Rethinking hypertension in the brain: from blood pressure control to temporal blood pressure stability—a scoping review

BACKGROUND: Temporal blood pressure variability (BPV) may contribute to cerebrovascular injury beyond mean blood pressure (BP), yet the mechanisms linking antihypertensive treatment patterns to temporal BP instability remain incompletely understood. This scoping review synthesised evidence linking treatment instability, pharmacodynamic determinants of BP control, temporal BPV, and cerebrovascular vulnerability. METHODS: PubMed and Embase were searched for studies evaluating antihypertensive medication adherence, pharmacodynamic persistence, BPV, and cerebrovascular outcomes. Data were charted using a standardised form and synthesised narratively according to predefined thematic domains. RESULTS: The available evidence suggests that inconsistent antihypertensive exposure and reduced pharmacodynamic persistence may contribute to increased temporal BPV. Generally BP fluctuations are associated with cerebral small vessel disease, white matter injury, vascular cognitive impairment, and other manifestations of cerebrovascular vulnerability independent of mean BP. This review investigates the relationship between treatment instability, pharmacodynamic determinants, and temporal BPV and proposes a hypothesis-generating conceptual framework to facilitate future individualised risk stratification and guide prospective investigation. CONCLUSIONS: Current evidence supports expanding hypertension management beyond achieving mean BP targets to include optimisation of temporal BP stability. Recognising treatment persistence and pharmacodynamic coverage as determinants of BP stability provides a clinically relevant framework for improving cerebrovascular protection and individualised risk assessment. These findings support consideration of temporal BP stability as a potential complementary dimension of hypertension management for preventing chronic cerebrovascular injury and vascular cognitive dysfunction. High blood pressure is usually assessed by looking at the average blood pressure measured in the clinic. However, blood pressure can also change substantially over hours, days, and weeks, even when the average appears well controlled.These fluctuations may be influenced by inconsistent use of antihypertensive medicines, differences in how long medicines maintain their effect, and other factors affecting sustained blood pressure control.We reviewed available research examining the links between antihypertensive treatment patterns, blood pressure variability, and vulnerability to brain and vascular injury.The evidence suggests that maintaining stable blood pressure over time may be an important aspect of hypertension management in addition to achieving recommended average blood pressure targets.Based on the available evidence, we propose a framework linking treatment consistency, duration of medication effects, and temporal blood pressure stability. We also propose hypothetical blood pressure patterns that may help guide future research into individualised hypertension management.Further prospective studies are needed to determine whether improving temporal blood pressure stability can reduce long-term vascular and cerebrovascular complications.