Clinical Significance and Therapeutic Implication of Nocturnal Hypertension: Relationship between Nighttime Blood Pressure and Quality of Sleep

Antihypertensive effect of esaxerenone and correlation between brachial and wrist home monitoring devices in patients with nocturnal hypertension: A post hoc analysis of the EARLY-NH study

Adequate management of nocturnal hypertension is crucial to reduce the risk of organ damage and cardiovascular events. The EARLY-NH study was a prospective, open-label, multicenter study conducted in Japanese patients with nocturnal hypertension who received esaxerenone treatment for 12 weeks. This post hoc analysis aimed to assess (1) the relationship between changes in morning home systolic blood pressure (SBP), bedtime home SBP, and nighttime home SBP based on changes in SBP and achievement rates of target SBP levels; and (2) the correlation between nighttime home SBP measurements using brachial and wrist home BP monitoring (HBPM) devices. This analysis evaluated 82 patients who completed the 12-week treatment period. Among those who achieved target morning home SBP (<135 mmHg) and target bedtime home SBP (<135 mmHg), the brachial HBPM device showed achievement rates of 63.6% and 56.4%, respectively, for target nighttime home SBP (<120 mmHg). The wrist device showed achievement rates of 66.7% and 63.4%, respectively, for the same targets. Significant correlations were observed between both devices for nighttime home SBP measurements at baseline (r = 0.790), Week 12 (r = 0.641), and change from baseline to Week 12 (r = 0.533) (all, p < .001). In this patient population, approximately 60% of individuals who reached target morning or bedtime home SBP levels <135 mmHg exhibited well-controlled nighttime home SBP. Although nighttime home SBP measurements obtained using both brachial and wrist HBPM devices displayed a significant correlation, the wrist device needs to be examined in more detail for clinical use.

Circadian and Diurnal Regulation of Cerebral Blood Flow

Circadian and diurnal variation in cerebral blood flow directly contributes to the diurnal variation in the risk of stroke, either through factors that trigger stroke or due to impaired compensatory mechanisms. Cerebral blood flow results from the integration of systemic hemodynamics, including heart rate, cardiac output, and blood pressure, with cerebrovascular regulatory mechanisms, including cerebrovascular reactivity, autoregulation, and neurovascular coupling. We review the evidence for the circadian and diurnal variation in each of these mechanisms and their integration, from the detailed evidence for mechanisms underlying the nocturnal nadir and morning surge in blood pressure to identifying limited available evidence for circadian and diurnal variation in cerebrovascular compensatory mechanisms. We, thus, identify key systemic hemodynamic factors related to the diurnal variation in the risk of stroke but particularly identify the need for further research focused on cerebrovascular regulatory mechanisms.

The mediating effect of sleep disturbance on the association between hypertension and depression: a national data analysis

BACKGROUND

Sleep disturbance is a common among people with hypertension. However, the mediating role of sleep disturbance in the association between hypertension and depression remains unclear. This study aims to investigate the mediating role of sleep disturbance in the association between hypertension and depression.

MATERIALS AND METHODS

This was cross-sectional study. The data were derived from the Indonesian Family Life Survey Fifth Wave (2014-2015). We include a total of 19,138 adults' participants with age range from 18 to 65 years old who completed response on the variable of hypertension, sleep disturbance, and depression. The mediating model analysis was processed using the PROCESS macro ins SPSS from Hayes model.

RESULTS

Depression was reported by 22% of total respondents. The group with hypertension showed a substantially higher prevalence of depression than non-hypertension group (P < 0.001). Hypertension had a significant overall effect on depression (β = 0.682; 95%CI 0.489 to 0.875, P < 0.001). The direct effect of hypertension on depression was significant (β = 0.418; 95%CI 0.244 to 0.592, P < 0.001) and the indirect effect that mediated by sleep disturbance was also significant (β = 0.264, 95%CI 0.174 to 0.356, P < 0.001). It is worth noting that sleep disturbance partially mediated the association between hypertension and depression.

CONCLUSION

The findings of this study indicated that sleep disturbance contributed to the etiology of depression and hypertension in adult populations. Nurses should be involved in managing sleep disturbances, such as using behavioral therapy, as it may serve as both a treatment and primary prevention measure for depression and hypertension.

Feasibility of Unobtrusively Estimating Blood Pressure Using Load Cells under the Legs of a Bed

The ability to monitor blood pressure unobtrusively and continuously, even during sleep, may promote the prevention of cardiovascular diseases, enable the early detection of cardiovascular risk, and facilitate the timely administration of treatment. Publicly available data from forty participants containing synchronously recorded signals from four force sensors (load cells located under each leg of a bed) and continuous blood pressure waveforms were leveraged in this research. The focus of this study was on using a deep neural network with load-cell data as input composed of three recurrent layers to reconstruct blood pressure (BP) waveforms. Systolic (SBP) and diastolic (DBP) blood pressure values were estimated from the reconstructed BP waveform. The dataset was partitioned into training, validation, and testing sets, such that the data from a given participant were only used in a single set. The BP waveform reconstruction performance resulted in an R2 of 0.61 and a mean absolute error < 0.1 mmHg. The estimation of the mean SBP and DBP values was characterized by Bland-Altman-derived limits of agreement in intervals of [-11.99 to 15.52 mmHg] and [-7.95 to +3.46 mmHg], respectively. These results may enable the detection of abnormally large or small variations in blood pressure, which indicate cardiovascular health degradation. The apparent contrast between the small reconstruction error and the limit-of-agreement width owes to the fact that reconstruction errors manifest more prominently at the maxima and minima, which are relevant for SBP and DBP estimation. While the focus here was on SBD and DBP estimation, reconstructing the entire BP waveform enables the calculation of additional hemodynamic parameters.

Should Antihypertensive Medications Be Routinely Administered in the Nighttime Instead of Daytime?

The optimal timing for administering antihypertensive medications remains a topic of debate. This review examines the effectiveness of nighttime vs daytime administration of antihypertensive medications in controlling blood pressure (BP). The MAPEC and Hygia trials suggest that nighttime dosing achieves better BP control and significantly lowers cardiovascular events. However, concerns about methodology and generalizability have been raised. In contrast, the HARMONY and TIME trials found no significant difference in BP control nor cardiovascular outcomes between daytime and nighttime dosing. Current research suggests that the timing of antihypertensive medication administration may not be a crucial factor. Therefore, the decision about the timing of antihypertensive medications administration should be individualized, taking into account patient preference and clinical context, in order to promote consistent compliance.

Clinical and life style factors related to the nighttime blood pressure, nighttime dipping and their phenotypes in Korean hypertensive patients

BACKGROUND

Non-dipping or reverse dipping patterns are known to be associated with adverse cardiovascular prognosis among the general population and clinical cohort. Few large sized studies have explored factors including sleep duration and sleep quality related to nighttime blood pressure (BP) and nocturnal dipping patterns.

METHODS

Among 5,360 patients enrolled  in Korean multicenter nationwide prospective Registry of ambulatory BP monitoring (KORABP), 981 subjects with complete data on sleep duration, sleep quality assessed using a 4-point Likert scale, and clinical variables were included in the analysis. Phenotypes of nighttime BP pattern were categorized as extreme dipper, dipper, non-dipper, and reverse dipper. Hypertension was defined as a 24-h ambulatory BPs were 130/80 mmHg or higher.

RESULTS

Among 981 subjects, 221 were normotensive, 359 were untreated hypertensive, and 401 were treated hypertensive. Age of the participants were 53.87 ± 14.02 years and 47.1% were female. In overall patients, sleep duration was 431.99 ± 107.61 min, and one to four points of sleep quality were observed in 15.5%, 30.0%, 30.4%, and 24.2%, respectively. Of the 760 hypertensive patients, extreme dipper, dipper, non-dipper, and reverse dipper were observed in 58 (7.63%), 277 (36.45%), 325 (42.76%), and 100 (13.16%), respectively. In multiple linear regression analysis, sleep duration (β = 0.0105, p < 0.001) and sleep quality (β = -0.8093, p < 0.001) were associated with nighttime systolic BP and sleep quality was associated with extent of nighttime systolic BP dipping (β = 0.7622, p < 0.001) in hypertensive patients. In addition, sleep quality showed positive association with dipper pattern (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.03-1.30) and showed negative association with reverse dipper pattern (OR = 0.73, 95% CI = 0.62-0.86) in multiple logistic regression analyses.

CONCLUSION

When adjusted covariates, less sleep duration and poor sleep quality were positively associated with nighttime systolic BP. Additionally, sleep quality was the independent associated factor for dipper and reverse dipper phenotypes. The study also found that male sex, low estimated glomerular filtration rate, high ambulatory BP, low office BP, and poor sleep quality were associated with blunted nighttime SBP dipping.

Heart Rate During Sleep in PTSD Patients: Moderation by Contact with a Service Dog

There is growing interest in the potential health benefits of dog ownership in both the lay and scientific communities. Large reductions in risk for cardiovascular disease and all-cause mortality in dog owners relative to non-owners have been observed in epidemiological samples. Persons diagnosed with posttraumatic stress disorder exhibit elevated risk for cardiovascular disease. The current study tested a sample of 45 U.S. military veterans with deployment-related posttraumatic stress disorder employing an intensive, longitudinal, within-subjects design contrasting sleep heart rate on nights with and without a service dog. As participants were engaged in residential psychiatric treatment, sleep opportunities, waking activities, meals, and medications, were consistently scheduled. The primary recording methodology, mattress actigraphy, enabled passive quantification of heart rate over a total sample of 1097 nights. Service dog contact was associated with reduced sleep heart rate especially in participants with more severe PTSD. Longer-term longitudinal studies will be needed to assess the durability and asymptotic magnitude of this effect. An unexpected effect of nights in study was associated with increased heart rate consistent with hospitalization-associated deconditioning.

Pathophysiology of the Nondipping Blood Pressure Pattern

The nondipping blood pressure (BP) pattern corresponds to a disruption in the circadian BP rhythm with an insufficient decrease in BP levels during nighttime sleep as observed using 24-hour ambulatory BP monitoring. Patients with nondipping BP pattern have poorer renal and cardiovascular outcomes, independent of their average 24-hour BP levels. The pathophysiology of nondipping BP is complex and involves numerous mechanisms: perturbations of (1) the circadian rhythm, (2) the autonomic nervous system, and (3) water and sodium regulation. This review provides an outline of the pathways potentially involved in the nondipping BP profile in different conditions. A recent hypothesis is also discussed involving the role of gut microbiota in the dipping/nondipping patterns, via the fecal diet-derived short chain fatty acids.

Impact of oscillometric measurement artefacts in ambulatory blood pressure monitoring on estimates of average blood pressure and of its variability: a pilot study

OBJECTIVE

Ambulatory blood pressure monitoring (ABPM) plays an important role in the diagnosis of hypertension. However, methodological factors and the measurement conditions affect the results and may lead to incorrect classification of the patient. We performed a pilot study to evaluate the impact of oscillometric measurement artefacts on ABPM-derived variables.

METHODS

Four classes of artefacts have been detected: motor activity artefacts, cuff errors, cardiovascular arousals, and arrhythmias. The data consisted of uncorrected measurements (all data), corrected measurements (all artefact free data), and artefact affected data.

RESULTS

A total of 30 individuals (9 female/21 male), aged between 36 and 86 years, mean: 65.5 (standard deviation: 9.5) were included in the study. The average blood pressure (BP) was higher in artefacts-affected measurements compared the artefact-free measurements both for systolic (4.6 mmHg) and diastolic (1.3 mmHg) measurements. Further, artefact-affected systolic BP (SBP) was 6.4 mmHg higher than artefact-free measurements during daytime. Nocturnal measurements showed no artefact-depended differences. Individual comparisons yielded that 23% of the participants crossed the threshold for BP classification for either 24-h, daytime or nocturnal hypertension when comparing uncorrected and artefact-free measurements. Dipping classification changed within 24% of participants. BP variability was 21 and 12% higher for SPB and DBP, respectively, during daytime. These differences were even higher (27% for SBP and 21% for DPB) during night-time.

CONCLUSION

The study reveals that measurement artefacts are frequently present during cuff-based ABPM and do relevantly affect measurement outcome. Exclusion of measurement artefacts is a promising approach to improving cuff-based ABPM accuracy.

Subjective social status and nocturnal blood pressure dipping

OBJECTIVE

Low social status has been linked to cardiovascular disease. Subjective social status (SSS), which represents one's perceived position in a social hierarchy, has been suggested to predict health outcomes beyond objective measures of socioeconomic status. The present study examined if lower SSS is related to reduced nocturnal blood pressure (BP) dipping, a risk factor for cardiovascular disease.

METHODS

In this cross-sectional study, a community sample of 53 healthy adults underwent 24-h ambulatory BP monitoring. All participants provided information on SSS and objective measures of socioeconomic status (i.e., education, occupation, and income). SSS was measured in comparison to others in the country (national SSS) as well as in comparison to one's social environment (local SSS) using the German versions of the MacArthur Scales.

RESULTS

Analyses found that participants with low local SSS exhibited attenuated nocturnal diastolic blood pressure dipping (β = 0.29, 95% CI [0.01, 0.57], p = .043) and mean arterial pressure dipping (β = 0.29, 95% CI [0.01, 0.57], p = .041). These associations remained significant after adjusting for objective socioeconomic status. No significant associations between national SSS and cardiovascular measures were observed.

CONCLUSION

In conclusion, one's perceived social position in the social environment (i.e., local SSS) is associated with nocturnal BP dipping. Therefore, local SSS may be an important psychosocial factor linking social inequality and cardiovascular health.

Lower ambulatory nocturnal SBP is associated with less cardiovascular and renal damage in normotensive hospitalized patients with chronic kidney disease

OBJECTIVE

The impact of nocturnal blood pressure (BP) on target organ damage (TOD) in chronic kidney disease (CKD) patients with normotension has not been established. In this study, we determined whether nocturnal BP is correlated with cardiovascular and renal damage independent of the 24-h BP in CKD patients with normotension or hypertension.

METHODS

A total of 1166 hospitalized patients with CKD not requiring dialysis were enrolled in this cross-sectional study, 421 and 745 of whom had normotension and hypertension, respectively. TOD was assessed by the left ventricular mass index (LVMI), estimated glomerular filtration rate (eGFR) and presence of proteinuria. Univariate and multivariable regression analyses were used to evaluate the relationships between nocturnal BP and TOD.

RESULTS

In the multivariable-adjusted models, including the 24-h BP, nocturnal SBP was independently associated with the LVMI, eGFR and proteinuria in patients with normotension (P < 0.05), while the nocturnal DBP was not correlated with proteinuria. The nocturnal SBP was associated with LVMI and proteinuria, but not the eGFR in patients with hypertension. We did not demonstrate an association between nocturnal DBP and TOD in these patients. When nocturnal SBP in patients with normotension was further divided into tertiles [tertile 1 (<104 mmHg), tertile 2 (104-114 mmHg) and tertile 3 (≥114 mmHg)], multivariate analysis showed that tertile 3 was independently associated with TOD.

CONCLUSION

Nocturnal SBP was shown to be an independent risk factor for TOD in patients with normotension. Targeting a nocturnal ambulatory SBP to less than 114 mmHg or even less than 104 mmHg may help prevent TOD in patients with CKD.

Influence of elevated sleep-time blood pressure on vascular risk and hypertension-mediated organ damage

We report the analysis of 252 hypertensive patients whose blood pressure (BP) was assessed by around-the-clock ambulatory BP monitoring compared to office BP measurement during a follow-up investigation of 8.7 y (SD: 2.43 y) that evaluated the added value of measuring sleep-time BP values. We found that 37.3% of the patients had mismatched diagnoses between the two techniques of BP assessment, with 11.5% of the patients showing white-coat hypertension and 25.8% masked hypertension. Only 12.3% of the diagnosed and treated patients presented normal BP values. Nocturnal (sleep-time) hypertension was present in 70.63%. The sleep-time systolic BP mean was found to be an independent vascular risk factor (F = 9.005, p < .001), indirectly measured through the 10-year risk of morbidity and mortality. Additionally, the elevated sleep-time systolic BP mean was a better marker of subclinical hypertension-mediated organ damage (ρ = 0.19, p < .01) than either the awake (ρ = 0.168, p < .01) or 24 (ρ = 0.184, p < .01) systolic BP means. In conclusion, the accuracy and sleep-time measurements provided by ambulatory BP make it particularly relevant in hypertension diagnosis and management. The use of the ambulatory BP measurement method could end up modifying current therapeutic targets, with sleep-time systolic BP mean becoming a main one, in order to optimize hypertension control and reduce hypertension-related organ pathology and cardiovascular disease morbidity and mortality.

Total Atherosclerosis Burden of Baroreceptor-Resident Arteries Independently Predicts Blood Pressure Dipping in Patients With Ischemic Stroke

Supplemental Digital Content is available in the text.

Nighttime blood pressure (BP) generally dips by 10% to 20% of the daytime values, and abnormal BP dipping may affect vascular health independently of BP level. The regulation of BP dipping involves arterial baroreflex, whose receptors mainly reside in carotid sinuses and aortic arch. Atherosclerosis in these baroreceptor-resident arteries (BRAs) is frequent among patients with ischemic stroke (IS) and might impair their BP-regulating capacity. We aimed to examine associations between atherosclerosis of BRA and BP dipping in patients with IS. BP dipping ratio was measured by 24-hour ambulatory blood pressure monitoring on the sixth day after IS. With computed tomography angiography, atherosclerosis conditions in 10 segments of carotid sinuses and aortic arch were scored and summed as total atherosclerosis burden of BRA. Among the 245 patients with IS, 78.0% had atherosclerosis in BRA. The total AS burden of BRA was negatively correlated with systolic BP dipping ratio (r=−0.331; P<0.001) and diastolic BP dipping ratio (r=−0.225; P<0.001). After adjusting for age, sex, vascular risk factors, 24-hour BP means, cervical and intracranial atherosclerosis scores, the negative correlations still existed (adjusted β, −0.259 [95% CI, −0.416 to −0.102] and adjusted β, −0.178 [95% CI, −0.346 to −0.010], respectively). In conclusion, higher total atherosclerosis burden of BRA was independently indicative of more blunted dipping of systolic BP and diastolic BP in IS. The total atherosclerosis burden of BRA might be important for predicting and managing BP dipping in patients with IS.

QTc Interval Predicts Disturbed Circadian Blood Pressure Variation

Background

The relationship between electrocardiographic evaluation and circadian blood pressure (BP) variation in young and middle-aged hypertensive patients remains unknown.

Methods

A total of 171 hypertensive patients were included in the study. First, patients were divided into a young and middle-aged group and an elderly group. The two groups were then separately classified into three subgroups on the basis of circadian variation of BP as dippers, non-dippers and reverse-dippers. The electrocardiographic evaluation was calculated from 12-lead electrocardiography (ECG).

Results

QTc intervals were shortest in the dippers and longest in the reverse-dippers in the young and middle-aged group (QTc dipper: 416.53±18.37ms; non-dipper: 438.30±29.71ms; reverse-dipper: 444.93±25.47ms; for dipper vs non-dipper, and dipper vs reverse-dipper P<0.05). QTc interval was found to be an independent risk factor for the non-dipper BP pattern (Odds ratio 1.049; 95% CI 1.01-1.089; P=0.012) and reverse-dipper BP pattern (Odds ratio 1.051; 95% CI 1.007-1.098; P=0.023) in young and middle-aged hypertensive patients. No significant differences in other ECG parameters were found among the three subgroups in the young and middle-aged group.

Conclusion

Our study suggested that QTc interval might serve as a risk factor for non-dipper BP pattern and reverse-dipper BP pattern in young and middle-aged hypertensive patients.

Heart rate acceleration and deceleration capacities associated with circadian blood pressure variation

Background

Heart rate acceleration and deceleration capacities are novel parameters that can quantify sympathetic and vagal modulation. However, how acceleration and deceleration capacities associated with circadian blood pressure (BP) variation remains unknown.

Methods

A total of 141 patients with essential hypertension were included in our study. Based on the nocturnal decline rate of systolic BP (SBP), patients were divided into two groups, as dippers and nondippers. Baseline demographic characteristics, ambulatory blood pressure monitoring (ABPM) parameters, Holter recordings, and echocardiographic parameters were collected.

Results

The absolute values of acceleration capacity (AC) (−7.75 [−8.45 ~ −6.3] ms vs. −6.6 [−8.25 ~ −5.2] ms, p = .047) and deceleration capacity (DC) (7.35 [6.1 ~ 8.1] ms vs. 6.3 [5.1 ~ 7.6] ms, p = .042) were significantly higher in dippers than in nondippers. By multivariate logistic regression analysis, left atrial diameter (LAd) was found to be an independent risk factor for nondipper status in acceleration capacity model (odds ratio 1.174, 95% confidence interval 1.019–1.354, p = .027) and deceleration model (odds ratio 1.146, 95% confidence interval 1.003–1.309, p = .045). Sleep SBP was positively correlated to acceleration capacity (r = .256, p = .002) and negatively correlated to deceleration capacity (r = −.194, p = .021).

Conclusions

The absolute values of acceleration capacity and deceleration capacity were higher in patients with dipper hypertension than in patients with nondipper hypertension. However, acceleration and deceleration capacities were not independent risk factors for blunted BP variation. Sleep SBP seemed to be better correlated to the impairment of autonomic nervous system (ANS) function than other ABPM parameters.