Blood pressure surge on rising

Effects of a maintenance period on ambulatory blood pressure and morning blood pressure surge in young normotensives post isometric training

Isometric resistance training (IRT) has emerged as an efficacious therapeutic intervention to reduce ambulatory blood pressure (BP), and BP diurnal variability. However, once the required decreases in BP have been achieved the efficacy of implementing a reduced maintenance dose is not understood. Therefore, the purpose of this study was to determine the effects of an 8-week maintenance period (8-week) following the cessation of the prescribed 8-week IRT in young normotensives. Twenty-two recreationally active, not resistance trained, normotensive (24-h ambulatory SBP, ≥130 mmHg) young adults were randomly assigned to a training-maintenance [TG-MT; n = 13 (female = 5); age 21 ± 2 years] or a non-training control [CON; n = 9 (female = 4); age 23 ± 3 years] group. Ambulatory BP, morning BP surge (MBPS) and average real variability (ARV) were measured prior to, after 8 weeks of bilateral leg IRT (4x2-minute contractions at 20% MVC with 2-min rest periods, 3 days/week) and following an 8-week (once per week) maintenance period. On completion of the maintenance period the significant reductions seen following the IRT were maintained within the TG-MT group in 24-h ambulatory SBP (6 ± 4 mmHg, p < 0.001), daytime (5 ± 5 mmHg, p = 0.002), MBPS (7 ± 10 mmHg, p = 0.019) and 24-h SBP ARV (2.03 ± 1.44 mmHg, p = 0.001), daytime SBP ARV (2.04 ± 1.78 mmHg, p = 0.003). These results show that reductions in ambulatory BP (24-h SBP and daytime SBP), in addition to BP diurnal variations (MBPS, 24-h SBP ARV and daytime SBP AVR) are maintained following an 8-week maintenance dose in young adults and add further weight to the growing body of evidence promoting IRT as an efficacious therapeutic exercise intervention to prevent or reduce BP.

Association between Morning Surge and Left Ventricular Hypertrophy in Obese Hypertensive Patients

BACKGROUND

Weight gain can trigger mechanisms that increase blood pressure. Nevertheless, obesity causes structural changes in the myocardium, including increased ventricular mass, atrial dilatation, and diastolic and systolic dysfunction. Additionally, blood pressure variations, like morning surge (MS) in obese hypertensive patients may have clinical relevance in cardiovascular events. Although morning blood pressure surge is a physiological phenomenon, excess MS can be considered an independent risk factor for cardiovascular events.

OBJECTIVE

To evaluate MS values and their association with left ventricular hypertrophy (LVH) and nocturnal dipping (ND) in obese and non-obese hypertensive patients.

METHODS

A cross-sectional study that evaluated BP measurements by ambulatory blood pressure monitoring (ABPM) and the presence of LVH by echocardiography in 203 hypertensive outpatients, divided into two groups: 109 non-obese and 94 obese hypertensives patients. The significance level was set at 0.05 in two-tailed tests.

RESULTS

A MS above 20 mmHg by ABPM was detected in 59.2% of patients in the non-obese group and 40.6% in the obese group. LVH was found in 18.1% and 39.3% of patients in the non-obese and obese groups, respectively, p<0.001. In the "obese group", it was observed that a MS>16 mmHg was associated with LVH, [prevalence ratio: 2.80; 95%CI (1.12-6.98), p=0.03]. For the non-obese group, the cut-off point of MS for this association was >22 mmHg.

CONCLUSION

High MS was positively associated with LVH, with a particular behavior in the hypertensive obese group.

A Prospective, Randomized Open-Label Study for Assessment of Antihypertensive Effect of Telmisartan Versus Cilnidipine Using Ambulatory Blood Pressure Monitoring (START ABPM Study)

Background

The antihypertensive agent telmisartan is an angiotensin II receptor blocker with a terminal elimination half-life of 24 h and has a high lipophilicity, thereby enhancing its bioavailability. Another antihypertensive agent, cilnidipine is a calcium antagonist and has dual mode of action on the calcium channels. This study aimed at determining effect of these drugs on ambulatory blood pressure (BP) levels.

Methods

A randomized, open-label, single-center study was conducted during 2021 - 2022 on newly diagnosed adult patients with stage-I hypertension, in a mega city of India. Forty eligible patients were randomized to telmisartan (40 mg) and cilnidipine (10 mg) groups, with once daily dose administered for 56 consecutive days. Ambulatory blood pressure monitoring (ABPM) (24 h) was performed pre- and post-treatment, and the ABPM-derived parameters were compared statistically.

Results

Statistically significant mean reductions were observed in all BP endpoints in telmisartan group but only in 24-h systolic blood pressure (SBP), daytime and nighttime SBP, and manual SBP and diastolic blood pressure (DBP) in cilnidipine group. The mean change from baseline to day 56 between two treatment groups showed statistical significance in last 6-h SBP (P = 0.01) and DBP (P = 0.014), and morning SBP (P = 0.019) and DBP (P = 0.028). The percent nocturnal drop within and between groups was statistically nonsignificant. Also, the between group mean SBP and DBP smoothness index differed nonsignificantly.

Conclusions

Telmisartan and cilnidipine once daily were effective and well tolerated in the treatment of newly diagnosed stage-I hypertension. Telmisartan provided sustained 24-h BP control and may offer advantages over cilnidipine in terms of BP reductions, particularly over the 18- to 24-h post-dose period or critical early morning hours.

A new risk factor for predicting stroke in patients with atrial fibrillation: morning blood pressure surge

BACKGROUND

Stroke, the most feared complication in patients with atrial fibrillation (AF), is still an important cause of mortality and morbidity. In our study, we aimed to investigate the frequency of stroke and related parameters in patients with atrial fibrillation, for whom 24-h ambulatory blood pressure monitoring (ABPM) was performed.

METHOD

A total of 282 patients with permanent AF were included in this study. 24-h ABPM was performed in all patients. Morning blood pressure surge (MBPS) was defined as the difference between the mean SBP in the first 2 h after awakening and the lowest blood pressure (BP) at night. We evaluated parameters associated with stroke in patients with atrial fibrillation using univariate and multivariate Cox regression analysis.

RESULT

Patients were followed for 19 ± 9.3 months and 22 ischemic strokes were detected during the follow-up period. Also, strokes were significantly lower in atrial fibrillation patients with a dipper BP pattern, whereas strokes were significantly higher in atrial fibrillation patients with a reverse-dipper BP pattern. In multivariate analysis, a history of hypertension ( P  = 0.020), BP pattern ( P  < 0.001) and MBPS ( P  < 0.001) were found to be significantly related to stroke. MBPS levels >32.5 mmHg predicted stroke with a sensitivity of 77% and a specificity of 60% (AUC, 0.741; 95% CI, 0.647-0.834; P  < 0.001).

CONCLUSION

MBPS, BP pattern and presence of hypertension as an independent risk factor in predicting stroke in patients with atrial fibrillation. The reduction of the MBPS may be a new therapeutic target for preventing stroke.

Establishment of an Individual-Specific Nomogram for Predicting the Risk of Left Ventricular Hypertrophy in Chinese Postmenopausal Hypertensive Women

Background and Objectives: The physiological phenomenon peculiar to women, namely menopause, makes the occurrence of left ventricular hypertrophy (LVH) in postmenopausal hypertensive women more characteristic. Less is known about the risk of developing LVH in Chinese postmenopausal hypertensive women. Thus, the present study was intended to design a nomogram for predicting the risk of developing LVH in Chinese postmenopausal hypertensive women. Materials and Methods: Postmenopausal hypertensive women aged between 49 and 68 years were divided into either the training set (n = 550) or the validation set (n = 284) in a 2:1 ratio. Patients in the validation set were followed up for one year. A stepwise multivariable logistic regression model was used to assess the predictors of LVH in postmenopausal women with hypertension. The best-fit nomogram was executed using R software. The calibration and decision curve were employed to verify the predictive accuracy of the nomogram. The results were evaluated in the validation set. Results: Menopause age (OR = 0.929, 95% CI 0.866–0.998, p = 0.044), BMI (OR = 1.067, 95% CI 1.019–1.116, p = 0.005), morning systolic blood pressure (SBP: OR = 1.050, 95% CI 1.032–1.069, p = 0.000), morning diastolic BP (DBP OR = 1.055, 95% CI 1.028–1.083, p = 0.003), angiotensin II receptor blocker (ARB) utilization rate (OR = 0.219, 95% CI 0.131–0.365, p = 0.000), LDL-C (OR = 1.460, 95% CI 1.090–1.954, p = 0.011) and cardio-ankle vascular index (CAVI) (OR = 1.415, 95% CI 1.139–1.757, p = 0.028) were associated with LVH in postmenopausal hypertension patients. The nomogram model was then developed using these variables. The internal validation trial showed that the nomogram model described herein had good performance in discriminating a C-index of 0.881 (95% CI: 0.837–0.924) and high quality of calibration plots. External validation of LVH-predictive nomogram results showed that the area under the ROC curve was 0.903 (95%CI 0.900–0.907). Conclusions: Our results indicate that the risk prediction nomogram model based on menopausal age, BMI, morning SBP, morning DBP, ARB utilization rate, LDL-C and CAVI has good accuracy and may provide useful references for the medical staff in the intuitive and individualized risk assessment in clinical practice.

Effects of isometric resistance training and detraining on ambulatory blood pressure and morning blood pressure surge in young normotensives

Isometric resistance training (IRT) has been shown to reduce resting and ambulatory blood pressure (BP), as well as BP variability and morning BP surge (MBPS). However, there are no data available regarding how long after cessation of IRT these effects are maintained. Therefore, the purpose of this study was to determine the effects of 8 weeks of detraining on resting BP, ambulatory BP and MBPS following 8 weeks of IRT in a population of young normotensive individuals and to further substantiate previously reported reductions in MBPS following IRT. Twenty-five apparently healthy participants with resting BP within the normal range (16 men, age = 23 ± 6 years; 9 women, age = 22 ± 4 years, resting BP: 123 ± 5/69 ± 7 mmHg) were randomly assigned to a training-detraining (TRA-DT, n = 13) or control (CON, n = 12) group. Resting BP, ambulatory BP and MBPS were measured prior to, after 8 weeks of bilateral leg IRT using an isokinetic dynamometer (4 × 2-min contractions at 20% MVC with 2-min rest periods, 3 days/week) and following an 8-week detraining period. There were significant reductions in 24-h ambulatory systolic BP (SBP) and calculated SBP average real variability (ARV) following IRT that were maintained after detraining (pre-to-post detraining, −6 ± 4 mmHg, p = 0.008, −2 ± 1.5 mmHg, p = 0.001). Similarly, the training-induced decreases in daytime SBP and daytime SBP ARV (pre-to-post detraining, −5 ± 6 mmHg, p = 0.001; −2 ± 1.2 mmHg, p = 0.001, respectively), MBPS (pre-to-post detraining, −6 ± 9 mmHg, p = 0.046) and resting SBP (pre-to-post detraining, −4 ± 6 mmHg, p = 0.044) were preserved. There were no changes in night-time or night-time SBP ARV across all time points (pre-to-post detraining, −1 ± 8 mmHg, p = 1.00, −0.7 ± 2.9 mmHg, p = 1.00). These results confirm that IRT causes significant reductions in resting BP, ambulatory BP, ambulatory ARV and MBPS. Importantly, the changes remained significantly lower than baseline for 8 weeks after cessation of training, suggesting a sustained effect of IRT.

Time point of nocturnal trough systolic blood pressure as an independent predictor of cardiovascular events

Nocturnal trough systolic blood pressure (NTSBP) and Time Point of Nocturnal Trough Systolic Blood Pressure (T‐NTSBP) were important parameters of nocturnal blood pressure, the predictive values of which are unclear for stroke outcome. This study aimed to examine the relationship between NTSBP/T‐NTSBP and stroke outcome. The authors used data from a nationwide ambulatory blood pressure monitoring cohort study conducted in China, which recruited 2348 ischemic stroke and transient ischemic attack (TIA) patients. NTSBP was defined as the lowest SBP during nighttime (22:00–6:00), and T‐NTSBP was defined as the corresponding time point of NTSBP. The associations between NTSBP/T‐NTSBP and stroke outcome (stroke recurrence and combined vascular event [CVE]) at 90 days or 1 year were analyzed using cox regression models. According to NTSBP classified by quartile, hazard ratio (HR) with 95% confidence interval (CI) for NTSBP quartile 4 (>129 mm Hg) was 2.727 (1.148–6.478) for CVE at 90‐day, compared with quartile 1 (≤102 mm Hg). However, an attenuated association between NTSBP and CVE was observed at 1 year. In addition, we observed the group of T‐NTSBP at 4:00–6:00 had a lowest CVE incidence at 90 days among four groups (22:00–23:59, 00:00–1:59 2:00–3:59, 4:00–6:00). After multivariable adjustment, T‐NTSBP was significantly associated with CVE incidence at 90 days (T‐NTSBP at the 4:00–6:00 versus the 22:00–23:59 group: HR, 0.433; 95%CI, 0.190–0.986), independent of NTSBP and average nocturnal SBP. Both of NTSBP and T‐NTSBP were important predictors for short‐term cardiovascular risk in ischemic stroke and TIA patients.

Differences in estimated glomerular filtration rate are associated with different patterns of 24-h ambulatory blood pressure in the general population

BACKGROUND

Alterations of the circadian blood pressure rhythm are associated with cardiovascular and chronic kidney diseases. We investigated the relationship between 24-h ambulatory blood pressure monitoring (ABPM) patterns and eGFR differences in participants without chronic kidney disease.

METHOD

This cross-sectional study was conducted using data from the ongoing Korean Genome and Epidemiology Study, which involves 1733 participants (age, 60 ± 7 years; 938 women) with an eGFR >60 ml/min per 1.73 m2. The blood pressure dipping status was stratified as reverse-dipper (<0%), nondipper (0 to <10%), and dipper (≥10%). They were also categorized into eGFR quartiles (Q4, 128.6-101.6; Q3, 101.5-95.7; Q2, 95.6-87.4; and Q1, 87.3-60.5), and Q4 was fixed as the reference.

RESULTS

The proportion of dippers progressively decreased and the proportions of reverse and nondippers significantly increased from the highest to the lowest eGFR quartile (P < 0.001). In the univariate analyses, the Q1 and Q2 groups were significantly associated with increasing odds ratios (ORs) for the nondipper, reverse-dipper, and nondipper plus reverse-dipper groups. After adjustment, the lowest eGFR group was significantly associated with the reverse-dipper and nondipper plus reverse-dipper patterns in comparison with the highest eGFR group [OR = 1.685, 95% confidence interval (CI), 1.002-2.834; OR = 1.422, 95% CI, 1.023-1.978, respectively). The significant linear trend for an association of the nondipper plus reverse-dipper pattern with a decrease in eGFR was confirmed with the test for trend (P = 0.023).

CONCLUSION

Differences in eGFR are associated with different 24-h ABPM patterns in non-CKD individuals. ABPM can identify individuals with a nondipper status in this population.

Effects of isometric leg training on ambulatory blood pressure and morning blood pressure surge in young normotensive men and women

Despite the reported association between diurnal variations in ambulatory blood pressure (BP) and elevated cardiovascular disease risk, little is known regarding the effects of isometric resistance training (IRT), a practical BP-lowering intervention, on ambulatory BP and morning BP surge (MBPS). Thus, we investigated whether (i) IRT causes reductions in ambulatory BP and MBPS, in young normotensives, and (ii) if there are any sex differences in these changes. Twenty normotensive individuals (mean 24-h SBP = 121 ± 7, DBP = 67 ± 6 mmHg) undertook 10-weeks of bilateral-leg IRT (4 × 2-min/2-min rest, at 20% maximum voluntary contraction (MVC) 3 days/week). Ambulatory BP and MBPS (mean systolic BP (SBP) 2 h after waking minus the lowest sleeping 1 h mean SBP) was measures pre- and post-training. There were significant reductions in 24-h ambulatory SBP in men (− 4 ± 2 mmHg, P = 0.0001) and women (− 4 ± 2 mmHg, P = 0.0001) following IRT. Significant reductions were also observed in MBPS (− 6 ± 8 mmHg, p = 0.044; − 6 ± 7 mmHg, P = 0.019), yet there were no significant differences between men and women in these changes, and 24-h ambulatory diastolic BP remained unchanged. Furthermore, a significant correlation was identified between the magnitude of the change in MBPS and the magnitude of changes in the mean 2-h SBP after waking for both men and women (men, r = 0.89, P = 0.001; women, r = 0.74, P = 0.014). These findings add further support to the idea that IRT, as practical lifestyle intervention, is effective in significantly lowering ambulatory SBP and MBPS and might reduce the incidence of adverse cardiovascular events that often occur in the morning.

Association of morning blood pressure surge with chronic kidney disease progression in patients with chronic kidney disease and hypertension

Blood pressure (BP) usually rise from being asleep to awake, which is named the morning blood pressure surge (MBPS). Researches have reported that elevated MBPS was related with CV events, incident CKD in hypertensive patients. However, there have been no studies that have investigated the association between MBPS and renal or heart outcomes in patients with CKD and hypertension, in these patients, the MBPS is much lower because of high prevalence of night hypertension and reduced BP dipping. In this prospective two-center observational study, we enrolled patients with CKD and hypertension and the 24 h ambulatory blood pressure monitoring (ABPM) was conducted in all patients. Time to total mortality, CKD progression and CV events was recorded; Finally, a total of 304 patients were enrolled and 94 (30.9%) of them had elevated MBPS. After a follow-up for median 30 months, 23 (7.6%), 34 (11.2%), and 95 (31.3%) patients occurred death, CKD progression and new-onset CV events, respectively. The Cox regression analysis suggested the elevated MBPS was a strong predictor of CKD progression (HR 2.35, 95%CI 1.2 -4.63, p = .013), independent of morning BP, while no associations were found between elevated MBPS and CV events (HR 1.02, 95%CI 0.66 -1.57), as well as death (HR 1.08, 95%CI 0.46 -2.55). In conclusion, we provided the first evidence that elevated MBPS was an important risk factor of CKD progression in patients with CKD and hypertension. Appropriate evaluation and management of MBPS may be helpful to postpone CKD progression.

Can Systemic Immune-Inflammation Index Detect the Presence of Exxaggerated Morning Blood Pressure Surge in Newly Diagnosed Treatment-Naive Hypertensive Patients?

Background: The exaggerated morning blood pressure surge (MS) is associated with target organ damage and cardiovascular events. Systemic immune-inflammation index (SII) has been detected as a useful marker in tumors and cardiovascular diseases. The role of inflammation in the pathogenesis of hypertension is a well-known issue. We aimed to investigate whether there is an association between SII and exaggerated MS in newly diagnosed treatment-naive hypertensive patients.Material and Methods: In total, 343 newly diagnosed in clinical and 24-h ambulatory blood pressure (BP) monitoring treatment-naive hypertensive patients were included in this study. Morning surge was defined as the difference between morning BP, which was the mean of BP during 2 h after wake-up, and the lowest BP, which was the mean of three lowest BP during nighttime. A cutoff value of 52.1 mmHg was used to discriminate the high- and low value MS groups. SII was calculated based on neutrophil, platelet, and lymphocyte counts.Results: Neutrophil, platelet, SII, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) were higher, whereas lymphocyte counts were lower in the high-value MS than the low-value MS. These indices were all independently associated with exaggerated MS and SII was superior to all other indices for detecting the presence of exaggerated MS. SII was moderately correlated with morning BP surge (r: 0.489, p < 0.0001).Conclusion: SII was higher in patients with exaggerated MS and was independently associated with exaggerated MS. Furthermore, SII might be a better indicator than platelet, neutrophil, lymphocyte, NLR, and PLR for the presence of exaggerated MS.

Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network

Hypertension is an important public health issue due to its association with a number of serious diseases, including cardiovascular disease and stroke. The importance of evaluating hypertension taking into account different blood pressure (BP) profiles and BP variability (BPV) is increasingly being recognized, and is particularly relevant in Asian populations given the specific features of hypertension in the region (including greater salt sensitivity and a high rate of nocturnal hypertension). Ambulatory BP monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour BP and provides data on several important parameters that cannot be obtained using any other form of BP measurement. In addition, ABPM parameters provide better information on cardio- and cerebrovascular risk than office BP. ABPM should be used in all patients with elevated BP, particularly those with unstable office or home BP, or who are suspected to have white-coat or masked hypertension. ABPM is also an important part of hypertension diagnosis and monitoring in high-risk patients. ABPM needs to be performed using a validated device and good practice techniques, and has a role both in hypertension diagnosis and in monitoring the response to antihypertensive therapy to ensure strict BP control throughout the 24-hour period. Use of ABPM in clinical practice may be limited by cost and accessibility, and practical education of physicians and patients is essential. The ABPM evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for ABPM in Asia.

Morning Blood Pressure Surge and Cardiovascular Disease Events and All-Cause Mortality in Blacks: The Jackson Heart Study

The cardiovascular disease (CVD) and mortality risk associated with morning blood pressure (BP) surge and its components among black adults, a population with high BP during the asleep period, is unknown. We studied Jackson Heart Study participants who completed 24-hour ambulatory BP monitoring at the baseline exam in 2000 to 2004 (n=761). The sleep-trough morning surge was calculated as the mean 2-hour postawakening systolic BP (SBP) minus the lowest nighttime SBP, preawakening morning surge as mean 2-hour postawakening SBP minus mean 2-hour preawakening SBP, and rising morning surge as the first postawakening SBP minus the last preawakening SBP. The primary outcome was the occurrence of CVD events including the composite of coronary heart disease or stroke. Over a median follow-up of 14.0 years, there were 74 CVD (coronary heart disease or stroke) events and 144 deaths. Higher tertiles of sleep-trough, preawakening, and rising SBP surge were not associated with CVD risk after multivariable adjustment. In contrast, the highest tertile of the individual components of morning surge, including postawakening SBP (tertiles 2 and 3 versus 1: hazard ratio [95% CI]: 1.58 [0.71-3.53] and 4.04 [1.91-8.52], respectively), lowest nighttime SBP (1.29 [0.59-2.84] and 2.87 [1.41-5.83]), preawakening SBP (1.26 [0.57-2.80] and 2.79 [1.32-5.93]), first postawakening SBP (1.60 [0.73-3.51] and 2.93 [1.40-6.16]), and last preawakening SBP (1.23 [0.57-2.68] and 2.99 [1.46-6.12]), was associated with increased CVD risk after multivariable adjustment. Among black adults, the components of morning SBP surge, but not morning SBP surge itself, were associated with increased CVD risk.

2020 Consensus summary on the management of hypertension in Asia from the HOPE Asia Network

Hypertension professionals from Asia have been meeting together for the last decade to discuss how to improve the management of hypertension. Based on these education and research activities, the Hypertension, brain, cardiovascular and renal Outcome Prevention and Evidence in Asia (HOPE Asia) Network was officially established in June 2018 and includes experts from 12 countries/regions across Asia. Among the numerous research and review papers published by members of the HOPE Asia Network since 2017, publications in three key areas provide important guidance on the management of hypertension in Asia. This article highlights key consensus documents, which relate to the Asian characteristics of hypertension, home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM). Hypertension and hypertension-related diseases are common in Asia, and their characteristics differ from those in other populations. It is essential that these are taken into consideration to provide the best opportunity for achieving "perfect 24-hour blood pressure control", guided by out-of-office (home and ambulatory) blood pressure monitoring. These region-specific consensus documents should contribute to optimizing individual and population-based hypertension management strategies in Asian country. In addition, the HOPE Asia Network model provides a good example of the local interpretation, modification, and dissemination of international best practice to benefit specific populations.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.

Comparison Between Home and Ambulatory Morning Blood Pressure and Morning Hypertension in Their Reproducibility and Associations With Vascular Injury

Morning blood pressure (BP) is recommended to be assessed by either 24-hour ambulatory or home BP monitoring. By which methods morning BP assessed is more reproducible and more closely associated with vascular injury remains unknown. We, therefore, addressed this issue in 1049 referred untreated outpatients (51.9% women; average age, 51 years) who had performed 24-hour ambulatory and 7-day home BP monitoring and vascular evaluations. Irrespective of the assessment methods, morning BPs were all significantly ( P≤0.027) associated with the arterial measures. The partial correlation coefficients of carotid-femoral pulse wave velocity and urinary albumin-to-creatinine ratio with home morning BPs were greater than those with the ambulatory morning pressures among the first 2 hours after awakening (0.21-0.37 versus 0.15-0.24; P<0.05). The associations with home morning systolic BP remained significant ( P≤0.002) after full adjustment for evening BP, whereas those with ambulatory morning BPs became nonsignificant after full adjustment for 24-hour BP except that of the carotid-femoral pulse wave velocity with ambulatory morning (6:00-10:00) systolic BP. Of the 135 subjects who had both home and repeated 24-hour ambulatory BP monitoring within 1 month, the coefficients of variation were ≈11% for ambulatory morning BPs and 5% for home self-measurements. In conclusion, morning BP, irrespective of the assessment methods and definitions, was generally reproducible and significantly associated with vascular indices. Nevertheless, home morning BP might be preferred than ambulatory measurements because of better reproducibility and stronger correlation with vascular indices.

Moderate morning rise in blood pressure has lowest risk of stroke but only in women

BACKGROUND

The morning period which is recognized as the highest risk for cardiovascular events is associated with a surge in blood pressure (BP). However, it is unclear what aspect of this rise is important.

AIM

To determine whether the rate of rise (RoR), the magnitude (day night difference) or the product [BP power (BPPower)] is associated with increased cardiovascular risk.

METHODS

We developed a logistic equation method to fit individual 24-h patterns of BP to determine RoR, amplitude and BPPower using the ambulatory recordings from the Ohasama study including 564 men and 971 women (16.6 years follow-up).

RESULTS

Men had a higher risk of cardiovascular events than women (24, 16%, P < 0.001). Age and night BP were strong linear risk predictors. In men sorting risk by quintiles of BPPower (adjusted for age, night BP, smoking status) revealed no clear linear or nonlinear pattern. However, in women BPPower had a U-shaped relationship with the lowest risk being the 2-3rd quintile for all cardiovascular events (Pquadratic = 0.01) including cardiovascular death (Pquadratic = 0.03) and nonfatal stroke (Pquadratic = 0.02). A similar but less clear trend was observed with the RoR but only stroke (infarct) reached significance (Pquadratic = 0.03) while sorting by range showed a U shaped pattern for combined cardiovascular events (Pquadratic = 0.04).

CONCLUSION

These findings suggest that the morning BPPower is an important independent risk factor for predicting cardiovascular events and stroke but only in women with median levels having the lowest risk.

Validation of the TM-2441 ambulatory blood pressure measurement device according to the ISO 81060-2: 2013 standard

OBJECTIVE

The aim of this study was to validate the TM-2441 ambulatory blood pressure monitoring (ABPM) device using the ISO 81060-2:2013 standard.

PARTICIPANTS AND METHODS

Participants were healthy individuals aged more than 12 years who were recruited from among the outpatients and volunteers of Jichi Medical University (Tochigi, Japan). The same-arm sequence protocol (clinical validation) and the opposite-limb simultaneous method (ambulatory validation) from the ISO 81060-2:2013 standard were used.

RESULTS

One hundred and seven participants were enrolled; 85 participated in the clinical validation and 35 participated in the ambulatory validation (13 participants were included in both validation protocols). The TM-2441 device performed well against the standard in both the clinical and ambulatory validations; the mean and SD values for the differences between device and observed systolic and diastolic blood pressure values in both tests fulfilled criterion 1 and criterion 2 of the standard. The Bland-Altman plots did not show any systematic variation in the error.

CONCLUSION

The TM-2441 ABPM device was accurate and fulfilled all ISO 81060-2:2013 standard requirements for ABPM determination in adults. It is therefore suitable for use for ABPM in adults with hypertension.

Morning surge in blood pressure and blood pressure variability in Asia: Evidence and statement from the HOPE Asia Network

Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases. To effectively prevent end-organ damage, maintain vascular integrity and reduce morbidity and mortality, it is essential to decrease and adequately control blood pressure (BP) throughout each 24-hour period. Exaggerated early morning BP surge (EMBS) is one component of BP variability (BPV), and has been associated with an increased risk of stroke and cardiovascular events, independently of 24-hour average BP. BPV includes circadian, short-term and long-term components, and can best be documented using out-of-office techniques such as ambulatory and/or home BP monitoring. There is a large body of evidence linking both BPV and EMBS with increased rates of adverse cardio- and cerebrovascular events, and end-organ damage. Differences in hypertension and related cardiovascular disease rates have been reported between Western and Asian populations, including a higher rate of stroke, higher prevalence of metabolic syndrome, greater salt sensitivity and more common high morning and nocturnal BP readings in Asians. This highlights a need for BP management strategies that take into account ethnic differences. In general, long-acting antihypertensives that control BP throughout the 24-hour period are preferred; amlodipine and telmisartan have been shown to control EMBS more effectively than valsartan. Home and ambulatory BP monitoring should form an essential part of hypertension management, with individualized pharmacotherapy to achieve optimal 24-hour BP control particularly the EMBS and provide the best cardio- and cerebrovascular protection. Future research should facilitate better understanding of BPV, allowing optimization of strategies for the detection and treatment of hypertension to reduce adverse outcomes.

An analysis of ambulatory blood pressure monitoring using multi-label classification

Ambulatory blood pressure monitoring (ABPM) involves measuring blood pressure by means of a tensiometer carried by the patient for a duration of 24 h, it currently occupies a central place in the diagnosis and follow-up of hypertensive patients, it provides crucial information which allows to make a specific diagnosis and adapt therapeutic attitude accordingly. The traditional analysis process suffers from different problems: it requires a lot of time and expertise, and several calculations should be performed manually by the expert, who is generally very busy. In this work, we attempt to improve the analysis of ABPM data using multi-label classification methods, where a record is associated with more than one label (class) at the same time. Seven algorithms are experimentally compared on a new multi-label ABPM-dataset. Experiments are conducted on 270 hypertensive patient records characterized by 40 attributes and associated with six labels. Results show that the multi-label modeling of ABPM data helps to investigate label dependencies and provide interesting insights, which can be integrated into the ABPM devices to dispense automatically detailed reports with possible future complications.

Diurnal blood pressure changes

The definition of diurnal blood pressure changes varies widely, which can be confusing. Short-term blood pressure variability during a 24-h period and the dipping status of diurnal blood pressure can be captured by ambulatory blood pressure monitoring, and these metrics are reported to have prognostic significance for cardiovascular complications. Morning blood pressure surge also indicates this risk, but its effect may be limited to populations with specific conditions. Meanwhile, the combined use of conventional office blood pressure and out-of-office blood pressure allows us to identify people with white-coat and masked hypertension. Current home devices can measure nocturnal blood pressure during sleep more conveniently than ambulatory monitoring; however, we should pay attention to blood pressure measurement conditions regardless of whether they are in a home, ambulatory, or office setting. The relatively poor reproducibility of diurnal blood pressure changes, including the nocturnal fall of blood pressure, is another underestimated issue to be addressed. Although information on diurnal blood pressure changes is expected to be used more effectively in the future, we should also keep in mind that blood pressure levels have remained central to the primary and secondary prevention of blood pressure-related cardiovascular diseases in clinical practice.

There is a significant relationship between morning blood pressure surge and increased abdominal aortic intima-media thickness in hypertensive patients

PURPOSE

There are limited data about increased aortic intima-media thickness (A-IMT) in the presence of subclinical target organ damage in hypertensive (HT) patients. In this study, we aimed to determine the frequency of increased A-IMT, the parameters determining increased A-IMT, and the relationship between increased A-IMT and other vascular IMT measurements.

MATERIALS AND METHODS

We prospectively included 265 patients (mean age 54.1 ± 10.6 years, male/female 91/174) with essential HT. Physical examination of all patients was performed. Laboratory data and antihypertensive treatments were recorded. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) was performed. Bilateral carotid, brachial, and femoral artery and abdominal A-IMT values were measured by B-mode ultrasonography (USG). Patients were categorized into two main groups: patients with increased A-IMT (≥ 3 mm) or normal A-IMT (< 3 mm).

RESULTS

Increased A-IMT was detected in 55 patients (20.8%). There was a close relationship between increased A-IMT and advanced age, presence of coronary artery disease, high morning blood pressure surge (MBPS), and bilateral carotid and femoral IMT. Parameters associated with increased A-IMT in univariate analysis were assessed by regression analysis. Left femoral IMT and MBPS were independently associated with increased A-IMT. In the regression model, each 5-mmHg elevation in MBPS increased the risk of increased A-IMT by 34.2%. The cutoff value of MBPS obtained by the ROC curve analysis was 32 mmHg for the prediction of increased A-IMT (sensitivity 76.3%, specificity 63.5%). The area under the curve was 0.784 (95% CI 0.720-0.847, p < 0.001).

CONCLUSION

Abdominal A-IMT increased at a significant rate in patients with HT. An independent association was found between MBPS and A-IMT, which can both be easily detected by ABPM and B-mode USG. The high MBPS level was considered to be a simple and inexpensive method for detecting subclinical target organ damage. A-IMT measurement should also be a part of abdominal USG, which is a routine examination in HT patients.

Morning blood pressure monitoring in the management of hypertension

: The aim of the current article is to review the current evidence on the role of morning blood pressure (BP) in the management of hypertension. Morning BP surge had been and will continue to be a hot topic of hypertension research. However, more evidence is needed to prove its clinical usefulness in the management of hypertension. Masked morning hypertension, as the other forms of masked hypertension, requires more research. The concept of morning BP monitoring could be clinically relevant in the therapeutic management of hypertension and in the prevention of cardiovascular complications by defining and treating morning hypertension. Antihypertensive medication is usually taken in the morning. The presence of uncontrolled morning BP during trough effect hours could be a hallmark of inadequate antihypertensive regimen, such as, for instance, the use of short-acting or intermediate-acting drugs, under dosing of drugs, or no or low use of combination therapy. To improve the management of hypertension in general and morning hypertension in particular, long-acting antihypertensive drugs should be used in appropriate often full dosages and in proper combinations. The clinical usefulness of antihypertensive drugs of specific mechanisms against morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation. In conclusion, there is some evidence that morning BP is critical in the incidence of cardiovascular complications. However, proving its clinical usefulness in the management of hypertension requires further research.

Disrupted day-night pattern of cardiovascular death in obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) patients who suffer sudden cardiac death die predominantly during the night. We aimed to investigate whether all cardiovascular-related deaths display the same night-time peak as sudden cardiac death.

METHODS

Data from a large cohort of adults who underwent full-night polysomnography between 1985 and 2015 in a university-affiliated sleep clinic were analyzed. Time and cause of death of these patients and of persons from the general population were identified in death certificates from the State Health Secretariat. The day-night pattern of cardiovascular death was compared among groups of non-OSA, OSA (apnea-hypopnea index, AHI ≥5), CPAP users, and persons from the general population.

RESULTS

Among 619 certificates, 160 cardiovascular-related deaths were identified. The time of death of the 142 persons with OSA was uniformly distributed over 24 h, with neither an identifiable peak nor a circadian pattern (Rayleigh test; P = 0.8); the same flat distribution was seen in those with purported CPAP use (n = 49). Non-OSA individuals presented a morning peak and a night nadir of deaths, clearer when analyzed in eight-hour intervals. The same pattern was observed in 92 836 certificates from the State general population, with cardiovascular deaths showing the expected morning peak, night nadir, and a significant circadian pattern (Rayleigh test; P < 0.001).

CONCLUSIONS

In OSA patients, the distribution of cardiovascular-related deaths throughout the 24-h period is virtually flat, in contrast with the described nighttime peak of sudden cardiac death. OSA-related phenomena during nighttime might be blunting the mechanisms, arrhythmic or not, behind the morning peak of cardiovascular-related deaths.

White-Coat Effect Is Uncommon in Patients With Refractory Hypertension

Refractory hypertension is a recently described phenotype of antihypertensive treatment failure defined as uncontrolled blood pressure (BP) despite the use of ≥5 different antihypertensive agents, including chlorthalidone and spironolactone. Recent studies indicate that refractory hypertension is uncommon, with a prevalence of ≈5% to 10% of patients referred to a hypertension specialty clinic for uncontrolled hypertension. The prevalence of white-coat effect, that is, uncontrolled automated office BP ≥135/85 mm Hg and controlled out-of-office BP <135/85 mm Hg, by awake ambulatory BP monitor in hypertensive patients overall is ≈30% to 40%. The prevalence of white-coat effect among patients with refractory hypertension has not been previously reported. In this prospective evaluation, consecutive patients referred to the University of Alabama at Birmingham Hypertension Clinic for uncontrolled hypertension were enrolled. Refractory hypertension was defined as uncontrolled automated office BP ≥135/85 mm Hg with the use of ≥5 antihypertensive agents, including chlorthalidone and spironolactone. Automated office BP measurements were based on 6 serial readings, done automatically with the use of a BpTRU device unobserved in the clinic. Out-of-office BP measurements were done by 24-hour ambulatory BP monitor. Thirty-four patients were diagnosed with refractory hypertension, of whom 31 had adequate ambulatory BP monitor readings. White-coat effect was present in only 2 patients, or 6.5% of the 31 patients with refractory hypertension, suggesting that white-coat effect is largely absent in patients with refractory hypertension. These findings suggest that white-coat effect is not a common cause of apparent lack of BP control in patients failing maximal antihypertensive treatment.

Prognostic Value of Nondipping and Morning Surge in Elderly Treated Hypertensive Patients With Controlled Ambulatory Blood Pressure

BACKGROUND

The independent prognostic significance of nondipping and morning surge (MS) of blood pressure (BP) in treated hypertensive patients with controlled ambulatory BP is not yet clear. We investigated the association between the aforesaid ambulatory BP parameters and cardiovascular risk in elderly treated hypertensive patients with normal achieved ambulatory BP.

METHODS

The occurrence of a composite end-point (stroke, coronary events, heart failure, and peripheral revascularization) was evaluated in 391 elderly treated hypertensive patients (age range 60-90 years) with controlled ambulatory BP (both daytime BP <135/85 mm Hg and nighttime BP <120/70 mm Hg). According to nighttime change and MS of systolic BP, subjects were divided in dippers with normal or high MS (>23 mm Hg) and nondippers.

RESULTS

During the follow-up (9.3 ± 4.6 years, range 0.5-20 years), 76 events occurred. The event-rate was 2.09 per 100 patient-years. After adjustment for age, gender, left ventricular (LV) hypertrophy, asymptomatic LV systolic dysfunction at baseline and left atrial enlargement, dippers with high MS (hazard ratio 2.45, 95% confidence interval 1.27-4.73, P = 0.007) and nondippers (hazard ratio 2.04, 95% confidence interval 1.18-3.53, P = 0.01) were at higher cardiovascular risk than dippers with normal MS.

CONCLUSIONS

In elderly treated hypertensive patients with normal achieved ambulatory BP, dippers with high MS and nondippers are at increased cardiovascular risk.

Target organ damage in primary hypertensive patients: role of the morning heart rate surge

BACKGROUND

The morning heart rate surge (MHRS) and morning blood pressure surge (MBPS) may be responsible for the high prevalence of cardiovascular events during the morning period. The clinical significance of the MBPS has been well established, but that of the MHRS remains unclear. Thus, we evaluated the association between the MHRS and target organ damage (TOD).

METHODS

A cross-sectional study of 580 hypertensive patients was performed. MHRS and heart rate variability (HRV) were analyzed by 24 h electrocardiogram. TOD was assessed by estimated glomerular filtration rate, carotid intima-media thickness (IMT), and left ventricular mass index.

RESULTS

The prevalence of TOD tended to decrease with sleep-trough MHRS (first to fourth quartiles: 71%, 70.3%, 58.6%, and 52.7%, respectively) or prewaking MHRS quartiles (first to fourth quartiles: 65.3%, 73.6%, 61.4%, and 54.2%, respectively), whereas the opposite trend was observed for standard deviation of all normal NN intervals (SDNN). Moreover, sleep-trough MHRS, prewaking MHRS, SDNN, and SDNN index were significantly lower in patients with TOD than in those without TOD. According to four logistic regression models, the associations of prewaking MHRS, SDNN, and SDNN index with TOD were lost after adjustment for age and BP. Patients in the first (≤11.125 bpm) and second sleep-trough MHRS quartiles (11.125-15.75 bpm) had a 1.95-2.06-fold increased risk of TOD compared with those in the fourth quartile (p < 0.05).

CONCLUSION

A blunted sleep-trough MHRS, which may serve as a surrogate marker for autonomic imbalance, was independently associated with TOD in primary hypertensive patients.

Secondary Stroke Prevention: Improving Diagnosis and Management with Newer Technologies

Treatment of hypertension, diabetes, high cholesterol, smoking cessation, and healthy lifestyle have all contributed to the decline in the incidence of vascular disease over the last several decades. Patients who suffer an acute stroke are at a high risk for recurrence. Introduction of newer technologies and their wider use allows for better identification of patients in whom the risk of recurrence following an acute stroke may be very high. Traditionally, the major focus for diagnosis and management has focused on patient history, examination, imaging for carotid stenosis/occlusion, and detection of AF and paroxysmal AF (PAF) with 24-48 h cardiac monitoring. This review focuses on the usefulness of three newer investigative tools that are becoming widely available and lead to better prevention. Continuous ambulatory blood pressure measurements for 24 h or longer and 3D Doppler measures of the carotid arteries provide key useful information on the state of vascular health and enhance our ability to monitor the response to preventive therapies. Furthermore, the detection of PAF can be significantly improved with prolonged cardiac monitoring for 3 weeks or longer, enabling the initiation of appropriate prevention therapy. This review will focus on the potential impact and importance of these emerging technologies on the prevention of recurrent stroke in high-risk patients.

Left Ventricular Hypertrophy – the Problem and Possible Solutions

Left ventricular hypertrophy (LVH), which describes pathological changes in cardiac structure, is a powerful and reversible predictor of cardiovascular risk. There is a continuous relationship between left ventricular mass (LVM) and the likelihood of cardiovascular events, with no cut-off between the absence of such events and heightened risk. A correlation between LVH and blood pressure is well established. There is a paradox, however, that the structural changes to the heart as a result of increased workload due to high blood pressure appear to promote cardiovascular disease. This may be partially explained by the fact that ambulatory blood pressure measurements correlate more closely with LVH than resting blood pressure. Blood pressure variation throughout the day is also emerging as an important correlate of LVH, and a strong association has been identified between an early morning rise in blood pressure and increased LVM. Use of anti-hypertensive agents not only lowers blood pressure, but can also bring about LVH regression. The pathological role of angiotensin II in LVH and target-organ damage within the cardiovascular continuum suggest that agents targeting the renin – angiotensin - aldosterone system (RAAS), such as the angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, may prove particularly effective and may confer beneficial effects in addition to the lowering of blood pressure. The angiotensin II receptor blockers may be very appropriate treatment options because of their placebo-like tolerability and the possibility of more complete blockade of the RAAS. Within this class of anti-hypertensive agents, pharmacological differences may mean that some agents afford greater cardioprotection than others.

Time of administration important? Morning versus evening dosing of valsartan

Objective:

Studies suggest that bedtime dosing of an angiotensin-converting enzyme (ACE)-inhibitor or angiotensin receptor blocker shows a more sustained and consistent 24-h antihypertensive profile, including greater night-time blood pressure (BP) reduction. We compared the antihypertensive effects of morning (a.m.) and evening (p.m.) dosing of valsartan on 24-h BP.

Methods:

This 26-week, multicentre, randomized, double-blind study evaluated the efficacy and safety of valsartan 320 mg, dosed a.m. or p.m., versus lisinopril 40 mg (a.m.), a long-acting ACE-inhibitor, in patients with grade 1–2 hypertension and at least one additional cardiovascular risk factor. Patients (n = 1093; BP = 156 ± 11/91 ± 8 mmHg; 62 years, 56% male, 99% white) received (1 : 1 : 1) valsartan 160 mg a.m. or p.m. or lisinopril 20 mg a.m. for 4 weeks, then force-titrated to double the initial dose for 8 weeks. At Week 12, hydrochlorothiazide (HCTZ) 12.5 mg was added for 14 weeks if office BP was more than 140/90 mmHg and/or ambulatory BP more than 130/80 mmHg.

Results:

Mean 24-h ambulatory SBP change from baseline to Weeks 12 and 26 was comparable between valsartan a.m. (–10.6 and –13.3 mmHg) and p.m. (–9.8 and –12.3 mmHg) and lisinopril (–10.7 and –13.7 mmHg). There was no benefit of valsartan p.m. versus a.m. on night-time BP, early morning BP and morning BP surge. Evening dosing also did not improve BP lowering in patients requiring add-on HCTZ or in nondippers at baseline. All treatments were well tolerated.

Conclusion:

Once-daily dosing of valsartan 320 mg results in equally effective 24-h BP efficacy, regardless of dosing time.

Trial Registration:

ClinicalTrials.gov Identifier: NCT00241124.

Morning Blood Pressure Surge, Dipping, and Risk of Coronary Events in Elderly Treated Hypertensive Patients

BACKGROUND

The independent prognostic significance of morning surge (MS) of blood pressure (BP) is not yet clear. We investigated the association between MS of systolic BP and risk of coronary events in elderly treated hypertensive patients.

METHODS

The occurrence of coronary events was evaluated in 1,191 elderly treated hypertensive patients (age range 60-90 years). Subjects were divided according to tertiles of MS of systolic BP of the population as a whole, by dipping status and by group-specific tertiles of MS of systolic BP in dippers and nondippers.

RESULTS

During the follow-up (9.1 ± 4.9 years, range 0.4-20 years), 120 coronary events occurred. In the population as a whole, coronary event risk was not significantly associated with tertiles of MS of systolic BP, whereas nondippers were at higher risk than dippers. When nondippers and dippers were analyzed separately, by group-specific tertiles of MS of systolic BP, coronary event risk was associated with MS of systolic BP in dippers but not in nondippers. After adjustment for various covariates, Cox regression analysis showed that dippers in the third tertile (>23 mm Hg) of MS of systolic BP (hazard ratio 1.912, 95% confidence interval 1.048-3.488, P = 0.03) and nondippers (hazard ratio 1.739, 95% confidence interval 1.074-2.815, P = 0.02) were at higher coronary event risk than dippers with MS of systolic BP <23 mm Hg .

CONCLUSIONS

In elderly treated hypertensive patients, high MS of systolic BP predicts coronary events in dippers but not in nondippers. Nondippers, however, show higher risk of coronary events independently of MS in systolic BP.

Morning blood pressure surge and target organ damage in newly diagnosed type 2 diabetic patients: a cross sectional study

BACKGROUND

Type 2 diabetic patients display significantly higher incidence of cardiovascular (CV) events including stroke compared to non-diabetics. Morning blood pressure surge (MBPS) and blunted systolic night-day (SND) ratio have been associated with CV events in hypertensive patients. No studies have evaluated MBPS in newly diagnosed diabetic patients or studied the association with vascular target organ damage at this early time point of the diabetes disease.

METHODS

Ambulatory blood pressure monitoring was performed in 100 patients with newly diagnosed type 2 diabetes and 100 age and sex matched controls. MBPS and SND-ratio were calculated. Markers of early vascular target organ damage included pulse wave velocity (PWV), white matter lesions (WML) on brain MRI, and urine albumin/creatinine ratio (UAE).

RESULTS

No significant differences in MBPS were found between diabetic patients and controls. Neither MBPS or SND-ratio were associated with PWV, UAE or WML in the diabetic group independently of age, gender and 24-h systolic blood pressure. 40.2 % of diabetic patients and 25.8 % of controls were classified as non-dippers (p = 0.03).

CONCLUSION

MBPS and SND-ratio are not associated with subclinical markers of vascular target organ damage in our study sample of newly diagnosed type 2 diabetic patients.

Blood pressure morning surge, exercise blood pressure response and autonomic nervous system

OBJECTIVE

We investigated blood pressure (BP) response to exercise with respect to BP morning surge (MS), and the association between MS, exercise treadmill test (ETT) and heart rate variability (HRV) indices.

DESIGN

Eighty-four healthy subjects without hypertension were enrolled. Ambulatory BP monitoring and 24-hour Holter recordings were obtained for sleep-trough MS and HRV indices: low-frequency (LF) component, high-frequency (HF) component and LF/HF ratio. ETT was performed, and BPs were obtained at rest, end of each stage, and recovery. Third-minute heart rate recovery (HRR) and BP recovery ratio (BPRR) were calculated.

RESULTS

When analysed in quartiles of MS, systolic BP at low workloads was higher in the highest than in the lowest quartile, although maximum BPs at maximum exercise were not significantly different. BPRR was highest in the highest quartile in contrast to HRR, which was lowest in the highest quartile. LF/HF was highest during both at daytime and night-time in the highest quartile. BPRR and LF/HF were positively, and HRR was inversely associated with MS.

CONCLUSIONS

Subjects with a high MS have higher BP at low workloads, at which most daily activities are performed, and impairment in some indices, which indirectly reflect the autonomic nervous system.

Prognostic significance of the morning blood pressure surge in clinical practice: a systematic review

BACKGROUND

An exaggerated morning blood pressure surge (MBPS) may be associated with stroke and other cardiovascular events, but the threshold at which an MBPS becomes pathological is unclear. This study aimed to systematically review the existing literature and establish the most appropriate definition of pathological MBPS.

METHODS

A MEDLINE search strategy was adapted for a range of literature databases to identify all prospective studies relating an exaggerated MBPS to cardiovascular endpoints. Hazard ratios (HRs) were extracted and synthesized using random-effects meta-analysis.

RESULTS

The search strategy identified 2,964 unique articles, of which 17 were eligible for the study. Seven different definitions of MBPS were identified; the most common was a prewaking surge (mean blood pressure for 2 hours after wake-up minus mean blood pressure for 2 hours before wake-up; n = 6 studies). Summary meta-analysis gave no clear evidence that prewaking MBPS (defined by a predetermined threshold: >25-55 mm Hg) was associated with all cardiovascular events (n = 2 studies; HR = 0.94, 95% confidence interval (CI) = 0.39-2.28) or stroke (n = 2 studies; HR = 1.26, 95% CI = 0.92-1.71). However, using a continuous scale, which has more power to detect an association, there was evidence that a 10 mm Hg increase in MBPS was related to an increased risk of stroke (n = 3 studies; HR = 1.11, 95% CI = 1.03-1.20).

CONCLUSIONS

These findings suggest that when measured and analyzed as a continuous variable, increasing levels of MBPS may be associated with increased risk of stroke. Large, protocol-driven individual patient data analyses are needed to accurately define this relationship further.

Effect of azilsartan versus candesartan on morning blood pressure surges in Japanese patients with essential hypertension

Morning blood pressure (BP) surge is reported as a risk factor for cardiovascular events and end-organ damage independent of the 24-h BP level. Controlling morning BP surge is therefore important to help prevent onset of cardiovascular disease. We compared the efficacy of azilsartan and candesartan in controlling morning systolic BP (SBP) surges by analyzing relevant ambulatory BP monitoring data in patients with/without baseline BP surges. As part of a 16-week randomized, double-blind study of azilsartan (20-40 mg once daily) and candesartan (8-12 mg once daily) in Japanese patients with essential hypertension, an exploratory analysis was carried out using ambulatory BP monitoring at baseline and week 14. The effects of study drugs on morning BP surges, including sleep trough surge (early morning SBP minus the lowest night-time SBP) and prewaking surge (early morning SBP minus SBP before awakening), were evaluated. Patients with sleep trough surge of at least 35 mmHg were defined by the presence of a morning BP surge (the 'surge group'). Sleep trough surge and prewaking surge data were available at both baseline and week 14 in 548 patients, 147 of whom (azilsartan 76; candesartan 71) had a baseline morning BP surge. In surge group patients, azilsartan significantly reduced both the sleep trough surge and the prewaking surge at week 14 compared with candesartan (least squares means of the between-group differences -5.8 mmHg, P=0.0395; and -5.7 mmHg, P=0.0228, respectively). Once-daily azilsartan improved sleep trough surge and prewaking surge to a greater extent than candesartan in Japanese patients with grade I-II essential hypertension.

Relationship Among Morning Blood Pressure Surge, 24-Hour Blood Pressure Variability, and Cardiovascular Outcomes in a White Population

Cardiovascular events have their greatest prevalence in the early morning period. Whether this is attributable to an arousal-dependent blood pressure (BP) increase is far from being clear. It is also not clear to what extent this phenomenon reflects overall 24-hour BP variability. In 2051 subjects (aged 25–74 years) representative of the population of Monza (Italy), we measured 24-hour ambulatory systolic BP (SBP) and calculated the difference between the 2-hour average values after morning arousal and the lowest 3 or average 2-hour values before arousal (morning BP surge 1 and 2, respectively). For either measure, we sought the relationship with a variety of indices of 24-hour SBP variability and collected information on (1) the occurrence of cardiovascular and all cause deaths during a follow-up of ≈16 years and (2) the appearance of echocardiographic left ventricular hypertrophy after 10 years from the baseline visit. Morning SBP surge 1 was directly related to indices of 24-hour SBP variability, including those made independent on the magnitude of the day–night SBP difference. There was a weak positive relationship between morning SBP surge 1 and the risk of cardiovascular and all-cause death, which disappeared after adjustment for confounders. This was the case also for development of left ventricular hypertrophy. Morning SBP surge 2 was smaller, inconsistently related to 24-hour SBP variability and not at all related to fatal events or new-onset left ventricular hypertrophy. In a white population, morning BP surge was not found to be an independent predictor of cardiovascular death, all-cause death, or development of high cardiovascular risk (as documented by new-onset cardiac damage) even when appropriately assessed by measures that reflect its association with 24-hour BP variability.