Figure 15A.
(Above and opposite) Percentages of vascular variability disorders (VVDs) or rather vascular variability anomalies (VVAs) and vascular variability syndromes (VVSs) missed in current practice. The incidence of VVDs in this graph is assessed in a clinic population of 297 patients. BP and HR of each subject were monitored around the clock for 2 days at 15-minute intervals at the start of study. Each record was analyzed chronobiologically and results interpreted in the light of time-specified reference limits qualified by gender and age. On this basis, MESOR-hypertension (MH, diagnosed in 176 patients), excessive pulse pressure (EPP), circadian hyper-amplitude-tension (CHAT), and deficient heart rate variability (DHRV) were identified and their incidence related to outcomes (cerebral ischemic attack, coronary artery disease, nephropathy, and/or retinopathy). Outcomes, absent at the start of study in these nondiabetic patients, were checked every 6 months for 6 years to estimate the relative risk associated with each VVD alone or in combination with 1, 2, or 3 additional VVDs, shown in columns complementing each circular display of incidences of variability disorders.
Earlier work showed that CHAT was associated with a risk of cerebral ischemic event and of nephropathy higher than MH and that the risks of CHAT, EPP, and DHRV were mostly independent and additive. It thus seemed important to determine the incidence of each VVD, present alone or in combination with one or more additional VVDs. Results from this investigation are summarized in this graph.
Results related to MH are shown in the upper section of the graph. The 176 patients with MH are broken down into 103 (34.7% of the whole study population of 297 patients) with uncomplicated MH, 55 (18.5%) with MH complicated by 1 additional VVD (EPP, CHAT, or DHRV), and 15 (5.1%) and 3 (1.0%) with MH complicated by 2 or 3 additional VVDs. In the latter group, all 3 patients had a morbid outcome within 6 years of the BP monitoring. Ambulatory BP monitoring over only 48 hours, used for diagnosis, is much better than a diagnosis based on casual clinic measurements, yet its results apply only to groups. With this qualification, of the 176 patients with MH, 73 (42.2%) have additional VVDs that further increase their vascular disease risk and that are not considered in the treatment plan of these patients since current practice does not assess these VVDs. This proportion may be smaller in a 7-day record (available for CHAT).
Results related to EPP (second row), CHAT (third row), and DHRV (bottom) illustrate that these conditions can be present in the absence of MH in as many as 12 (4.0%) of the 297 subjects. Since they do not have MH, it is unlikely that these subjects would be treated from a conventional viewpoint even though their vascular disease risk can be as high as or even higher than MH. Evidence suggests that treatment of these conditions may translate into a reduction in morbidity and/or mortality from vascular disease. Another lesson from these results is that around-the-clock monitoring of BP and HR interpreted chronobiologically is needed, even in the absence of MH, to detect vascular disease risk associated with VVDs such as CHAT and DHRV that cannot be assessed on the basis of casual clinic measurements so that nonpharmacologic and/or pharmacologic intervention can be instituted in a timely fashion before the occurrence of adverse outcomes. Once implemented across the board rather than in selected patient populations, vascular disease could be curbed to a much larger extent at relatively low cost if the monitoring is offered directly to the public and care providers become involved only after detection of a VVD. A website has to be built to interest many people and to provide cost-free analyses in exchange for the data, as is now provided worldwide by the BIOCOS project on a small scale.