Nocturnal hypotension in patients after ischemic stroke: does it really matter?

Novel blood pressure targets in patients with high-normal levels and grade 1 hypertension: Room for monotherapy?

The 2018 European and 2017 American guidelines recommend to start antihypertensive treatment with combinations of two or more drugs in most hypertensive patients, as a consequence of the suggested more ambitious blood pressure (BP) targets (systolic BP between 130 and 120 mmHg in most patients, diastolic BP between 80 and 70 mmHg). Monotherapy, however, is still suggested as first choice in some specific classes of patients. In this article, we analyze the subgroups of hypertensive patients that should properly started and even maintained on monotherapy, with a focus on subjects with BP in the high-normal range or grade 1 hypertension, young adults with estimated low cardiovascular risk, women during pregnancy or menopause, elderly patients aged >80 years or with frailty parameters. Altogether, these subgroups cover a relatively large proportion of patients with hypertension. Thus, we conclude that, despite the upgrowing role of combination therapy, there is still ample room for the approach with monotherapy in clinical management of hypertension.

Chronic Management of Hypertension after Stroke: The Role of Ambulatory Blood Pressure Monitoring

Hypertension is the most important potentially reversible risk factor for stroke in all age groups; high blood pressure (BP) is also associated with increased risk of recurrent stroke in patients who have already had an ischemic or hemorrhagic event. Twenty-four hour ambulatory BP monitoring (ABPM) has become an important tool for improving the diagnosis and management of hypertension, and is increasingly used to assess patients with hypertension. Nevertheless, although ABPM devices are increasingly used for assessment of hypertension, their value in the chronic management of hypertension in patients with stroke has not been systematically studied. In fact, among large-scale randomized trials for secondary stroke prevention, only the Morbidity and Mortality After Stroke, Eprosartan Compared With Nitrendipine for Secondary Prevention trial included 24-hour ABPM. ABPM has demonstrated chronic disruption of the circadian rhythm of BP after acute phase of stroke and has shown higher sensitivity compared to office BP in evaluating the effectiveness of antihypertensive treatment among stroke survivors. High 24-hour BP is an independent predictor for cerebrovascular events, brain microbleeds, and subsequent development of dementia. Nevertheless, although stroke care guidelines endorse the importance of hypertension management, the specific role of ABPM among stroke survivors after the acute phase of disease has not been established. Further studies are needed to clarify whether routine application of ABPM among these patients should be recommended.

[Physiological and pathophysiological role of the circadian clock system]

It has been well known for ages that in living organisms the rhythmicity of biological processes is linked to the ~ 24-hour light-dark cycle. However, the exact function of the circadian clock system has been explored only in the past decades. It came to light that the photosensitive primary "master clock" is situated in the suprachiasmatic photosensitive nuclei of the special hypothalamic region, and that it is working according to ~24-hour changes of light and darkness. The master clock sends its messages to the peripheral "slave clocks". In many organs, like pancreatic β-cells, the slave clocks have autonomic functions as well. Two essential components of the clock system are proteins encoded by the CLOCK and BMAL1 genes. CLOCK genes are in interaction with endonuclear receptors such as peroxisoma-proliferator activated receptors and Rev-erb-α, as well as with the hypothalamic-pituitary-adrenal axis, regulating the adaptation to stressors, energy supply, metabolic processes and cardiovascular system. Melatonin, the product of corpus pineale has a significant role in the functions of the clock system. The detailed discovery of the clock system has changed our previous knowledge about the development of many diseases. The most explored fields are hypertension, cardiovascular diseases, metabolic processes, mental disorders, cancers, sleep apnoe and joint disorders. CLOCK genes influence ageing as well. The recognition of the periodicity of biological processes makes the optimal dosing of certain drugs feasible. The more detailed discovery of the interaction of the clock system might further improve treatment and prevention of many disorders.