Objective To investigate the independent and joint associations of long-term blood pressure variability (BPV) in magnitude and direction with the risk of new-onset stroke among community-dwelling middle-aged and older adults aged 45 years and above in Hubei Province.

Methods Based on the Hubei Provincial Stroke High-risk Population Screening and Intervention Project, a prospective cohort study design was adopted. A baseline survey was conducted in 2018 in one large community each in Jingmen and Shiyan cities of Hubei Province, with two subsequent follow-up visits completed in 2020 and 2022. Long-term BPV magnitude was defined as the standard deviation of blood pressure measurements obtained in 2018 and 2020. The direction of long-term BPV was determined by normalizing the difference in blood pressure values between 2020 and 2018 by the mean blood pressure, and was categorized into decrease, stable, and increase groups. Spectral clustering and weighted Logistic regression models were used to analyze the independent and combined associations of the magnitude and direction of long-term BPV with incident stroke.

Results A total of 4,196 residents free of stroke at baseline were included. During follow-up, 73 incident stroke cases occurred. Weighted Logistic regression analysis revealed that, after adjusting for covariates, compared with the lowest tertile group of long-term systolic BPV magnitude, the highest tertile group had a 48% increased risk of incident stroke [aOR=1.48, 95%CI (1.05, 2.09)]; the highest tertile group of long-term diastolic BPV magnitude had a 50% increased risk compared with the lowest tertile group [aOR=1.50, 95%CI (1.02, 2.20)]. When considering the joint effect of systolic and diastolic BPV magnitude, the group with higher variability had a 54% increased risk of stroke compared with the lower variability group [aOR=1.54, 95%CI (1.09, 2.18)]. Regarding BPV direction, compared with the stable group, the group with increased systolic blood pressure had a 131% higher risk of stroke [aOR=2.31, 95%CI (1.63, 3.30)]; the group with decreased long-term diastolic blood pressure had a 54% lower risk than those with the stable group [aOR=0.46, 95%CI (0.32, 0.65)].

Conclusion Increased long-term BPV magnitude and an upward direction of BPV change significantly elevate the risk of incident stroke among community-dwelling middle-aged and older adults, whereas decreased long-term diastolic blood pressure may serve as a protective factor. Concurrent assessment of both the magnitude and direction of BPV can facilitate comprehensive risk evaluation and early warning of stroke.

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