Author + information
- Received May 22, 2016
- Revision received June 13, 2016
- Accepted June 21, 2016
- Published online September 27, 2016.
- Elvira O. Gosmanova, MDa,b,
- Margit K. Mikkelsen, BSc,
- Miklos Z. Molnar, MD, PhDd,
- Jun L. Lu, MDd,
- Lenar T. Yessayan, MD, MSe,
- Kamyar Kalantar-Zadeh, MD, MPH, PhDf and
- Csaba P. Kovesdy, MDd,g,∗ ()
- aNephrology Section, Stratton Veterans Affairs (VA) Medical Center, Albany, New York
- bDivision of Nephrology, Albany Medical College, Albany, New York
- cUniversity of Texas Health Science Center, San Antonio, Texas
- dDivision of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- eDivision of Nephrology, University of Michigan, Ann Arbor, Michigan
- fHarold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, California
- gNephrology Section, Memphis VA Medical Center, Memphis, Tennessee
- ↵∗Reprint requests and correspondence:
Dr. Csaba P. Kovesdy, Division of Nephrology, Memphis VA Medical Center, 1030 Jefferson Avenue, Memphis, Tennessee 38104.
Background Intraindividual blood pressure (BP) fluctuates dynamically over time. Previous studies suggested an adverse link between greater visit-to-visit variability in systolic blood pressure (SBP) and various outcomes. However, these studies have significant limitations, such as a small size, inclusion of selected populations, and restricted outcomes.
Objectives This study investigated the association of increased visit-to-visit variability and all-cause mortality, cardiovascular events, and end-stage renal disease (ESRD) in a large cohort of U.S. veterans.
Methods From among 3,285,684 U.S. veterans with and without hypertension and normal estimated glomerular filtration rates (eGFR) during 2005 and 2006, we identified 2,865,157 patients who had 8 or more outpatient BP measurements. Systolic blood pressure variability (SBPV) was measured using the SD of all SBP values (normally distributed) in 1 individual. Associations of SD quartiles (<10.3, 10.3 to 12.7, 12.7 to 15.6, and ≥15.6 mm Hg) with all-cause mortality, incident coronary heart disease (CHD), stroke, and ESRD was examined using Cox models adjusted for sociodemographic characteristics, baseline eGFR, comorbidities, body mass index, SBP, diastolic BP, and antihypertensive medication use.
Results Several sociodemographic variables (older age, male sex, African-American race, divorced or widowed status) and clinical characteristics (lower baseline eGFR, higher SBP and diastolic BP), and comorbidities (presence of diabetes, hypertension, cardiovascular disease, and lung disease) were all associated with higher intraindividual SBPV. The multivariable adjusted hazard ratios and 95% confidence intervals for SD quartiles 2 through 4 (compared with the first quartile) associated with all-cause mortality, CHD, stroke, and ESRD were incrementally higher.
Conclusions Higher SBPV in individuals with and without hypertension was associated with increased risks of all-cause mortality, CHD, stroke, and ESRD. Further studies are needed to determine interventions that can lower SBPV and their impact on adverse health outcomes.
This study was supported by grant R01DK096920 to Drs. Kalantar-Zadeh and Kovesdy and is the result of work supported with resources and the use of facilities at the Memphis VA Medical Center and the Long Beach VA Medical Center. Support for VA/Centers for Medicare and Medicaid Services (CMS) data is provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). Opinions expressed in this paper are those of the authors and do not necessarily represent the opinion of the Department of Veterans Affairs. Drs. Gosmanova, Kalantar-Zadeh, and Kovesdy are employees of the U.S. Department of Veterans Affairs. All authors have reported that they have no relationships relevant to the contents of this paper to disclose. Dr. Gosmanova and Ms. Mikkelsen contributed equally to this work.
- Received May 22, 2016.
- Revision received June 13, 2016.
- Accepted June 21, 2016.