Day-Night Dip and Early-Morning Surge in Blood Pressure in Hypertension

Abstract

Abstract-We investigated the relationship between the day-night blood pressure (BP) dip and the early morning BP surge in an cohort of 3012 initially untreated subjects with essential hypertension. The day-night reduction in systolic BP showed a direct association with the sleep trough (rϭ0.564; PϽ0.0001) and the preawakening (rϭ0.554; PϽ0.0001) systolic BP surge. Over a mean follow-up period of 8.44 years, 268 subjects developed a major cardiovascular event (composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and heart failure requiring hospitalization) and 220 subjects died. In a Cox model, after adjustment for predictive covariates, including age, sex, diabetes mellitus, cigarette smoking, total cholesterol, left ventricular hypertrophy on ECG, estimated glomerular filtration rate, and average 24-hour systolic BP, a blunted sleep trough (Յ19.5 mm Hg; quartile 1) and preawakening (Յ9.5 mm Hg; quartile 1) BP surge was associated with an excess risk of events (hazard ratio, 1.66 [95% CI, 1.14 -2.42]; Pϭ0.009; hazard ratio, 1.71 [95% CI, 1.12-2.71]; Pϭ0.013). After adjustment for the same covariates, neither the dipping pattern nor the measures of early morning BP surge were independent predictors of mortality. In conclusion, in initially untreated subjects with hypertension, a blunted day-night BP dip was associated with a blunted morning BP surge and vice versa. In these subjects, a blunted morning BP surge was an independent predictor of cardiovascular events, whereas an excessive BP surge did not portend an increased risk of events. (Hypertension. 2012;60:34-42.)Key Words: hypertension Ⅲ dippers Ⅲ nondippers Ⅲ blood pressure monitoring Ⅲ sleep Ⅲ morning blood pressure surge Ⅲ ambulatory blood pressure O ccurrence of major cardiovascular complications, including myocardial infarction (MI), 1 stroke, 2 and sudden cardiac death, 3 peaks in the early morning hours, typically in the first 4 to 6 hours after awakening. Therefore, the hypothesis has been raised that the extent of blood pressure (BP) surge in the early morning may be associated with the risk of cardiovascular complications. This hypothesis is potentially relevant because it might imply the possibility that reducing the early morning rise in BP may lower the risk of major events that occur in the early morning. By using 24-hour ambulatory BP (ABP) monitoring in cohorts of hypertensive patients 4-6 or randomized samples from the general population, 7,8 several investigators examined the association between the morning BP surge and the subsequent outcome, but results were not univocal. On the other hand, many studies showed that the risk of cardiovascular disease directly increases with nighttime BP and a blunted BP dip from day to night. 6,[9][10][11][12] The adverse prognostic impact of a blunted or reversed diurnal BP rhythm seems difficult to reconcile with the hypothesis that an excessive rise in BP from the nighttime period to the early morning is also predictive of a worse outcome. None of the studies that addresse...

Ethnic Differences in the Degree of Morning Blood Pressure Surge and in Its Determinants Between Japanese and European Hypertensive Subjects

“…For instance, our data in Japanese patients are similar to those obtained in the study by Kario et al 27 in elderly hypertensive patients. Also the MS size we observed in the European population was comparable to that reported in the Italian population of PIUMA study 14 and to that observed in the meta-analysis by Li et al 3 Conversely, in the latter meta-analysis, MS size reported in Asian subjects was markedly smaller than that in our study, possibly because of the inclusion of Chinese subjects. In fact, it seems that sleep-trough MS values may be higher in the Japanese compared with other Asian ethnic groups.…”

“…In Japanese elderly hypertensive patients, a significant association between stroke and the degree of MS was found, 10 whereas this was not the case when an international ABPM database or a European ABPM database was analyzed. 12,14,15 In the latter case, the inability to find a significant relationship between BP MS and cerebrovascular events was suggested to possibly depend on the occurrence of a different degree of sleep-trough MS among different ethnic groups contributing to this database, 3 but to date, no data are available on the occurrence of systematic differences in BP MS when comparing subjects of different ethnic origin.…”

Latin American consensus on hypertension in patients with diabetes type 2 and metabolic syndrome

“…O MAPA de 24 horas é considerado uma ferramenta útil para otimizar a avaliação clínica de idosos hipertensos (125,126). Neles há uma queda anormal da pressão arterial noturna e ondas de aumento pela manhã, o que está associado com aumento do risco de doença cerebrovascular (127,128), embora esses achados recentemente têm sido questionados (129).…”

Prognostic Utility of Morning Blood Pressure Surge for 20‐Year All‐Cause and Cardiovascular Mortalities: Results of a Community‐Based Study

“…In a meta‐analysis of 5645 subjects from 8 cohorts, sleep‐trough MS (STMS) significantly and independently associated with cardiovascular outcomes 5. However, the prognostic value of MS for cardiovascular disease was not confirmed by recent prospective studies 7, 8, 9…”