Our aim is to determine the optimal time schedule for home blood pressure (BP) monitoring that best predicts stroke and coronary artery disease in general practice. The Japan Morning Surge-Home Blood Pressure (J-HOP) study is a nationwide practice-based study that included 4310 Japanese with a history of or risk factors for cardiovascular disease, or both (mean age, 65 years; 79% used antihypertensive medication). Home BP measures were taken twice daily (morning and evening) over 14 days at baseline. During a mean follow-up of 4 years (16 929 person-years), 74 stroke and 77 coronary artery disease events occurred. Morning systolic BP (SBP) improved the discrimination of incident stroke ( C statistics, 0.802; 95% confidence interval, 0.692–0.911) beyond traditional risk factors including office SBP (0.756; 0.646–0.866), whereas the changes were smaller with evening SBP (0.764; 0.653–0.874). The addition of evening SBP to the model (including traditional risk factors plus morning SBP) significantly reduced the discrimination of incident stroke ( C statistics difference, −0.008; 95% confidence interval: −0.015 to −0.008; P =0.03). The category-free net reclassification improvement (0.3606; 95% confidence interval, 0.1317–0.5896), absolute integrated discrimination improvement (0.015; SE, 0.005), and relative integrated discrimination improvement (58.3%; all P <0.01) with the addition of morning SBP to the model (including traditional risk factors) were greater than those with evening SBP and with combined morning and evening SBP. Neither morning nor evening SBP improved coronary artery disease risk prediction. Morning home SBP itself should be evaluated to ensure best stroke prediction in clinical practice, at least in Japan. This should be confirmed in the different ethnic groups. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr/ . Unique identifier: UMIN000000894.

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These findings suggest that ABPM is a better predictor of cardiovascular risk than clinic BP, and that this holds true for patients with or without T2DM.

Stroke occurs most frequently in the morning hours, but the impact of the morning blood pressure (BP) level on stroke risk has not been fully investigated in hypertensives. We studied stroke prognosis in 519 older hypertensives in whom ambulatory BP monitoring was performed, and who were followed prospectively. During an average duration of 41 months (range: 1-68 months), 44 stroke events occurred. The morning systolic BP (SBP) was the strongest independent predictor for stroke events among clinic, 24-h, awake, sleep, evening, and pre-awake BPs, with a 10 mmHg increase in morning SBP corresponding to a relative risk (RR) of 1.44 (p <0.0001). The average of the morning and evening SBP (Av-ME-SBP; 10 mmHg increase: RR =1.41, p =0.0001), and the difference between the morning and evening SBP (Di-ME-SBP; 10 mmHg increase: RR =1.24, p =0.0025) were associated with stroke risks independently of each other. The RR of morning hypertension (Av-ME-SBP ≥ 135 mmHg and Di-ME-SBP≥20 mmHg) vs. sustained hypertension (Av-ME-SBP ≥135 mmHg and Di-ME-SBP <20 mmHg) for stoke events was 3.1 after controlling for other risk factors (p =0.01). In conclusion, morning hypertension is the strongest independent predictor for future clinical stroke events in elderly hypertensive patients, and morning and evening BPs should be monitored in the home as a first step in the treatment of hypertensive patients. (Hypertens Res 2006; 29: 581-587)