title: Visit-to-Visit Variability of BP and CKD Outcomes: Results from the ALLHAT.
abstract: OBJECTIVE
  Increased visit-to-visit variability of BP is associated with cardiovascular disease risk. We examined the association of visit-to-visit variability of BP with renal outcomes among 21,245 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.
  
  
  METHODS
  We measured mean BP and visit-to-visit variability of BP, defined as SD, across five to seven visits occurring 6-28 months after participants were randomized to chlorthalidone, amlodipine, or lisinopril. The composite outcome included incident ESRD after assessment of SD of systolic BP or ≥50% decline in eGFR between 24 months and 48 or 72 months after randomization. We repeated the analyses using average real variability and peak value of systolic BP and for visit-to-visit variability of diastolic BP.
  
  
  RESULTS
  Over a mean follow-up of 3.5 years, 297 outcomes occurred. After multivariable adjustment, including baseline eGFR and mean systolic BP, the hazard ratios for the composite end point were 1.29 (95% confidence interval [95% CI], 0.75 to 2.22), 1.76 (95% CI, 1.06 to 2.91), 1.46 (95% CI, 0.88 to 2.45), and 2.05 (95% CI, 1.25 to 3.36) for the second through fifth (SD of systolic BP =6.63-8.82, 8.83-11.14, 11.15-14.56, and >14.56 mmHg, respectively) versus the first (SD of systolic BP <6.63 mmHg) quintile of SD of systolic BP, respectively (P trend =0.004). The association was similar when ESRD and a 50% decline in eGFR were analyzed separately, for other measures of visit-to-visit variability of systolic BP, and for visit-to-visit variability of diastolic BP.
  
  
  CONCLUSIONS
  Higher visit-to-visit variability of BP is associated with higher risk of renal outcomes independent of mean BP.
authors.affiliation: Primary Care Division, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; jeffrey.whittle@va.gov.
authors.forename: Jeff
authors.initials: J
authors.lastname: Whittle
authors.affiliation: Departments of Epidemiology and.
authors.forename: Amy I
authors.initials: AI
authors.lastname: Lynch
authors.affiliation: Departments of Epidemiology and.
authors.forename: Rikki M
authors.initials: RM
authors.lastname: Tanner
authors.affiliation: Division of Biostatistics, University of Texas School of Public Health, Houston, Texas;
authors.forename: Lara M
authors.initials: LM
authors.lastname: Simpson
authors.affiliation: Division of Biostatistics, University of Texas School of Public Health, Houston, Texas;
authors.forename: Barry R
authors.initials: BR
authors.lastname: Davis
authors.affiliation: Department of Medicine, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio; Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio; and.
authors.forename: Mahboob
authors.initials: M
authors.lastname: Rahman
authors.affiliation: Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana.
authors.forename: Paul K
authors.initials: PK
authors.lastname: Whelton
authors.affiliation: Medicine, University of Alabama, Birmingham, Alabama;
authors.forename: Suzanne
authors.initials: S
authors.lastname: Oparil
authors.affiliation: Departments of Epidemiology and Medicine, University of Alabama, Birmingham, Alabama;
authors.forename: Paul
authors.initials: P
authors.lastname: Muntner
mesh_terms: D000368:Aged; D017311:Amlodipine / Q000627:therapeutic use; D065067:Antihyperkalemic Agents / Q000627:therapeutic use; D001794:Blood Pressure / Q000187:drug effects; D001795:Blood Pressure Determination; D002752:Chlorthalidone / Q000627:therapeutic use; D018450:Disease Progression; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D006973:Hypertension / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy / Q000503:physiopathology*; D007668:Kidney / Q000503:physiopathology*; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000503:physiopathology; D017706:Lisinopril / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology*; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D065067:Antihyperkalemic Agents; D017311:Amlodipine; D017706:Lisinopril; D002752:Chlorthalidone
keywords: antihypertensive agents; blood pressure; blood pressure variability; cardiovascular diseases; clinical trial; follow-up studies; glomerular filtration rate; hypertension; kidney failure, chronic; random allocation