Blood pressure variability independent predictor of fracture
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A database analysis of more than 3 million South Korean adults shows blood pressure variability is an independent predictor of fracture incidence during 7 years of follow-up, even among adults without hypertension.
“Controlling BP variability should be considered a new goal in addition to lowering mean BP values, although the current guidelines do not include the use of BP variability as a target in hypertension management,” Jung Eun Yoo, MD, PhD, a professor in the department of family medicine at Seoul National University Hospital, South Korea, told Healio. “Poor drug adherence is one of the most common factors affecting BP variability. Indeed, recent data reported nearly 50% of patients do not take medications as prescribed. Improving drug adherence should be the first target for BP variability reduction.”
In a retrospective, population-based study, Yoo and colleagues analyzed data from 3,256,070 adults aged at least 50 years who participated in at least three health exams within 5 years, including the index year (2009-2010), using the Korean National Health Insurance System database (mean age, 60 years; 52% men). Researchers assessed outcome data through the end of 2016. BP variability was calculated using variability independent of the mean; high variability was defined as the highest quartile of variability. The primary outcome was newly diagnosed fractures. The findings were published in The Journal of Clinical Endocrinology & Metabolism.
During median follow-up of 7 years, researchers observed 337,045 cases of any fracture (10.4%), including 143,633 vertebral fractures and 19,694 hip fractures. After adjusting for age, sex, income, lifestyle factors and comorbidities, a higher risk for fracture was observed with higher quartiles of BP variability compared with the lowest quartile group.
Compared with the lowest quartile of BP variability, adjusted HRs for any incident fracture were 1.07 (95% CI, 1.06-1.08) for the highest quartile of systolic BP variability, 1.06 (95% CI, 1.05-1.07) for the highest quartile of diastolic BP variability and 1.07 (95% CI, 1.06-1.08) for the highest quartile of both systolic and diastolic BP variability.
Results persisted in analyses restricted to vertebral fractures and hip fractures.
“Even after excluding participants with antihypertensive agents during the whole study period, the results remained consistent,” the researchers wrote.
The researchers noted that associated changes in BP and subsequent sudden reductions in blood flow could interfere with the mechanism for controlling postural balance, leading to fracture. Inflammation and oxidative stress may also underlie mechanisms of BP variability and osteoporosis, they wrote.
“Growing evidence from post hoc analyses of controlled clinical trials confirms the superiority of calcium channel blockers on reducing BP variability compared with regimens using other therapeutic classes,” Dong Wook Shin, MD, DrPH, MBA, a professor in the department of family medicine/supportive care center at Sungkyunkwan University School of Medicine, South Korea, told Healio. “These findings suggest that calcium channel blockers can be prioritized when treating hypertension, at least for groups with high fracture risk who are not indicated for preferential other antihypertensive classes.”
Perspective
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Bart Clarke, MD
Blood pressure variability could certainly place patients at greater fall risk with greater variability in control. Lower BP might lead to orthostatic symptoms that might cause patients to fall or faint, but greater variability in BP control might also contribute to these symptoms. Different BP medications might affect renal function or electrolytes differently, which could also affect heart rhythm and lead to slower or more rapid heart rates that could lead to syncope or lightheadedness. Steady adequate control of BP would likely minimize these symptoms and subsequent events that lead to fracture.
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