Abnormal Circadian Blood Pressure Patterns Research Articles

Non-dipping circadian pattern as a predictor of incipient nephropathy in normotensive normoalbuminuric type 1 diabetics

ABSTRACT The objective of this study was to assess the value of the abnormal circadian blood pressure pattern by ambulatory blood pressure monitoring (ABPM) to predict the onset of abnormal albuminuria in normotensive and normoalbuminuric DM1 patients. The participators were submitted to ABPM and followed prospectively until the onset of albuminuria or the end of follow-up. The patients with normal circadian blood pressure pattern were compared with the non-dippers in regard of the time interval free of albuminuria. The survival curves were evaluated by the Kaplan–Meier method. Of 34 patients screened, 10 patients matched the exclusion criteria. Therefore, 24 patients were submitted to ABPM, aged 24 ± 8.3 y, 18 men, and all Caucasian. Elevated levels of albuminuria did not occurin any individual with normal systolic blood pressure dip (>10%) at 54 months of follow-up. Only 22% of patients among non-dippers were free of albuminuria (<30 mg/g maintained for 3 months) at the same time (p = 0.049). Patients that reached the outcome were homogeneous in regard to other clinical and ABPM data evaluated. Abnormal systolic blood pressure circadian pattern predicts the evolution to incipient nephropathy in normotensive normoalbuminuric DM1 patients.

Orthostatic hypotension and night-time dipper patterns in geriatric outpatients

Orthostatic hypotension (OH) and blood pressure circadian dysfunctions are common in older adults and may be related to aging-related autonomic nervous system deficits. This study aimed to evaluate the relationship between orthostatic and nocturnal blood pressure changes in geriatric outpatients. This cross-sectional study was carried out with 425 Italian individuals aged ≥65 years (mean age 75.8 ± 7.1 years) who attended a hypertension outpatient clinic from January 2013 to January 2020. Each patient underwent orthostatic testing and noninvasive 24-h blood pressure monitoring (ABPM). OH was detected in 38.1% of patients, and these individuals were more likely to have abnormal circadian blood pressure patterns (reverse and nondipper) than those without OH (61.7% vs. 51.7%; p = 0.045). In linear regression, after adjusting for potential confounders, orthostatic and nocturnal changes in systolic blood pressure were inversely associated (β = -0.63, 95% CI [-0.95; -0.32]; p < 0.001). This association was stronger in patients ≥80 years. OH is highly prevalent in older patients and is associated with altered nocturnal blood pressure profiles, especially in the oldest old. Because both OH and altered blood pressure patterns are associated with elevated cardiovascular risk and mortality, our study suggests that elderly patients with OH should undergo noninvasive 24-h blood pressure monitoring.

The assessment of hypertension in kidney transplant patients: time to change our approach?

ABSTRACTKidney transplantation (KT) is an increasingly utilized treatment for end-stage kidney disease. Hypertension either as a cause of kidney disease or as a complication of chronic kidney disease is the most frequently encountered comorbidity of KT patients. Hence, the management of hypertension in KT patients is crucial to prolong patient and graft survival. Ambulatory blood pressure monitoring (ABPM) appeared as a promising technique that has superiority over office and home blood pressure (BP) monitoring to correctly diagnose and manage hypertension. A recent meta-analysis by Pisano et al. including 42 studies with 4115 participants provided strong data for the comparison of ABPM with office BP monitoring in KT patients. In addition to the current literature knowledge, the findings of Pisano et al. filled the long-awaited evidence gap to suggest ABPM as a first-line BP monitoring technique for KT patients. Despite its disadvantages, such as patient discomfort, cost–effectiveness and limited availability, ABPM has crucial advantages in the management of hypertension including the detection of abnormal circadian BP patterns, the assessment of effects of physical activity and short-term variability of BP, and the exclusion of masked and white-coat hypertension.

Blood pressure monitoring in kidney transplantation: a systematic review on hypertension and target organ damage.

Sparse studies show that ambulatory blood pressure monitoring (ABPM) is superior to office BP (oBP) measurements to predict target organ damage and cardiovascular (CV) events in kidney transplant recipients (KTRs). We performed a systematic review aimed at determining the potential associations between BP recordings by different methods and renal and CV outcomes in this population. Major medical databases were searched for studies enrolling adult KTRs undergoing 24h ABPM compared to office or home BP measurements. Main outcomes were: associations between different BP recordings and renal and CV outcomes. Additionally, any association between the circadian BP pattern (dipping/non-dipping status) and outcomes was assessed. Twenty-two studies (2078 participants) were reviewed. Amongst 12 studies collecting data on renal endpoints, ten studies found that BP assessed by ABPM was a stronger predictor of renal function decline, assessed by serum creatinine (SCr) and/or creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR), than traditional office measurements. Twelve studies analyzed the relation between different BP recordings and CV target organ damages and reported robust correlations between echocardiographic abnormalities [i.e. left ventricular mass index (LVM/LVMI)] and 24h ABPM, but not with office BPs. Furthermore, 24h ABPM correlated better than oBP with markers of vascular damage, such as carotid intima-media thickness (IMT), diffuse thickening, and endothelial dysfunction. Additionally, abnormal circadian BP pattern (non-dippers and reverse dippers) identified a group of kidney recipients at risk for kidney function loss and CV abnormalities. In our systematic review, ABPM reflected target organ damage more closely than oBP in KTRs. Furthermore, altered circadian BP profile associated with renal and CV target organ damages.

CUFF-LESS BLOOD PRESSURE MONITORING DURING SLEEP

Objective:Home blood pressure monitoring as well as clinic blood pressure monitoring are recommended for the diagnosis or management of hypertension. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is helpful to detect abnormal circadian blood pressure patterns such as morning blood pre

3157 Relationship between abnormal nocturnal blood pressure patterns and end-organ damage following heart transplantation.

OBJECTIVES/SPECIFIC AIMS: Heart transplant (HTx) recipients are more likely to exhibit abnormal circadian blood pressure (BP) patterns (e.g., lack of nocturnal dip in BP) compared with the general population. Our goal was to assess the relationship between abnormal circadian BP patterns and end-organ damage in HTx recipients. METHODS/STUDY POPULATION: The retrospective study included 30 patients who were ≥ 6 months post-heart transplant and had 24-hour ambulatory BP data collected during a parent study. Nocturnal BP decline was categorized as: ≥10% decline, dipper; &lt;10% decline, non-dipper. The primary end-organ damage outcomes we plan to analyze are left ventricular hypertrophy (LVH), chronic kidney disease (CKD), and proteinuria. The association between nocturnal BP decline and the primary outcomes will be analyzed using logistic regression. RESULTS/ANTICIPATED RESULTS: The study cohort consists of 83% men and 83% Caucasians (mean age=57±14 years; mean time post-transplant =9.0±6.6 years). Systolic and diastolic non-dippers represent 53.3% and 40% of the cohort, respectively. Data are currently being analyzed for the association between nocturnal BP dipping status and LVH, CKD, and proteinuria. These findings will be presented at the conference. DISCUSSION/SIGNIFICANCE OF IMPACT: An understanding of factors, such as abnormal circadian BP patterns, that contribute to the development of end-organ damage following HTx may provide opportunities to improve BP management and prevent adverse complications in this high-risk population.

Ambulatory Blood Pressure Monitoring: Profiles in Chronic Kidney Disease Patients and Utility in Management.

Optimal control of blood pressure (BP) may reduce the risk of progression of CKD. Misclassification of hypertension (HTN) and status of control may result in suboptimal management. Clinic or home BP may overestimate or underestimate status of control compared with ambulatory BP monitoring (ABPM), which is considered the gold standard. The latter relates not only to the superiority of ABPM concerning outcome prognosis but also to its ability to accurately diagnose white coat and masked HTN, which is critical in assuring adequate BP control. However, ABPM has not gained widespread use in practice because of limited third-party reimbursement and a paucity of high quality randomized controlled intervention studies evaluating its use. Herein, we review HTN phenotypes that have been identified in patients with CKD, and the potential value of ABPM in this high-risk population.

Circadian and short-term blood pressure abnormalities after liver transplantation

ABSTRACTLiver transplantation remains the only therapeutic method in end-stage liver disease. Cardiovascular system diseases, including arterial hypertension, are considered one of the main risk factors increasing mortality in this population. The aim of the study was the evaluation of circadian blood pressure patterns in liver transplant recipients. In a group of 107 liver transplant recipients, a 24-hour ambulatory blood pressure monitoring (ABPM) was performed. The ABPM revealed arterial hypertension in 88.79% and unsatisfactory blood pressure (BP) control in 71.03% of the study participants. The abnormal circadian BP pattern was observed in 90.65% of liver recipients. The subgroup of patients with preserved BP circadian rhythm was characterized by higher standard deviation (SD) and coefficient of variation (CV) values for 24-hour systolic, diastolic and mean arterial blood pressure (SBP, DBP, and MAP). There were no such differences for other short-term blood pressure variability (ST BPV) parameters: SD and CV of day-time and night-time SBP, DBP and MAP values. Arterial hypertension and circadian BP abnormalities are present in a majority of liver transplant recipients. BP circadian rhythm is not associated with ST BPV parameters assessed separately during awake and sleep period which suggests that both groups of parameters could reflect different cardiovascular phenomena after liver transplantation.

Masked Hypertension and Morning Blood Pressure Surge in Patients with Obstructive Sleep Apnea Syndrome

Objective: Frequent hypoxic episodes and arousal during sleep in obstructive sleep apnea syndrome (OSAS) result in increased nocturnal blood pressure, which in turn may lead to sustained hypertension. Patients with severe OSAS exhibit attenuated nocturnal blood pressure (BP) dipping, as well as marked and rapid BP elevation in the morning shortly after waking. We examined the prevalence of masked hypertension and morning BP surge in patients with OSAS, and the relationship between the severity of OSAS and abnormal circadian BP patterns. Methods: We performed 24-hour ambulatory BP monitoring in the absence of antihypertensive medication on 26 patients with OSAS (49.3 ± 8.4 yrs) to investigate masked hypertension and morning BP surge. Results: Results of the 26 patients, three (11.7%) were normotensive, six (23.0%) exhibited masked hypertension, and 17 (65.3%) were hypertensive. The apnea/hypopnea index was significantly correlated with 24-hour mean, daytime, and night time systolic and diastolic BP. 24-hour mean, daytime, and night time BPs in the severe OSAS group were significantly higher than in the mild to moderate OSAS group. We observed morning BP surge in 16 patients (61.5%). There were no significant differences in the prevalence of morning BP surge and masked hypertension between the mild to moderate and the severe OSAS groups. Conclusion: Mild to moderate OSAS may play an important role in masked hypertension and morning BP surge.

Effect of glycaemic control on the diurnal blood pressure variation and endogenous secretory receptor for advanced glycation end product (esRAGE) levels in type 1 diabetes mellitus

The relationship between plasma endogenous secretory receptor for advanced glycation end product (esRAGE) level and diurnal variation of blood pressure in type 1 diabetic patients based on their glycemic status has not yet been studied. So, the aim of the present study was to see if a correlation exists between plasma esRAGE levels and dipper status in type 1 diabetic patients based on their glycaemic status. Type 1 diabetic patients were divided as good and poor glycaemic controlled groups based on their HbA1c values. Blood glucose levels, insulin, insulin antibodies, homocysteine and esRAGE levels were determined. The hourly daytime and night-time blood pressure was monitored by using a non-invasive blood pressure (NIBP) apparatus. Of the 16 patients in the well-controlled group, most (14/16) were dippers (95 % confidence interval 1.5 to 20.7 vs. P = 0.006, Fisher’s exact test) when compared to those in the poorly controlled group (5/18). There was a significant correlation between plasma esRAGE levels and % decline in nocturnal blood pressure in both the good (r = 0.69, P = 0.003) and poorly (r = 0.79, P = 0.0002) controlled groups. Most of the poorly controlled patients showed abnormal circadian blood pressure pattern and low esRAGE level and hence were more prone to end organ damage.

Abstract P235: Employing the DASH Diet to Treat Non-dippers: A Two-month Intervention Study

Introduction: Hypertensive patients with abnormal circadian blood pressure patterns, including a lack of nocturnal blood pressure dipping or rises in blood pressure from daytime to night-time, are at an increased risk for numerous cardiovascular events including strokes, heart failure and renal failure. Currently, limited therapeutic strategies exist to treat non-dippers. In this study, we examine the role of obesity on circadian blood pressure patterns and the impact of lifestyle intervention on nocturnal dip. Methodology: 24-hour ambulatory blood pressure monitoring was performed before and after a 2-month intervention employing the DASH diet and lifestyle program with a targeted 5% weight loss in 80 volunteers. 20 control patients had a healthy nocturnal dip, 30 patients had a non-dipping blood pressure pattern, and 30 patients had a rise in blood pressure nocturnally from daytime. Results: At baseline, there was a linear correlation between individuals' BMI and nocturnal blood pressure aberrancies (r= 0.60, p&lt;0.0001). The control group had the lowest average BMI of 28.1 kg/m2. Non-dippers had a slightly higher average BMI of 30.3 kg/m2, and those with a rise in blood pressure nocturnally had the greatest average BMI of 35.3 kg/m2. After the two-month lifestyle intervention, individuals who achieved weight loss had significantly greater average reductions in nocturnal blood pressure (24.3 mm Hg), compared to daytime (12.1 mm Hg), resulting in the restoration of a more normal nocturnal dip and circadian blood pressure pattern. Non-dippers who achieved a 5% reduction in weight during the intervention had an average 8.31% nocturnal dip by the end of the study. Individuals who lost less than 5% of their weight or who gained weight continued to have a non-dipping blood pressure pattern by the end of the study. Conclusions: The results of this study would suggest that perhaps reducing weight by adhering to the DASH diet and lifestyle intervention could be examined as therapeutic avenues for non-dippers in the future. The long-term effects of a restoration of normal circadian blood pressure pattern warrants further investigation.

PP.17.18

Objective: Evaluate circadian blood pressure (BP) variation in hypertensive patients and analyze it's association with kidney function. Design and method: Retrospective analysis of 24-h BP monitoring results in 63 hypertensive patients and their clinical, laboratory data was performed. According to nocturnal fall (NF) of BP patients were categorized into following groups. Group A were dippers (NF 10–20%), group B were non-dippers (NF 0–10%), group C were risers (NF < 0%) and group D were extreme dippers (NF > 20%). The relation between circadian BP and renal function was compared with dipping pattern of the patients. Statistical analysis was performed using SPSS 22.0 program. P < 0,05 was considered statistically significant. Results: Results: The 24-h BP monitoring was performed in 63 patients, 26 (41,26%) of them were males, 37 (58,73%) were females. Their mean age was 53,1 ± 18,14 years. Group A consisted of 18 (28,57%) patients, group B of 35 (55,56%) patients, group C of 8 (12,70%) patients and group D of 2 (3,17%) patients. Group D was excluded from further analysis due to low numbers. Mean nocturnal systolic/diastolic BP was 125 ± 19,24/72,61 ± 9,17 mmHg in group A, 135,71 ± 23,22/79,02 ± 14,79 mmHg in group B and 144,25 ± 30,98/77,38 ± 15,7 mmHg in group C, respectively. The differences between the groups in patients mean age and gender were not statistically significant (p = 0,261 and p = 0,286, respectively). We found a statistically significant negative correlation between mean nocturnal systolic BP and glomerular filtration rate (GFR) (r = -0,32; p = 0,011) and positive correlation between mean nocturnal systolic BP and serum creatinine concentration (r = 0,263; p = 0,038). There were no significant differences between groups regarding other values studied, such as cholesterol levels and poteinuria. Conclusions: Abnormal circadian BP pattern was found in more than 70% of patients. We found a statistically significant correlation between circadian BP variation and kidney function: increased nocturnal systolic BP correlated with decreased GFR and increased serum creatinine concentration.

Effect of dipeptidyl peptidase-4 inhibition on circadian blood pressure during the development of salt-dependent hypertension in rats.

A growing body of evidence has indicated that dipeptidyl peptidase-4 (DPP-4) inhibitors have antihypertensive effects. Here, we aim to examine the effect of vildagliptin, a DPP-4-specific inhibitor, on blood pressure and its circadian-dipping pattern during the development of salt-dependent hypertension in Dahl salt-sensitive (DSS) rats. DSS rats were treated with a high-salt diet (8% NaCl) plus vehicle or vildagliptin (3 or 10 mg kg(-1) twice daily by oral gavage) for 7 days. Blood pressure was measured by the telemetry system. High-salt diet for 7 days significantly increased the mean arterial pressure (MAP), systolic blood pressure (SBP) and were also associated with an extreme dipping pattern of blood pressure in DSS rats. Treatment with vildagliptin dose-dependently decreased plasma DPP-4 activity, increased plasma glucagon-like peptide 1 (GLP-1) levels and attenuated the development of salt-induced hypertension. Furthermore, vildagliptin significantly increased urine sodium excretion and normalized the dipping pattern of blood pressure. In contrast, intracerebroventricular infusion of vildagliptin (50, 500 or 2500 μg) did not alter MAP and heart rate in DSS rats. These data suggest that salt-dependent hypertension initially develops with an extreme blood pressure dipping pattern. The DPP-4 inhibitor, vildagliptin, may elicit beneficial antihypertensive effects, including the improvement of abnormal circadian blood pressure pattern, by enhancing urinary sodium excretion.

Does Abnormal Circadian Blood Pressure Pattern Really Matter in Patients With Transient Ischemic Attack or Minor Stroke?

Patients with stroke are more likely to have impaired autonomic nervous function and abnormal circadian blood pressure (BP) patterns. It remains unclear whether circadian BP patterns in patients with transient ischemic attack or minor stroke (National Institutes of Health Stroke Scale ≤3) differ from those in the normal population. Participants were assessed using a 24-hour ambulatory BP monitor and a short-term measurement of heart rate variability. There were 76 patients (mean age, 67.2 years; 57.9% men; and 61.8% transient ischemic attack) and 82 controls (65.6 years; 54.9% men). A history of hypertension was more prevalent in patients (72.4%; controls 48.8%). Circadian BP patterns were distributed similarly among patients and controls, and heart rate variability was also consistent between patients and controls. In contrast to previous findings among patients with acute stroke, patients with transient ischemic attack or minor stroke had similar BP patterns and autonomic nervous system function, when compared with controls.

Differences in circadian time structure of diastolic blood pressure between diabetes mellitus and essential hypertension

BackgroundAbnormal circadian blood pressure patterns have been associated with cardiovascular disease in diabetes mellitus. We have described that the acrophase of diastolic blood pressure (DBP) registered in type 1 diabetes (T1D) patients was significantly earlier than normal and DBP ecphasia was more pronounced in patients with lower heart rate variability during deep breathing. The aim of this study was to compare the circadian rhythm characteristics of BP among different groups: normotensive (NT) control subjects, patients affected by T1D and type 2 diabetes (T2D), and patients with essential hypertension (HT).FindingsWe retrospectively evaluated ambulatory blood pressure monitoring records in 30 NT, 20 T1D, 20 T2D, 20 HT whose fasting plasma glucose and HbA1c were contemporaneously measured. The four groups were well-matched regarding age, gender, and BMI.Systolic blood pressure (SBP) and DBP midline-estimating statistic of rhythm were higher in T1D, T2D, and HT groups. DBP ecphasia was present only in the diabetic individuals: the acrophase of DBP occurred four hours earlier than normal in T1D group, whereas two hours earlier in T2D group. In a multiple regression analysis, only HbA1c and SBP acrophase were statistically significant correlates of DBP acrophase.ConclusionsPeople with diabetes mellitus, both type 1 and type 2, have their circadian acrophase of DBP occurring 2–4 hours earlier than normotensive and hypertensive subjects. Altered circadian timing of DBP, potential trigger of cardiovascular events, seems to be a distinguishing feature of diabetes mellitus and correlates with the previous 2–3 months of glycaemic control.

Abnormal circadian blood pressure pattern 1-year after kidney transplantation is associated with subsequent lower glomerular filtration rate in recipients without rejection

Abnormal circadian blood pressure (BP) pattern is common after kidney transplantation but its relationship to long term allograft function is unclear. Of 119 kidney recipients who had ambulatory BP monitoring 1 year from transplantation, 36 patients without history of rejection were selected. Twenty-nine recipients were followed for 4 years and seven for 3 years. Iothalamate glomerular filtration rate (GFR) was obtained at 3 weeks then annually. Dippers (n = 10) had day-night systolic BP (SBP) drop (ΔSBP) of ≥10%, nondippers (n = 15) had ΔSBP 0%–9%, whereas reverse dippers (n = 11) had nocturnal rise in SBP. Compared with dippers, reverse and nondippers had a higher Banff cv score at 1 year ( P = .03), lower GFR at last follow-up (73.7 ± 18.1, 55.7 ± 16.3, and 56.6 ± 21 mL/min/1.73 m 2 for dippers, non-, and reverse dippers, respectively, P = .05) and higher kidney function loss (8.0 ± 20, −9 ± 17, and 1 ± 14 mL/min/1.73 m 2 for dippers, non-, and reverse dippers, respectively, P = .02). GFR at 4 years and at last follow-up independently correlated with ΔSBP at 1 year ( r = 0.46, P = .01; r = 0.34, P = .03). The current study indicates that abnormal circadian BP pattern at 1 year identifies a group of kidney recipients at risk for increased kidney function loss and lower GFR 3–4 years from transplantation.

Management of nocturnal hypertension

Nocturnal hypertension is a common complication of essential and secondary hypertension. Abnormal circadian blood pressure patterns associated with elevated sleep blood pressure include nondipping and reverse dipping, both of which are associated with increased target-organ damage and adverse cardiovascular outcomes. Nocturnal hypertension can be treated with several approaches that include both lifestyle changes, such as sodium restriction and potassium supplementation, and pharmacological treatments, primarily through the use of bedtime dosing of antihypertensive agents. Evening administration of blockers of the renin–angiotensin–aldosterone system is the most consistently effective of these treatment strategies. In this review, we provide a detailed discussion of the options available for the management of nocturnal hypertension.

Factors Associated with Incident Ischemic Stroke in Hospitalized Heart Failure Patients: A Pilot Study

Stroke is sometimes seen in patients with congestive heart failure (CHF). The factors that best predict incident stroke in hospitalized CHF patients are not well known. We performed this pilot study to explore the clinical markers of incident stroke in CHF patients. We studied 111 hospitalized patients with CHF (mean age, 67+/-11 years). Ambulatory blood pressure (BP) monitoring, blood tests, and echocardiography were performed in these patients just before they left the hospital, and all cardiovascular events during the study period were followed for an average of 18+/-9 months. Cox regression analysis was performed to explore the predictors of incident stroke using age, sex, body mass index (BMI), casual and ambulatory systolic BP (SBP), and brain-type natriuretic peptide (BNP). There were 10 stroke events (9%) during the follow-up period. The stroke group had higher nocturnal SBP and plasma BNP levels than the non-stroke group. With Cox regression analysis, both nocturnal SBP and BNP were significant predictors of incident stroke independent of other covariates. When nocturnal BP of 120 mmHg and BNP of 600 pg/mL (75th percentile) were used as cutoffs, nocturnal SBP > or =120 mmHg was associated with a 7-fold increase in the risk of incident stroke, while BNP > or =600 pg/mL was associated with a 46.6-fold increase. However, abnormal circadian BP patterns were not associated with incident stroke. In this pilot study, elevated nocturnal BP and high plasma BNP just before patients left the hospital were significant predictors of stroke events in CHF patients. Further study is needed to confirm this hypothesis.

Assessment of blood pressure control in hypertensive stroke survivors: an ambulatory blood pressure monitoring study

We compared the sensitivity of office blood pressure and ambulatory blood pressure monitoring recordings in evaluating the effectiveness of antihypertensive treatment and identified factors related to inadequate blood pressure control among hypertensive stroke survivors. Office blood pressure and ambulatory blood pressure monitoring measurements were performed at 120+/-30 days after ictus in 187 first-ever consecutive hypertensive stroke survivors who were receiving blood pressure-lowering medications according to international guidelines. Handicap was assessed by the modified Rankin Scale. Blood pressure was regarded as controlled if office and daytime ambulatory systolic and diastolic blood pressure values were <140/90 and <135/85 mmHg, respectively. Patients were subclassified according to the degree of their nocturnal systolic blood pressure fall [(mean daytime values-mean night-time values)100/mean daytime values] as dippers (>or=10%), nondippers (>or=0% and <10%) and reverse dippers (<0%). Effective blood pressure control was documented in significantly (P<0.001) fewer patients using ambulatory blood pressure monitoring (32.1%) than those using office recordings (43.3%), whereas in 16% of the study population a masked lack of per-treatment blood pressure control (elevated ambulatory blood pressure in the presence of normal office blood pressure levels) was identified. The distribution of dipping patterns differed significantly (P=0.01) between controlled hypertensive individuals (normal office and ambulatory measurements) and patients with isolated ambulatory hypertension (dippers: 31.3 vs. 10.0%; nondippers:56.9 vs. 53.3%; reverse dippers: 11.8 vs. 36.7%). Logistic regression analysis revealed diabetes mellitus and functional independency (modified Rankin Scale score<2) as independent predictors of inadequate blood pressure control. Ambulatory blood pressure monitoring detects a substantial number of treated hypertensive stroke survivors with a masked lack of per-treatment blood pressure control, who present a higher prevalence of abnormal circadian blood pressure patterns (reverse dipping). Diabetes mellitus and poststroke functional independency are the main factors contributing to inadequate blood pressure control.

Circadian melatonin concentration rhythm is lost in pregnant women with altered blood pressure rhythm

We assessed the correlation between the rhythm of melatonin concentration and circadian blood pressure patterns in normal and hypertensive pregnancy. Ambulatory 24-h blood pressure and blood samples every 4 h were monitored in 16 primigravidae who had shown an abnormal circadian blood pressure pattern (eight pre-eclamptic and eight normotensive) in pregnancy and 6–12 months after pregnancy. The circadian rhythm was analyzed by chronobiological measures. Eight normotensive women with maintained blood pressure rhythm served as controls. During pregnancy, melatonin concentration was significantly higher in pre-eclamptic than in normotensive women (pre-eclampsia, 29.4±1.9 pg/ml, normotensin, altered rhythm, 15.6±2.1; controls, 22.7±1.8; p<0.001). This difference faded after pregnancy, owing to the fall observed in pre-eclampsia (11.8±3.2 pg/ml, 9.8±2.1, and 11.1±2.0, respectively; NS). The rhythm of melatonin concentration was lost in all pregnant women with loss of blood pressure rhythm. After pregnancy, normotensive women showed a reappearance of both melatonin and blood pressure rhythm, whereas pre-eclamptic women showed a reappearance of blood pressure but not melatonin rhythm. The loss of blood pressure rhythm in pregnancy is consistent with the loss of melatonin concentration rhythm. In pre-eclamptic women, the normalization of blood pressure rhythm, while melatonin rhythm remained altered, suggests a temporal or causal priority of circadian concentration of melatonin in the determination of blood pressure trend.