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Visit-to-visit blood pressure variability and mortality and cardiovascular outcomes after acute myocardial infarction


The relationship between visit-to-visit blood pressure variability (BPV) and cardiovascular outcomes remains unclear. Our study assessed the prognostic implications of visit-to-visit BPV in patients after acute myocardial infarction (AMI). The present study enrolled 7,375 patients who underwent percutaneous coronary intervention for AMI and at least five measurements of blood pressure after hospital discharge. Visit-to-visit BPV was estimated as variability independent of mean. The primary endpoint was all-cause mortality. The secondary endpoints were major cardiovascular events (the composite of cardiovascular death, myocardial infarction, and ischemic stroke) and hospitalization for heart failure. During a median follow-up of 5.8 years, adjusted risks of all-cause mortality, major cardiovascular events, and hospitalization for heart failure continuously increased as systolic BPV and diastolic BPV increased. Patients in the highest quartile of systolic BPV (versus lowest) had increased risk of all-cause mortality (adjusted hazard ratio (aHR) 1.51 [95% confidence interval (CI) 1.23–1.85]), major cardiovascular events (aHR 1.31 [95% CI 1.1–1.55]), and hospitalization for heart failure (aHR 2.15 [95% CI 1.49–3.1]). Patients in the highest quartile of diastolic BPV was also associated with all-cause mortality (aHR 1.39 [95% CI 1.14–1.7]), major cardiovascular events (aHR 1.29 [95% CI 1.08–1.53]), and hospitalization for heart failure (aHR 2.01[95% CI 1.4–2.87]). Both systolic and diastolic BPV improved the predictive ability of the GRACE (Global Registry of Acute Coronary Events) risk score for both all-cause mortality and major cardiovascular events. Higher visit-to-visit BPV was associated with increased risks of mortality and cardiovascular events in patients after AMI.

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Fig. 1: Cumulative incidence of clinical outcomes by visit-to-visit systolic blood pressure variability.


  1. 1.

    Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Himmelfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults a report of the American College of Cardiology/American Heart Association Task Force on Clinical pr. 2018.

  2. 2.

    Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 Practice Guidelines for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36:2284–309.

    CAS  Article  Google Scholar 

  3. 3.

    Muntner P, Whittle J, Lynch AI, Colantonio LD, Simpson LM, Einhorn PT, et al. Visit-to-visit variability of blood pressure and coronary heart disease, stroke, heart failure, and mortality a cohort study. Ann Intern Med. 2015;163:329–38.

    Article  Google Scholar 

  4. 4.

    Rothwell PM, Howard SC, Dolan E, O’Brien E, Dobson JE, Dahlöf B, et al. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010;375:895–905.

    Article  Google Scholar 

  5. 5.

    Wang J, Shi X, Ma C, Zheng H, Xiao J, Bian H, et al. Visit-to-visit blood pressure variability is a risk factor for all-cause mortality and cardiovascular disease: A systematic review and meta-analysis. J Hypertens. 2017;35:10–7.

    CAS  Article  Google Scholar 

  6. 6.

    Asayama K, Kikuya M, Schutte R, Thijs L, Hosaka M, Satoh M, et al. Home blood pressure variability as cardiovascular risk factor in the population of ohasama. Hypertension. 2013;61:61–9.

    CAS  Article  Google Scholar 

  7. 7.

    Yano Y, Reis JP, Lewis CE, Sidney S, Pletcher MJ, Bibbins-Domingo K, et al. Association of blood pressure patterns in young adulthood with cardiovascular disease and mortality in middle age. JAMA Cardiol. 2020;5:382–9.

    Article  Google Scholar 

  8. 8.

    Clark D, 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 

  9. 9.

    Gosmanova EO, Mikkelsen MK, Molnar MZ, Lu JL, Yessayan LT, Kalantar-Zadeh K, et al. Association of systolic blood pressure variability with mortality, coronary heart disease, stroke, and renal disease. J Am Coll Cardiol. 2016;68:1375–86.

    Article  Google Scholar 

  10. 10.

    Vidal-Petiot E, Stebbins A, Chiswell K, Ardissino D, Aylward PE, Cannon CP, et al. Visit-to-visit variability of blood pressure and cardiovascular outcomes in patients with stable coronary heart disease. Insights from the STABILITY trial. Eur Heart J. 2017;38:2813–22.

    CAS  Article  Google Scholar 

  11. 11.

    Soh MS, Park JS, Seo KW, Yang HM, Lim HS, Choi BJ, et al. Visit-to-visit systolic blood pressure variability in patients with ST-elevation myocardial infarction predicts long-term cardiovascular outcomes. J Hum Hypertens. 2019;33:259–66.

    Article  Google Scholar 

  12. 12.

    Seo SM, Chung WB, Choi IJ, Koh YS, Ihm SH, Kim PJ, et al. Visit-to-visit variability of systolic blood pressure predicts all-cause mortality in patients received percutaneous coronary intervention with drug-eluting stents. Heart Vessels. 2018;33:489–97.

    Article  Google Scholar 

  13. 13.

    Ferreira JP, Duarte K, Pitt B, Dickstein K, McMurray JJV, Zannad F, et al. Visit-to-visit blood pressure variation is associated with outcomes in a U-shaped fashion in patients with myocardial infarction complicated with systolic dysfunction and/or heart failure: findings from the EPHESUS and OPTIMAAL trials. J Hypertens. 2018;36:1736–42.

    CAS  Article  Google Scholar 

  14. 14.

    Schutte R, Thijs L, Liu YP, Asayama K, Jin Y, Odili A, et al. Within-subject blood pressure level-not variability-predicts fatal and nonfatal outcomes in a general population. Hypertension. 2012;60:1138–47.

    CAS  Article  Google Scholar 

  15. 15.

    Mancia G, Facchetti R, Parati G, Zanchetti A. Visit-to-visit blood pressure variability, carotid atherosclerosis, and cardiovascular events in the European lacidipine study on atherosclerosis. Circulation. 2012;126:569–78.

    Article  Google Scholar 

  16. 16.

    Chang TI, Reboussin DM, Chertow GM, Cheung AK, Cushman WC, Kostis WJ, et al. Visit-to-visit offce blood pressure variability and cardiovascular outcomes in SPRINT (systolic blood pressure intervention trial). Hypertension. 2017;70:751–8.

    CAS  Article  Google Scholar 

  17. 17.

    Parati G, Ochoa JE, Lombardi C, Bilo G. Assessment and management of blood-pressure variability. Nat Rev Cardiol. 2013;10:143–55.

    Article  Google Scholar 

  18. 18.

    Hoshide S. Clinical implication of visit-to-visit blood pressure variability. Hypertens Res. 2018;41:993–9.

    CAS  Article  Google Scholar 

  19. 19.

    Bangalore S, Gong Y, Cooper-Dehoff RM, Pepine CJ, Messerli FH. 2014 eighth joint national committee panel recommendation for blood pressure targets revisited: Results from the invest study. J Am Coll Cardiol. 2014;64:784–93.

    Article  Google Scholar 

  20. 20.

    Cowley AW. Long-term control of arterial blood pressure. Physiol Rev. 1992;72:231–300.

    Article  Google Scholar 

  21. 21.

    Kronish IM, Lynch AI, Oparil S, Whittle J, Davis BR, Simpson LM, et al. The association between antihypertensive medication nonadherence and visit-to-visit variability of blood pressure: findings from the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Hypertension. 2016;68:39–45.

    CAS  Article  Google Scholar 

  22. 22.

    Xu X, Ding X, Zhang X, Su S, Treiber FA, Vlietinck R, et al. Genetic and environmental influences on blood pressure variability. J Hypertens. 2013;31:690–7.

    CAS  Article  Google Scholar 

  23. 23.

    Spallone V. Blood pressure variability and autonomic dysfunction. Curr Diab Rep. 2018;18:1–14.

    CAS  Article  Google Scholar 

  24. 24.

    Eto M, Toba K, Akishita M, Kozaki K, Watanabe T, Kim S, et al. Reduced endothelial vasomotor function and enhanced neointimal formation after vascular injury in a rat model of blood pressure lability. Hypertens Res. 2003;26:991–8.

    Article  Google Scholar 

  25. 25.

    Zhou TL, Henry RMA, Stehouwer CDA, Van Sloten TT, Reesink KD, Kroon AA. Blood pressure variability, arterial stiffness, and arterial remodeling the Maastricht study. Hypertension. 2018;72:1002–10.

    CAS  Article  Google Scholar 

  26. 26.

    Bae EH, Lim SY, Han KDO, Oh TR, Choi HS, Kim CS, et al. Association between systolic and diastolic blood pressure variability and the risk of end-stage renal disease. Hypertension. 2019;74:880–7.

    CAS  Article  Google Scholar 

  27. 27.

    Webb AJ, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis. Lancet. 2010;375:906–15.

    CAS  Article  Google Scholar 

  28. 28.

    Osterberg L, Blaschke T, Kaleva V. Adherence to medication. N Engl J Med. 2005;353:487–97.

    CAS  Article  Google Scholar 

  29. 29.

    Thom S, Poulter N, Field J, Patel A, Prabhakaran D, Stanton A, et al. Effects of a fixed-dose combination strategy on adherence and risk factors in patients with or at high risk of CVD: the UMPIRE randomized clinical trial. JAMA. 2013;310:918–29.

    CAS  Article  Google Scholar 

  30. 30.

    Xu X, Meng X, Oka S. Long term habitual vigorous physical activity is associated with lower visit-to-visit systolic blood pressure variability. Am J Hypertens. 2020.

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The authors thank Jinseob Kim, MD, MPH, and Misun Park, MS, for their excellent statistical support and analyses. The authors also thank the clinical research coordinators and members of the cardiac catheterization laboratories at the participating centers.

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Conception and design: KC. Acquisition of data: KC, YA, SL, IJC, KYL, B-HH, CJK, M-WP, JML, DBK, SHH, CSP, HYK, KDY, DSJ, HJY, WSC, MCK, MHJ. Analysis and interpretation of data: SL, IJC, EHC. Drafting of the manuscript or revising it critically for important intellectual content: EHC, J-S Mok, WBC, KC. Final approval of the manuscript submitted: KC.

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Correspondence to Kiyuk Chang.

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Choo, E.H., Mok, JS., Chung, W.B. et al. Visit-to-visit blood pressure variability and mortality and cardiovascular outcomes after acute myocardial infarction. J Hum Hypertens (2021).

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