COMPARISON OF INFLUENCE OF VARIOUS REGIMENS OF DRUG INTAKE ON 24 HOUR bLOOD PRESSURE, CENTRAL AORTIC PRESSURE AND VASCULAR WALL STIFFNESS IN SYSTEMIC HYPERTENSION PATIENTS WITH ISCHEMIC STROKE

Chronotherapy for Hypertension: A Meta-Analysis and Systematic Review of RCTs

AIM

The aim of this study was to evaluate the efficacy of chronotherapy for patients with essential hypertension with a range of clinical characteristics.

METHODS

We searched the PubMed, EMBASE, and Cochrane Library databases for randomized controlled trials of antihypertensive therapies in which patients were randomized to morning or evening administration. The primary outcomes of the included studies were ambulatory blood pressure (BP) parameters and patient characteristics, including age, body mass index, percentage of female participants, and drug ingestion, which were described in subgroup analyses.

RESULTS

In total, 56 studies were included in the analyses. Meta-analyses and subgroup analyses revealed that specific populations of patients benefited more from bedtime dosing than from morning dosing in both 24-h or 48-h ambulatory systolic BP (SBP) and nighttime SBP, including (1) groups aged < 60 years, (2) those with body mass index ≥ 30 kg/m2, (3) studies with ≥ 50% female participants, and (4) patients receiving antihypertensive calcium channel blockers. However, when controversial data by Hermida et al. were omitted, the effects of BP controls were observed in patients with overweight, particularly obesity. Furthermore, calcium channel blockers contributed to an obvious reduction in nighttime SBP with chronotherapy.

CONCLUSIONS

Chronotherapy for hypertension may not be completely ineffective, and the clinical program and timing of medication administration can be selected according to the patient's clinical characteristics. Registration PROSPERO identifier number CRD42021292795.

Ingestion-time differences in the pharmacodynamics of dual-combination hypertension therapies: Systematic review and meta-analysis of published human trials

The pharmacodynamics of hypertension medications can be significantly affected by circadian rhythms in the biological mechanisms of the 24 h blood pressure (BP) pattern. Hypertension guidelines fail to recommend the time of day when patients, including those who require treatment with multiple medications, are to ingest BP-lowering therapy. We conducted a systematic review of published prospective trials that investigated hypertension medications for ingestion-time differences in BP-lowering, safety, patient adherence, and markers of target organ pathology. Among the search-retried 155 trials, 17 published between 1991 and 2020 totaling 1,508 hypertensive participants concerned the differential ingestion-time dependent effects of 14 unique dual-combination therapies. All but one (94.1%) of the trials, involving 98.5% of the total number of investigated individuals, reported clinically and statistically significant benefits - including enhanced reduction of asleep BP without induction of sleep-time hypotension, reduced prevalence of BP non-dipping, decreased adverse effects, improved kidney function, and reduced cardiac pathology - when dual-combination hypertension medications were ingested at-bedtime/evening rather than upon-waking/morning. A systematic and comprehensive review of the literature published in the past three decades reveals no single dual-combination hypertension trial reported significantly better benefit of the still conventional, yet unjustified by medical evidence, upon-waking/morning hypertension treatment scheme.

Extent of asleep blood pressure reduction by hypertension medications is ingestion-time dependent: Systematic review and meta-analysis of published human trials

Combined evidence of published prospective outcome trials and meta-analyses substantiate elevated asleep blood pressure (BP) and blunted sleep-time relative BP decline (non-dipping), regardless of wake-time office BP and awake or 24 h BP means, are jointly the most highly significant independent prognostic markers of cardiovascular disease (CVD) risk and worthy therapeutic targets for prevention. Nonetheless, current guidelines continue to recommend the diagnosis of hypertension, when based on ambulatory BP monitoring (ABPM), rely, solely, on either the 24 h or "daytime" BP means. They also fail to recommend the time to treat patients. We conducted a systematic review of published human trials regarding ingestion-time differences in the effects of hypertension medications on asleep BP and sleep-time relative BP decline. Some 62 such trials published between 1992 and 2020, totaling 6120 hypertensive persons, evaluated 21 different single and 8 dual-fixed combination therapies. The vast (82.3%) majority of the trials substantiate the bedtime/evening vs. upon-waking/morning treatment schedule produces statistically significant better clinical benefits, including enhanced reduction of asleep systolic BP by an average 5.17 mmHg (95%CI [4.04, 6.31], P < 0.001 between treatment-time groups) without inducing sleep-time hypotension, reduced prevalence of the high CVD risk non-dipper 24 h BP pattern, improved kidney function, and reduced cardiac pathology. Furthermore, systematic and comprehensive review of the ABPM-based literature published the past 29 years reveals no single study that reported significantly better benefits of the most recommended, yet unjustified by medical evidence, morning hypertension treatment-time scheme.

Antihypertensive and vasoprotective effectiveness of the chronopharmacotherapy in patients with arterial hypertension after acute cerebrovascular accident

AIM

To evaluate the effectiveness of combined antihypertensive chronopharmacotherapy and estimate the daily blood pressure profle (BP) parameters, such as: stiffness of the vascular wall and central aortic pressure in patients with arterial hypertension (AH) who underwent transient ischemic atack (TIA) or ischemic stroke (IS).

MATERIALS AND METHODS

235 patients with hypertension who underwent acute cerebrovascular accident were examined. Tere were 116 patients with TIA and 119 with IS. All patients were randomized in 4 groups according to regimen of antihypertensive drugs combination. Te 1st group (n = 59) included patients with AH, who underwent TIA and received indapamide retard 1.5 mg and valsartan 160 mg in the morning regiment of drug therapy. Te 2nd group (n = 57) included patients with AH, who underwent TIA and received indapamide retard 1.5 mg in the morning and valsartan 80 mg twice a day (morning and evening). Te 3rd group (n = 47) included patients with AH, who underwent IS and received indapamide retard 1.5 mg and valsartan at a dose of 160 mg in the morning. Te 4th group (n = 56) included patients with AH, who underwent IS and received indapamide retard 1.5 mg in the morning and valsartan 80 mg twice a day (morning and evening). Ambulatory blood pressure monitoring (ABPM), central aortic pressure (CAP) measurement and vessel wall stiffness values were evaluated before treatment and afer 12 months of therapy.

RESULTS

Before the start of combined antihypertensive chronopharmacotherapy, most of the parameters for ABPM, vessel wall stiffness values and CAP in groups 1 and 2, 3 and 4 were comparable. Achievement of the target level of BP afer 8 weeks of treatment, was signifcantly more ofen in groups with a double sartan therapy (group 2 and group 4) in compare with its single time application only in the morning hours (group 1 and group 3) (p&lt;0.05). Statistically signifcant positive dynamics of the main values of the daily profle of blood pressure, stiffness of the vascular wall and central aortic pressure (p &lt;0,05) were registered in all groups. However, more pronounced decline of main parameters of ABPM, stiffness of the vascular wall and central aortic pressure values were noted in group with double use sartan therapy in compare with single time sartan therapy in the morning time. (p &lt;0.05). Signifcant positive dynamics of the main values of the ABPM, stiffness of the vascular wall and CAP were registered in patients who underwent IS and received double application sartan therapy (4th group) in compare with patients with TIA (2nd group) (p = 0.02).

CONCLUSION

Double use sartan therapy, combined with a thiazide diuretics in patients, who underwent IS or TIA more ofen promotes to get target values of blood pressure, improve the main values of the ABPM, stiffness of the vascular wall and CAP in compare with single time sartan therapy in the morning time.