Reassessing blood pressure control: the role of long-term blood pressure variability and time in target range

This review summarizes current evidence on visit-to-visit blood pressure variability (BPV) and blood pressure time in target range (TTR) as complementary measures of blood pressure (BP) control, and to evaluate their ability to predict cardiovascular (CV) risk beyond mean BP values in hypertensive populations.

We performed a narrative review of observational studies, post-hoc analyses of randomised clinical trials, and population-based cohorts evaluating long-term systolic BPV and TTR in relation to adverse CV outcomes. Evidence comparing BPV and TTR, including studies assessing their combined prognostic value, was synthesised to examine their relative and complementary roles in CV risk prediction beyond mean BP levels.

Long-term systolic visit-to-visit BPV has been consistently associated with increased risks of CV morbidity, mortality, stroke, and cognitive decline, independent of mean BP. Similarly, higher systolic TTR has been associated with lower risks of all-cause mortality, CV events, heart failure, and composite CV outcomes across diverse populations and BP monitoring strategies. Studies evaluating both indices concurrently demonstrate that BPV and TTR provide independent and complementary prognostic information, with patients exhibiting low TTR and high BPV experiencing the highest CV risk. While TTR reflects the duration and stability of BP control within target ranges, BPV captures the magnitude of BP fluctuations, aspects not fully conveyed by average BP values alone.

BPV and TTR represent complementary, clinically meaningful measures that improve CV risk stratification beyond mean BP. Their integration into routine hypertension management may enhance identification of residual risk, and support more individualized treatment strategies .