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Whether sex or apolipoprotein E (ApoE) affect these associations over longer-term follow-up is unknown. We investigated the association between BPV and long term risks of dementia and cognitive decline using data from the ASPREE-eXTension (ASPREE-XT) study (median 8.3 year follow-up for dementia, 7.3 years for cognitive decline, after BPV estimation). Long-term BPV was estimated using standard deviation (SD) of the mean systolic BPs measured at ASPREE baseline, year 1 and 2 visits. Incident dementia was an adjudicated secondary endpoint and cognitive decline was defined as \u22651.5\u2009SD decline in score from baseline sustained on the same of one, or more, standardized cognitive tests administered annually\/biennially throughout ASPREE\/ASPREE-XT. Analyses were stratified a priori by sex, using sex-specific SD tertiles of systolic BPV. Multivariable Cox proportional hazards regression comparing the highest BPV tertile to the lowest showed increased risk of dementia (HR\u2009=\u20091.33, 1.10\u20131.61) and cognitive decline (HR\u2009=\u20091.17, 1.06\u20131.30) in males, and cognitive decline in females (HR\u2009=\u20091.17, 1.07\u20131.28). In ApoE genotyped participants (81%), females in the highest BPV tertile lacking the \u025b4 allele had increased risk of dementia (HR\u2009=\u20091.39; 1.04\u20131.84), while risk of cognitive decline was increased in both sexes lacking the \u025b4 allele (males HR\u2009=\u20091.25; 1.09\u20131.43; females HR\u2009=\u20091.14; 1.01\u20131.29). These findings suggest both sex and ApoE impact the association of high BPV with long-term cognitive changes.<\/jats:p>","DOI":"10.1038\/s41371-025-01087-5","type":"journal-article","created":{"date-parts":[[2025,10,18]],"date-time":"2025-10-18T15:31:29Z","timestamp":1760801489000},"page":"831-840","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Late-life, visit-to-visit blood pressure variability and its association with sex-specific long-term cognitive outcomes"],"prefix":"10.1038","volume":"39","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0267-4888","authenticated-orcid":false,"given":"Michael E.","family":"Ernst","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kerry M.","family":"Sheets","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9380-6075","authenticated-orcid":false,"given":"Katherine L.","family":"Webb","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michelle A.","family":"Fravel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robyn L.","family":"Woods","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4853-7360","authenticated-orcid":false,"given":"Lawrence","family":"Beilin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Suzanne G.","family":"Orchard","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9706-9730","authenticated-orcid":false,"given":"Raj C.","family":"Shah","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kevan R.","family":"Polkinghorne","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher M.","family":"Reid","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rory","family":"Wolfe","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anne","family":"Murray","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paul","family":"Lacaze","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joanne","family":"Ryan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2025,10,18]]},"reference":[{"key":"1087_CR1","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1016\/S1474-4422(18)30403-4","volume":"18","author":"GBD 2016 Dementia Collaborators","year":"2019","unstructured":"GBD 2016 Dementia Collaborators. 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A portion of this work was presented as a flatboard poster abstract at the 2024 AHA Hypertension Sessions, September 5\u20137, 2024, Chicago, Ill.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}