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Blood pressure variability in patients with angina and non-obstructive coronary artery disease


There is a real challenge in the management of ischemia with non-obstructive coronary artery disease. So, we need to study the mechanisms of persistent angina and non-obstructive coronary artery (ANOCA) patients. One of those possible mechanisms is blood pressure variability (BPV). We aimed to study the relation between BPV and angina in patients with non-obstructive coronary artery disease. Our study included 150 patients with chest pain and positive non-invasive stress test suggestive of myocardial ischemia and normal coronary angiography or non-obstructive coronary artery disease. We used an ambulatory blood pressure monitoring device. We found a positive correlation between BPV as measured by average real variability (ARV) as well as standard deviation (SD) parameters and the severity of anginal symptoms with P values for all parameters was 0.001 except day systolic SD P-value was 0.021. We performed a regression analysis for all statistically significant parameters. We found that 24H diastolic ARV, day diastolic ARV, night diastolic ARV, 24H diastolic SD, day diastolic SD, and night diastolic SD were independent predictors of the severity of angina with P-values (0.015, 0.007, 0.011, 0.037, 0.014, and 0.029), respectively. We concluded that short-term BPV represented by ARV and SD had a consistent association with angina in patients with non-obstructive coronary artery disease. The diastolic parameters of ARV and SD were independent predictors of the severity of angina with non-obstructive coronary artery disease.

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  1. Marinescu MA, Loffler AI, Ouellette M, Smith L, Kramer CM, Bourque JM. Coronary microvascular dysfunction, microvascular angina, and treatment strategies. JACC Cardiovasc Imaging. 2015;8:210–20.

    Article  Google Scholar 

  2. Bairey Merz CN, Pepine CJ, Walsh MN, Fleg JL. Ischemia and no obstructive coronary artery disease (INOCA): developing evidence‐based therapies and research agenda for the next decade. Circulation. 2017;135:1075–92.

    Article  Google Scholar 

  3. Libby P, Pasterkamp G. Requiem for the ‘vulnerable plaque’. Eur Heart J. 2015;36:2984–7.

    PubMed  Google Scholar 

  4. Agha M, Agha R. The rising prevalence of obesity: part A: impact on public health. Int J Surg Oncol. 2017;2:e17.

    Article  Google Scholar 

  5. Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ. et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet. 2011;378:31–40.

    Article  CAS  Google Scholar 

  6. Tona F, Serra R, Di Ascenzo L, Osto E, Scarda A, Fabris R, et al. Systemic inflammation is related to coronary microvascular dysfunction in obese patients without obstructive coronary disease. Nutr Metab Cardiovasc Dis. 2014;24:447–53.

    Article  CAS  Google Scholar 

  7. Li CL, Liu R, Wang JR, Yang J. Relationship between blood pressure variability and target organ damage in elderly patients. Eur Rev Med Pharm Sci. 2017;21:5451–5.

    Google Scholar 

  8. Pierdomenico SD, Di Nicola M, Esposito AL, Di Mascio R, Ballone E, Lapenna D, et al. Prognostic value of different indices of blood pressure variability in hypertensive patients. Am J Hypertens. 2009;22:842–7.

    Article  Google Scholar 

  9. Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, et al. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr. 2008;9:415–37.

    Article  Google Scholar 

  10. Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: stress, protocols, and tracers [published correction appears in J Nucl Cardiol. 2016 Jun;23(3):640–2]. J Nucl Cardiol. 2016;23:606–39.

    Article  Google Scholar 

  11. Campeau Lucien. Grading of angina pectoris. Circulation. 1976;54:5223.

    Google Scholar 

  12. Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. ESC/ESH guidelines for the management of arterial hypertension. J Hypertens. 2018;2018:1953–2041.

    Article  Google Scholar 

  13. Volpe M, Gallo G, Battistoni A, Tocci G. Highlights of ESC/ESH 2018 guidelines on the management of hypertension: what every doctor should know. High Blood Press Cardiovasc Prev. 2019;26:1–8.

    Article  Google Scholar 

  14. O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G, et al. European society of hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31:1731–68.

    Article  Google Scholar 

  15. Sander D, Kukla C, Klingelhöfer J, Winbeck K, Conrad B. Relationship between circadian blood pressure patterns and progression of early carotid atherosclerosis: a 3-year follow-up study. Circulation. 2000;102:1536–41.

    Article  CAS  Google Scholar 

  16. Björklund K, Lind L, Zethelius B, Berglund L, Lithell H. Prognostic significance of 24-h ambulatory blood pressure characteristics for cardiovascular morbidity in a population of elderly men. J Hypertens. 2004;22:1691–7.

    Article  Google Scholar 

  17. Pringle E, Phillips C, Thijs L, Davidson C, Staessen JA, de Leeuw PW, et al. Systolic blood pressure variability as a risk factor for stroke and cardiovascular mortality in the elderly hypertensive population. J Hypertens. 2003;21:2251–7.

    Article  CAS  Google Scholar 

  18. Kikuya M, Hozawa A, Ohokubo T, Tsuji I, Michimata M, Matsubara M, et al. Prognostic significance of blood pressure and heart rate variabilities: the Ohasama study. Hypertension. 2000;36:901–6.

    Article  CAS  Google Scholar 

  19. Verdecchia P, Angeli F, Gattobigio R, Rapicetta C, Reboldi G. Impact of blood pressure variability on cardiac and cerebrovascular complications in hypertension. Am J Hypertens. 2007;20:154–61.

    Article  Google Scholar 

  20. Clark D III, Nicholls SJ, St John J, Elshazly MB, Ahmed HM, Khraishah H, et al. Visit-to-visit blood pressure variability, coronary atheroma progression, and clinical outcomes. JAMA Cardiol. 2019;4:437–43.

    Article  Google Scholar 

  21. Sebo P, Pechere-Bertschi A, Herrmann FR, Haller DM, Bovier P. Blood pressure measurements are unreliable to diagnose Hypertension in primary care. J Hypertens. 2014;32:509–17.

    Article  CAS  Google Scholar 

  22. Aoyama R, Takano H, Suzuki K, Kubota Y, Inui K, Tokita Y, et al. The impact of blood pressure variability on coronary plaque vulnerability in stable angina: an analysis using optical coherence tomography. Coron Artery Dis 2017;28:225–31.

    Article  Google Scholar 

  23. Schlaich MP, Parnell MM, Ahlers BA, Finch S, Marshall T, Zhang WZ, et al. Arginine transport and endothelial function in hypertensive and genetically predisposed normotensive subjects. Circulation. 2004;110:3680–6.

    Article  CAS  Google Scholar 

  24. Owlia M, Dodson JA, King JB, Derington CG, Herrick JS, Sedlis S. et al. Angina severity, mortality, and healthcare utilization among veterans with stable angina. J Am Heart Assoc. 2019;8:e012811.

    Article  Google Scholar 

  25. Campeau L. The Canadian cardiovascular society grading of angina pectoris revisited 30 years later. Can J Cardiol. 2002;18:371–9.

    PubMed  Google Scholar 

  26. Kaul P, Naylor CD, Armstrong PW, Mark DB, Theroux P, Dagenais GR. Assessment of activity status and survival according to the Canadian cardiovascular society angina classification. Can J Cardiol. 2009;25:e225–31.

    Article  Google Scholar 

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We want to thank the nurses and residents for helping us in conducting this study.


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Correspondence to Ahmed Alaarag.

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Alaarag, A., Amin, O. Blood pressure variability in patients with angina and non-obstructive coronary artery disease. J Hum Hypertens 35, 1074–1080 (2021).

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