University of Milano-Bicocca, Milan.
Policlinico di Monza, Monza, Italy.
J Hypertens. 2020 Oct;38(10):2050-2058. doi: 10.1097/HJH.0000000000002567.
There is conflicting evidence on whether in treated hypertensive patients the risk of renal outcomes is associated with visit-to-visit SBP variability. Furthermore, limited evidence is available on how important is SBP variability for prediction of renal outcomes compared with on-treatment mean SBP. We addressed these issues in 28 790 participants of the Ongoing Treatment Alone and in combination with Ramipril Global End point Trial and Telmisartan Randomized AssessmeNt Study in ACE iNtolerant Subjects with Cardiovascular Disease trials.
SBP variability was expressed as the coefficient of variation of the mean with which it showed no relationship. SBP variability and mean values were obtained from five visits during the first 2 years of treatment after the end of the titration phase. Incidence of several renal outcomes (end-stage renal disease, doubling of serum creatinine, new microalbuminuria, new macroalbuminuria and their composite) was calculated from the third year of treatment onward. Patients were divided in quintiles of SBP-coefficient of variation (SBP-CV) or mean SBP, which exhibited superimposable mean blood pressure and SBP-CV values, respectively. A progressive increase of SBP-CV was not accompanied by a parallel increase in a widely adjusted (baseline and on-treatment confounders) risk of most renal outcomes (end-stage renal disease, new macroalbuminuria, new microalbuminuria and their composite) in the subsequent on-treatment years. In contrast, the adjusted risk of most renal outcomes increased progressively from the lowest to the highest quintile of on-treatment mean SBP. Progression from lowest to highest mean on-treatment SBP, but not SBP-CV, was also associated with a less frequent return to normoalbuminuria in patients with initial micro or macroalbuminuria. Renal outcome prediction was slightly improved by the combined use of SBP-CV and mean SBP quintiles.
Visit-to-visit SBP variability had no major predictive value for the risk of renal outcomes, which, in contrast, was sensitively predicted by mean on-treatment SBP. A further slight increase in prediction of renal outcomes was seen by combining on-treatment mean SBP and variability.
在接受治疗的高血压患者中，血压变异性与肾脏结局风险之间的关系存在相互矛盾的证据。此外，关于血压变异性对肾脏结局预测的重要性与治疗中平均收缩压相比，证据有限。我们在 Ongoing Treatment Alone 和 Ramipril Global End point Trial 以及 Telmisartan Randomized AssessmeNt Study in ACE iNtolerant Subjects with Cardiovascular Disease 试验的 28790 名参与者中解决了这些问题。
血压变异性用平均收缩压的变异系数表示，两者之间没有关系。血压变异性和平均值是在滴定阶段结束后治疗的前 2 年内的 5 次就诊中获得的。从治疗的第 3 年开始计算几种肾脏结局（终末期肾病、血清肌酐加倍、新微量白蛋白尿、新大量白蛋白尿及其复合终点）的发生率。患者根据收缩压-变异系数（SBP-CV）或平均 SBP 的五分位数进行分组，分别显示出可叠加的平均血压和 SBP-CV 值。SBP-CV 的逐渐增加并没有伴随广泛调整（基线和治疗期间的混杂因素）的大多数肾脏结局（终末期肾病、新大量白蛋白尿、新微量白蛋白尿及其复合终点）风险的平行增加，在随后的治疗年份。相比之下，从最低到最高的治疗中平均 SBP 五分位数，大多数肾脏结局的调整风险逐渐增加。从最低到最高的平均治疗 SBP 的进展，而不是 SBP-CV，也与初始微量或大量白蛋白尿患者恢复正常白蛋白尿的频率降低有关。SBP-CV 和平均 SBP 五分位数的联合使用略微改善了肾脏结局的预测。
收缩压变异性与肾脏结局风险之间没有主要的预测价值，而治疗中的平均收缩压则对肾脏结局风险具有敏感的预测性。通过将治疗中的平均 SBP 和变异性结合起来，观察到对肾脏结局预测的略微增加。
