title: 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.
abstract: Low adherence to antihypertensive medication has been hypothesized to increase visit-to-visit variability (VVV) of blood pressure (BP). We assessed the association between antihypertensive medication adherence and VVV of BP in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). VVV of BP was calculated using SD independent of mean, SD, and average real variability across study visits conducted 6 to 28 months after randomization. Participants who reported taking <80% of their antihypertensive medication at ≥1 study visits were categorized as nonadherent. Participants were followed up for cardiovascular events and mortality after the assessment of adherence and VVV of BP. SD independent of mean of BP was higher for nonadherent (n=2912) versus adherent (n=16 878) participants; 11.4±4.9 versus 10.5±4.5 for systolic BP; 6.8±2.8 versus 6.2±2.6 for diastolic BP (each P<0.001). SD independent of mean of BP remained higher among nonadherent than among adherent participants after multivariable adjustment (0.8 [95% confidence interval, 0.7-1.0] higher for systolic BP and 0.4 [95% confidence interval, 0.3-0.5] higher for diastolic BP]. SD and average real variability of systolic BP and diastolic BP were also higher among nonadherent than among adherent participants. Adjustment for nonadherence did not explain the association of VVV of BP with higher fatal coronary heart disease or nonfatal myocardial infarction, stroke, heart failure, or mortality risk. In conclusion, improving medication adherence may lower VVV of BP. However, VVV of BP is associated with cardiovascular outcomes independent of medication adherence.
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.). ik2293@cumc.columbia.edu.
authors.forename: Ian M
authors.initials: IM
authors.lastname: Kronish
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Amy I
authors.initials: AI
authors.lastname: Lynch
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Suzanne
authors.initials: S
authors.lastname: Oparil
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Jeff
authors.initials: J
authors.lastname: Whittle
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Barry R
authors.initials: BR
authors.lastname: Davis
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Lara M
authors.initials: LM
authors.lastname: Simpson
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Marie
authors.initials: M
authors.lastname: Krousel-Wood
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: William C
authors.initials: WC
authors.lastname: Cushman
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Tara I
authors.initials: TI
authors.lastname: Chang
authors.affiliation: From the Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY (I.M.K.); Department of Epidemiology (A.I.L., P.M.) and Division of Cardiology (S.O.), University of Alabama at Birmingham; Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI (J.W.); Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston (B.R.D., L.M.S.); Department of Medicine, Tulane University School of Medicine, Department of Epidemiology, Tulane University School of Public Health, and Tropical Medicine, Research Division, Ochsner Health System (M.K.-W.); Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN (W.C.C.); and Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA (T.I.C.).
authors.forename: Paul
authors.initials: P
authors.lastname: Muntner
mesh_terms: D000317:Adrenergic alpha-Antagonists / Q000008:administration & dosage; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage; D000959:Antihypertensive Agents / Q000008:administration & dosage* / Q000494:pharmacology; D001795:Blood Pressure Determination; D002121:Calcium Channel Blockers / Q000008:administration & dosage; D004311:Double-Blind Method; D004562:Electrocardiography / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D000960:Hypolipidemic Agents / Q000008:administration & dosage* / Q000494:pharmacology; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000517:prevention & control*; D009819:Office Visits / Q000706:statistics & numerical data*; D018579:Patient Selection; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D016903:Drug Monitoring
chemical_list: D000317:Adrenergic alpha-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D002121:Calcium Channel Blockers; D000960:Hypolipidemic Agents
keywords: blood pressure; cardiovascular disease; hypertension; medication adherence; prognosis