Short-term blood pressure variability (BPV) and circadian BP abnormalities are important cardiovascular risk predictors of mean BP levels, but their combined prognostic significance in essential hypertension remains incompletely understood. To evaluate the independent and combined prognostic value of 24-hour BPV and circadian BP patterns for predicting major adverse cardiovascular events (MACE) in patients with essential hypertension. This retrospective cohort study included 500 adults with essential hypertension who underwent 24-hour ambulatory BP monitoring. Short-term BPV was assessed using the standard deviation of 24-hour systolic BP. Circadian patterns were classified as dipper, non-dipper, or reverse dipper based on nighttime systolic BP decline. The primary outcome was MACE, including myocardial infarction, stroke, hospitalization for heart failure, or cardiovascular death. Cox proportional hazards regression models were used to evaluate associations with outcomes. During a median follow-up of 4.2 years, 128 patients (25.6%) experienced MACE. High BPV was associated with a significantly greater incidence of MACE than low BPV (34.2% vs. 17.1%, p < 0.001) and remained an independent predictor (adjusted HR 1.89, 95% CI 1.32-2.71, p < 0.001). Reverse dipping was also associated with increased risk. Patients with both elevated BPV and abnormal circadian patterns had the highest risk. Elevated short-term BPV and abnormal circadian BP patterns are independent predictors of MACE in essential hypertension. Their coexistence identifies a particularly high-risk phenotype. ABPM-based dynamic BP assessment may improve cardiovascular risk stratification beyond mean BP levels.
