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Description : Check out this medical presentation on Blood Pressure, which is titled "Blood Pressure Variability: The Good And The Bad", to know about blood pressure variability, its mechanisms and clinical relevance.

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Slide 1-

Blood Pressure Variability: The Good And The Bad Sola Aoun Bahous LAU Medical Center – Rizk Hospital Master Course in Hypertension
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Blood Pressure Variability: Mechanisms and Clinical Relevance BPV: a physiological characteristic of the cardiovascular system Assessment of BPV Prognostic importance of BPV BPV reduction: CV risk lowering independent of BP reduction?
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Blood Pressure Variability: Mechanisms and Clinical Relevance BPV is a physiological characteristic of the cardiovascular system Assessment of BPV Prognostic importance of BPV BPV reduction: CV risk lowering independent of BP reduction?
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Blood Pressure Variability: Mechanisms and Clinical Relevance Weber M, J Hypertens 2006
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A. Zanchetti, Residual Risk in Treated Hypertension In Special Issues in Hypertension, 2012, A. Berbari and G. Mancia
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A. Zanchetti, Residual Risk in Treated Hypertension In Special Issues in Hypertension, 2012, A. Berbari and G. Mancia
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A. Zanchetti, Residual Risk in Treated Hypertension In Special Issues in Hypertension, 2012, A. Berbari and G. Mancia
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Blood Pressure Parameters What BP parameter to use? What anatomical site? What time to consider?
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BP Variability Site variability Time variability
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BP is a highly variable parameter Intra-arterial BP recording in a subject lying supine, at rest
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Time Variability of Arterial BP Mancia G, Parati G, J Hypertens 1990;8(suppl. 7):S1-S13
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Within-individual BPV over time varies from one patient to another Rothwell PM. Lancet. 2010;375:938-948. Patient 1 with lower BPV Patient 2 with higher BPV Weeks
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BP Variability “Rather than representing a “background noise” or a phenomenon occurring at random, these variations are known to be the result of complex interactions between extrinsic environmental and behavioral factors and intrinsic cardiovascular regulatory mechanisms (neural central, neural reflex, and humoral influences) that are not yet completely understood”. (Parati G. et al, Nat. Rev. Cardiol. 2013; 10:143)
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BP Variability Subtypes Short-term BPV (within 24hrs): Very short: beat-to-beat Short: within a 24-h period (minute-to-minute, hour-to-hour, and day-to-night) Long-term BPV: Day-to-day Visit-to-visit Seasonal
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BP Variability: Mechanism Short-time Variability: Beat-to-beat Baroreceptors Respiration Sleep Chemoreceptors Mechanisms: central and reflex autonomic modulation, reduced arterial compliance, humoral effects, rheological factors, emotional factors, behavioral influences/physical activity, sleep, postural changes.
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BP Contour
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BP Variability: Mechanism Long-time Variability: Day-to-day (behavioral changes) Visit-to-visit Seasonal: SBP and DBP have been reported to be lower during summer and higher during winter. Inappropriate down dosing of drugs leads to increase in night-time BP with hot weather reported in some studies. Mechanisms: less well studied. Behavioral factors, increased arterial stiffness, poor BP control, or inconsistent office readings.
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Blood Pressure Variability BPV is a known and natural characteristic of blood pressure BPV is secondary to mechanisms of varied nature Divided into short-term and long-term
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24h Intra-Arterial BP Different Prognostic Impact of Nocturnal BP Fall and Short Term BPV Mancia G, Parati G 1983
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Blood Pressure Variability: Mechanisms and Clinical Relevance BPV is a physiological characteristic of the cardiovascular system Assessment of BPV Prognostic importance of BPV BPV reduction: CV risk lowering independent of BP reduction?
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Assessment of BPV Indices: SD, CV, day-to-night BP changes, ARV, residual BPV, trough-to-peak, night-to-day Setting: Continuous beat-to-beat BP recordings: SD Repeated OBPM: SD, CV, ARV 24h ABPM: SD, CV, residual BPV, ARV, day-to-night, trough-to-peak, night-to-day HBPM: SD and CV Visit-to-visit: SD and CV Smoothness Index: used to assess the amplitude and distribution over time of BP reduction by treatment. 24-hourly BP changes/SD
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Assessment of BPV CV: (SD/BP)100 Residual BPV: fast fluctuations that remain after exclusion of the slower components of the 24h profile through spectral analysis ARV: (BP2-BP1) + (BP3-BP2) + (BP4-BP3) + etc. /N Day-to-night: Dipping status Night-to-day: Morning surge
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Circadian Variability of BP Beat-to-beat variability Day-to-night variability Dippers Non-dippers Reverse dippers/risers Excessive dippers Night-to-day variability: morning surge
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Nocturnal Dipping Status The correct time period of sleep and awakening should be considered Poor reproducibility of the classification of hypertensives into dippers and nondippers based on 1 ABPM
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Nocturnal Dipping Status Mechanisms underlying nondipping status: Persistence of sympathetic drive at night Reduced sensibility of baroreceptors at night Volume overload in specific conditions Autonomic dysfunction
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Nocturnal Dipping Status Nondipping status is associated with CV risk Nocturnal BP independently predicts outcome Extreme dipping is associated with higher risk for cerebral and retinal ischemia Chronotherapy?
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Morning Surge No consensus on the definition and threshold value of pathological MBPS Usually assessed using the ABPM Exaggerated surge is associated with TOD and leads to increased risk of CV events or death Weekly and seasonal variations in MBPS: augmented on Mondays and in winter MBPS increases with age, HTN, glucose intolerance, inflammation, alcohol, smoking , stress, etc…
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Kazuomi Kario, In Special Issues in Hypertension, 2012, A. Berbari and G. Mancia
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Blood Pressure Variability: Mechanisms and Clinical Relevance BPV is a physiological characteristic of the cardiovascular system Assessment of BPV Prognostic importance of BPV Reduction of BPV on top of BP reduction may represent a new target for treatment to further reduce cardiovascular risk (?)
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Prognostic Importance of BPV Clinical Relevance of Short-Term BPV
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Study Parati, 1987 Palatini, 1992 Mancia, Parati, 2001 Liu, 2003 Frattola, Parati, 1993 Sander, 2000 Dawson, 2000 Kikuya, 2000 Pringle, Parati, 2003 Mena, 2005 Mancia, 2007 Tatasciore, Parati, 2007 Parati, 2009 Hansen, 2010 Design Cross-sectional Cross-sectional Cross-sectional Longitudinal (rats) Longitudinal Longitudinal Longitudinal Longitudinal Longitudinal Longitudinal Longitudinal Cross-sectional Longitudinal Longitudinal Endpoint TOD score TOD score Carotid IMT Cardiac /renal damage LV mass (echo) Carotid IMT / CV events Dead / dependency (after acute stroke) CV mortality Stroke CV events CV mortality Carotid IMT, LVMI CV events Only DBP for CV events / stroke Clinical Relevance of 24h BP Variability
Slide 35-

Mancia G, Short-Term and Long-Term Blood Pressure Variability, In Special Issues in Hypertension, 2012, A. Berbari and G. Mancia
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Relation Between Risk of Stroke and Morning BP Surge In The Ohasama Study Metoki et al. Hypertension.2006 N = 1430
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Incidence of CV events, 24 h BP and Night/day SBP ratio in Syst Eur study Staessen JA, Parati G et al. for the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. JAMA 1999; 282: 539-546 Nocturnal BP Dipping
Slide 38-

CV Fatal Events in Relation with DBP Variability Mancia G, Short-Terma and Long-Term Blood Pressure Variability, In Special Issues in Hypertension, 2012, A. Berbari and G. Mancia CV Events CV Events
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10 9 8 7 6 5 4 3 2 10 9 8 7 6 5 4 3 2 7 9 11 13 15 17 5 7 9 11 13 150 133 123 114 105 np=8938 ne=1049 Parv=0.03 Pbp<0.001 89 79 73 67 60 np=8938 ne=1049 Parv=0.04 Pbp<0.001 10-year risk of combined CV events, % Average real variability (mmHg) 10-year risk associated with ARV24 at different levels of 24-h BP Systolic BP Diastolic BP Hansen TW et al, Hypertension 2010; 55: 1049-57
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Prognostic Importance of BPV Clinical Relevance of Long Term BPV
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17164 M SD of SBP SD of DBP CV mortality (%) Follow-up (years) 15 10 5 0 0 3 6 9 12 0 3 6 9 12 Q4 Q3 Q2 Q1 Q4 Q3 Q2 Q1 Home measurements once a day for 4 weeks Follow-up (years) CV mortality (%) 15 10 5 0 Max Min Max Min Kikuya et al. Hypertension. 2008 OHASAMA STUDY - Kaplan-Meier Survival Estimates for CV Mortality across Quartiles of Day-by-Day BP Variability (HBPM) (n= 2455)
Slide 42-

Visit-to-visit Variability and Risk of Stroke and Coronary Events in UK-TIA and ASCOT-BPLA Rothwell PM et al., Lancet 2010; 375: 895-905
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BPV: Types and Prognostic Significance Parati G et al. Nature Reviews Cardiology. 2013.10:143-155
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Blood Pressure Variability: Mechanisms and Clinical Relevance BPV: a physiological characteristic of the cardiovascular system Assessment of BPV Prognostic importance of BPV BPV reduction: CV risk lowering independent of BP reduction?
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Target for Research WHICH ANTIHYPERTENSIVE DRUG DO REDUCE BP VARIABILITY BEST?
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PM Rothwell et al., www.thelancet.com/neurology Published online March 12, 2010 6083 P Within-visit variability of systolic blood pressure in ASCOT-BPLA
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§ § † † § § † ‡ * * L50, losartan 50 mg; R10, ramipril 10 mg; V80–160, valsartan 80–160 mg; T40–80, telmisartan 40–80 mg; A5, amlodipine 5 mg *p < 0.05; †p < 0.01; ‡p < 0.001; §p < 0.0001 vs telmisartan 80 mg (n = 160) (n = 50) (n = 712) (n = 197) (n = 430) (n = 140) (n = 2033) (n = 206) Parati G et al J.Hypertens 2010; 28: 2177-2183 Comparison of Monotherapies
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Does Treatment-Induced Reduction in BPV Improve Outcome? Target for Research Studies in rats showed improvement outcome related to TOD Conclusive clinical studies are pending
Slide 51-

BPV – Need of additional studies Average BP levels and/or BPV? Short or Long Term BPV? Which measure of BPV to choose? Relationships with physiological variables (e.g. endothelial function, SpO2, arterial stiffness)? BPV in Risk Stratification?
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BPV – Need of additional studies Is a drug-induced reduction in BPV accompanied by a reduction in event rate? Do different drug classes have a different effect on BPV and on outcome? Is there enough evidence to consider BPV as a new target for treatment?
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Conclusions Average BP levels and/or BPV? Short or Long Term BPV? Which measure of BPV to choose? Relationships with physiological variables (e.g. endothelial function, SpO2, arterial stiffness)? BPV in Risk Stratification? Both Mainly short SD Some correlations exist ?
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Conclusions Is a drug-induced reduction in BPV accompanied by a reduction in event rate? Do different drug classes have a different effect on BPV and on outcome? Is there enough evidence to consider BPV as a new target for treatment? ? Probably CCBs and long-acting ARBs? ?
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Conclusions 24 h BP values more closely related to TOD and future events than office readings Higher 24 h BP Variability = Higher CV risk Long lasting CCBs seem to score best in reducing short term and long term BPV Prospective outcome studies needed to confirm that treatment-induced reduction in BPV improves outcome
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Lebanese Variability Thank You