From the Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (M.P., G.F.R., G.Y.H.L.); Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City (B.O.); and Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Denmark (G.Y.H.L.).
Hypertension. 2017 Nov;70(5):949-958. doi: 10.1161/HYPERTENSIONAHA.117.10106. Epub 2017 Oct 3.
Hypertension and atrial fibrillation predict major adverse events independently. Visit-to-visit variability (VVV) in systolic blood pressure (SBP) predicts outcomes beyond SBP itself, but risk associated with SBP-VVV in atrial fibrillation remains uncertain. We evaluated relationships between SBP-VVV, quality of oral anticoagulation control, and outcomes in patients with atrial fibrillation. Data from the AFFIRM trial (atrial fibrillation follow-up investigation of rhythm management) were analyzed. SBP-VVV was defined according to SD of SBP (SBP-SD) during follow-up. SBP-VVV was categorized by quartiles (1st, <10.09; 2nd, 10.09-13.85; 3rd, 13.86-17.33; and 4th, ≥17.34 mm Hg) and as a continuous variable. Among the original cohort, 3843 (94.7%) patients were eligible. Time in therapeutic range and percentage of international normalized ratio in range were progressively lower by quartiles (both <0.001). An inverse linear association existed between SBP-SD and time in therapeutic range/percentage of international normalized ratio in range (<0.001). After a median (interquartile range) follow-up of 3.6 (2.7-4.6) years, stroke and major bleeding rates progressively increased by SBP-VVV quartile (both <0.001). Patients in the 4th quartile had the highest rate of cardiovascular and all-cause death (=0.005 and <0.001). A Cox multivariate analysis confirmed that 3rd and 4th quartiles were associated independently with a higher risk for stroke (=0.042 and =0.004) and major bleeding (=0.009 and <0.001). Patients in 4th quartile had also a higher risk for all-cause death (=0.048). SBP-SD as a continuous variable was associated with increased risk for all outcomes. In conclusion, SBP-VVV is inversely associated with quality of anticoagulation control and independently predicts major adverse outcomes. Management of blood pressure variability may improve outcomes in atrial fibrillation.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000556.
高血压和心房颤动可独立预测主要不良事件。收缩压（SBP）的随访间变异性（VVV）可预测 SBP 本身以外的结果，但心房颤动中 SBP-VVV 相关风险仍不确定。我们评估了心房颤动患者中 SBP-VVV、口服抗凝控制质量与结局之间的关系。分析了 AFFIRM 试验（心房颤动节律管理随访调查）的数据。根据随访期间 SBP 的标准差（SBP-SD）定义 SBP-VVV。SBP-VVV 按四分位数（1 分位，<10.09；2 分位，10.09-13.85；3 分位，13.86-17.33；4 分位，≥17.34mmHg）和连续变量进行分类。在原始队列中，3843 例（94.7%）患者符合条件。治疗范围内时间和国际标准化比值在范围内的百分比逐四分位数降低（均<0.001）。SBP-SD 与治疗范围内时间/国际标准化比值在范围内的百分比之间存在负线性关联（均<0.001）。中位（四分位间距）随访 3.6（2.7-4.6）年后，按 SBP-VVV 四分位数递增，卒中发生率和大出血发生率逐渐增加（均<0.001）。第 4 四分位数的患者心血管和全因死亡发生率最高（=0.005 和<0.001）。Cox 多变量分析证实，第 3 四分位和第 4 四分位与卒中（=0.042 和=0.004）和大出血（=0.009 和<0.001）风险增加独立相关。第 4 四分位的患者全因死亡风险也较高（=0.048）。SBP-SD 作为连续变量与所有结局风险增加相关。结论：SBP-VVV 与抗凝控制质量呈负相关，可独立预测主要不良结局。血压变异性的管理可能改善心房颤动的结局。
