Taylor, Addison A.

Orthostatic hypotension (OH) is frequently observed with hypertension treatment, but its contribution to adverse outcomes is unknown. The SPRINT (Systolic Blood Pressure Intervention Trial) was a randomized trial of adults, age ≥50 years at high risk for cardiovascular disease with a seated systolic blood pressure (BP) of 130 to 180 mm Hg and a standing systolic BP ≥110 mm Hg. Participants were randomized to a systolic BP treatment goal of either <120 or <140 mm Hg. OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mm Hg 1 minute after standing from a seated position. We used Cox models to examine the association of OH with cardiovascular disease or adverse study events by randomized BP goal. During the follow-up period (median 3years), there were 1170 (5.7%) instances of OH among those assigned a standard BP goal and 1057 (5.0%) among those assigned the intensive BP goal. OH was not associated with higher risk of cardiovascular disease events (primary outcome: hazard ratio 1.06 [95% CI, 0.78–1.44]). Moreover, OH was not associated with syncope, electrolyte abnormalities, injurious falls, or acute renal failure. OH was associated with hypotension-related hospitalizations or emergency department visits (hazard ratio, 1.77 [95% CI, 1.11–2.82]) and bradycardia (hazard ratio, 1.94 [95% CI, 1.19–3.15]), but these associations did not differ by BP treatment goal. OH was not associated with a higher risk of cardiovascular disease events, and BP treatment goal had no effect on OH’s association with hypotension and bradycardia. Symptomless OH during hypertension treatment should not be viewed as a reason to down-titrate therapy even in the setting of a lower BP goal. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT01206062.

Background Blood pressure ( BP ) varies over time within individual patients and across different BP measurement techniques. The effect of different BP targets on concordance between BP measurements is unknown. The goals of this analysis are to evaluate concordance between (1) clinic and ambulatory BP , (2) clinic visit‐to‐visit variability and ambulatory BP variability, and (3) first and second ambulatory BP and to evaluate whether different clinic targets affect these relationships. Methods and Results The SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP monitoring ancillary study obtained ambulatory BP readings in 897 participants at the 27‐month follow‐up visit and obtained a second reading in 203 participants 293±84 days afterward. There was considerable lack of agreement between clinic and daytime ambulatory systolic BP with wide limits of agreement in Bland‐Altman plots of −21 to 34 mm Hg in the intensive‐treatment group and −26 to 32 mm Hg in the standard‐treatment group. Overall, there was poor agreement between clinic visit‐to‐visit variability and ambulatory BP variability with correlation coefficients for systolic and diastolic BP all <0.16. We observed a high correlation between first and second ambulatory BP ; however, the limits of agreement were wide in both the intensive group (−27 to 21 mm Hg) and the standard group (−23 to 20 mm Hg). Conclusions We found low concordance in BP and BP variability between clinic and ambulatory BP and second ambulatory BP . Results did not differ by treatment arm. These results reinforce the need for multiple BP measurements before clinical decision making.

Blood pressure (BP) varies over time within individual patients and across different BP measurement techniques. The effect of different BP targets on the concordance between BP measurements is unknown. The goal of this analysis was to evaluate concordance in: 1) clinic BP and ambulatory BP, 2) clinic visit-to-visit variability and ambulatory BP variability and 3) initial and repeat ambulatory BP. We also sought to evaluate whether treatment assignment of intensive vs standard BP target affected these relationships. The Systolic Blood Pressure Intervention Trial (SPRINT) ambulatory blood pressure monitoring ancillary study obtained ambulatory BP readings in 897 SPRINT participants at the 27 month follow up visit and 203 consecutive repeat ambulatory BP readings taken an average of 9.8 months later. There was poor agreement between clinic systolic BP and daytime ambulatory systolic BP (limits of agreement in Bland-Altman plots of -21 to 34 mm Hg in the intensive treatment group and -26 to 32 mm Hg in the standard treatment group). There was poor agreement between clinic visit-to-visit variability (coefficient of variation) and ambulatory BP variability (coefficient of variation of a 24 hr ambulatory BP) with correlation coefficients for systolic BP <0.16. While there was a high correlation between ambulatory BP at 27 months and repeat ambulatory BP (r ~0.56), there was significant variability between repeat ambulatory BP assessments (limits of agreement of -27 to 21 mm Hg in the intensive group and -23 to 20 mm Hg in the standard group). In conclusion, irrespective of treatment target, we found low concordance in BP and BP variability between clinic BP and ambulatory BP, and additionally between repeat ambulatory BP assessments. These results reinforce the need for multiple guideline adherent BP measurements prior to clinical decision making.