Diastolic Reverse Dipping Pattern Is the Predictor for the Echocardiographic Changes in the Untreated Masked Hypertensive Patients

Nocturnal Hypertension and Heart Failure: Mechanisms, Evidence, and New Treatments

Heart failure (HF) is a common condition with an increasing prevalence. Despite a variety of evidence-based treatments for patients with HF with reduced ejection fraction, morbidity and mortality rates remain high. Furthermore, there are currently no treatments that have yet been shown to reduce complication and death rates in patients who have HF with preserved ejection fraction. Hypertension is a common comorbidity in patients with HF, contributing to disease development and prognosis. For example, hypertension is closely associated with the development of left ventricular hypertrophy, which an important precursor of HF. In particular, nighttime blood pressure (BP) appears to be an important, modifiable risk factor. Both nighttime BP and an abnormal circadian pattern of nighttime BP dipping have been shown to predict development of HF and the occurrence of cardiovascular events, independent of office BP. Key mechanisms for this association include sodium handling/salt sensitivity and increased sympathetic activation. These pathogenic mechanisms are targeted by several new treatment options, including sodium-glucose cotransporter 2 inhibitors, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and renal denervation. All of these could form part of antihypertensive strategies designed to control nighttime BP and contribute to the goal of achieving perfect 24-hour BP management. Nevertheless, additional research is needed to determine the effects of reducing nighttime BP and improving the circadian BP profile on the rate of HF, other cardiovascular events, and mortality.

Which is responsible for target organ damage in masked hypertension? Is it an increase in blood pressure or a disruption of the circadian rhythm?

OBJECTIVE

Masked hypertension (MH) and non-dipping pattern are conditions associated with target organ damage and cardiovascular risk, which are frequently observed together. We aimed to show the relationship between the target organ damage observed in MH and the deterioration in the dipping pattern.

METHODS

Patients who underwent ambulatory blood pressure monitoring (ABPM) and office blood pressure (BP) <140/90 mmHg were retrospectively screened. In ABPM data, those with daytime BP ≥135/85 mmHg and night BP ≥120/70 mmHg were included in the MH group, while the others were included in the normotensive group. The patients were grouped as dipper, non-dipper and reverse-dipper according to ABPM results. Left ventricular mass index (LVMI), glomerular filtration rate (GFR) and serum creatinine levels were used to determine target organ damage.

RESULTS

289 patients [mean age 46.6 ± 12.4 years, 136 (47.1%) males], 154 (53.3%) of whom had MH were included in our study. GFR value was found to be significantly lower, serum creatinine levels and LVMI were significantly higher in patients with MH compared to normotensives (p < .05, for all). When the subgroups were examined, it was found that this difference was associated with the disruption in the dipping pattern. In patients with MH, dipping pattern disruption without change in systolic BP was independently associated with an increase in LVMI (p < .05, for both).

CONCLUSION

Target organ damage seen in MH may be due to the deterioration of the dipping pattern.

Reverse dipping and subclinical cardiac organ damage: a meta-analysis of echocardiographic studies

AIM

Available evidence on the association between reverse dipping pattern and subclinical cardiac damage is scanty. We performed a systematic meta-analysis of echocardiographic studies in order to provide an updated and comprehensive information on this issue.

METHODS

The PubMed, OVID-MEDLINE, and Cochrane library databases were analyzed to search English-language articles published from January from the inception up to 31 July 2020. Studies were identified by using MeSH terms and crossing the following search items: 'reverse dipping', 'nondipping', 'inverted dipping', 'ambulatory blood pressure', 'cardiac damage', 'hypertensive heart disease', 'left ventricular mass', 'left ventricular hypertrophy', and 'echocardiography'.

RESULTS

Data from 14 studies including 1429 patients with reverse dipping, 2584 dippers and 3508 nondippers were considered. Left ventricular (LV) mass index and relative wall thickness were greater in reverse dippers than in dippers (SMD: 0.40 ± 0.04 g/m2, P < 0.0001; 0.31 ± 0.07, P < 0.0001) and nondippers (SMD: 0.25 ± 0.04 g/m2, P < 0.0001; 0.21 ± 0.07, P = 0.004). The reverse dipping group had an increased risk of LV hypertrophy compared with dipping (OR = 1.85, CI 1.47-2.32, P < 0.0001) and nondipping group (OR = 1.45, CI 1.19-1.78, P < 0.0001). A significant progressive reduction in the E/A ratio, paralleled by an increase in left atrium diameter occurred from dippers, to nondippers and reverse dippers.

CONCLUSION

The present meta-analysis provides a novel piece of information about the unfavourable association between the reverse dipping pattern and subclinical cardiac alterations and suggests that the detection of this blood pressure phenotype may identify individuals at increased risk for subclinical organ damage.