Association Between Frailty and Blood Pressure Variability: A Systematic Review and Meta-analysis

Background and aim: Blood pressure variability (BPV) has been identified as a novel determinant of adverse cardiovascular and cognitive outcomes, while frailty represents a state of heightened vulnerability strongly linked to morbidity and mortality in older adults. This meta-analysis aims to clarify the association between BPV and frailty. Methods Databases (PubMed, Embase, Web of Science, Ovid MEDLINE, and the Cochrane Library) were searched for studies reporting both frailty assessments (e.g., Fried phenotype, FRAIL scale, K-FRAIL, Frailty Index) and BPV measures until July 28, 2025. Results Nine eligible studies were included, six of which were eligible for meta-analysis. Pooled analyses showed that frail individuals exhibited significantly higher systolic and diastolic BPV (CV of SBP: MD = 0.90%, 95% CI: 0.14–1.66; CV of DBP: MD = 1.03%, 95% CI: 0.38–1.67) compared with robust or pre-frail participants. Frailty was also associated with a reduced nocturnal systolic BP decline (MD = − 4.12%, 95% CI: − 6.41 to − 1.82) and smaller daytime–nighttime BP differences. No significant association was found between frailty and SBP non-dipping status, with pooled analysis showing an odds ratio of 2.76 (95% CI: 0.26 to 29.59, P = 0.40; I² = 85%). Furthermore, frail individuals had a significantly smaller daytime–nighttime systolic blood pressure (SBP) difference compared with non-frail participants (MD = − 3.93 mmHg, 95% CI: − 7.56 to − 0.30, P = 0.03; I² = 64%). Frail individuals had reduced awake–sleep blood pressure differences compared with non-frail (SBP: − 7.84 mmHg, 95% CI − 12.46 to − 3.23, p = 0.0009; DBP: − 4.34 mmHg, 95% CI − 8.20 to − 0.48, p = 0.03). Conclusions Frailty is consistently associated with elevated BPV across multiple indices and timeframes, suggesting that BPV may serve as a hemodynamic marker of frailty. However, standardized approaches to frailty measurement, harmonized BPV indices, and longitudinal studies are necessary to clarify causality and inform hypertension management in older, frail populations.