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.

Clinic and ambulatory blood pressures, blood pressure phenotypes and mortality in patients with a previous stroke.

There is scarce evidence of the role of clinic and ambulatory BP indices, as well as blood pressure phenotypes in the prognosis of stroke survivors. We aimed to evaluate the association between ambulatory BP indices and mortality in patients with a previous stroke. Our study was an observational cohort study from individuals included in the Spanish Ambulatory Blood Pressure Registry from March 2004 to December 2014. The Cox model was used to estimate associations between usual clinic and ambulatory BP and mortality, adjusted for confounders and additionally for alternative measures of BP. Two thousand one hundred and eighty-three patients with a previous stroke were included. During a median of 9.2 years, 632 (28.9%) patients died: 236 (10.8%) from cardiovascular causes. In the confounder-adjusted model, clinic systolic BP was not associated with the risk of all-cause or cardiovascular mortality. In contrast, systolic BP indices obtained through ABPM (24 h, day and night) were all associated with all-cause and cardiovascular death. In the simultaneous adjustment of daytime and night-time systolic BP, only night-time systolic BP remained significantly associated with all-cause and cardiovascular death: HR 1.35 (95% CI 01.21-1.51) and 1.44 (1.20-1.72), respectively. For diastolic BP, only night-time BP was associated with all-cause and cardiovascular mortality: HR 1.32 (1.18-1.48) and 1.57 (1.31-1.88), respectively. According to the circadian pattern, a riser pattern was associated with all-cause and cardiovascular mortality: HR 1.49 (1.18-1.87) and 1.70 (1.14-2.52), respectively. In conclusion, in patients who have suffered a stroke, night-time BP is the BP estimate most closely associated with all-cause and cardiovascular mortality.

Associations of ambulatory blood pressure measurements with high-sensitivity troponin and natriuretic peptide levels in SPRINT.

BACKGROUND: Nighttime blood pressure (BP) has greater prognostic importance for cardiovascular disease (CVD) than daytime BP, but less is known about nighttime and daytime BP associations with measures of subclinical CVD. METHODS: Among 897 Systolic Blood Pressure Intervention Trial Study (SPRINT) participants with 24-hour ambulatory BP monitoring obtained near the 27-month study visit, 849 (95%) had N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) measured at the 24-month study visit. Multivariable linear regression analyses were performed to evaluate the associations of nighttime and daytime BP with cardiac biomarker levels. RESULTS: Mean age was 69 ±12 years, 28% were African American, and mean nighttime and daytime SBP were 121 ±16 mm Hg and 132 ±14 mm Hg, respectively. In multivariable models, compared with the lowest tertile of nighttime systolic BP, the highest tertile was associated with 48% higher NT-proBNP levels (adjusted geometric mean ratio [GMR] = 1.48, 95% CI: 1.22, 1.79), and 19% higher hs-cTnT levels (adjusted GMR = 1.19, 95% CI: 1.07, 1.32). In contrast, the highest versus lowest tertile of daytime systolic BP was not associated with NT-proBNP (adjusted GMR = 1.09, 95% CI: 0.88, 1.34) but was associated with 16% higher hs-cTnT levels (adjusted GMR = 1.16, 95% CI: 1.04, 1.30). Similar results were observed using diastolic BP. CONCLUSION: In SPRINT, both higher nighttime and daytime BP were independently associated with higher hs-cTnT levels, but only higher nighttime BP was associated with higher NT-proBNP levels.

Association of obstructive sleep apnea and diurnal variation of cystatin C.

PURPOSE: Obstructive sleep apnea is a known risk factor for the progression of chronic kidney disease. To find early signs of the progression in subjects with obstructive sleep apnea., we assessed the diurnal variation of kidney biomarkers. METHODS: A prospective observational study was conducted at Kangwon National University Hospital, Chuncheon, South Korea. All participants underwent in-laboratory polysomnography and phlebotomy in the evening before the polysomnography and in the morning after the polysomnography. Kidney biomarkers, including serum creatinine, blood urea nitrogen, and serum cystatin C, were measured. Delta kidney biomarkers were calculated by subtracting the evening level of the biomarkers from the morning level. RESULTS: Twenty-six of 50 participants had severe obstructive sleep apnea. Delta cystatin C was significantly correlated with apnea-hypopnea index, oxygen desaturation index, and total arousal index with coefficients of -0.314, -0.323, and -0.289, respectively. In participants without severe obstructive sleep apnea, the morning cystatin C level (0.84 ± 0.11 mg/L) was significantly higher than the evening cystatin C level (0.81 ± 0.11 mg/L) (P = 0.005). With severe obstructive sleep apnea, the cystatin C levels were not different between the morning (0.85 ± 0.11 mg/L) and the evening (0.85 ± 0.10 mg/L). CONCLUSIONS: Cystatin C level was increased in the morning in participants without severe obstructive sleep apnea, but not in participants with severe obstructive sleep apnea.

Non-Dipping Blood Pressure or Nocturnal Hypertension: Does One Matter More?

PURPOSE OF REVIEW: Nocturnal hypertension and non-dipping are both associated with increased cardiovascular risk; however, debate remains over which is a better prognosticator of cardiovascular outcomes. This review explores current literature on nocturnal hypertension and non-dipping to assess their relationship to cardiovascular disease and implications for clinical practice. RECENT FINDINGS: While current data remain inconclusive, some suggest that nocturnal hypertension is a more reliable and clinically significant marker of cardiovascular risk than non-dipping status. Importantly, reducing nocturnal HTN and non-dipping through chronotherapy, specifically evening dosing of antihypertensives, has not been conclusively shown to provide long-term cardiovascular benefits. Recent data suggests that non-dipping, compared to nocturnal hypertension, may be falling out of favor as a prognostic indicator for adverse cardiovascular outcomes. However, additional information is needed to understand how aberrant nighttime blood pressure patterns modulate cardiovascular risk to guide clinical management.

Isolated Nocturnal Hypertension in People Living With Human Immunodeficiency Virus: A Cross-Sectional Study.

BACKGROUND: Nocturnal hypertension (NH) is a potent cardiovascular risk factor described frequently in people with HIV (PWH). Isolated NH (INH) is less well reported in PWH because of the need for ambulatory blood pressure monitoring (ABPM) in office normotensive patients. We aim to document the prevalence of NH and INH and the clinical factors associated with these phenotypes. METHODS: Cross-sectional study from an HIV program in Argentina. Office and ABPM measurements, as well as clinical and laboratory exploration, were performed. We defined INH as NH with daytime normotension in patients with office normotension. RESULTS: We obtained ABPM in 66 PWH, 60% male, aged 44.7 (IQR 27-69) years; 87% receiving antiretroviral therapy, and 86.2% virologically suppressed. ABPM-based hypertension prevalence was 54.7% (95% CI: 42.5-66.3). The prevalence of NH was 48.5% (32/66), while the INH prevalence was 19.7% (95% CI: 11.7-30.9). No differences were found regarding sex, HIV viral load, CD4+ T lymphocytes count, or years of infection between normotensive and INH patients. Multiple linear regression model adjusted for sex and age determined that body mass index (ß = 0.93, P < 0.01), plasma uric acid (ß = 0.25, P = 0.04), plasma potassium (ß = -10.1, P = 0.01), and high-sensitivity C-reactive protein (hs-CRP) (ß = 0.78, P = 0.02) independently predicted nocturnal systolic blood pressure (BP) in PWH. In a multiple logistic regression model adjusted for age and sex, the presence of sedentariness, plasma potassium <4 mEq/L, BMI, and hs-CRP levels were predictors of INH. CONCLUSION: INH is highly prevalent in PWH. Metabolic and inflammatory markers predict nocturnal SBP in PWH.

Clinical Significance of Nocturnal Hypertension and Nighttime Blood Pressure Dipping in Hypertension.

PURPOSE OF REVIEW: This narrative review article aims to discuss more recent evidence, current challenges, and future perspectives regarding the clinical importance of nocturnal hypertension and nighttime blood pressure dipping, with particular reference to diagnosis, prognostic value, and therapeutic approach. RECENT FINDINGS: The importance of nighttime blood pressure and nighttime blood pressure dipping has been demonstrated in decades. Increased nighttime blood pressure has been acknowledged as an unfavorable clinical trait. However, more recent evidence suggests that the abolishment of normal circadian blood pressure rhythm is not always a solid predictor of adverse cardiovascular events and needs to be interpreted in the light of each patients' individual characteristics. Physicians treating hypertensive patients with adverse nighttime blood pressure profiles often face the dilemma of chronotherapy. This has been a blurred field for years, yet very recent evidence from appropriately designed studies attempts to shed light on this puzzling question. As 24-h ambulatory blood pressure monitoring is being increasingly recommended and applied in real-world practice for the diagnosis and monitoring of hypertension, information on nighttime blood pressure and nocturnal dipping profile is collected but is not always easy to interpret.

Nocturnal Hypertension and Left Ventricular Diastolic Dysfunction in Patients With Diabetes With the Absence of Heart Failure: Prospective Cohort HSCAA Study.

BACKGROUND: Diabetes is an important risk factor for heart failure (HF) and is associated with left ventricular (LV) diastolic dysfunction. However, diabetic comorbid conditions, such as nocturnal hypertension, as predictors of diastolic dysfunction are not known in the absence of an HF period. The present study was conducted as the longitudinal examination of the predictive value of nocturnal hypertension profiles on the progression of LV diastolic dysfunction in patients with and without diabetes without HF. METHODS: The subjects (154 diabetes and 268 nondiabetes) in the absence of HF were followed for 36.8±18.2 months. The relationships among the patterns of nocturnal hypertension and the outcome of LV diastolic dysfunction, defined as an increase in E/e'>14, were investigated in the patients with and without diabetes. RESULTS: The interaction effect of the diabetes status and the patterns of nocturnal hypertension on the hazard rate of the occurrence of E/e'>14 was statistically significant (P=0.017). Kaplan-Meier analysis results revealed that patients with diabetes with nondipper (P=0.021 versus dipper) and riser (P=0.006 versus dipper) had a greater risk for a diastolic dysfunction event. Furthermore, multivariable Cox proportional hazards analysis revealed that nondipper (hazard ratio, 4.56 [95% CI, 1.49-13.96]; P=0.007) and riser (hazard ratio, 3.89 [95% CI, 1.31-11.57]; P=0.014) patterns were associated with elevated risk of the outcome of LV diastolic dysfunction. In contrast, no similar significant associations were found in patients without diabetes. CONCLUSIONS: During the absence of HF periods, nocturnal hypertension is an important predictor for the progression of LV diastolic dysfunction in patients with diabetes.

Management of nocturnal hypertension: An expert consensus document from Chinese Hypertension League.

Nocturnal hypertension is highly prevalent among Chinese and Asian populations, which is mainly attributed to high salt intake and high salt sensitivity. Nocturnal hypertension increases the risk of cardiovascular and all-cause mortality, independent of daytime blood pressure (BP). However, it can usually be detected by 24-h ambulatory BP monitoring, rather than routine office or home BP measurement, thus is often underdiagnosed in clinical practice. Currently, no specific guidance is available for the management of nocturnal hypertension in China or worldwide. Experts from the Chinese Hypertension League summarized the epidemiologic and pathophysiologic characteristics and clinical phenotype of nocturnal hypertension and provided consensus recommendations on optimal management of nocturnal hypertension, with the goal of maximally reducing the cardiovascular disease risks. In this consensus document, 24-h ABPM is recommended for screening and diagnosis of nocturnal hypertension, especially in the elderly, patients with diabetes, chronic kidney diseases, obstructive sleep apnea and other conditions prone to high nocturnal BP. Lifestyle modifications including salt intake restriction, exercise, weight loss, sleep improvement, and mental stress relief are recommended. Long-acting antihypertensive medications are preferred for nocturnal and 24-h BP control. Some newly developed agents, renal denervation, and other device-based therapy on nocturnal BP reduction are evaluated.

Reclassification of Adolescent Ambulatory Prehypertension and Unclassified Blood Pressures by 2022 American Heart Association Pediatric Ambulatory Blood Pressure Monitoring Guidelines.

OBJECTIVE: To describe the epidemiology of reclassification of prehypertensive and unclassified adolescents by 2022 American Heart Association pediatric ambulatory blood pressure monitoring (ABPM) guidelines, and to evaluate the association of the new diagnostic categories with left ventricular hypertrophy (LVH). STUDY DESIGN: A single-center, retrospective review of ABPM reports from adolescents 13-21 years old, from 2015 through 2022, was performed. Adolescents with prehypertension or unclassified by 2014 guidelines were reclassified by 2022 definitions. Logistic regression models evaluated the association of reclassification phenotypes with LVH. RESULTS: A majority of prehypertensive adolescents reclassified to hypertension (70%, n = 49/70). More than one-half (57%, n = 28/49) of the hypertension was isolated nocturnal hypertension, and 80% was systolic hypertension. Reclassification to hypertension was more common in males. The majority (55.6%) of unclassified adolescents were reclassified to normotension. No demographic or clinical variables were associated with reclassification categories. LVH was not associated with hypertension in the reclassified prehypertensive or unclassified groups. CONCLUSIONS: The 2022 ABPM guidelines clearly define blood pressure phenotypes. However, reclassification to hypertension was not associated with an increased odds of LVH. Because most prehypertensive adolescents reclassified as hypertensive by nighttime BPs alone, this study highlights the lowered threshold for nocturnal hypertension. Prospective studies in larger, well-defined cohorts are needed to describe better the predictive value of 2022 BP phenotypes for target organ damage.

The Association Among Post-hemodialysis Blood Pressure, Nocturnal Hypertension, and Cardiovascular Risk Factors.

Background: Most hemodialysis (HD) patients suffer from hypertension and have a heightened cardiovascular risk. While blood pressure (BP) control is essential to end-stage kidney disease (ESKD) patients, overly stringent control can lead to intradialytic hypotension (IDH). This study aimed to examine BP variations during and after HD to determine whether these variations correlate with IDH risk. Methods: BP measurements during dialysis were taken from 28 ESKD patients, and ambulatory BP monitoring was applied post-dialysis. Laboratory parameters and risk factors, including diabetes, coronary disease, and LV mass index, were compared between IDH and non-IDH groups using an independent t-test. Results: Of the 28 patients with an average age of 57.4 years, 16 (57.1%) had diabetes, 5 (17.9%) had coronary artery disease, and 1 (3.6%) had cerebrovascular disease. The mean systolic blood pressure (SBP) during and post-HD was 142.26 mmHg and 156.05 mmHg, respectively (p=0.0003). Similarly, the mean diastolic blood pressure (DBP) also demonstrated a significant increase, from 74.59 mmHg during HD to 86.82 mmHg post-HD (p<0.0001). Patients with IDH exhibited a more substantial SBP difference (delta SBP, 36.38 vs. 15.07 mmHg, p=0.0033; age-adjusted OR=1.58, p=0.0168) and a lower post-dialysis BUN level (12.75 vs. 18.77 mg/dL, p=0.0015; age-adjusted OR=0.76, p=0.0242). No significant variations were observed in daytime and nocturnal BP between the IDH and non-IDH groups. Conclusion: Hemodialysis patients exhibited a marked increase in post-dialysis BP and lacked a nocturnal BP dip, suggesting augmented cardiovascular risks. This highlights the importance of more stringent BP control after hemodialysis.

Effect of Cuff Inflation on Blood Pressure, Arousals, Sleep Efficiency, and Desaturations: Sub-Analysis of the VAST Pilot Study.

The influence of cuff inflations on night-time measurements during 24 h ambulatory blood pressure (BP) measurements is unknown. We investigated the potential effect of cuff inflations on sleep parameters using measurements taken simultaneously with a cuffless device using pulse-transit-time (PTT). On the first day of measurement, standard cuff-based 24 h BP and cuffless measurements were simultaneously performed on the right and left arms (CUFF/PTT-D). In this experiment, 1-2 days after the first measurement, the cuffless device was worn alone (PTT-D). Only data from the cuffless device were analyzed. The following mean sleep parameters were analyzed: mean systolic and diastolic BP, arousals, sleep efficiency, total arousals, arousal per hour, and desaturations. In total, 21 individuals were prospectively enrolled. The mean (SD) age was 47 (±15) years, and 57% were female. The mean systolic asleep BP during CUFF/PTT-D and during PTT-D were 131 (±21) and 131 (±26) mmHg, respectively. The mean diastolic asleep BP values during CUFF/PTT-D and during PTT-D were 80 (±14) and 84 (±14) mmHg, respectively (p = 0.860, p = 0.100, respectively). Systolic and diastolic asleep mean difference was 0.1 (±18.0) and -3.6 (±9.8) mmHg, respectively. There were significantly more total arousals during PTT-D (p = 0.042). There were no significant differences seen in sleep efficiency (p = 0.339) or desaturations (p = 0.896) between the two measurement periods. We could not show any significant impact from cuff inflations during sleep, as documented by PTT-D measurements.

Is it Mandatory to do a 24 hour ABPM in all Patients with Moderate to Severe Obstructive Sleep Apnoea?

Background Obstructive sleep apnoea (OSA) has been described as a risk factor for arterial hypertension (HT). One of the proposed mechanisms linking these conditions is non dipping (ND) pattern in nocturnal blood pressure, however evidence is variable and based on specific populations with underlying conditions. Data for OSA and ND in subjects residing at high altitude are currently unavailable. Objective Identify the prevalence and association of moderate to severe OSA with HT and ND pattern in hypertensive and non-hypertensive otherwise healthy middle-aged individuals in residing at high altitude (Bogotá:2640 mt) Methods Adult individuals with diagnosis of moderate to severe OSA underwent 24 hour- ambulatory blood pressure monitoring (ABPM) between 2015 and 2017. Univariable and multivariable logistic regression analysis were performed to identify predictors of HT and ND pattern. Results Ninety-three (93) individuals (male 62.4% and median age 55) were included in the final analysis. Overall, 30.1% showed a ND pattern in ABPM and 14.9% had diurnal and nocturnal hypertension. Severe OSA (higher apnea-hiponea index [AHI]) was associated with HT (p = 0.006), but not with ND patterns (p = 0.54) in multivariable regression. Smoking status and lowest oxygen saturation during respiratory events where independently associated with ND pattern (p = 0.04), whereas age (p = 0.001) was associated with HT. Conclusions In our sample, one in three individuals with moderate to severe OSA have non dipping patterns suggesting lack of straight association between OSA and ND. Older individuals who have higher AHI are more likely to have HT, and those who smoke have a higher risk of ND. These findings add aditional information to the multiple mechanisms involved in the relationship between OSA and ND pattern, and questions the routine use of 24-hour ABPM, particullary in our region, with limited resources and healthcare acces. However, further work with more robust methodology is needed to draw conclusions.

Prevalence and Characteristics of Isolated Nocturnal Hypertension and Masked Nocturnal Hypertension in a Tertiary Hospital in the City of Buenos Aires.

Isolated nocturnal hypertension (INH) and masked nocturnal hypertension (MNH) increase cardiovascular risk. Their prevalence and characteristics are not clearly established and seem to differ among populations. We aimed to determine the prevalence and associated characteristics of INH and MNH in a tertiary hospital in the city of Buenos Aires. We included 958 hypertensive patients ≥ 18 years who underwent an ambulatory blood pressure monitoring (ABPM) between October and November 2022, as prescribed by their treating physician to diagnose or to assess hypertension control. INH was defined as nighttime BP ≥ 120 mmHg systolic or ≥70 diastolic in the presence of normal daytime BP (<135/85 mmHg regardless of office BP; MNH was defined as the presence of INH with office BP < 140/90 mmHg). Variables associated with INH and MNH were analyzed. The prevalences of INH and MNH were 15.7% (95% CI 13.5-18.2%) and 9.7 (95% CI 7.9-11.8%), respectively. Age, male sex, and ambulatory heart rate were positively associated with INH, whereas office BP, total cholesterol, and smoking habits showed a negative association. In turn, diabetes and nighttime heart rate were positively associated with MNH. In conclusion, INH and MNH are frequent entities, and determination of clinical characteristics such as those detected in this study is critical since this might contribute to a more appropriate use of resources.

Ambulatory Blood Pressure Monitoring for Diagnosis and Management of Hypertension in Pregnant Women.

Hypertension disorders during pregnancy has a wide range of severities, from a mild clinical condition to a life-threatening one. Currently, office BP is still the main method for the diagnosis of hypertension during pregnancy. Despite of the limitation these measurements, in clinical practice office BP of 140/90 mmHg cut point is used to simplify diagnosis and treatment decisions. The out-of-office BP evaluations are it comes to discarding white-coat hypertension with little utility in practice to rule out masked hypertension and nocturnal hypertension. In this revision, we analyzed the current evidence of the role of ABPM in diagnosing and managing pregnant women. ABPM has a defined role in the evaluation of BP levels in pregnant women, being appropriate performing an ABPM to classification of HDP before 20 weeks of gestation and second ABMP performed between 20-30 weeks of gestation to detected of women with a high risk of development of PE. Furthermore, we propose to, discarding white-coat hypertension and detecting masked chronic hypertension in pregnant women with office BP > 125/75 mmHg. Finally, in women who had PE, a third ABPM in the post-partum period could identify those with higher long-term cardiovascular risk related with masked hypertension.

Nighttime home blood pressure lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension: the EARLY-NH study.

There is limited evidence on the blood pressure (BP)-lowering effect of esaxerenone on home BP, including nighttime BP. Using two newly developed nocturnal home BP monitoring devices (brachial and wrist), this multicenter, open-label, prospective study investigated the nighttime home BP-lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension being treated with an angiotensin receptor blocker (ARB) or calcium-channel blocker (CCB). In total, 101 patients were enrolled. During the 12-week study period, change in nighttime home systolic/diastolic BP from baseline to end of treatment measured by the brachial device was -12.9/-5.4 mmHg in the total population and -16.2/-6.6 and -10.0/-4.4 mmHg in the ARB and CCB subcohorts, respectively (all p < 0.001). For the wrist device, the change was -11.7/-5.4 mmHg in the total population and -14.6/-6.2 and -8.3/-4.5 mmHg in each subcohort, respectively (all p < 0.001). Similar significant reductions were shown for morning and bedtime home BP and office BP. Urinary albumin-to-creatinine ratio, N-terminal pro-brain natriuretic peptide, and cardio-ankle vascular index improved in the total population and each subcohort. Incidences of treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 38.6% and 16.8%, respectively; most were mild or moderate. The most frequent drug-related TEAEs were associated with serum potassium elevation (hyperkalemia, 9.9%; blood potassium increased, 3.0%); however, no new safety concerns were raised. Esaxerenone was effective in lowering nighttime home BP as well as morning and bedtime home BP and office BP, safe, and showed organ-protective effects in patients with uncontrolled nocturnal hypertension. Caution is warranted regarding elevated serum potassium levels. This study investigated the effect of esaxerenone on nighttime home BP and organ damage (UACR and NT-proBNP) in patients with uncontrolled nocturnal hypertension despite treatment with an ARB or CCB. Our results show that safe 24-h BP control and organ protection are possible with esaxerenone.

Controversies in Hypertension III: Dipping, Nocturnal Hypertension, and the Morning Surge.

A comprehensive approach to hypertension requires out-of-office determinations by home or ambulatory monitoring. The 4 phenotypes comparing office and out-of-office pressures in treated and untreated patients include normotension, hypertension, white-coat phenomena, and masked phenomena. Components of out-of-office pressure may be equally as important as mean values. Nighttime pressures are normally 10%-20% lower than daytime (normal "dipping") pressures. Abnormalities include dipping more than 20% (extreme dippers), less than 10 % (nondippers), or rising above daytime (risers) and have been associated with elevated cardiovascular risk. Nighttime pressure may be elevated (nocturnal hypertension) in isolation or together with daytime hypertension. Isolated nocturnal hypertension theoretically changes white-coat hypertension to true hypertension and normotension to masked hypertension. Pressure normally peaks in the morning hours ("morning surge") when cardiovascular events are most common. Morning hypertension may result from residual nocturnal hypertension or an exaggerated surge and has been associated with enhanced cardiovascular risk, especially in Asian populations. Randomized trials are needed to determine whether altering therapy based solely on either abnormal dipping, isolated nocturnal hypertension, or an abnormal surge is justified.