A new meta-analysis suggests that the more time an individual's ambulatory blood pressure (ABP) is within the target range proposed by the 2024 European Society of Cardiology (ESC) guidelines, the lower their risk of mortality and cardiovascular events.¹ The findings also highlight that office blood pressure measurements frequently misclassify patients with regard to their actual blood pressure control.
This person-level meta-analysis was conducted by the International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes (IDACO) investigators. The study included data from 14,230 individuals across 14 population cohorts in Europe, Asia, and South America. Researchers used ABP monitoring to assess the percentage of time in target range (PTTR) over 24-hour, daytime, and nighttime periods. The thresholds for non-elevated ABP were based on the 2024 ESC guidelines: <115/65 mmHg for 24 hours, <120/70 mmHg for daytime, and <110/60 mmHg for nighttime.²
The co-primary endpoints were total mortality and a composite cardiovascular endpoint, which included cardiovascular mortality, non-fatal coronary events, heart failure, and stroke. The median follow-up period was 10.9 years.
The median 24-hour PTTR across the cohort was 18%, corresponding to just 4.3 hours per day. A clear inverse relationship was observed between PTTR and adverse outcomes. As the 24-hour PTTR increased across quartiles, the rate of death decreased from 21.3 to 16.1 per 1000 person-years. Similarly, the rate of cardiovascular endpoints fell from 20.3 to 11.3 per 1000 person-years.
After multivariable adjustment, the standardized hazard ratio for each standard deviation increase in 24-hour PTTR was 0.57 (95% CI 0.46–0.71) for total mortality and 0.30 (95% CI 0.23–0.39) for cardiovascular endpoints. These findings were consistent for daytime and nighttime ABP measurements and across various subgroups. The analysis also showed that office blood pressure measurements misclassified the majority of participants regarding their level of blood pressure control when compared with 24-hour PTTR.
These findings support the use of the lower ABP targets recommended in the latest ESC guidelines for managing hypertension. According to the IDACO investigators, “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.” The study underscores the value of out-of-office blood pressure monitoring to accurately assess cardiovascular risk and guide treatment, as office-based measurements may not provide a complete picture of a patient's blood pressure status.
This study was funded by multiple sources, including the European Union, the European Research Council, Research Foundation Flanders, the National Natural Science Foundation of China, and a non-binding grant from OMRON Healthcare.
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References
1. Zhang DY, An DW, Yu YL, et al. Ambulatory blood pressure monitoring, European guideline targets, and cardiovascular outcomes: an individual patient data meta-analysis. Eur Heart J. 2025;46(30):2974-2987. https://doi.org/10.1093/eurheartj/ehaf220
2. McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45:3912–4018. https://doi.org/10.1093/eurheartj/ehae178