Systolic Blood Pressure Variability and Risk of Ischemic Stroke in Patients Receiving Hemodialysis.

BACKGROUND AND OBJECTIVES: Blood pressure variability (BPV) has been recognized as a cardiovascular risk factor beyond mean blood pressure, but its role in ischemic stroke among patients receiving hemodialysis remains incompletely defined, particularly across stroke subtypes. We evaluated the association between visit-to-visit BPV and incident ischemic stroke in a multicenter hemodialysis cohort. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: In this prospective cohort study, 1,136 patients undergoing maintenance hemodialysis were enrolled from 12 centers. Pre-dialysis blood pressure measurements were collected over a standardized 12-week baseline period (approximately 36 readings per patient). BPV was quantified using the coefficient of variation (CV) and analyzed per 10% greater CV and by tertiles. The primary outcome was incident ischemic stroke, including large artery atherosclerosis (LAA) and small vessel occlusion (SVO). Fine-Gray competing risk models were used to estimate subdistribution hazard ratios (sHRs), adjusting for demographics, blood pressure, comorbidities, medication, and dialysis-related factors. RESULTS: During a median follow-up of 54 months, 144 patients developed ischemic stroke. Higher systolic BPV was independently associated with greater stroke risk (sHR per 10% greater CV, 1.74; 95% confidence interval [CI], 1.10-2.76, P=0.02) in the clinically adjusted model, with consistent findings in extended analyses. In subtype-specific analyses, systolic BPV was significantly associated with LAA and showed a directionally consistent but attenuated association with SVO after extended adjustment. In contrast, diastolic BPV showed weaker associations that were not statistically significant after multivariable adjustment. CONCLUSIONS: Higher systolic BPV was independently associated with ischemic stroke in patients receiving hemodialysis, with the most consistent subtype-specific association observed for large artery atherosclerosis. These findings suggest that systolic BPV may serve as a clinically accessible marker of cerebrovascular risk beyond mean blood pressure in this high-risk population.