Visit-to-Visit Blood Pressure Variability
An Insight Into the Mechanisms
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See related article, pp 39–45
One of the most interesting findings of hypertension research in the past 10 years has been that the cardiovascular protective effects of antihypertensive drugs depend not only on the mean blood pressure (BP) values achieved during treatment but also on the consistency of BP control between on-treatment visits. This was suggested in 2007 by the observation that in patients with hypertension and coronary disease, the protective effect of antihypertensive drugs increased because the percentage of on-treatment visits in which BP was reduced to <140/90 mm Hg increased, even when data were adjusted for the average BP achieved throughout the treatment period.1 It was documented on a more precise numeric basis in 2010 by the observation that, in hypertensive patients at high cardiovascular risk, the risk of stroke and, to a lesser extent, coronary events increased because visit-to-visit BP variability increased.2 Similar findings have since been obtained in studies on patients with diabetes mellitus, chronic renal damage, and other diseases,3,4 which have also shown that visit-to-visit BP variability may impact not only on major cardiovascular events but also on other types of outcomes, including alterations of renal function and cognitive decline. Although few discordant data have also been reported,5 this has led to the currently accepted concept that, to maximize cardiovascular protection, BP control needs to be as much as possible steady over time. This implies that physicians should not consider absence of BP control at single visits as of marginal clinical importance (and thus indulge in therapeutic inertia) because this may reduce patients’ chance of survival free of diseases.
The studies that have addressed visit-to-visit BP variability are unfortunately also characterized by limitations.6 One, this phenomenon has to date only be analyzed post hoc, which means that data …