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Salles GF, Reboldi G, Fagard RH, Cardoso CRL, Pierdomenico SD, Verdecchia P, Eguchi K, Kario K, Hoshide S, Polonia J, de la Sierra A, Hermida RC, Dolan E, O'Brien E, Roush GC. Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta-Analysis. Hypertension 2016; 67:693-700. [PMID: 26902495 DOI: 10.1161/hypertensionaha.115.06981] [Citation(s) in RCA: 339] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/02/2016] [Indexed: 11/16/2022]
Abstract
The prognostic importance of the nocturnal systolic blood pressure (SBP) fall, adjusted for average 24-hour SBP levels, is unclear. The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) examined this issue in a meta-analysis of 17 312 hypertensives from 3 continents. Risks were computed for the systolic night-to-day ratio and for different dipping patterns (extreme, reduced, and reverse dippers) relative to normal dippers. ABC-H investigators provided multivariate adjusted hazard ratios (HRs), with and without adjustment for 24-hour SBP, for total cardiovascular events (CVEs), coronary events, strokes, cardiovascular mortality, and total mortality. Average 24-hour SBP varied from 131 to 140 mm Hg and systolic night-to-day ratio from 0.88 to 0.93. There were 1769 total CVEs, 916 coronary events, 698 strokes, 450 cardiovascular deaths, and 903 total deaths. After adjustment for 24-hour SBP, the systolic night-to-day ratio predicted all outcomes: from a 1-SD increase, summary HRs were 1.12 to 1.23. Reverse dipping also predicted all end points: HRs were 1.57 to 1.89. Reduced dippers, relative to normal dippers, had a significant 27% higher risk for total CVEs. Risks for extreme dippers were significantly influenced by antihypertensive treatment (P<0.001): untreated patients had increased risk of total CVEs (HR, 1.92), whereas treated patients had borderline lower risk (HR, 0.72) than normal dippers. For CVEs, heterogeneity was low for systolic night-to-day ratio and reverse/reduced dipping and moderate for extreme dippers. Quality of included studies was moderate to high, and publication bias was undetectable. In conclusion, in this largest meta-analysis of hypertensive patients, the nocturnal BP fall provided substantial prognostic information, independent of 24-hour SBP levels.
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Affiliation(s)
- Gil F Salles
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
| | - Gianpaolo Reboldi
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Robert H Fagard
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Claudia R L Cardoso
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Sante D Pierdomenico
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Paolo Verdecchia
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Kazuo Eguchi
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Kazuomi Kario
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Satoshi Hoshide
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Jorge Polonia
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Alejandro de la Sierra
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Ramon C Hermida
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Eamon Dolan
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - Eoin O'Brien
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
| | - George C Roush
- From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.)
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