Ambulatory blood pressure monitoring, European guideline targets, and cardiovascular outcomes: an individual patient data meta-analysis.

Summary

Across 14 cohorts (n=14,230; median follow-up 10.9 years), more time that ambulatory BP remains within ESC 2024 targets (PTTR) was strongly associated with lower mortality and cardiovascular events, independent of covariates. PTTR outperformed office BP at classifying BP control and the ESC 2024 thresholds shortened the time required to achieve meaningful risk reduction.

Key Findings

• Each increase in 24-h PTTR was associated with substantially lower all-cause mortality (HR 0.57) and cardiovascular endpoints (HR 0.30).
• Daytime/nighttime PTTR and cause-specific outcomes (CV mortality, coronary events, stroke) confirmed the association across subgroups.
• ESC 2024 targets reduced the time needed to achieve a 60% relative risk reduction from 14.4 to 4.3 hours compared with 2018 definitions; office BP misclassified most individuals versus PTTR.

Clinical Implications

Incorporate ABPM-derived PTTR into routine risk assessment and treatment titration; prioritize achieving longer time-in-target rather than single office readings; consider ESC 2024 thresholds to accelerate risk reduction.

Limitations

• Observational cohorts may retain residual confounding despite adjustment
• Heterogeneity in ABPM protocols and devices across cohorts cannot be fully excluded

Future Directions

Prospective interventional trials targeting PTTR, integration into digital hypertension management, and validation in high-risk and underrepresented populations.