Blood pressure variability and cardiovascular disease: systematic review and meta-analysis.
Blood pressure variability and cardiovascular disease: systematic review and meta-analysis.
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DOI：
10.1136/bmj.i4098
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发表时间：
2016-08-09
期刊：
影响因子：
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通讯作者：
McManus RJ
中科院分区：
文献类型：
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作者：
Stevens SL;Wood S;Koshiaris C;Law K;Glasziou P;Stevens RJ;McManus RJ
目的系统回顾量化长期（门诊）、中期（家庭）和短期（动态）血压变异性（独立于平均血压）与心血管疾病事件和死亡率相关性的研究。数据来源Medline、Embase、Cinahl和Web of Science，检索截止日期为2016年2月15日的英文全文文章。研究选择的合格性标准成人前瞻性队列研究或临床试验，接受血液透析的患者除外，其中疾病可能直接影响血压变异性。提取标准化风险比，如果混杂风险很小，则在主要分析中使用随机效应荟萃分析进行合并。结局包括全因和心血管疾病死亡率和心血管疾病事件。变异性指标包括标准差、变异系数、独立于平均值的变异和平均真实的变异，但不包括夜间浸渍或昼夜变异。结果确定了41篇论文，代表19项观察性队列研究和17项临床试验队列，包括46项单独的分析。24篇论文研究了血压的长期变异性，4篇研究了中期变异性，15篇研究了短期变异性（2篇研究了长期和短期变异性）。由于混杂风险高，23项分析的结果从主要分析中排除。收缩压长期变异性增加与全因死亡风险相关（风险比1.15，95%置信区间1.09 - 1.22），心血管疾病死亡率（1.18，1.09至1.28），心血管疾病事件（1.18，1.07至1.30），冠心病（1.10，1.04至1.16）和中风（1.15，1.04至1.27）。白天收缩压的中期和短期变异性增加也与全因死亡率相关（分别为1.15、1.06 - 1.26和1.10、1.04 - 1.16）。结论：血压的长期变异性与心血管和死亡结局相关，其影响超过平均血压。相关性与胆固醇测量与心血管疾病的相关性在程度上相似。中期和短期变异性的有限数据显示了类似的关联。未来的工作应该集中在评估血压变异性的临床意义上，避免迄今为止观察到的常见混淆陷阱。系统综述注册PROSPERO CRD 42014015695。
Objective To systematically review studies quantifying the associations of long term (clinic), mid-term (home), and short term (ambulatory) variability in blood pressure, independent of mean blood pressure, with cardiovascular disease events and mortality. Data sources Medline, Embase, Cinahl, and Web of Science, searched to 15 February 2016 for full text articles in English. Eligibility criteria for study selection Prospective cohort studies or clinical trials in adults, except those in patients receiving haemodialysis, where the condition may directly impact blood pressure variability. Standardised hazard ratios were extracted and, if there was little risk of confounding, combined using random effects meta-analysis in main analyses. Outcomes included all cause and cardiovascular disease mortality and cardiovascular disease events. Measures of variability included standard deviation, coefficient of variation, variation independent of mean, and average real variability, but not night dipping or day-night variation. Results 41 papers representing 19 observational cohort studies and 17 clinical trial cohorts, comprising 46 separate analyses were identified. Long term variability in blood pressure was studied in 24 papers, mid-term in four, and short-term in 15 (two studied both long term and short term variability). Results from 23 analyses were excluded from main analyses owing to high risks of confounding. Increased long term variability in systolic blood pressure was associated with risk of all cause mortality (hazard ratio 1.15, 95% confidence interval 1.09 to 1.22), cardiovascular disease mortality (1.18, 1.09 to 1.28), cardiovascular disease events (1.18, 1.07 to 1.30), coronary heart disease (1.10, 1.04 to 1.16), and stroke (1.15, 1.04 to 1.27). Increased mid-term and short term variability in daytime systolic blood pressure were also associated with all cause mortality (1.15, 1.06 to 1.26 and 1.10, 1.04 to 1.16, respectively). Conclusions Long term variability in blood pressure is associated with cardiovascular and mortality outcomes, over and above the effect of mean blood pressure. Associations are similar in magnitude to those of cholesterol measures with cardiovascular disease. Limited data for mid-term and short term variability showed similar associations. Future work should focus on the clinical implications of assessment of variability in blood pressure and avoid the common confounding pitfalls observed to date. Systematic review registration PROSPERO CRD42014015695.