Ambulatory blood pressure monitoring, European guideline targets, and cardiovascular outcomes: an individual patient data meta-analysis

Dong-Yan Zhang; De-Wei An; Yu-Ling Yu; Jesus D Melgarejo; José Boggia; Dries S Martens; Tine W Hansen; Kei Asayama; Takayoshi Ohkubo; Katarzyna Stolarz-Skrzypek; Sofia Malyutina; Edoardo Casiglia; Lars Lind; Gladys E Maestre; Ji-Guang Wang; Yutaka Imai; Kalina Kawecka-Jaszcz; Edgardo Sandoya; Marek Rajzer; Tim S Nawrot; Eoin O'Brien; Wen-Yi Yang; Jan Filipovský; Auxiliadora Graciani; José R Banegas; Yan Li; Jan A Staessen; International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes Investigators

doi:10.1093/eurheartj/ehaf220

Ambulatory blood pressure monitoring, European guideline targets, and cardiovascular outcomes: an individual patient data meta-analysis

Eur Heart J. 2025 Apr 18:ehaf220. doi: 10.1093/eurheartj/ehaf220. Online ahead of print.

Authors

Dong-Yan Zhang^{1

2

3}, De-Wei An¹, Yu-Ling Yu^{2

3}, Jesus D Melgarejo^{4

5

6}, José Boggia⁷, Dries S Martens⁸, Tine W Hansen^{9

10

11}, Kei Asayama^{2

12

13}, Takayoshi Ohkubo¹³, Katarzyna Stolarz-Skrzypek¹⁴, Sofia Malyutina¹⁵, Edoardo Casiglia¹⁶, Lars Lind¹⁷, Gladys E Maestre^{4

5

6}, Ji-Guang Wang¹, Yutaka Imai¹², Kalina Kawecka-Jaszcz¹⁴, Edgardo Sandoya¹⁸, Marek Rajzer¹⁴, Tim S Nawrot^{3

8}, Eoin O'Brien¹⁹, Wen-Yi Yang²⁰, Jan Filipovský²¹, Auxiliadora Graciani²², José R Banegas²², Yan Li¹, Jan A Staessen^{1

2

23}; International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes Investigators

Collaborators

International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes Investigators:
B Mujaj, J A Staessen, F F Wei, Y L Yu, D Y Zhang, D W An, Y B Cheng, Q H Guo, Y Y Kang, Y Li, J F Huang, Q F Huang, C S Sheng, J G Wang, Y Wang, D Y Zhang, W Zhang, W Y Yang, C Liu, F F Wei, J Filipovský, J Seidlerová, M Tichá, T W Hansen, H Ibsen, J Jeppesen, C Torp-Pedersen, E Dolan, E O'Brien, E Casiglia, V Tikhonoff, K Asayama, M Kikuya, M Satoh, Y Tatsumi, T Murakami, M Tsubota-Utsugi, T Hirose, K Nomura, H Metoki, A Hozawa, Y Imai, T Ohkubo, N Gilis-Malinowska, A Łebek-Szatańska, K Narkiewicz, M Cwynar, J Gąsowski, T Grodzicki, K Kawecka-Jaszcz, W Lubaszewski, A Olszanecka, K Stolarz-Skrzypek, B Wizner, W Wojciechowska, J Zyczkowska, J R Banegas, V Cabanas, F F Caballero, A Graciani, E López-García, P Guallar, F Rodriguez-Artalejo, S Malyutina, E Pello, G Simonova, M Voevoda, K Björklund-Bodegård, L Lind, B Zethelius, M Bianchi, J Boggia, E Sandoya, C Schettini, E Schwedt, H Senra, G E Maestre, J D Melgarejo

Affiliations

¹ Department of Cardiovascular Medicine, Shanghai Institute of Hypertension, Shanghai Key Laboratory of Hypertension, National Research Centre for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin Er Road 197, 200025 Shanghai, China.
² Non-Profit Research Association Alliance for the Promotion of Preventive Medicine, Leopoldstraat 59, BE-2800 Mechelen, Belgium.
³ Research Unit Environment and Health, KU Leuven Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium.
⁴ Institute of Neuroscience, Neuro and Behavioral Health Integrated Service Unit, University of Texas Rio Grande Valley, Harlingen, TX, USA.
⁵ South Texas Alzheimer's Disease Research Center, San Antonio/Harlingen, TX, USA.
⁶ Laboratory of Neurosciences, Faculty of Medicine, University of Zulia, Zulia, Venezuela.
⁷ Centro de Nefrología, Departamento de Fisiopatología, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay.
⁸ Center for Environmental Sciences, Hasselt University, Diepenbeek, Belgium.
⁹ The Steno Diabetes Center Copenhagen, Gentofte, Denmark.
¹⁰ Center for Health, Capital Region of Denmark, Copenhagen, Denmark.
¹¹ Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
¹² Tohoku Institute for Management of Blood Pressure, Sendai, Japan.
¹³ Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan.
¹⁴ The First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland.
¹⁵ Institute of Internal and Preventive Medicine-Branch of the Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russian Federation.
¹⁶ Department of Medicine, University of Padua, Padua, Italy.
¹⁷ Section of Geriatrics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
¹⁸ Asociación Española, Montevideo, Uruguay.
¹⁹ Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland.
²⁰ Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
²¹ Department of Internal Medicine II, University Hospital, Charles University Medical School, Pilsen, Czechia.
²² Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/CIBERESP, Madrid, Spain.
²³ Biomedical Research Group, Faculty of Medicine, University of Leuven, Herestraat 49, BE-3000 Leuven, Belgium.

PMID: 40249369
DOI: 10.1093/eurheartj/ehaf220

Abstract

Background and aims: Hypertension is the predominant modifiable cardiovascular risk factor. This cohort study assessed the association of risk with the percentage of time that the ambulatory blood pressure (ABP) is within the target range (PTTR) proposed by the 2024 European Society of Cardiology (ESC) guidelines for blood pressure (BP) management.

Methods: In a person-level meta-analysis of 14 230 individuals enrolled in 14 population cohorts, systolic and diastolic ABPs were combined to assess 24-h, daytime, and nighttime PTTR with thresholds for non-elevated ABP set at <115/65, <120/70, and <110/60 mmHg, respectively.

Results: Median 24-h PTTR was 18% (interquartile range 5-33) corresponding to 4.3 h (1.2-7.9). Over 10.9 years (median), deaths (N = 3117) and cardiovascular endpoints (N = 2265) decreased across increasing 24-h PTTR quartiles from 21.3 to 16.1 and from 20.3 to 11.3 events per 1000 person-years. The standardized multivariable-adjusted hazard ratios for 24-h PTTR were 0.57 (95% confidence interval 0.46-0.71) for mortality and 0.30 (0.23-0.39) for cardiovascular endpoints. Analyses of daytime and nighttime ABP, cardiovascular mortality, coronary endpoints and stroke, and subgroups produced confirmatory results. The 2024 ESC non-elevated 24-h PTTR, compared with the 2018 ESC/European Society of Hypertension non-hypertensive 24-h PTTR, shortened the interval required to reduce relative risk for adverse outcomes from 60% to 18% (14.4-4.3 h). Office BP, compared with 24-h PTTR, misclassified most participants with regard to BP control.

Conclusions: Longer time that ABP is within the 2024 ESC target range is associated with reduced adverse outcomes; PTTR derived from ABP refines risk prediction and compared with office BP avoids misclassification of individuals with regard to BP control.

Keywords: Ambulatory blood pressure; Guidelines; Morbidity; Mortality; Population science; Risk stratification.

Abstract

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