Visit-to-visit systolic blood pressure variability and risk of incident hypertension

Introduction Visit-to-visit blood pressure variability (BPV) has been proposed as a predictor of future hypertension1. However, whether BPV is associated with incident hypertension independently of mean blood pressure remains uncertain2. Purpose We aimed to examine whether BPV derived from 4 consecutive annual health examinations predicts incident hypertension independently of mean systolic blood pressure (SBP). Methods We conducted a longitudinal cohort study using a Japanese annual health-checkup database collected between 2017 and 2025. Participants who completed 4 consecutive annual examinations with systolic blood pressure (SBP) measurements between 2017 and 2024 and who were free from hypertension at the fourth visit were included. Visit-to-visit SBP variability was defined as the standard deviation (SD) of SBP across the 4 visits, and mean SBP was calculated from the same measurements. BPV was categorized into quartiles. Participants were followed from the fourth visit (landmark) until incident hypertension or the last available examination through 2025. Incident hypertension was defined as SBP ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or initiation of antihypertensive medication. Multivariable Cox proportional hazards models were used to estimate hazard ratios adjusting for age, sex, body mass index (BMI), and mean SBP. Results Among 12,144 participants, 1,143 developed hypertension during a median follow-up of 2.0 years. SBP variability showed only a weak correlation with mean SBP (r = 0.11). In models adjusted for age, sex, and BMI, SBP variability was significantly associated with incident hypertension (HR per 1-SD increase: 1.15; 95% CI 1.09–1.21). The association remained significant after further adjustment for mean SBP (HR: 1.09; 95% CI 1.03–1.15). Participants in the highest BPV quartile had a higher risk of hypertension than those in the lowest quartile (HR: 1.29; 95% CI 1.09–1.53; P for trend = 0.003; Figure 1). Restricted cubic spline analysis demonstrated a linear association between SBP variability and hypertension risk without evidence of non-linearity (P for non-linearity = 0.89; Figure 2). Conclusions Visit-to-visit SBP variability assessed across 4 annual measurements was associated with incident hypertension after adjustment for mean SBP. These findings suggest that repeated BP measurements may help characterize BP variability in population screening settings.