International Journal of Clinical Medicine, 2013, 4, 378-383
http://dx.doi.org/10.4236/ijcm.2013.49068 Published Online September 2013 (http://www.scirp.org/journal/ijcm)
The Effect of Baroreflex Function on Blood Pressure
Variability
Xiufang Wei, Xinhui Fang, Lina Ren, Yanyan Meng, Zixin Zhang, Yongquan Wang, Guoxian Qi
Department of Cardiology, The First Affiliated Hospital, China Medical University, Shenyang, China.
Received May 16th, 2013; revised June 19th, 2013; accepted July 1st, 2013
Copyright © 2013 Xiufang Wei et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objective: The aim of this study was to assess the relationship of blood pressure variability (BPV) and heart rate vari-
ability (HRV) to investigate the effect of baroreflex function on blood pressure variability. Methods: This study consisted
of 111 subjects, including 32 normotensives and 79 hypertensives. All the subjects were given two concurrent tests:
24-hour Holter ECG and ambulatory blood pressure monitoring. According to standard deviation of normal-to-normal
sinus RR intervals (SDNN) derived from the Holter ECG, the hypertensives were divided into two groups: an HRV
normal group with SDNN > 100 ms and an HRV abnormal group with SDNN < 100 ms. HRV analysis used the time
domain measure SDNN and two frequency domain analyses using low-frequency and high-frequency power. BPV
analysis involved a formula correlated to each blood pressure value. Results: BPV was significantly higher in the HRV
abnormal group compared with the HRV normal group in the hypertensives (0.018 ± 0.0033 vs 0.014 ± 0.0032, P <
0.05). In the HRV abnormal group, BPV value of the older hypertensive participants was higher than the younger par-
ticipants (0.019 ± 0.0024 vs 0.017 ± 0.0037, P = 0.048). BPV and HRV were correlated in the younger hypertensives (r
= −0.314, P < 0.05) and older hypertensives (r = −0.692, P < 0.001). Conclusions: Baroreflex function had effect on
BPV. Factors like aging could cause damage to the baroreflex sensitivity, which in turn had influence on BPV. There
may be benefits in restoration of baroreflex function to reduce BPV, especially in hypertensive patients.
Keywords: Blood Pressure Variability; Heart Rate Variability; Baroreflex Function; Hypertension
1. Introduction
The variation of blood pressure with sleep, emotional
stimulation or physical activity has been recognized for
many years. Continuous blood pressure monitoring has
shown that the 24-hour blood pressure profile is charac-
terized by a marked variability due to the large difference
in daytime and nighttime blood pressure, and spontane-
ous shifts in blood pressure that takes place in hour-to-
hour, even minute-to-minute. Studies have shown that
blood pressure variability is related to target organ dam-
age, which makes blood pressure variability to be a new
goal to predict the risk of cardiovascular disease [1-6].
However, the factors that are responsible for the variabil-
ity of blood pressure have not been specifically clarified.
Beat-by-beat analysis of blood pressure in animals has
provided insight into the role of baroreflex effect on
blood pressure variability. In this study, we attempted to
investigate the baroreflex function on human beings, to
find the effect of baroreflex function on blood pressure
variability.
Previous work has shown that baroreflex activity can
be studied by examining heart rate variability (HRV) [7,
8], and the activity declines with aging [9-11]. Thus, we
assessed the correlation of BPV and HRV with aging.
There are several ways to express variability. The sim-
plest could be the mean value and the standard deviation
from the mean of all readings during a day. However,
these parameters indicate only a steady distribution of
blood pressure readings without reflecting time-related
information. In the present study, a mathematical formula
was introduced to represent hemodynamic characteristics
of blood pressure.
2. Methods
2.1. Patient Population
The study was comprised of 111 outpatients (51 male, 60
female), including 32 normotensives and 79 hyperten-
sives, ranging in age from 43 to 87 years. The hyperten-
sives had been examined and had systolic blood pressure

The Effect of Baroreflex Function on Blood Pressure Variability 379
greater than 140 mmHg, or diastolic blood pressure
greater than 90 mmHg on at least three occasions, and
the normotensives had been examined and had blood
pressure less than 140 mmHg systolic and 90 mmHg
diastolic. In the hypertensive group, there were 37 hy-
pertensives who were older than 65 and 42 who were
younger than 65. All subjects had either never been
treated or had stopped treatment one to two weeks before
the study. Subjects were excluded from the study if there
was any evidence of sinus node or conduction system
disease on the electrocardiogram, or if they had a history
of angina pectoris, myocardio infarction, heart failure,
nephropathy, chronic liver disease, diabetes mellitus,
obstructtive sleep apnea, or cerebral ischemic. Subjects
with a history of drug abuse and those who required
other drugs affecting BP also were excluded. All patients
gave informed consent to the enrollment, which was ap-
proved by the Hospital Ethics Committee.
2.2. Recording Procedures
Twenty-four hour blood pressure was measured with
Tonoport V (GE Medical system IT Inc., Milwaukee WI,
USA) using the software CardioSoft V6.0 Software (GE
Medical System IT Inc.). Analysis of the 24-hour HRV
was performed using the MARS PC system (GE Health-
care Inc., Milwaukee, WI, USA) with running software
version 7.2. All subjects were administered 24-hour Hol-
ter ECG and 24-hour ambulatory blood pressure moni-
toring, and both tests were started and stopped concur-
rently. The examinations were performed when the pa-
tients were relaxed; they went to sleep at 22:00 and woke
up at 6:00.
2.3. Baroreflex Function
Previous work have shown that HRV can be used as a
noninvasive index to represent baroreflex function. The
data sampled from a 24-hour Holter ECG can be ex-
pressed as HRV using a time domain measure: standard
deviation of normal-to-normal sinus RR intervals during
a 24-hour period (SDNN), and two frequency domain
analysis estimates respiratory-dependent low-frequency
(LF) and high-frequency (HF) power through spectral
analysis. Low-frequency power (LF: 0.04 - 0.15 Hz) was
analyzed as an index of sympathetic and parasympathetic
nervous system activity, and high-frequency power (HF:
0.15 - 0.4 Hz) was analyzed as an index of parasympa-
thetic nervous system activity [7,12]. SDNN can be used
to analyze HRV in as long a range as 24 hours. As HRV
analysis in this study was applied in 24 hours, we chose
to use SDNN to represent baroreflex function, and we
divided the hypertensives into two groups according to
SDNN: the HRV normal group with SDNN > 100 ms
and the HRV abnormal group with SDNN < 100 ms. The
normotensives were screened as normal HRV with
SDNN > 100 ms. In the literature, SDNN < 100 ms was
considered a cutoff value of the HRV decrease [13].
2.4. Blood Pressure Variability
Noninvasive ambulatory blood pressure monitoring was
set up to record BP every 30 minutes during the day and
every hour at night. Mean systolic blood pressure (mSBP)
and diastolic blood pressure (mDBP), and the coefficient
of variability of systolic blood pressure (cvSBP) and dia-
stolic blood pressure (cvDBP) were calculated. The BPV
was calculated by the following formula which correlated
to each blood pressure value [14,15]: N = total number of
measurements, n = number of sequential measurements.
2
1
1
1nnn
n
n
SBP SBP
BPV NSBP


 



2.5. Statistical Analysis
SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) was
used for data analysis. All values were presented as mean
and standard deviation (SD). Continuous variables were
performed by Student’s t-test. A value of P < 0.05 was
considered statistically significant. Linear correlation
was estimated by the Pearson product-moment correla-
tion coefficient.
3. Results
Baseline physical characteristics in the normotensives
and the two hypertensive groups were similar. Baseline
values for blood urea nitrogen, serum creatinine, triglyc-
eride, total cholesterol, fasting blood glucose, and the
thickness of left ventricular posterior wall were also
comparable at baseline (Table 1).
BPV was significantly higher in the HRV abnormal
group compared with the HRV normal group in the hy-
pertensives (0.018 ± 0.0033 vs 0.014 ± 0.0032, P <
0.001). The mean systolic and diastolic blood pressure
showed significant differences between the HRV normal
group of the hypertensives and the normotensives (135.7
± 10.60 vs 115.4 ± 5.78, P < 0.001; 86.6 ± 7.42 vs 74.1 ±
6.24, P < 0.001), but there was no difference in BPV
between the two groups (0.014 ± 0.0032 vs 0.014 ±
0.0035, P = 0.828). There was also no significant differ-
ence in the coefficient of variability of systolic blood
pressure between either of the two hypertensive groups
(0.092 ± 0.0232 vs 0.089 ± 0.0281, P = 0.536) or the two
HRV normal groups (0.083 ± 0.0234 vs 0.089 ± 0.0281,
P = 0.360). The coefficient of variation of diastolic blood
pressure was significantly different between the HRV
normal hypertensives and the normotensives (0.100 ±
0.0298 vs 0.116 ± 0.0295, P = 0.025), but showed no

The Effect of Baroreflex Function on Blood Pressure Variability 380
Table 1. Characteristics of the study subjects and 24-h HRV and BPV indexes.
Normotensives Hypertensives
HRV abnormal group HRV normal group
No. 32 38 41
Age (yrs) 58.47 ± 7.73 61.74 ± 8.18 60.83 ± 12.48
BMI (kg/m2) 25.07 ± 3.66 26.67 ± 2.49 25.94 ± 2.91
BUN (mmol·L−1) 5.35 ± 0.85 5.67 ± 0.93 5.00 ± 1.25
Scr (umol·L−1) 58.96 ± 8.40 59.95 ± 9.99 61.95 ± 12.38
TG (mmol·L−1) 1.67 ± 0.85 1.54 ± 0.87 1.53 ± 0.55
TC (mmol·L−1) 4.89 ± 1.01 5.34 ± 0.97 5.20 ± 0.95
FBG (mmol·L−1) 5.73 ± 0.57 5.75 ± 0.70 5.96 ± 0.54
LVPW (mm) 8.19 ± 0.84 8.54 ± 1.11 8.58 ± 0.78
HRV
LF power (ms) 16.56 ± 3.32 11.57 ± 3.17a 14.77 ± 4.47
HFpower (ms) 11.56 ± 4.11 6.98 ± 2.67a 10.87 ± 3.21
SDNN (ms) 127.91 ± 16.41 84.42 ± 8.86a 126.90 ± 15.98
BPV
mSBP (mmHg) 115.36 ± 5.78b 135.14 ± 12.20 135.68 ± 10.60
mDBP (mmHg) 74.09 ± 6.24b 87.88 ± 8.01 86.56 ± 7.42
cvSBP (ratio) 0.083 ± 0.0234 0.092 ± 0.0232 0.089 ± 0.0281
cvDBP (ratio) 0.100 ± 0.0298 0.126 ± 0.0374 0.116 ± 0.0295
BPV (ratio) 0.014 ± 0.0035 0.018 ± 0.0033a 0.014 ± 0.0032
BMI = body mass index; BUN = blood urea nitrogen; Scr = serum creatinine; TG = triglyceride; TC = total cholesterol; FBG = fasting blood glucose; LVPW =
left ventricular posterior wall; HRV = heart rate variability; LF = low-frequency power; HF = high-frequency power; SDNN = standard deviation of all normal
sinus RR intervals during a 24-hour period; BPV = blood pressure variability; mSBP = mean systolic blood pressure in a 24-hour period; mDBP = mean dia-
stolic blood pressure in a 24-hour period; cvSBP = coefficient of variation of systolic blood pressure; cvDBP = coefficient of variation of diastolic blood pres-
sure. aGroup HRV abnormal hypertensives versus group HRV normal hypertensives, P < 0.001; bGroup HRV normal hypertensives versus group normoten-
sives, P < 0.001.
difference between the two hypertensive groups (0.126 ±
0.0374 vs 0.116 ± 0.0295, P = 0.183) (Table 1).
We divided the HRV abnormal hypertensives into two
groups according to the cutoff value of age 65, and there
was a significant difference between the younger hyper-
tensives and the older hypertensives (0.017 ± 0.0037 vs
0.019 ± 0.0024, P = 0.048) (Table 2).
Regarding the relationship of BPV and HRV, we
studied both the younger hypertensives and the older
hypertensives from the hypertensive group. We con-
cluded that BPV and HRV were moderately correlated in
both the younger hypertensives (r = −0.314, P = 0.043)
and the older hypertensives (r = −0.692, P < 0.001) (Fig-
ure 1).
4. Discussion
The purpose of the study was to examine the effect of the
baroreflex function on BPV. Kathleen et al. [16]. Admin-
istered nitroprusside intravenous to change their subjects’
baroreflex function, and Bartels et al. [17]. Changed the
baroreflex function through exercise. In this study, we
chose to use HRV to represent the baroreflex function, as
the analysis of HRV from 24-hour Holter ECG has aris-
ing as a simple and non-invasive measure of the auto-
nomic impulses among the techniques used in the baro-
reflex function evaluation [7]. Changes in the HRV pat-
terns provided a sensible and advanced indicator of the
baroreflex function.
In regards to the parameters that can be used to repre-
sent BPV, there are several ways. According to many
articles, the simplest representations could be the mean
value and the standard deviation (SD) from the mean of
all readings during a day or a certain time. Rothwell et al
[18]. Introduced a coefficient of variation (CV) and vari-
ability independent of mean (VIM) to the articles from
the Anglo-Scandinavian Cardiac Outcomes Trial Blood
Pressure Lowering Arm [ASCOT-BPLA]. However,
these parameters, derived from SD, which indicate only a
steady distribution of blood pressure readings, cannot
reflect time-related information [14]. In this study, we
chose to use the index expressed at the beginning of our
article, the formula which involved every blood pressure
value and could represent hemodynamic characteristics
of blood pressure mathematically.

The Effect of Baroreflex Function on Blood Pressure Variability 381
Table 2. HRV and BPV indexes in different age groups of HRV abnormal hypertensives.
Younger Hypertensives
(N = 19)
Older Hypertensives
(N = 19) P-Value
Age (yrs) 54.74 ± 5.38 68.74 ± 2.28 P < 0.001
HRV
LF power (ms) 13.51 ± 3.15 9.63 ± 1.67 P < 0.001
HF power (ms) 7.98 ± 2.50 5.97 ± 2.50 P = 0.018
SDNN (ms) 89.84 ± 6.37 79.00 ± 7.67 P < 0.001
BPV
mSBP (mmHg) 128.94 ± 11.26 141.33 ± 9.90 P = 0.001
mDBP(mmHg) 84.92 ± 7.38 90.84 ± 7.68 P = 0.021
cvSBP (ratio) 0.087 ± 0.0212 0.098 ± 0.0244 P = 0.161
cvDBP (ratio) 0.126 ± 0.0444 0.126 ± 0.0301 P = 0.976
BPV (ratio) 0.017 ± 0.0037 0.019 ± 0.0024 P = 0.048
HRV = heart rate variability; LF = low-frequency power; HF = high-frequency power; SDNN = standard deviation of all normal sinus RR intervals during a
24-hour period; BPV = blood pressure variability; mSBP = mean systolic blood pressure in a 24-hour period; mDBP = mean diastolic blood pressure in a
24-hour period; cvSBP = coefficient of variation of systolic blood pressure; cvDBP = coefficient of variation of diastolic blood pressure.
In the study, we observed that in the hypertensives,
BPV was elevated in the HRV abnormal group. As to the
two HRV normal groups, although there were significant
differences in mean systolic and diastolic blood pressure
between the normotensives and the hypertensives, there
was no difference in BPV. In the HRV abnormal hyper-
tensives, the older hypertensives had a greater BPV value
than the younger ones, which showed more variation of
blood pressure. In addition, we found there was a linear
correlation between BPV and HRV.
As we know, arterial blood pressure is the product of
cardiac output and systemic vascular resistance, which is
regulated through various local, humoral, and neural
factors. Neural regulation of BP occurs via tonic and
reflexive modulation of autonomic nervous system out-
flow, which in turn makes the baroreflex function play a
critical role on BP regulation [19]. As we observed in the
study, BPV was significantly higher in the HRV abnor-
mal group compared with the HRV normal group in the
hypertensives. Comparing the two HRV normal groups,
although the hypertensives had a greater mean value of
systolic and diastolic blood pressure than the normoten-
sives, the BPV showed no difference. Thus we concluded
that baroreflex dysfunction, not hypertension itself, has
an impact on the BPV. Correspondingly, Mancia et al.
[20]. observed that baroreflex mechanisms account for a
fraction of the overall difference in BPV and Imai et al.
[21]. Suggested that decreases in the cardiovagal-baro-
reflex function contribute to an increase in BPV. Laitinen
et al [22]. Demonstrated that a sympathovagal balance of
cardiovascular regulation was the major determinant of
BPV.
Many studies have demonstrated that aging is associ-
ated with decreased cardiovagal-baroreflex sensitivity.
Vagally-modulated HRV continues to decline with ad-
vancing age [9-11]. This is further supported by our
finding that the mean value of BPV was significantly
higher in the HRV abnormal group of the older hyper-
tensives than the younger hypertensives. The BPV and
HRV correlation degree also supported the influence that
aging had on baroreflex function, with a correlation coef-
ficient of minus 0.314 in the younger hypertensives and
minus 0.692 in the older hypertensives. BPV had a
stronger correlation with HRV in the older hypertesives
with more damage of the baroreflex sensitivity due to
aging. Considering how the baroreflex function acts on
the BPV, a restoration of baroreflex function to reduce
BPV may be beneficial especially in the hypertensives. A
series of articles focusing on the baroreflex function ob-
served that exercise training, weight loss, high sodium,
and non-exposure to smoking could improve the barore-
flex modulation [23-25]. These tools could all be used as
nondrug treatments in the therapy of hypertension.
This study has some limitations. First, there were not
enough subjects involved in the study. As an overview of
the results, there was no difference in CV in any com-
parison of our study. Given that CV has been used in
many articles to represent BPV, the fact that it did not
display any differences in comparison between HRV
normal and abnormal hypertensives, and younger and
older hypertensives could be due to the limited number
of subjects. However, the index we used to represent
BPV manifested a significant difference, which in turn
suggested that this index may be more sensitive in meas-
uring BPV. Second, this study analyzed only the BPV
difference as compared between the groups but failed to
give normal ranges of BPV in different groups of people.
There is still no article to demonstrate any reference

The Effect of Baroreflex Function on Blood Pressure Variability 382
The linear correlation of blood pressure variability and standard deviation of all normal sinus RR intervals during a
24-hour period (SDNN) in the younger hypertensives (r = −0.314, P = 0.043).
The linear correlation of blood pressure variability and standard deviation of all normal sinus RR intervals during a
24-hour period (SDNN) in the older hypertensives (r = −0.692, P < 0.001).
Figure 1. The relationship of blood pressure variability (BPV) and heart rate variability (HRV) were moderately correlated
in both the younger hypertensives (r = −0.314, P = 0.043) and the older hypertensives (r = −0.692, P < 0.001).
value. Therefore, this question could be considered in
future studies.
5. Conclusion
In summary, in this study baroreflex function does have
effect on BPV. The damage of baroreflex function can
cause greater variability of blood pressure. Factors like
aging could cause damage to the baroreflex sensitivity,
which in turn had influence on BPV.
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