Associations of ambulatory blood pressure measurements with high-sensitivity troponin and natriuretic peptide levels in SPRINT

BACKGROUND

Nighttime blood pressure (BP) has greater prognostic importance for cardiovascular disease (CVD) than daytime BP, but less is known about nighttime and daytime BP associations with measures of subclinical CVD.

METHODS

Among 897 Systolic Blood Pressure Intervention Trial Study (SPRINT) participants with 24-hour ambulatory BP monitoring obtained near the 27-month study visit, 849 (95%) had N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) measured at the 24-month study visit. Multivariable linear regression analyses were performed to evaluate the associations of nighttime and daytime BP with cardiac biomarker levels.

RESULTS

Mean age was 69 ±12 years, 28% were African American, and mean nighttime and daytime SBP were 121 ±16 mm Hg and 132 ±14 mm Hg, respectively. In multivariable models, compared with the lowest tertile of nighttime systolic BP, the highest tertile was associated with 48% higher NT-proBNP levels (adjusted geometric mean ratio [GMR] = 1.48, 95% CI: 1.22, 1.79), and 19% higher hs-cTnT levels (adjusted GMR = 1.19, 95% CI: 1.07, 1.32). In contrast, the highest versus lowest tertile of daytime systolic BP was not associated with NT-proBNP (adjusted GMR = 1.09, 95% CI: 0.88, 1.34) but was associated with 16% higher hs-cTnT levels (adjusted GMR = 1.16, 95% CI: 1.04, 1.30). Similar results were observed using diastolic BP.

CONCLUSION

In SPRINT, both higher nighttime and daytime BP were independently associated with higher hs-cTnT levels, but only higher nighttime BP was associated with higher NT-proBNP levels.

Nocturnal Hypertension and Left Ventricular Diastolic Dysfunction in Patients With Diabetes With the Absence of Heart Failure: Prospective Cohort HSCAA Study

BACKGROUND

Diabetes is an important risk factor for heart failure (HF) and is associated with left ventricular (LV) diastolic dysfunction. However, diabetic comorbid conditions, such as nocturnal hypertension, as predictors of diastolic dysfunction are not known in the absence of an HF period. The present study was conducted as the longitudinal examination of the predictive value of nocturnal hypertension profiles on the progression of LV diastolic dysfunction in patients with and without diabetes without HF.

METHODS

The subjects (154 diabetes and 268 nondiabetes) in the absence of HF were followed for 36.8±18.2 months. The relationships among the patterns of nocturnal hypertension and the outcome of LV diastolic dysfunction, defined as an increase in E/e'>14, were investigated in the patients with and without diabetes.

RESULTS

The interaction effect of the diabetes status and the patterns of nocturnal hypertension on the hazard rate of the occurrence of E/e'>14 was statistically significant (P=0.017). Kaplan-Meier analysis results revealed that patients with diabetes with nondipper (P=0.021 versus dipper) and riser (P=0.006 versus dipper) had a greater risk for a diastolic dysfunction event. Furthermore, multivariable Cox proportional hazards analysis revealed that nondipper (hazard ratio, 4.56 [95% CI, 1.49-13.96]; P=0.007) and riser (hazard ratio, 3.89 [95% CI, 1.31-11.57]; P=0.014) patterns were associated with elevated risk of the outcome of LV diastolic dysfunction. In contrast, no similar significant associations were found in patients without diabetes.

CONCLUSIONS

During the absence of HF periods, nocturnal hypertension is an important predictor for the progression of LV diastolic dysfunction in patients with diabetes.

Management of nocturnal hypertension: An expert consensus document from Chinese Hypertension League

Nocturnal hypertension is highly prevalent among Chinese and Asian populations, which is mainly attributed to high salt intake and high salt sensitivity. Nocturnal hypertension increases the risk of cardiovascular and all-cause mortality, independent of daytime blood pressure (BP). However, it can usually be detected by 24-h ambulatory BP monitoring, rather than routine office or home BP measurement, thus is often underdiagnosed in clinical practice. Currently, no specific guidance is available for the management of nocturnal hypertension in China or worldwide. Experts from the Chinese Hypertension League summarized the epidemiologic and pathophysiologic characteristics and clinical phenotype of nocturnal hypertension and provided consensus recommendations on optimal management of nocturnal hypertension, with the goal of maximally reducing the cardiovascular disease risks. In this consensus document, 24-h ABPM is recommended for screening and diagnosis of nocturnal hypertension, especially in the elderly, patients with diabetes, chronic kidney diseases, obstructive sleep apnea and other conditions prone to high nocturnal BP. Lifestyle modifications including salt intake restriction, exercise, weight loss, sleep improvement, and mental stress relief are recommended. Long-acting antihypertensive medications are preferred for nocturnal and 24-h BP control. Some newly developed agents, renal denervation, and other device-based therapy on nocturnal BP reduction are evaluated.

Effect of Cuff Inflation on Blood Pressure, Arousals, Sleep Efficiency, and Desaturations: Sub-Analysis of the VAST Pilot Study

The influence of cuff inflations on night-time measurements during 24 h ambulatory blood pressure (BP) measurements is unknown. We investigated the potential effect of cuff inflations on sleep parameters using measurements taken simultaneously with a cuffless device using pulse-transit-time (PTT). On the first day of measurement, standard cuff-based 24 h BP and cuffless measurements were simultaneously performed on the right and left arms (CUFF/PTT-D). In this experiment, 1-2 days after the first measurement, the cuffless device was worn alone (PTT-D). Only data from the cuffless device were analyzed. The following mean sleep parameters were analyzed: mean systolic and diastolic BP, arousals, sleep efficiency, total arousals, arousal per hour, and desaturations. In total, 21 individuals were prospectively enrolled. The mean (SD) age was 47 (±15) years, and 57% were female. The mean systolic asleep BP during CUFF/PTT-D and during PTT-D were 131 (±21) and 131 (±26) mmHg, respectively. The mean diastolic asleep BP values during CUFF/PTT-D and during PTT-D were 80 (±14) and 84 (±14) mmHg, respectively (p = 0.860, p = 0.100, respectively). Systolic and diastolic asleep mean difference was 0.1 (±18.0) and -3.6 (±9.8) mmHg, respectively. There were significantly more total arousals during PTT-D (p = 0.042). There were no significant differences seen in sleep efficiency (p = 0.339) or desaturations (p = 0.896) between the two measurement periods. We could not show any significant impact from cuff inflations during sleep, as documented by PTT-D measurements.

Is it Mandatory to do a 24 hour ABPM in all Patients with Moderate to Severe Obstructive Sleep Apnoea?

Background  Obstructive sleep apnoea (OSA) has been described as a risk factor for arterial hypertension (HT). One of the proposed mechanisms linking these conditions is non dipping (ND) pattern in nocturnal blood pressure, however evidence is variable and based on specific populations with underlying conditions. Data for OSA and ND in subjects residing at high altitude are currently unavailable. Objective  Identify the prevalence and association of moderate to severe OSA with HT and ND pattern in hypertensive and non-hypertensive otherwise healthy middle-aged individuals in residing at high altitude (Bogotá:2640 mt) Methods  Adult individuals with diagnosis of moderate to severe OSA underwent 24 hour- ambulatory blood pressure monitoring (ABPM) between 2015 and 2017. Univariable and multivariable logistic regression analysis were performed to identify predictors of HT and ND pattern. Results  Ninety-three (93) individuals (male 62.4% and median age 55) were included in the final analysis. Overall, 30.1% showed a ND pattern in ABPM and 14.9% had diurnal and nocturnal hypertension. Severe OSA (higher apnea-hiponea index [AHI]) was associated with HT (p = 0.006), but not with ND patterns (p = 0.54) in multivariable regression. Smoking status and lowest oxygen saturation during respiratory events where independently associated with ND pattern (p = 0.04), whereas age (p = 0.001) was associated with HT. Conclusions  In our sample, one in three individuals with moderate to severe OSA have non dipping patterns suggesting lack of straight association between OSA and ND. Older individuals who have higher AHI are more likely to have HT, and those who smoke have a higher risk of ND. These findings add aditional information to the multiple mechanisms involved in the relationship between OSA and ND pattern, and questions the routine use of 24-hour ABPM, particullary in our region, with limited resources and healthcare acces. However, further work with more robust methodology is needed to draw conclusions.

Ambulatory Blood Pressure Monitoring for Diagnosis and Management of Hypertension in Pregnant Women

Hypertension disorders during pregnancy has a wide range of severities, from a mild clinical condition to a life-threatening one. Currently, office BP is still the main method for the diagnosis of hypertension during pregnancy. Despite of the limitation these measurements, in clinical practice office BP of 140/90 mmHg cut point is used to simplify diagnosis and treatment decisions. The out-of-office BP evaluations are it comes to discarding white-coat hypertension with little utility in practice to rule out masked hypertension and nocturnal hypertension. In this revision, we analyzed the current evidence of the role of ABPM in diagnosing and managing pregnant women. ABPM has a defined role in the evaluation of BP levels in pregnant women, being appropriate performing an ABPM to classification of HDP before 20 weeks of gestation and second ABMP performed between 20-30 weeks of gestation to detected of women with a high risk of development of PE. Furthermore, we propose to, discarding white-coat hypertension and detecting masked chronic hypertension in pregnant women with office BP > 125/75 mmHg. Finally, in women who had PE, a third ABPM in the post-partum period could identify those with higher long-term cardiovascular risk related with masked hypertension.

Controversies in Hypertension III: Dipping, Nocturnal Hypertension, and the Morning Surge

A comprehensive approach to hypertension requires out-of-office determinations by home and/or ambulatory monitoring. The 4 phenotypes comparing office and out-of-office pressures in treated and untreated patients include normotension, hypertension, white-coat phenomena, and masked phenomena. Components of out-of-office pressure may be equally as important as mean values. Nighttime pressures are normally 10 - 20% lower than daytime (normal "dipping"). Abnormalities include dipping more than 20% (extreme dippers), less than 10 % (non-dippers), or rising above daytime (risers) and have been associated with elevated cardiovascular risk. Nighttime pressure may be elevated (nocturnal hypertension) in isolation or together with daytime hypertension. Isolated nocturnal hypertension theoretically changes white-coat hypertension to true hypertension and normotension to masked hypertension. Pressure normally peaks in the morning hours ("morning surge") when cardiovascular events are most common. Morning hypertension may result from residual nocturnal hypertension or an exaggerated surge and has been associated with enhanced cardiovascular risk, especially in Asian populations. Randomized trials are needed to determine whether altering therapy based solely on either abnormal dipping, isolated nocturnal hypertension, and/or an abnormal surge is justified.

Significant correlates of nocturnal hypertension in patients with hypertension who are treated with antihypertensive drugs

OBJECTIVE

Nocturnal hypertension assessed by a home blood pressure monitoring (HBPM) device is associated with an increased risk of cardiovascular events. However, it is still difficult to assess nighttime blood pressure (BP) frequently. The purpose of this cross-sectional study was to identify significant correlates of nocturnal hypertension assessed by an HBPM device in patients with hypertension who are treated with antihypertensive drugs.

METHODS

We measured nighttime BP, morning BP, and evening BP by an HBPM device for 7 consecutive days in 365 medicated patients with hypertension.

RESULTS

Of the 365 subjects, 138 (37.8%) had nocturnal hypertension defined as a mean nighttime systolic BP of ≥120 mmHg. Receiver operating characteristic curve analyses showed that the diagnostic accuracy of morning systolic BP for subjects with nocturnal hypertension was significantly superior to that of evening systolic BP (P=0.04) and that of office systolic BP (P<0.001). Multivariate analysis revealed that morning systolic BP of 125-<135 mmHg (OR, 2.26; 95% CI, 1.13-4.58; P=0.02), morning systolic BP of ≥135 mmHg (OR, 16.4; 95% CI, 8.20-32.7; P<0.001), and a history of cerebrovascular disease (OR, 3.99; 95% CI, 1.75-9.13; P=0.001) were significantly associated with a higher risk of nocturnal hypertension and that bedtime dosing of antihypertensive drugs was significantly associated with a lower risk of nocturnal hypertension (OR, 0.56; 95% CI, 0.32-0.97; P=0.04).

CONCLUSIONS

Morning systolic BP of ≥125 mmHg, a history of cerebrovascular disease, and bedtime dosing were significant correlates of nocturnal hypertension in medicated patients with hypertension, and may help detect this risky BP condition.

Dipping Status, Ambulatory Blood Pressure Control, Cardiovascular Disease, and Kidney Disease Progression: A Multicenter Cohort Study of CKD

RATIONALE & OBJECTIVE

Ambulatory blood pressure (BP) monitoring allows concurrent evaluation of BP control and nocturnal BP dipping status, both related to adverse outcomes. However, few studies have assessed the prognostic role of combining information on dipping status and achieved ambulatory BP in patients with chronic kidney disease (CKD).

STUDY DESIGN

Prospective observational cohort study.

SETTING & PARTICIPANTS

906 patients with hypertension and CKD attending 1 of 3 Italian nephrology clinics.

EXPOSURE

Four groups were defined by simultaneously classifying systolic ambulatory BP levels as being at goal (daytime SBP <135 and nighttime SBP <120 mm Hg) or above goal, and the presence or absence of nocturnal dipping (nighttime to daytime SBP ratio of <0.9 versus ≥0.9).

OUTCOME

The composite of time to initiation of maintenance dialysis or estimated glomerular filtration rate (eGFR) decline ≥50%, and the composite of fatal and nonfatal cardiovascular events.

ANALYTICAL APPROACH

Multivariable Cox proportional hazards models were used to estimate risks of kidney disease progression and cardiovascular disease in the 4 exposure groups where nocturnal dipping with systolic ambulatory BP at goal was the reference group.

RESULTS

The mean patient age was 63.8 years, 61% were male, and 26.4% had diabetes; eGFR was 41.1 ± 20.8 mL/min/1.73 m². The dipping prevalence in each of the 4 groups was as follows: nocturnal dipping with ambulatory BP at goal, 18.6%; no nocturnal dipping with ambulatory BP at goal, 20.5%; nocturnal dipping with ambulatory BP above goal, 11.8%; and no nocturnal dipping with ambulatory BP above goal, 49.1%. Among patients with ambulatory BP above goal, the risk of cardiovascular events was greater in the absence (HR, 2.79 [95% CI, 1.64-4.75]) and presence (HR, 2.05 [95% CI, 1.10-3.84]) of nocturnal dipping. The same held true for risk of kidney disease progression (HRs of 2.40 [95% CI, 1.58-3.65] and 2.11 [95% CI, 1.28-3.48] in the absence and presence of nocturnal dipping, respectively). Patients at the ambulatory BP goal but who did not experience nocturnal dipping had an increased risk of the cardiovascular end point (HR, 2.06 [95% CI, 1.15-3.68]) and the kidney disease progression outcome (HR, 1.82 [95% CI, 1.17-2.82]).

LIMITATIONS

Lack of a diverse cohort (all those enrolled were White). Residual uncontrolled confounding.

CONCLUSIONS

Systolic ambulatory BP above goal or the absence of nocturnal dipping, regardless of ambulatory BP, is associated with higher risks of cardiovascular disease and kidney disease progression among patients with CKD.

PLAIN-LANGUAGE SUMMARY

Among patients with chronic kidney disease (CKD), ambulatory blood pressure (BP) monitoring improves the identification of individuals at high risk of clinical disease outcomes. Those with uncontrolled ambulatory BP are known to have a higher risk of developing cardiovascular disease and kidney disease progression, particularly when their ambulatory BP does not decline by at least 10% at night. Whether this is also true for patients with presence of optimal ambulatory BP levels but a BP pattern of no nighttime decline is largely unknown. We measured ambulatory BP in 900 Italian patients with CKD and followed them for several years. We found that, independent of ambulatory BP level, the absence of nighttime reductions in BP was associated with worsening of CKD and more frequent cardiovascular events. The absence of nighttime declines in BP is an independent risk factor for adverse events among patients with CKD. Future studies are needed to examine whether treating the absence of nighttime declines in BP improves clinical outcomes.

Prevalence of Isolated Nocturnal Hypertension and Development of Arterial Stiffness, Left Ventricular Hypertrophy, and Silent Cerebrovascular Lesions: The KoGES (Korean Genome and Epidemiology Study)

Background Apart from nondippers' impact on cardiovascular events, the prevalence of isolated nocturnal hypertension (INH) and its consequences on both the heart and brain were not clearly investigated in the general population. Methods and Results The participants underwent ambulatory blood pressure monitoring evaluations for arterial stiffness, echocardiography, and brain magnetic resonance imaging. They were grouped into normotension, INH, and overt diurnal hypertension, based on ambulatory blood pressure monitoring and history of antihypertensive treatment. White matter hyperintensity, arterial stiffness, and echocardiographic parameters were compared. Of the 1734 participants, there were 475 (27.4%) subjects with normotension, 314 with INH (18.1%), and 945 with overt diurnal hypertension (54.5%). Prevalence of INH was not different between sex or age. Of INH, 71.3% (n=224) was caused by elevated diastolic blood pressure. After multivariable adjustment, INH showed higher pulse wave velocity (P<0.001) and central systolic blood pressure (P<0.001), left ventricular mass index (P=0.026), and worse left ventricular diastolic function (early diastolic mitral annular velocity) (P<0.001) than normotension. Mean white matter hyperintensity scores of INH were not different from normotension (P=0.321), but the odds for white matter hyperintensity presence were higher in INH than normotension (odds ratio, 1.504 [95% CI, 1.097-2.062]; P=0.011). Conclusions INH was common in the general population and associated with increased arterial stiffness, left ventricular hypertrophy, and diastolic dysfunction. White matter hyperintensity was more likely to be present in the INH group than in the normotension group. The use of ambulatory blood pressure monitoring should be encouraged to identify masked INH and prevent the occurrence of cardiovascular events.

Utility of ambulatory blood pressure monitoring in detection of masked hypertension and risk of hypertension mediated organ damage in normotensive patients with type 2 diabetes mellitus

PURPOSE

In patients with diabetes, unrecognised hypertension is a serious problem risk factor for the development and progression of chronic complications. The study aimed to determine the prevalence of masked hypertension in normotensive diabetic patients, the factors affecting it, and its association with diabetes complications using ambulatory blood pressure monitoring (ABPM).

MATERIALS AND METHODS

A cross-sectional observational study was conducted on 150 normotensive diabetic patients. Patients were subjected to an interview and clinical examination to record demographic data, epidemiological data, and significant past history. ABPM was performed for each patient. Urine samples, echocardiogram, and ophthalmologic fundoscopy were done to check for diabetes-related complications.

RESULTS

The mean age of all participants was 56.7 ± 7.8 years. A total of 93 patients (62%) were males. 99 (66%) patients had masked hypertension. A total of 85 (56.7%) were non-dippers, 49 (32.7%) were dippers, 1 (0.7%) was extreme dipper and 15 (10%) were reverse dippers. Non-dipping and reverse dipping were associated with concentric left ventricular hypertrophy LVH (p < .001). Masked hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.008) whereas, nocturnal hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.003).

CONCLUSIONS

A single office blood pressure (BP) reading cannot rule out hypertension in patients with diabetes. Regardless of hypertension, clinicians should have all patients, especially patients with diabetes, undergo ABPM at least once. Masked hypertension, changes in nocturnal dipping and other phenomena that raise the risk of diabetes complications but cannot be measured by office BP can be measured by ABPM, and thus ABPM can provide a good prognostic benefit.

Management of Orthostatic Hypotension in Parkinson's Disease

Orthostatic hypotension (OH) is a common non-motor feature of Parkinson's disease that may cause unexplained falls, syncope, lightheadedness, cognitive impairment, dyspnea, fatigue, blurred vision, shoulder, neck, or low-back pain upon standing. Blood pressure (BP) measurements supine and after 3 minutes upon standing screen for OH at bedside. The medical history and cardiovascular autonomic function tests ultimately distinguish neurogenic OH, which is due to impaired sympathetic nerve activity, from non-neurogenic causes of OH, such as hypovolemia and BP lowering drugs. The correction of non-neurogenic causes and exacerbating factors, lifestyle changes and non-pharmacological measures are the cornerstone of OH treatment. If these measures fail, pharmacological interventions (sympathomimetic agents and/or fludrocortisone) should be introduced stepwise depending on the severity of symptoms. About 50% of patients with neurogenic OH also suffer from supine and nocturnal hypertension, which should be monitored for with in-office, home and 24 h-ambulatory BP measurements. Behavioral measures help prevent supine hypertension, which is eventually treated with non-pharmacological measures and bedtime administration of short-acting anti-hypertensive drugs in severe cases. If left untreated, OH impacts on activity of daily living and increases the risk of syncope and falls. Supine hypertension is asymptomatic, but often limits an effective treatment of OH, increases the risk of hypertensive emergencies and, combined with OH, facilitates end-organ damage. A timely management of both OH and supine hypertension ameliorates quality of life and prevents short and long-term complications in patients with Parkinson's disease.

Effect of Chronotherapy of Antihypertensives in Chronic Kidney Disease: A Randomized Control Trial

Introduction:

There is a higher prevalence of non-dipping pattern in hypertensive chronic kidney disease (CKD) patients. Nocturnal hypertension has been shown to predict cardiovascular mortality and morbidity and is often superior to daytime blood pressure. We studied the effect of shifting or adding antihypertensive to night time on blood pressure profile of CKD III-IV patients.

Methods:

In this single-center, prospective, randomized controlled trial, eligible participants were adults from eastern India aged 18–65 years with CKD stages 3 and 4, with a non-dipping pattern on ambulatory blood pressure monitor (ABPM). The intervention group received all the antihypertensives in the night time whereas the standard care group continued to take the medication in the morning. Both groups were followed up for 1 year. The primary outcome was the number of patients changed from non-dippers to dippers in the standard care group and intervention group. Secondary outcomes included a change in estimated glomerular filtration rate (eGFR) and change in the cardiac structure.

Results:

39 patients in the intervention group and 36 patients in the standard care group were analyzed. 10 patients (26%) reverted to dipping pattern in the intervention group as compared to none in the standard care group. Mean changes in eGFR were −2.55 and −0.18 mL/min/1.73 m² in the standard care and intervention group at the end of the study, respectively. Between-group difference in eGFR was significant at 1 year (5.22 [95% CI, 4.3–6.1] ml/min/1.73 m²); (P = 0.03). The cardiac structure showed no significant changes in either group.

Conclusions:

Bedtime administration of antihypertensives reverted non-dippers to dippers and slowed the decline in eGFR in CKD stages 3 and 4 compared to morning administration of antihypertensives.

Continuous positive airway pressure adherence and blood pressure lowering in patients with obstructive sleep apnoea syndrome and nocturnal hypertension

PURPOSE

We investigated continuous positive airway pressure (CPAP) adherence and its association with the blood pressure (BP) and pulse rate changes in patients with obstructive sleep apnoea syndrome (OSAS) and hypertension.

MATERIALS AND METHODS

In a single-blind trial, patients were randomly assigned to CPAP or sham CPAP treatment for 3 months. We performed clinic, ambulatory and home BP measurements at baseline and during follow-up. CPAP adherence was assessed as the CPAP frequency per week and time per night. Non-adherence was defined as a CPAP use for <5 days/week or <4 h/night.

RESULTS

In the CPAP (n = 26) and sham CPAP groups (n = 21), the CPAP frequency was 5.5 and 4.8 days/week (p = 0.17), respectively, and the CPAP time was 5.0 and 4.1 h/night (p = 0.03), respectively. The corresponding prevalence of non-adherence was 46.2% and 66.7% (p = 0.16), respectively. The CPAP frequency but not time tended to be associated with the changes in BP and pulse rate at 3 months of follow-up, especially home systolic/diastolic BP in the CPAP group (3.2/1.3 mmHg greater reductions per 1 day increment, p ≤ 0.01). Adherent, compared with non-adherent patients, had greater reductions in BP or pulse rate at 3 months of follow-up. In the CPAP and sham CPAP groups combined, statistical significance was achieved for the adjusted between adherence and non-adherence differences in home systolic/diastolic BP (-5.0/-3.8 mmHg) and 24-h, daytime and night-time ambulatory pulse rate (-6.2, -7.8 and -4.4 beats/min, respectively, p ≤ 0.04).

CONCLUSION

CPAP adherence was associated with the BP lowering and pulse rate slowing effects, especially the CPAP frequency.

Different effects of morning and nocturnal hypertension on target organ damage in chronic kidney disease

Both morning hypertension (MH) and nocturnal hypertension (NH) are associated with severe target organ damage in patients with chronic kidney disease (CKD). However, the isolated or combined effects of MH and NH on target organ damage are less well‐defined. A cross‐sectional study was conducted among 2386 non‐dialysis CKD patients with ambulatory blood pressure monitoring. The authors categorized patients into four groups based on the presence or absence of MH and NH. Multivariate logistic analyses were used to evaluate the correlation between hypertension subtypes and target organ damage, including left ventricular hypertrophy (LVH), abnormal carotid intima‐media thickness (CIMT), low estimated glomerular filtration rate (eGFR), and albuminuria. The percentages of isolated MH, isolated NH, and combined MH and NH were 2.3%, 24.0%, and 49.3%, respectively. Compared to patients without MH and NH, isolated MH was only related to low eGFR (2.26 [95% confidence interval: 1.00–5.09]) and albuminuria (2.17 [95% CI: 1.03–4.54]). Meanwhile, combined MH and NH group compared to the group without MH and NH had a higher risk of LVH (2.87 [95% CI: 2.01–4.09]), abnormal CIMT (2.01 [95% CI: 1.47–2.75]), low eGFR (3.18 [95% CI: 2.23–4.54]), and albuminuria (1.79 [95% CI: 1.33–2.40]), even in patients without daytime hypertension. The risk of cardiovascular and renal damage was also observed in the isolated NH group. In conclusion, morning hypertension is associated with kidney dysfunction and has combined effects with nocturnal hypertension on cardiovascular damage in chronic kidney disease patients.

Blood Pressure Patterns in Patients with Parkinson's Disease: A Systematic Review

(1) Background: Cardiovascular autonomic dysfunction is a non-motor feature in Parkinson’s disease with negative impact on functionality and life expectancy, prompting early detection and proper management. We aimed to describe the blood pressure patterns reported in patients with Parkinson’s disease, as measured by 24-h ambulatory blood pressure monitoring. (2) Methods: We conducted a systematic search on the PubMed database. Studies enrolling patients with Parkinson’s disease undergoing 24-h ambulatory blood pressure monitoring were included. Data regarding study population, Parkinson’s disease course, vasoactive drugs, blood pressure profiles, and measurements were recorded. (3) Results: The search identified 172 studies. Forty studies eventually fulfilled the inclusion criteria, with 3090 patients enrolled. Abnormal blood pressure profiles were commonly encountered: high blood pressure in 38.13% of patients (938/2460), orthostatic hypotension in 38.68% (941/2433), supine hypertension in 27.76% (445/1603) and nocturnal hypertension in 38.91% (737/1894). Dipping status was also altered often, 40.46% of patients (477/1179) being reverse dippers and 35.67% (310/869) reduced dippers. All these patterns were correlated with negative clinical and imaging outcomes. (4) Conclusion: Patients with Parkinson’s disease have significantly altered blood pressure patterns that carry a negative prognosis. Ambulatory blood pressure monitoring should be validated as a biomarker of PD-associated cardiovascular dysautonomia and a tool for assisting therapeutic interventions.

Restoration of nocturnal blood pressure dip and reduction of nocturnal blood pressure with evening anti-hypertensive medication administration in pediatric kidney transplant recipients: A pilot randomized clinical trial

Non-dipping and nocturnal hypertension are commonly found during ABPM in pediatric kidney transplant recipients. These entities are independently associated with increased cardiovascular disease risk in adults. Kidney transplant recipients aged 5-21 years with eGFR > 30 mL/min/1.73 m² and ABPM demonstrating non-dipping status and normal daytime BP were randomized to intervention (short acting BP medication added in the evening) or control (no medication change) in this pilot, randomized, open-label, blinded end-point clinical trial. ABPM, echocardiography, and PWV were performed at baseline, 3 months, and 6 months. The trial included 17 intervention and 16 control participants. Conversion to dipper status occurred in 53.3% vs 7.7% (P = .01) at 6 months for intervention and controls, respectively. Systolic dip was greater in the intervention group compared to controls (10.9 ± 4.5 vs 4.2 ± 4.6, P = .001), and average systolic nighttime BP was significantly lower in the intervention group (106 ± 8.3 vs 114.9 ± 9.5 mm Hg, P = .01) at 6 months. There were no significant differences in LVMI, PWV, or eGFR between groups. Within-group changes in the intervention group demonstrated improvements in non-dippers, dipping, systolic nighttime BP and nighttime BP load. Restoration of nocturnal dip and improvement in nocturnal BP were observed in the population following chronotherapy. Future studies are needed with larger sample sizes over a longer period of time to delineate the long-term effect of improved nocturnal dip on target organ damage.

Using Predicted Atherosclerotic Cardiovascular Disease Risk for Discrimination of Awake or Nocturnal Hypertension

BACKGROUND

Several atherosclerotic cardiovascular disease (ASCVD) risk factors are associated with awake and nocturnal hypertension.

METHODS

We assessed the association between a composite ASCVD risk score and awake or nocturnal hypertension using data from participants aged 40-79 years who completed ambulatory blood pressure monitoring at the Year 30 Coronary Artery Risk Development in Young Adults study exam in 2015-2016 (n = 716) and the baseline Jackson Heart Study exam in 2000-2004 (n = 770). Ten-year predicted ASCVD risk was calculated using the Pooled Cohort risk equations. Awake hypertension was defined as mean awake systolic blood pressure (SBP) ≥135 mm Hg or diastolic blood pressure (DBP) ≥85 mm Hg and nocturnal hypertension was defined as mean asleep SBP ≥120 mm Hg or DBP ≥70 mm Hg.

RESULTS

Among participants with a 10-year predicted ASCVD risk <5%, 5% to <7.5%, 7.5% to <10%, and ≥10%, the prevalence of awake or nocturnal hypertension as a composite outcome was 29.5%, 47.8%, 62.2%, and 69.7%, respectively. After multivariable adjustment, higher ASCVD risk was associated with higher prevalence ratios for awake or nocturnal hypertension among participants with clinic-measured SBP/DBP <130/85 mm Hg but not ≥130/85 mm Hg. The C-statistic for discriminating between participants with vs. without awake or nocturnal hypertension was 0.012 (95% confidence interval 0.003, 0.016) higher when comparing a model with ASCVD risk and clinic-measured blood pressure (BP) together vs. clinic-measured BP without ASCVD risk.

CONCLUSIONS

Using 10-year predicted ASCVD risk in conjunction with clinic BP improves discrimination between individuals with and without awake or nocturnal hypertension.

Nighttime Blood Pressure Phenotype and Cardiovascular Prognosis: Practitioner-Based Nationwide JAMP Study

Supplemental Digital Content is available in the text.

Ambulatory and home blood pressure (BP) monitoring parameters are better predictors of cardiovascular events than are office BP monitoring parameters, but there is a lack of robust data and little information on heart failure (HF) risk. The JAMP study (Japan Ambulatory Blood Pressure Monitoring Prospective) used the same ambulatory BP monitoring device, measurement schedule, and diary-based approach to data processing across all study centers and determined the association between both nocturnal hypertension and nighttime BP dipping patterns and the occurrence of cardiovascular events, including HF, in patients with hypertension.

Influence of elevated sleep-time blood pressure on vascular risk and hypertension-mediated organ damage

We report the analysis of 252 hypertensive patients whose blood pressure (BP) was assessed by around-the-clock ambulatory BP monitoring compared to office BP measurement during a follow-up investigation of 8.7 y (SD: 2.43 y) that evaluated the added value of measuring sleep-time BP values. We found that 37.3% of the patients had mismatched diagnoses between the two techniques of BP assessment, with 11.5% of the patients showing white-coat hypertension and 25.8% masked hypertension. Only 12.3% of the diagnosed and treated patients presented normal BP values. Nocturnal (sleep-time) hypertension was present in 70.63%. The sleep-time systolic BP mean was found to be an independent vascular risk factor (F = 9.005, p < .001), indirectly measured through the 10-year risk of morbidity and mortality. Additionally, the elevated sleep-time systolic BP mean was a better marker of subclinical hypertension-mediated organ damage (ρ = 0.19, p < .01) than either the awake (ρ = 0.168, p < .01) or 24 (ρ = 0.184, p < .01) systolic BP means. In conclusion, the accuracy and sleep-time measurements provided by ambulatory BP make it particularly relevant in hypertension diagnosis and management. The use of the ambulatory BP measurement method could end up modifying current therapeutic targets, with sleep-time systolic BP mean becoming a main one, in order to optimize hypertension control and reduce hypertension-related organ pathology and cardiovascular disease morbidity and mortality.

Prevalence and clinical correlates of ambulatory blood pressure phenotypes in a Saudi hypertensive population

International Guidelines recommend ambulatory blood pressure monitoring (ABPM) for the management of hypertension. ABPM phenotypes predict outcomes independent of office blood pressure (BP). The authors explored the prevalence and clinical correlates of ABPM phenotypes and relationship with office BP in Saudi patients (n = 428, mean age 53.5 ± 14.6, 55% male) referred to a Specialist Hypertension clinic in Riyadh, Saudi Arabia. ABPM phenotypes included sustained normotension (27%), masked hypertension, MHT(32%), sustained hypertension, SHT(52%), and white coat hypertension(2.6%). MHT was more prevalent using asleep than 24-hours (26.4% vs 12.9%, P < .01) or awake BP (26.4% vs 8.5%, P < .001) and observed in 85% of pre-hypertensive patients. Isolated nocturnal hypertension was more prevalent in MHT vs SHT (70% vs 30%, P < .001). Office BP overestimated control rates compared with ABPM (48% vs 12.9%, P < .001). Our study shows that one in three Saudi patients will be managed inappropriately if office BP alone was relied upon for management of hypertension.

Diurnal rhythm of blood pressure among Nigerians with hypertension using 24-hour ambulatory blood pressure monitoring

Introduction

hypertension is the most common cardiac disease in Nigeria. There are very limited studies in Nigeria on the use of 24-hour ambulatory blood pressure monitoring (24-h ABPM) for evaluation of hypertensive patients. Twenty four-hour ABPM, unlike office blood pressure (OBP), can assess diurnal variation using parameters like awake blood pressure (BP), asleep (nocturnal) BP, mean 24-hour BP and dipping pattern. This can help in assessment of increased cardiovascular risk and management of hypertensive patients. We purposed to assess the diurnal rhythm of BP among Nigerians with hypertension.

Methods

this was a prospective cross-sectional study. Consecutive 77 hypertensive subjects were studied using Schiller MT-300 for 24-h ABPM.

Results

out of the 77 patients reviewed, 39 (50.6%) were females. The mean age was 50.9 years (SD 13.5). The mean awake systolic and diastolic BP were 135.6mmHg (SD 15.0) and 83.2mmHg (SD 10.0) respectively; mean asleep systolic and diastolic BP were 127.6mmHg (SD 17.9) and 76.2mmHg (SD 12.2) respectively; and mean 24-h systolic and diastolic BP were 133.6mmHg (SD 15.3) and 81.4mmHg (SD 10.2) respectively. Awake BP was elevated in 59.7% of study subjects. Elevated awake systolic BP and awake diastolic BP were present in 50.6% and 41.6% of the study population. Nocturnal (asleep) BP was elevated in 79.2%. Non-dipping pattern was the most prevalent pattern at 55.8%, followed by dipping (24.7%), reverse dipping (15.6%) and extreme dipping (3.9%).

Conclusion

a high proportion had nocturnal hypertension (79.2%) and non-dipping pattern was the most prevalent pattern (55.8%). Mean awake systolic BP, mean asleep systolic and diastolic BP and mean 24-h systolic and diastolic BP were elevated. The use of 24-h ABPM will enhance assessment of increased cardiovascular risk and management of Nigerians with hypertension.

Nocturnal hypertension in primary care patients with high office blood pressure: A regional study of the MAPAGE project

Nocturnal hypertension (NH) is an independent cardiovascular risk factor. We aimed to describe the frequency of NH among primary care hypertensive patients and to analyze NH determinants. This observational, cross-sectional, multicenter study enrolled the patients of 23 general practitioners in Burgundy region, France. We included the first patient of the day with office blood pressure ≥ 140/90 mm Hg, whatever the reason for consultation. All included patients had 24-hour ambulatory blood pressure monitoring (ABPM). Nocturnal hypertension was considered nighttime mean blood pressure ≥ 120/70 mm Hg, as per current guidelines. Medical, sociodemographic, and deprivation data were collected. Nocturnal hypertensive and non-hypertensive patients were compared. The determinants of NH were identified using logistic regression models. From July 2015 to November 2018, 447 patients were analyzed. Mean office blood pressure was 158.6/91.5 mm Hg, and 255 patients (57.0%) were taking at least one antihypertensive drug. Among the 409 (91.5%) valid ABPM, 316 (77.3%) showed NH. In multivariate analyses, male sex (odds ratio [OR] = 2.20, 95% confidence interval [CI] 1.29-3.75), first office diastolic blood pressure >100 mm Hg (OR = 5.71, 95% CI 1.53-21.40), and current smoking (OR = 5.91, 95% CI 2.11-16.56) were independent predictors of NH. Obesity was associated with a reduced risk of NH (OR = 0.43, 95% CI 0.25-0.75). No association was found between deprivation status or sociodemographic factors and NH. To conclude, NH was identified in more than three out of four patients with high office blood pressure. Male smokers with high diastolic blood pressure were most affected by NH. ABPM may improve hypertension management in these patients.

Nocturnal hypertension and left ventricular hypertrophy in pediatric renal transplant recipients in South India

HTN after renal transplantation is associated with cardiovascular morbidity. ABPM allows diagnosis of masked HTN and isolated nocturnal HTN. Longitudinal ABPM data in children post-transplant are limited. ABPM was performed in children post-transplant and repeated in 6-12 months. BP indices were used to determine the prevalence of masked HTN, masked uncontrolled HTN (masked HTN in patients on antihypertensive medications), and isolated nocturnal HTN. Linear regression determined the association between LVMI and ABPM indices. Thirty children underwent a baseline ABPM. Ambulatory HTN was present in 25 (83%). Masked HTN was present in 18 (60%) and isolated nocturnal HTN in 13 (43%). Nocturnal ambulatory BP was higher than corresponding daytime BPs (P < .001 for systolic and diastolic) and 25 (83%) had a blunted nocturnal dip. Prednisone dose predicted nocturnal DBP index and DBP load (r²  = .40, P = .024 and r²  = .178, P = .02). ABPM was repeated in 18 patients within 11 (±3) months. BP indices decreased with time, but nocturnal BPs remained higher than daytime (P < .001 for SBP and DBP). Blunted nocturnal dip did not improve. LVH was present in 12 (57%). LVMI was directly related to the nocturnal SBP index (r²  = .377, P = .003) and nocturnal DBP index (r²  = .493, P < .001). We found no association between LVMI and daytime BP indices. The prevalence of masked HTN, isolated nocturnal HTN, and blunted nocturnal dip was high in children with kidney transplants. Nocturnal BP predicted LVMI. Ambulatory BP improved on longitudinal follow-up, but the pattern of isolated nocturnal HTN persisted.

Isolated Nocturnal Hypertension: What Do We Know and What Can We Do?

Nocturnal hypertension has been recognized as a significant risk factor for cardio- and cerebrovascular diseases. Blood pressure (BP) monitoring significantly increased our awareness of nocturnal hypertension and studies revealed its influence on target organ damage. Nocturnal hypertension is associated with nonphysiological 24-h BP patterns, which consider inadequate drop or even increment of nighttime BP in comparison with daytime BP (nondipping and reverse dipping). Nevertheless, investigations showed that nocturnal hypertension was a predictor of adverse outcome independently of circadian BP pattern. There are still many uncertainties regarding diagnosis, mechanisms and treatment of nocturnal hypertension. There is a small difference between American and European guidelines in cutoff values defining nocturnal hypertension. Pathophysiology is also not clear because many conditions such as diabetes, metabolic syndrome, obesity, sleep apnea syndrome, and renal diseases are related to nocturnal hypertension and nonphysiological circadian BP pattern, but mechanisms of nocturnal hypertension still remain speculative. Therapeutic approach is another important issue and chronotherapy provided the best results so far. There are studies which showed that some groups of antihypertensive medications are more effective in regulation of nocturnal BP, but it seems that the timing of drug administration has a crucial role in the reduction of nighttime BP and conversion of circadian patterns from nonphysiologic to physiologic. Follow-up studies are necessary to define clinical benefits of nocturnal BP reduction and restoring unfavorable 24-h BP variations to physiological variant.

Association of Sleep Characteristics With Nocturnal Hypertension and Nondipping Blood Pressure in the CARDIA Study

Background Sleep characteristics and disorders are associated with higher blood pressure (BP) when measured in the clinic setting. Methods and Results We tested whether self-reported sleep characteristics and likelihood of obstructive sleep apnea (OSA) were associated with nocturnal hypertension and nondipping systolic BP (SBP) among participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study who completed 24-hour ambulatory BP monitoring during the year 30 examination. Likelihood of OSA was determined using the STOP-Bang questionnaire. Global sleep quality, habitual sleep duration, sleep efficiency, and midsleep time were obtained from the Pittsburgh Sleep Quality Index. Nocturnal hypertension was defined as mean asleep SBP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping SBP was defined as a decline in awake-to-asleep SBP <10%. Among 702 participants, the prevalence of nocturnal hypertension and nondipping SBP was 41.3% and 32.5%, respectively. After multivariable adjustment including cardiovascular risk factors, the prevalence ratios (PRs) for nocturnal hypertension and nondipping SBP associated with high versus low likelihood of OSA were 1.32 (95% CI, 1.00-1.75) and 1.31 (95% CI, 1.02-1.68), respectively. The association between likelihood of OSA and nocturnal hypertension was stronger for white participants (PR: 2.09; 95% CI, 1.23-3.48) compared with black participants (PR: 1.11; 95% CI, 0.79-1.56). The PR for nondipping SBP associated with a 1-hour later midsleep time was 0.92 (95% CI, 0.85-0.99). Global sleep quality, habitual sleep duration, and sleep efficiency were not associated with either nocturnal hypertension or nondipping SBP. Conclusions These findings suggest that addressing OSA risk and sleep timing in a clinical trial may improve BP during sleep.

Development of Predictive Equations for Nocturnal Hypertension and Nondipping Systolic Blood Pressure

Background Nocturnal hypertension, defined by a mean asleep systolic blood pressure (SBP)/diastolic blood pressure (BP) ≥120/70 mm Hg, and nondipping SBP, defined by an awake-to-asleep decline in SBP <10%, are each associated with increased risk for cardiovascular disease. Methods and Results We developed predictive equations to identify adults with a high probability of having nocturnal hypertension or nondipping SBP using data from the CARDIA (Coronary Artery Risk Development in Young Adults) study (n=787), JHS (Jackson Heart Study) (n=1063), IDH (Improving the Detection of Hypertension) study (n=395), and MHT (Masked Hypertension) study (n=772) who underwent 24-hour ambulatory BP monitoring. Participants were randomized to derivation (n=2511) or validation (n=506) data sets. The prevalence rates of nocturnal hypertension and nondipping SBP were 39.7% and 44.9% in the derivation data set, respectively, and 36.6% and 44.5% in the validation data set, respectively. The predictive equation for nocturnal hypertension included age, race/ethnicity, smoking status, neck circumference, height, high-density lipoprotein cholesterol, albumin/creatinine ratio, and clinic SBP and diastolic BP. The predictive equation for nondipping SBP included age, sex, race/ethnicity, waist circumference, height, alcohol use, high-density lipoprotein cholesterol, and albumin/creatinine ratio. Concordance statistics (95% CI) for nocturnal hypertension and nondipping SBP predictive equations in the validation data set were 0.84 (0.80-0.87) and 0.73 (0.69-0.78), respectively. Compared with reference models including antihypertensive medication use and clinic SBP and diastolic BP as predictors, the continuous net reclassification improvement (95% CI) values for the nocturnal hypertension and nondipping SBP predictive equations were 0.52 (0.35-0.69) and 0.51 (0.34-0.69), respectively. Conclusions These predictive equations can direct ambulatory BP monitoring toward adults with high probability of having nocturnal hypertension and nondipping SBP.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.

Extreme Dipping: Always Means Nocturnal Hypotension?

AIM

Although nocturnal hypotension is considered the key factor responsible for the increased cardiovascular risk associated with the extreme dipping (ED) pattern, no information is available on its prevalence in this setting. Therefore, we have assessed this topic in a cohort of patients referred to a single out-patient hypertension center.

METHODS

A large database of individual 24-hour ambulatory BP recordings from untreated individuals with a history of hypertension and treated individuals with hypertension was analyzed.

RESULTS

A total of 339 of 7,074 patients (4.5%) exhibited an ED pattern (207 had a nighttime reduction in both systolic and diastolic BP ≥ 20% compared to daytime values and 132 a nighttime reduction in diastolic BP ≥ 20%). Among patients with ED, the prevalence of nocturnal hypotension varied from 9.1% to 45.0% depending on the criteria used (i.e., mean nighttime BP < 90/50 mm Hg or < 100/60 mm Hg), and the prevalence of nocturnal hypertension (i.e., mean nighttime BP ≥ 120/70 mm Hg) was 19.5%. Compared with untreated patients, those taking antihypertensive drugs were more likely to have nocturnal hypotension and less likely to have nocturnal hypertension.

CONCLUSIONS

Our findings support the view that ED pattern is a condition not always associated with nocturnal hypotension because a large fraction of ED patients has normal or elevated mean BP nocturnal values.

Health Behaviors, Nocturnal Hypertension, and Non-dipping Blood Pressure: The Coronary Artery Risk Development in Young Adults and Jackson Heart Study

BACKGROUND

Several health behaviors have been associated with hypertension based on clinic blood pressure (BP). Data on the association of health behaviors with nocturnal hypertension and non-dipping systolic BP (SBP) are limited.

METHODS

We analyzed data for participants with ambulatory BP monitoring at the Year 30 Coronary Artery Risk Development in Young Adults (CARDIA) study exam in 2015-2016 (n = 781) and the baseline Jackson Heart Study (JHS) exam in 2000-2004 (n = 1,046). Health behaviors (i.e., body mass index, physical activity, smoking, and alcohol intake) were categorized as good, fair, and poor and assigned scores of 2, 1, and 0, respectively. A composite health behavior score was calculated as their sum and categorized as very good (score range = 6-8), good (5), fair (4), and poor (0-3). Nocturnal hypertension was defined as mean asleep SBP ≥ 120 mm Hg or mean asleep diastolic BP ≥ 70 mm Hg and non-dipping SBP as < 10% awake-to-asleep decline in SBP.

RESULTS

Among CARDIA study and JHS participants, 41.1% and 56.9% had nocturnal hypertension, respectively, and 32.4% and 72.8% had non-dipping SBP, respectively. The multivariable-adjusted prevalence ratios (95% confidence interval) for nocturnal hypertension associated with good, fair, and poor vs. very good health behavior scores were 1.03 (0.82-1.29), 0.98 (0.79-1.22), and 0.96 (0.77-1.20), respectively in CARDIA study and 0.98 (0.87-1.10), 0.96 (0.86-1.09), and 0.86 (0.74-1.00), respectively in JHS. The health behavior score was not associated non-dipping SBP in CARDIA study or JHS after multivariable adjustment.

CONCLUSIONS

A health behavior score was not associated with nocturnal hypertension or non-dipping SBP.

Race and sex differences in asleep blood pressure: The Coronary Artery Risk Development in Young Adults (CARDIA) study

Nocturnal hypertension and non-dipping blood pressure are each associated with increased risk of cardiovascular disease. We determined differences in nocturnal hypertension and non-dipping systolic/diastolic blood pressure among black and white men and women who underwent 24-hour ambulatory blood pressure monitoring at the Coronary Artery Risk Development in Young Adults study Year 30 Exam in 2015-2016. Asleep and awake periods were determined from actigraphy complemented by sleep diaries. Nocturnal hypertension was defined as mean asleep systolic/diastolic blood pressure ≥ 120/70 mm Hg. Non-dipping systolic and diastolic blood pressure, separately, were defined as a decline in awake-to-asleep blood pressure < 10%. Among 767 participants, the prevalence of nocturnal hypertension was 18.4% and 44.4% in white and black women, respectively, and 36.4% and 59.9% in white and black men, respectively. After multivariable adjustment and compared with white women, the prevalence ratio (95% confidence interval) for nocturnal hypertension was 1.65 (1.18-2.32) for black women, 1.63 (1.14-2.33) for white men, and 2.01 (1.43-2.82) for black men. The prevalence of non-dipping systolic blood pressure was 21.5% and 41.0% in white and black women, respectively, and 20.2% and 37.9% in white and black men, respectively. Compared with white women, the multivariable-adjusted prevalence ratio (95% confidence interval) for non-dipping systolic blood pressure was 1.66 (1.18-2.32), 0.91 (0.58-1.42) and 1.66 (1.15-2.39) among black women, white men, and black men, respectively. Non-dipping diastolic blood pressure did not differ by race-sex groups following multivariable adjustment. In conclusion, black women and men have a high prevalence of nocturnal hypertension and non-dipping systolic blood pressure.

Ambulatory Blood Pressure Monitoring in Type 2 Diabetes Mellitus: A Cross-sectional Study

Background: Ambulatory blood pressure (ABP) monitoring in type 2 diabetes (T2DM) is not yet routine in clini-cal practice.

Objectives: To quantify abnormal ABP patterns and their associations with diabetic complications, and to assess the reliabil-ity of office blood pressure (OBP) for assessing BP in T2DM.

Methods: In a cross-sectional study, eligible patients with T2DM underwent OBP and 24- hour ABP measurements under standardized conditions and screening for diabetic complications.

Results: 56 patients (mean age 67 + 10 years, males 50%) completed assessment. 43(73%) had a known history of hyper-tension. Non-dipping and nocturnal systolic hypertension (SHT) were prevalent in 31(55%) and 32(57%) patients, respec-tively. 16(29%) demonstrated masked phenomenon, but only three (7%) demonstrated white coat effect. Nocturnal SHT had a significant association with composite microvascular complications independent of daytime systolic BP control (adjusted odds ratio (OR) 1.72(CI 1.41-4.25). There was no association between other abnormal ABP patterns and diabetic complica-tions. The sensitivity and specificity of OBP for diagnosing HT or assessing BP control was 59% and 68% respectively. The positive and negative predictive values were 74% and 52% respectively.

Conclusion: Non-dipping, reverse dipping, nocturnal SHT and masked phenomenon are highly prevalent in patients with T2DM with or without a known history of hypertension. Compared with non-dipping, nocturnal SHT may be a stronger predictor of end organ damage. The reliability of OBP for assessing BP in T2DM is only modest. Patients with T2DM are likely to benefit from routine ABP monitoring.

Role of melatonin in blood pressure regulation: An adjunct anti-hypertensive agent

Cardiovascular diseases account for approximately one-third of all deaths each year. Of this, hypertension accounts for approximately 9.4 million deaths. Melatonin, the primary circadian hormone, has been substantiated as an effective and safe adjunct anti-hypertensive agent. In support of this, melatonin receptors have been identified within the central and peripheral nervous system, as well as the cardiovascular system, including various vascular tissues. Therefore, it is not surprising that recent research has emerged highlighting a key role of melatonin in autonomic regulation of blood pressure. In animals, pinealectomies elicit peripheral vasoconstriction and hypertension. In studies involving humans, both healthy controls and patient populations of essential and nocturnal hypertension, melatonin administration demonstrates significant hypotensive effects that yield clinically significant results. However, the precise mechanism by which melatonin elicits its hypotensive effects in humans require further investigation. This review focuses on melatonin, its role within the cardiovascular system and the emerging implications for its use as an anti-hypertensive agent. Additionally, this review will discuss the current thinking on potential mechanisms behind the hypotensive effects of melatonin including: endothelium-dependent vasodilation, anti-oxidant defence mechanisms and sympatho-vagal autonomic regulation.

The association of nocturnal hypertension and nondipping blood pressure with treatment-resistant hypertension: The Jackson Heart Study

Apparent treatment-resistant hypertension (aTRH), nocturnal hypertension, and nondipping blood pressure (BP) have shared risk factors. The authors studied the association between aTRH and nocturnal hypertension and aTRH and nondipping BP among 524 black Jackson Heart Study participants treated for hypertension. Nocturnal hypertension was defined by mean nighttime systolic BP ≥120 mm Hg or diastolic BP ≥70 mm Hg. Nondipping BP was defined by mean nighttime to daytime systolic BP ratio >0.90. aTRH was defined by mean clinic systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg with three medication classes or treatment with four or more classes. The risk for developing aTRH associated with nondipping BP and nocturnal hypertension was estimated. After multivariable adjustment, participants with aTRH were more likely to have nocturnal hypertension (prevalence ratio, 1.20; 95% confidence interval, 1.03-1.39) and nondipping (prevalence ratio, 1.25; 95% confidence interval, 1.09-1.43). Over a median 7.3 years of follow-up, nocturnal hypertension and nondipping BP at baseline were not associated with developing aTRH after adjustment.

Orthostatic hypotension: pathophysiology, assessment, treatment and the paradox of supine hypertension

Both hypertension and orthostatic hypotension (OH) are strongly age-associated and are common management problems in older people. However, unlike hypertension, management of OH has unique challenges with few well-established treatments. Not infrequently, they both coexist, further compounding the management. This review provides comprehensive information on OH, including pathophysiology, diagnostic workup and treatment, with a view to provide a practical guide to its management. Special references are made to patients with supine hypertension and postprandial hypotension and older hypertensive patients.

Nocturnal but not Diurnal Hypertension Is Associated to Insulin Resistance Markers in Subjects With Normal or Mildly Elevated Office Blood Pressure

OBJECTIVE

The aim was to evaluate the relationships among insulin resistance markers and nocturnal and diurnal hypertension in normotensive or mildly untreated hypertensive adults.

METHODS

The study was performed in both female and male adults referred to the Cardiometabolic Unit of the Hospital San Martín, La Plata, Argentina, in order to perform an ambulatory blood pressure measurement (ABPM) for the evaluation of a possible hypertensive disorder. The population was stratified according to their ABPM in: 1-presence or absence of diurnal hypertension and 2-presence or absence of nocturnal hypertension; both conditions were analyzed separately. Fasting plasma insulin (FPI), homeostasis model assessment of insulin resistance (HOMA-IR), and triglycerides (TG)/high-density lipoprotein cholesterol (HDL-C) ratio were used as surrogate markers of insulin resistance and compared among subjects with vs. without diurnal or nocturnal hypertension.

RESULTS

One hundred and five patients, 55 women, 47 (11) years old, and 50 men, 44 (16) years old, were included. Diurnal and nocturnal hypertension were found in 60% and 64% of the sample, respectively. There were no significant differences among the levels of insulin resistance markers between individuals with or without diurnal hypertension. In contrast, individuals with nocturnal hypertension were more insulin resistant irrespectively of whether they were evaluated using FPI (P = 0.016), HOMA-IR (P = 0.019), or TG/HDL-C ratio (P = 0.011); FPI differences remained significant after adjustment for sex, age, and obesity indicators (P = 0.032).

CONCLUSIONS

Nocturnal but not diurnal hypertension was related to higher levels of 3 insulin resistance markers in normotensive and untreated mildly hypertensive adults; this relationship seems partially independent of obesity.

The Reproducibility of Racial Differences in Ambulatory Blood Pressure Phenotypes and Measurements

BACKGROUND

We examined the reproducibility of differences in ambulatory blood pressure (BP) monitoring (ABPM) phenotypes and other parameters (sustained hypertension, masked hypertension, nocturnal hypertension, and nondipping) between African Americans and Whites.

METHODS

A total of 420 participants untreated for hypertension attended 2 research visits 1 week apart during which traditional office BP averages and ABPM session averages were determined. We computed percent agreement in ABPM phenotypes across the 2 visits stratified by race and associated kappa statistics with 95% confidence intervals.

RESULTS

Whites on average were older, more likely to be male, and had a higher body mass index. There was no significant difference in sleep quality as defined by sleep diary between the 2 races. There were also no significant differences between races in the proportions of participants with sustained hypertension, sustained normotension, or masked hypertension at either testing session. The prevalence of nocturnal hypertension was 59% vs. 75% (P = 0.012) at session 1 and 59% vs. 73% (P = 0.024) at session 2 for Whites and African Americans, respectively, with moderate reproducibility for both (kappas 0.45 and 0.44). Nocturnal BP nondipping had a prevalence 29% vs. 53% (P < 0.001) at session 1 and 29% vs. 47% (P = 0.004) at session 2 for Whites and African Americans, respectively, with fair reproducibility (kappas 0.28 and 0.29).

CONCLUSIONS

Our findings support that African Americans indeed exhibit a greater preponderance of abnormal nocturnal BP patterns than Whites. Our work is some of the first to demonstrate that these abnormal patterns are modestly reproducible.

Circadian blood pressure abnormalities in patients with primary nephrotic syndrome

BACKGROUND

Only a few studies have evaluated the abnormalities of ambulatory blood pressure (ABP) in patients with nephrotic syndrome (NS).

METHODS

The 24-h ABPs were measured in primary NS patients with acute onset of disease and analyzed in relation to the clinical variables.

RESULTS

Our subjects comprised 21 patients: 17 with minimal change disease and 4 with focal segmental glomerulosclerosis. Of these patients, 8 (38%) had daytime hypertension, 13 (62%) had nighttime hypertension, and 13 (62%) were non-dippers (nighttime-to-daytime ratio of ABP: NDR > 0.9). The serum sodium level was correlated with the average 24-h ABP and NDR, after adjustment for other clinical variables, such as the increase in body weight, serum albumin level, and urinary protein excretion. The data from repeated ABP measurements, before and after the achievement of remission, showed a marked decrease in the average 24-h ABP after remission. Furthermore, change in the serum sodium level was significantly correlated with the change in NDR.

CONCLUSION

These results suggest that alteration in renal handling of sodium and water, which might be reflected in serum sodium level, is involved in the abnormality of circadian blood pressure in primary NS patients.

Clinic and ambulatory blood pressure in a population-based sample of African Americans: the Jackson Heart Study

Blood pressure (BP) can differ substantially when measured in the clinic versus outside of the clinic setting. Few population-based studies with ambulatory blood pressure monitoring (ABPM) include African Americans. We calculated the prevalence of clinic hypertension and ABPM phenotypes among 1016 participants in the population-based Jackson Heart Study, an exclusively African-American cohort. Mean daytime systolic BP was higher than mean clinic systolic BP among participants not taking antihypertensive medication (127.1[standard deviation 12.8] vs. 124.5[15.7] mm Hg, respectively) and taking antihypertensive medication (131.2[13.6] vs. 130.0[15.6] mm Hg, respectively). Mean daytime diastolic BP was higher than clinic diastolic BP among participants not taking antihypertensive medication (78.2[standard deviation 8.9] vs. 74.6[8.4] mm Hg, respectively) and taking antihypertensive medication (77.6[9.4] vs. 74.3[8.5] mm Hg, respectively). The prevalence of daytime hypertension was higher than clinic hypertension for participants not taking antihypertensive medication (31.8% vs. 14.3%) and taking antihypertensive medication (43.0% vs. 23.1%). A high percentage of participants not taking and taking antihypertensive medication had nocturnal hypertension (49.4% and 61.7%, respectively), white-coat hypertension (30.2% and 29.3%, respectively), masked hypertension (25.4% and 34.6%, respectively), and a nondipping BP pattern (62.4% and 69.6%, respectively). In conclusion, these data suggest hypertension may be misdiagnosed among African Americans without using ABPM.

Association of Morning Hypertension Subtype With Vascular Target Organ Damage and Central Hemodynamics

BACKGROUND

A recent study reported that morning hypertension is associated with poor cardiovascular outcomes in hypertensive patients. However, it is unclear whether morning hypertension associated with sustained nocturnal hypertension and that associated with morning blood pressure (BP) surge differ in terms of their effects on cardiovascular target organ damage and clinical outcomes. The present study aimed to determine the association of morning hypertension with/without nocturnal hypertension with vascular target organ damage and central hemodynamics in patients at high risk for cardiovascular disease.

METHODS AND RESULTS

Ambulatory BP monitoring was performed and central BP was measured in 1070 consecutive patients with high cardiovascular risk. We grouped morning hypertension into the following 3 subtypes: (I) morning normotension; (II) morning hypertension without nocturnal hypertension; and (III) morning hypertension with nocturnal hypertension. Morning hypertension was noted in 469 (43.8%) patients and morning hypertension with nocturnal hypertension was noted in 374 (34.9%) patients. The central systolic/diastolic BP and carotid to femoral pulse wave velocity were significantly higher in the subtype III group than in the subtype I and II groups (all P<0.001). Subtype III (versus subtype I) was an independent predictor of central hypertension and high-risk arterial stiffness (P<0.001 and P=0.018, respectively) but not vascular damage in a fully adjusted model (model Y).

CONCLUSIONS

Morning hypertension, especially that associated with nocturnal hypertension, is related to high central BP and increased arterial stiffness. Further studies on whether morning hypertension with or without nocturnal hypertension is related to clinical outcomes should be performed.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02003781.

Nocturnal hypertension or nondipping: which is better associated with the cardiovascular risk profile?

BACKGROUND

Both increased night blood pressure (BP) and nondipping are associated with worse cardiovascular risk and prognosis. However, as they are often related features, their relative importance has been difficult to assess separately. In this study we address separate associations of nocturnal hypertension and nondipping with cardiovascular risk profile in treated and untreated hypertensive patients.

METHODS

A total of 37,096 untreated patients and 62,788 patients receiving antihypertensive treatment from the Spanish Ambulatory Blood Pressure Monitoring Registry were included. Each cohort was separated into 4 groups: group 1, night systolic blood pressure (SBP) <120 mm Hg and normal dipping (>10%); group 2, night SBP <120 mm Hg and nondipping (≤10%); group 3, nocturnal hypertension (SBP ≥120 mm Hg) and normal dipping; and group 4, nocturnal hypertension and nondipping.

RESULTS

The smallest proportion of patients with additional cardiovascular risk factors, organ damage, and history of previous events was observed in the group with both normal night SBP and dipping, whereas those with both nocturnal hypertension and nondipping showed the largest proportion of cardiovascular risk factors and diseases. When groups showing only 1 abnormality were compared, nondipping was associated with female sex, reduced renal function, and previous cardiovascular events, whereas nocturnal hypertension was associated with male sex, smoking, and increased urinary albumin excretion. In treated patients, it was also associated with the presence of diabetes.

CONCLUSION

Nondipping is related to more advanced disease (reduced renal function and clinical evidence of cardiovascular disease), whereas nocturnal hypertension is associated with albuminuria. The worst cardiovascular risk profile is present in patients exhibiting both nocturnal hypertension and nondipping.

Can nocturnal hypertension predict cardiovascular risk?

Nocturnal hypertension and non-dipping of blood pressure during sleep are distinct entities that often occur together and are regarded as important harbingers of poor cardiovascular prognosis. This review addresses several aspects related to these blood pressure abnormalities including definitions, diagnostic limitations, pathogenesis and associated patient profiles, prognostic significance, and therapeutic strategies. Taken together, persistent nocturnal hypertension and non-dipping blood pressure pattern, perhaps secondary to abnormal renal sodium handling and/or altered nocturnal sympathovagal balance, are strongly associated with deaths, cardiovascular events, and progressive loss of renal function, independent of daytime and 24-hour blood pressure. Several pharmacological and non-pharmacological approaches may restore nocturnal blood pressure and circadian blood pressure rhythm to normal; however, whether this translates to a clinically meaningful reduction in unfavorable cardiovascular and renal consequences remains to be seen.