertension\/<\/a> . And in particular,\n<ul>\n<li><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/05\/04\/primary-care-corner-with-geoffrey-modest-md-chlorthalidone-is-better-than-hctz-for-hypertension\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/05\/04\/primary-care-corner-with-geoffrey-modest-md-chlorthalidone-is-better-than-hctz-for-hypertension\/<\/a> showed that hydrochlorothiade is a poor choice, given both its very poor 24-hour effect (despite the fact that the blood pressure seems better controlled when we see the patients during the daytime\u00a0in the office), and \u00a0there are several other analyses confirming this result (e.g.,\u00a0the seminal studies on HCTZ in mild hypertension, done decades\u00a0ago, involved using 50mg\/d, which is higher than most of us use now. And the 50mg\/d dose does decrease\u00a0BP variability (see Messerli FH. JACC 2011; 57:590.)<\/li>\n<li><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/05\/03\/primary-care-corner-with-geoffrey-modest-md-home-blood-pressure-monitoring\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/05\/03\/primary-care-corner-with-geoffrey-modest-md-home-blood-pressure-monitoring\/<\/a>\u00a0which shows that home BP monitoring is superior in terms of clinical outcomes over office-based\u00a0BP, and refers to the UK&#8217;s\u00a02011\u00a0NICE guidelines which documented lots of studies showing that ambulatory BP monitoring was superior to clinic BP measurement,\u00a0leading NICE to strongly support using ambulatory or home BP for diagnosis of hypertension. Though it was done in 2011,\u00a0I\u00a0think the NICE document is the single best review of hypertension I have seen, with a detailed\u00a0analysis of the studies up till\u00a02011 (it even reviewed 5 or so studies showing that spironolactone was great in patients with resistant hypertension, well before it was adopted in the US), but this document unfortunately is\u00a0not accessible on the internet (The NICE guidelines\u00a0were\u00a0updated in 2015, with the\u00a0summary at\u00a0<a href=\"https:\/\/www.nice.org.uk\/Guidance\/QS28\">https:\/\/www.nice.org.uk\/Guidance\/QS28<\/a>).<\/li>\n<li>Using a non-clinic based BP\u00a0was adopted\u00a0in 2015 by the USPSTF giving an &#8220;A&#8221; rating to screen BP outside of the clinical setting.\u00a0For the USPSTF recommendations and my review, see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/11\/02\/primary-care-corner-with-geoffrey-modest-md-uspstf-guidelines-on-blood-pressure-screening\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/11\/02\/primary-care-corner-with-geoffrey-modest-md-uspstf-guidelines-on-blood-pressure-screening\/<\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Blood Pressure Variability Increases Cardiovasc Disease [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/04\/primary-care-corner-with-geoffrey-modest-md-blood-pressure-variability-increases-cardiovasc-disease\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1133","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1133","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1133"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1133\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1133"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1133"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1133"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}