Department of Internal Medicine and Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville.
Center for Integrative Cardiovascular and Metabolic Diseases, University of Florida, Gainesville.
JAMA Netw Open. 2021 Apr 1;4(4):e218418. doi: 10.1001/jamanetworkopen.2021.8418.
Accumulating evidence indicates that higher blood pressure (BP) variability from one physician office visit to the next (hereafter referred to as visit-to-visit BP variability) is associated with poor outcomes. Short-term measurement (throughout 1 year) of visit-to-visit BP variability in high-risk older patients may help identify patients at increased risk of death.
To evaluate whether short-term visit-to-visit BP variability is associated with increased long-term mortality risk.
DESIGN, SETTING, AND PARTICIPANTS: The US cohort of the International Verapamil SR-Trandolapril Study (INVEST), a randomized clinical trial of 16 688 patients aged 50 years or older with hypertension and coronary artery disease, was conducted between September 2, 1997, and December 15, 2000, with in-trial follow-up through February 14, 2003. The study evaluated a calcium antagonist (sustained-release verapamil plus trandolapril) vs β-blocker (atenolol plus hydrochlorothiazide) treatment strategy. Blood pressure measurement visits were scheduled every 6 weeks for the first 6 months and biannually thereafter. Statistical analysis was performed from September 2, 1997, to May 1, 2014.
Visit-to-visit systolic BP (SBP) and diastolic BP variability during the first year of enrollment using 4 different BP variability measures: standard deviation, coefficient of variation, average real variability, and variability independent of the mean.
All-cause death, assessed via the US National Death Index, beginning after the exposure assessment period through May 1, 2014.
For the present post hoc analysis, long-term mortality data were available on 16 688 patients (9001 women [54%]; mean [SD] age, 66.5 [9.9] years; 45% White patients, 16% Black patients, and 37% Hispanic patients). During a mean (SD) follow-up of 10.9 (4.2) years, 5058 patients (30%) died. All 4 variability measures for SBP were significantly associated with long-term mortality after adjustment for baseline demographic characteristics and comorbidities. After comparison of lowest vs highest variability measure quintiles, the magnitude of the association with death remained statistically significant even after adjustment for baseline demographic characteristics and comorbidities (average real variability: adjusted hazard ratio [aHR], 1.18; 95% CI, 1.08-1.30; standard deviation: aHR, 1.14; 95% CI, 1.04-1.24; coefficient of variation: aHR, 1.15; 95% CI, 1.06-1.26; variability independent of the mean: aHR, 1.15; 95% CI, 1.05-1.25). The signal was stronger in women compared with men. Associations of diastolic BP variability measures with death were weaker than for SBP and were not significant after adjustment.
This study suggests that, in a large population of older patients with hypertension and coronary artery disease, short-term visit-to-visit SBP variability was associated with excess long-term mortality, especially for women. Efforts to identify and minimize visit-to-visit SBP variability may be important in reducing excess mortality later in life.
ClinicalTrials.gov Identifier: NCT00133692.
越来越多的证据表明，从一次就诊到下一次就诊的血压变异性（以下简称就诊间血压变异性）较高与预后不良有关。在高危老年患者中，通过短期（1 年内）测量就诊间血压变异性，可能有助于识别死亡风险增加的患者。
评估短期就诊间血压变异性是否与长期死亡率风险增加相关。
设计、地点和参与者：这项在美国进行的国际维拉帕米 SR-曲多普利研究（INVEST）的队列研究是一项随机临床试验，纳入了 16688 名年龄在 50 岁及以上的高血压和冠心病患者，研究于 1997 年 9 月 2 日至 2000 年 12 月 15 日进行，在临床试验期间通过 2003 年 2 月 14 日进行随访。该研究评估了钙拮抗剂（缓释维拉帕米加曲多普利）与β受体阻滞剂（阿替洛尔加氢氯噻嗪）治疗策略。血压测量访视每 6 周进行一次，前 6 个月进行，此后每 6 个月进行一次。统计分析于 1997 年 9 月 2 日至 2014 年 5 月 1 日进行。
在登记后的第一年，使用 4 种不同的血压变异性测量方法（标准差、变异系数、平均真实变异性和均值独立变异性）来评估就诊间收缩压（SBP）和舒张压（DBP）变异性。
通过美国国家死亡指数评估所有原因死亡，起始于暴露评估期之后，直至 2014 年 5 月 1 日。
本事后分析纳入了 16688 名患者（9001 名女性[54%]；平均[标准差]年龄 66.5[9.9]岁；45%为白人患者，16%为黑人患者，37%为西班牙裔患者）的长期死亡率数据。在平均（标准差）10.9（4.2）年的随访期间，5058 名患者（30%）死亡。SBP 的所有 4 种变异性测量方法在调整基线人口统计学特征和合并症后，均与长期死亡率显著相关。在比较最低和最高变异性测量五分位数时，即使在调整基线人口统计学特征和合并症后，与死亡的关联仍然具有统计学意义（平均真实变异性：调整后的危险比[aHR]，1.18；95%CI，1.08-1.30；标准差：aHR，1.14；95%CI，1.04-1.24；变异系数：aHR，1.15；95%CI，1.06-1.26；均值独立变异性：aHR，1.15；95%CI，1.05-1.25）。女性的相关性比男性更强。舒张压变异性测量与死亡的相关性较弱，且在调整后无统计学意义。
本研究表明，在患有高血压和冠心病的老年患者中，短期就诊间 SBP 变异性与长期死亡率过高有关，尤其是女性。努力识别和尽量减少就诊间 SBP 变异性可能对降低日后的死亡率很重要。
ClinicalTrials.gov 标识符：NCT00133692。
