adssx
#1
There are various definitions of blood pressure variability (BPV):
- Very-short-term BPV: beat-to-beat, using intra-arterial recordings or non-invasive devices,
- Short-term: during the day, using a 24-hour ambulatory BP monitor,
- Medium-term: day-to-day, at home,
- Long-term: visit-to-visit, over months or years at the doctor.
There’s a growing body of evidence pointing to BPV being as important as BP measurements: Blood pressure variability: methodological aspects, clinical relevance and practical indications for management - a European Society of Hypertension position paper
Increased blood pressure variability (BPV) may indicate an impaired cardiovascular regulation and may represent a cardiovascular risk factor itself, having been associated with increased all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia incidence.
The long-acting DHP CCB amlodipine seems to be the best intervention to lower BPV, followed by long-acting thiazide diuretics (e.g., indapamide SR) and maybe the long-acting ARB telmisartan. On the other hand, beta-blockers worsen BPV.
See also:
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Blood pressure variability: a review 2025:
- “We believe that BPV should be incorporated into blood pressure management guidelines and based on current evidence, long-acting dihydropyridines should be preferred drugs in subjects with elevated BPV.”
- “A systematic review found that a unit increase in BPV resulted in an odds ratio (OR) of 1.25 for dementia, suggesting a strong association”
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Long-term blood pressure variability: an emerging cardiovascular risk factor 2024
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Legacy benefits of blood pressure treatment on cardiovascular events are primarily mediated by improved blood pressure variability: the ASCOT trial 2024
- “Using BP data from the in-trial period, in the post-trial period, although mean SBP was a predictor of CV outcomes {HR per 10 mmHg, 1.14 [95% confidence interval (CI) 1.10–1.17], P < .001}, systolic BPV independent of mean SBP was a strong predictor of CV events [HR per 5 mmHg 1.22 (95% CI 1.18–1.26), P < .001] and predicted events even in participants with well-controlled BP. During 21-year follow-up, those on amlodipine-based compared with atenolol-based in-trial treatment had significantly reduced risk of stroke [HR 0.82 (95% CI 0.72–0.93), P = .003], total CV events [HR 0.93 (95% CI 0.88–0.98), P = .008], total coronary events [HR 0.92 (95% CI 0.86–0.99), P = .024], and atrial fibrillation [HR 0.91 (95% CI 0.83–0.99), P = .030], with weaker evidence of a difference in CV mortality [HR 0.91 (95% CI 0.82–1.01), P = .073]. There was no significant difference in the incidence of non-fatal myocardial infarction and fatal coronary heart disease, heart failure, and all-cause mortality.”
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Blood pressure variability supersedes heart rate variability as a real-world measure of dementia risk 2024: “We found that clinically derived measures of BPV, but not HRV, were consistently associated with incident ADRD. In combined analyses, only patients in both the highest quartile of BPV and lowest quartile of HRV had increased ADRD risk (HR 2.34, 95% CI 1.44–3.81).”
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Blood Pressure Variability and Plasma Alzheimer’s Disease Biomarkers in the SPRINT Trial 2024: “Higher BPV was associated with increased plasma total tau under standard BP treatment. Findings add new evidence to prior observational work linking BPV to AD pathophysiology and suggest that, despite strict control of mean BP, BPV remains a risk for pathophysiological change underlying risk for AD.”
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Blood pressure variability: no longer a mASCOT for research nerds 2024: “In this regard, BPV appears at least non-inferior to other emerging cardiovascular risk factors listed in recent international guidelines for cardiovascular prevention and hypertension management. Its association with outcomes appears as strong as that of, for example, Lp(a), birthweight, or air pollution. At variance from BPV, many of these factors have no formal evidence supporting their ability to reclassify risk. Moreover, accumulating evidence suggests that a specific pharmacological intervention can modify BPV. In contrast, many factors listed in the guidelines such as arterial stiffness or air pollution are not easily or not at all modifiable on an individual level.”
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Elevated blood pressure variability is associated with an increased risk of negative health outcomes in adults aged 65 and above—a systematic review and meta-analysis 2024: “High systolic BPV and high systolic mBP are associated with 33% and 6% higher odds of cardiovascular disease in adults aged ≥65, respectively. High BPV is also related to an 18%–28% and 11% increased odds of cerebral deterioration and poor stroke recovery.”
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Blood pressure variability and arterial stiffness: the chicken or the egg? 2024
"However, the underlying mechanism of the relationship between BPV and cardiovascular events is not fully understood. […] Therefore, it has remained unknow whether increased BPV is a cause or a consequence of impaired arterial stiffness
7 Likes
I personally take my B/P very seriously. Weight myself and take B/P when I first get up every morning. Have a 7 yr log. I am 79 yo. which is another reason to agressively control B/P. This morning I had a B/P of 95/56. I keep it between 90-100 by taking Linsopril (ACE inhibitor) along with Amlodipine (Calcium Channel Blocker). I require 2 drugs to keep it where I need it to be. No side-effects. Now BPV is all new to me, but will continue to explore. Thanks for trial data.
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Last night, for the first time ever, my SBP dropped below 90. I have been trying to keep it between 100-120. I don’t know what happened. When I go to my doctor’s office in the afternoon, my SBP ranges from 115-145 so I thought Telmisartan 40 would be safe.
However, this low blood pressure causes me a feeling of nausea which made me feel like throwing up. I walked to the toilet and blacked out. My wife found me on the floor with my forehead gashed open (1 cm wound). I don’t remember falling at all, but I must have hit the toilet bowl on the way down.
I had been taking Telmisartan 40 mg every day at night since the summer. I also take Citrulline with my evening tea. My best guess is that my helper added too much to my tea. I measured my SBP in the morning and it was the lowest I have recorded at 96, so I believe this is the culprit. Also, my arms and legs were constantly ‘falling asleep’ all night.
It’s also possible that I had low blood sugar as well as I only had my mashed broccoli and two pieces of fish and blueberries for dinner. Hypoglycemia also makes me feel nauseated. So it may have been one or both causes.
I’m posting this as a warning to others so you can recognize the symptoms and avoid a similar problem.
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Thank you, Chris, that is concerning as I am looking to take telmisartan myself. Recently I don’t know what’s been going on with my BP, it seems to have come down dramatically since I went on empa, way more than it should have. I take readings at home, get results like 114/75. I started wondering about if my device is accurate. Awkward numbers - not quite enough headroom to take 40mg telmi. I would like 100-110/60-70, but am wondering if 40mg might not get me your experience. BP that’s too low might be dipping at night as you sleep into some crazy territory - you start wondering if you’re getting enough blood to the brain or heart. I was hoping to eventually get to 80mg telmi, but that might be a bridge too far.
After further investigation and thought, I am leaning towards hypoglycemia as the nausea feels similar To past episodes. I really did not eat much sugar yesterday. I’m going to start a CGM today and also have a brain scan done at the hospital. I’ll also get the doctors opinion.
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Please let us know what you find. And stay safe and healthy… I don’t need to tell you this, but next time you feel like that, don’t go to hard surface places like the bathroom, instead, LIE DOWN IMMEDIATELY, couch, bed, even carpeted floor!
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Yoo
#7
Yes, please see a doctor!
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It’s hypoglycemia. The nausea hit me again and I went for a sugary drink. The nausea was gone in minutes. The low SBP probably exacerbated the problem.
Maybe the stock market stress played into it as well.
I’m still going to see the doctor.
Thank you for all your well wishes and I have to be even more careful of maintaining my sugar levels.
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adssx
#9
So sorry to read that. Hopefully the doctor will be able to confirm the source of the problem. Hypoglycemia is a good guess. Citrulline has a short half-life (2-3 hours) so it’s more likely to lead to blood pressure variability than telmisartan (24h half life). Even more so if the dosing is not exactly identical every day and/or if it’s a supplement (there are often big differences between the stated dose and the actual dose).
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You mean from making a fortune? Big movements in the broad market means a huge earning opportunity, especially on the options side. Congratulations, you must be really raking it in. And it was such an easy call, too! DJT announced exactly what he was going to do and when, and everyone knew what the market reaction would be! The easiest call in the last 50 years. All you had to do is go all in. Which of course you did. Congratulation! Although I know it must have been stressful to see such huge amounts of $ flowing into your accounts! I read about the guy who fainted when he realized his lottery ticket was a winning one. It can be stressful🤣!
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No. I wish. I was playing defensive. I didn’t want to short the market as Mr. Trump has usually backtracked quickly on his tarrifs and I didn’t want to get whipsawed. I’m coming out of this whole fiasco with a small 1.7% loss YTD. Prior to the tarrifs announcement it was a positive 4.1%.
Yes, I should have just gone with options strangles that would have made me lots of money if the markets moved greatly in either direction. By the time the realized ‘Oh shit!’ moment occurred, volatility was sky high and strangles were no longer cheap.
You don’t need to hit a home run every time. Not losing your shirt in this market can be good enough. Now’s the time to figure out where the bottom is going to come in at.
My sources say a minimum of 8% more should be expected with the possibility to be much worse if Trump stays in denial.
I hope you did well. It seems you recognized the winning strategy ahead of time!
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Well, I can’t take much credit for what was obvious to many. But here’s the wrinkle. I actually believe you did what a ton of people did - market behaviour was saying “we don’t believe DJT is serious”. Because if the market believed that he was serious, we should have been seeing steady market declines for awhile now. The fact that the market plunged after that announcement tells us that it came as a shock/surprise to most sellers… so you can’t beat yourself up too much, because you thought what the general market thought😎.
And I go by the advice “when people tell you who they are, believe them”. DJT has been obsessed with tariffs for decades. I fully believed he’d go nuclear - the guy has a history of recklessness.
But hey, win some, lose some. As long as you live to play another day.
The market is looking for a bottom, sure. Unless there’s some exceptions that will be carved out, look at where for example Apple is headed. Lost almost 10% in one day. Now imagine costs go up like crazy, earnings tank. What happens when institutional investors like big pension funds start dumping positions. Another 8% might be optimistic. The way it’s worked since the last 30+ years, is buying dips, so the bottom was reached pretty fast. But if the whole economy tanks, it may not work like that anymore - people have forgotten what a bear looks like, lol.
OK, enough of this, it’s really off topic. I’m done.
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BPV at hospital. Doctor thinks passing out is BP related.
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That is fascinating - thank you for posting this, and as usual, with a fair bit of reference materials.
The “gold standard” of looking at BP is a 24 hour ambulatory measurement. Almost never done in practice. I’d suggest that doing this repetitively over time is of value. I have one of these devices, and not free - but <$200 to own one.
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Sorry to hear of all this happening. I’d get a 24 hr ambulatory blood pressure monitor.
Hypoglycemia - unless very severe doesn’t cause loss of consciousness, and certainly not suddenly.
As much as BP in someone who usually is looking at average SBP of 125 mmHg might feel a little off with a SBP in the 90’s it won’t cause loss of consciousness.
Syncope (loss of consciousness) is pretty much always loss of cardiac output sufficient to keep the brain functioning. So EKG, CBC, BMP is reasonable. Brain scans not - as there is nothing you can see on a brain scan that would cause syncope. It sounds like there was nausea - which is possibly the bigger clue - most likely this was a vaso-vagal syncope due to the nausea.
Sure, need to get it checked out - but not over investigated. The ER workup for syncope, unless there are other factors where we think it was syncope (e.g. seizure) should be a limited workup, in general, unless there are other features involved that might indicate an ongoing risk (e.g. palpitations, chest pain, fever, breathlessness).
Obviously, you are seeing a physician who will look into this, but in general if a basic workup is normal, I’d generally not be too excited.
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Thank you @DrFraser Your comments, as always, are invaluable.
So should I stop taking Telmisartan? I posted what my BP readings were above. I’ve also had 2 more in the 115 range while at the hospital.
They did a brain CT scan for me to see if there was hemorrhaging or a tumor. Here’s hoping I have a clean bill of health!
115 mmHg in normal individuals won’t cause symptoms. Now if you usually run a SBP of 220 mmHg and we suddenly put you down to 115 mmHg - that can cause problems. In general for individuals who are running BP in the 120’s - it’s going to take SBP<<70mmHg to see a loss of consciousness.
When I see someone who has low blood pressure in the ER - passing out is just not a thing unless the BP is profoundly low. We also like to get standing BP/HR just to make sure it isn’t low with that (e.g. postural hypotension).
