Diastolic Nondippers Research Articles

Relationship between nocturnal blood pressure patterns and end organ damage and diastolic dysfunction in heart transplant recipients.

We assessed the relationship between circadian blood pressure (BP) patterns and clinical outcomes in a contemporary cohort of adult heart transplant recipients. This retrospective, cross-sectional study included adult heart transplant recipients at least 6months post-transplant. Ambulatory BP measurements were recorded over 24hours. Nondippers were defined as a decline in average nighttime BP≤10% compared with daytime. Primary outcomes were the presence of end organ damage, that is, microalbuminuria, chronic kidney disease, and/or left ventricular hypertrophy. Secondary outcomes were measures of diastolic dysfunction (ie, mitral valve deceleration time, e/e', E/A, and isovolumetric relaxation time), microalbumin/creatinine ratio, eGFR, interventricular septal thickness, and left ventricular posterior wall thickness. Of 30 patients, 53.3% (n=16) were systolic nondippers and 40% (n=12) were diastolic nondippers. Diastolic nondippers had three times higher urine microalbumin/creatinine ratios than diastolic dippers (P=.03). Systolic nondippers had 16.3% lower mitral valve deceleration time (P=.05) than systolic dippers, while diastolic nondippers had 20.4% higher e/e' (P=.05) than diastolic dippers. There were no significant relationships between BP dipping status and any of the primary outcomes. These data suggest that systolic and diastolic nondipping BP patterns are associated with subclinical kidney damage and diastolic dysfunction in heart transplant recipients.

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; <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.

Increasing ambulatory pulse pressure predicts the development of left ventricular hypertrophy during long-term follow-up.

Ambulatory blood pressure (ABP) has been shown to have an association with left ventricular hypertrophy (LVH). We evaluated the association between ABP characteristics and the development of LVH during long-term follow-up (20 years) in 420 middle-aged subjects from OPERA cohort. ABP measurements (ABPM) were recorded and echocardiographic examinations were performed at baseline and revisit. Anthropometrics were measured and laboratory analyses performed at visit. The questionnaire presented to all participants elicited detailed information about their habits. Left ventricular mass index (LVMI) was calculated according to Troys method. Baseline LVMI was a significant independent predictor of LVMI change (p < 0.001). None of the baseline continuous ABPM predicted the change in LVMI. A greater increase in daytime and night-time systolic blood pressure (BP) (p from 0.006 to 0.048) and 24 h, daytime and night-time pulse pressure (PP) (p from 0.005 to 0.034) predicted a greater increase in LVMI. Especially the increase in night-time SBP (p = 0.006) and PP (p = 0.005) predicted a greater increase in LVMI. We also considered circadian BP profiles among subjects, whose ABPM at baseline and echocardiographic measurements both at baseline and follow-up were available. Diastolic non-dippers were observed to show a greater increase in LVMI compared to diastolic dippers (10.6 ± 33.0 g/m2 vs. 7.0 ± 28.8 g/m2, p = 0.032), when baseline LVMI and in-office DBP were taken account. These findings suggest that an increasing ambulatory PP increases and a diastolic non-dipping status may increase the risk for the development of LVH during later life course.

PP.07.26] REPRODUCIBILITY OF CIRCADIAN BLOOD PRESSURE VARIATIONS IN CHRONIC KIDNEY DISEASE PATIENTS

Objective: Previous studies have demonstrated a significant link between the circadian rhythm of blood pressure (BP) and cardiovascular events, namely that the absence of a nocturnal fall in BP and an exaggerated morning BP surge, are associated with more severe target organ damage and increased cardiovascular risk in chronic kidney disease (CKD) patients. Aim of our study was to investigate the reproducibility of circadian BP variations in CKD patients. Design and method: A total of 35 CKD patients underwent 24-h ambulatory BP monitoring at baseline and 1 month. Morning BP surge was defined as the sleep-trough surge, calculated by subtracting the morning BP (mean of 4 readings over 2 hours just after wake-up) from the lowest nocturnal BP (mean of 3 readings centered around the lowest nighttime BP) and as the prewaking surge (morning BP minus the 4 readings over 2 hours before waking). The degree of nocturnal BP dipping (%) was calculated as 100[1 – nighttime BP/daytime BP] for both systolic and diastolic BP. Dippers were defined as subjects with nocturnal BP fall >10% and non-dippers as patients with nocturnal BP fall <10%. Nocturnal hypertension was defined as nighttime SBP >= 120 mmHg and/or DBP >= 70 mmHg. Statistical analysis was performed by means of reliability analysis (intraclass correlation coefficient (ICC)) for continuous variables and kappa agreement coefficient for categorical variables. Results: The ICC for sleep-trough surge was 0.360 (p = 0.097) and for prewaking surge was 0.541 (p = 0.012). As far as systolic and diastolic dipping are concerned, the ICC values were 0.674 (p = 0.001) and 0.371 (p = 0.087), respectively. The kappa agreement coefficient for systolic non-dippers was 0.517 (p = 0.002), for diastolic non-dippers was 0.157 (p = 0.332), and for nocturnal hypertensives was 0.208 (p = 0.215). Conclusions: Prewaking morning BP surge is more reproducible than sleep-trough surge in CKD patients. Systolic BP dipping demonstrates greater reproducibility than diastolic BP dipping and nocturnal hypertension in CKD patients.

PP.16.18] REPRODUCIBILITY OF DIPPING PATTERN AND NOCTURNAL HYPERTENSION IN NORMOTENSIVE AND ESSENTIAL HYPERTENSIVE SUBJECTS

Objective: It is well known that non-dipping pattern, nocturnal hypertension and isolated nocturnal hypertension are associated with target organ damage development and cardiovascular morbidity and mortality in hypertensive patients. Aim of our study was to evaluate the reproducibility of dipping pattern, nocturnal hypertension and isolated nocturnal hypertension in normotensive and essential hypertensive subjects. Design and method: A total of 68 consecutive never treated individuals referred for evaluation at the Hypertension Unit of our department, underwent 24-h ambulatory blood pressure (BP) monitoring at baseline and 1 month. Subjects with 24-h BP values > = 130/80mmHg were defined as hypertensives, whereas those with 24-h BP <130/80mmHg as normotensives. The degree of nocturnal BP dipping (%) was calculated as 100[1 – nighttime BP/daytime BP] for both systolic and diastolic BP. Dippers were defined as subjects with nocturnal BP fall >10% and non-dippers as patients with nocturnal BP fall <10%. Nocturnal hypertension was defined as nighttime SBP > = 120 mmHg and/or DBP > = 70 mmHg. Isolated nocturnal hypertension Statistical analysis was performed by means of reliability analysis (intraclass correlation coefficient (ICC)) for continuous variables and kappa agreement coefficient for categorical variables. Results: Our study population consisted of 22 normotensives (32%) and 46 hypertensive (68%) subjects. In normotensive subjects the ICC for systolic dipping was 0.172 (p = 0.332) and for diastolic dipping was 0.647 (p = 0.009). The kappa agreement coefficient for systolic non-dippers was 0.273 (p = 0.170), for diastolic non-dippers was 0.507 (p = 0.006), for nocturnal hypertension was 0.560 (p = 0.003) and for isolated nocturnal hypertension was 0.389 (p = 0.068). In hypertensive patients the ICCs for systolic and diastolic dipping were 0.671 (p < 0.001) and 0.557 (p = 0.003), respectively. The kappa agreement coefficient for systolic non-dippers was 0.521 (p < 0.001), for diastolic non-dippers was 0.322 (p = 0.029), for nocturnal hypertension was 0.254 (p = 0.030) and for isolated nocturnal hypertension was 0.237 (p = 0.102). Conclusions: In hypertensive patients, non-dipping pattern is more reproducible than nocturnal hypertension. In contrast, systolic non-dipping pattern is less reproducible than diastolic non-dipping pattern and nocturnal hypertension in normotensive subjects. The reproducibility of isolated nocturnal hypertension is limited.

Association between nocturnal blood pressure dipping and insulin resistance in children affected by NAFLD.

The aim of this study was to analyse the relationship between insulin-glucose metabolism, nocturnal blood pressure dipping and nonalcoholic fatty liver disease (NAFLD) in obese adolescents without diabetes. One hundred one consecutive children, with biopsy-proven NAFLD, were included in this study. Blood samples were drawn for the analyses of liver function tests, insulin-glucose metabolism and lipid profile appraisal. An ambulatory blood pressure measurement (ABPM) was performed. Seventy-six children (75.3%) were systolic nondippers, and 23 of them were diastolic nondippers (30.3%). No differences were found in the anthropometric parameters between the two groups. When compared to the systolic dippers, the systolic nondippers had higher medians of mean nocturnal blood pressure, glucose at 0, 60 and 120min in the oral glucose tolerance test (OGTT), OGTT insulin at all time points and insulin-resistance values. No correlation of histopathological features with dipping/nondipping statuses was found. We found an association between a nocturnal blood pressure fall and measures of insulin levels, independent of obesity, or daytime blood pressure levels, among the obese patients with NAFLD. Although no association between nondipping profiles and NAFLD was observed in our study, further studies with a longer term follow-up are needed, to better elucidate the complex link between these particular entities.

Nocturnal blood pressure non‐dipping is prevalent in severely obese, prepubertal and early pubertal children

To investigate the prevalence of nocturnal blood pressure dipping among obese prepubertal and early pubertal children and to analyse the relationship between dipping and measures of insulin-glucose metabolism or sleep-disordered breathing. We studied 76 obese children (41% girls) under clinical care, with an average age of 10.4 ± 1.7 and a body mass index Z-score (BMI Z-score) of 6.2 ± 1.6. We performed a 24-h ambulatory blood pressure measurement. Non-dipping was defined as a nocturnal blood pressure reduction of <10%. We calculated measures of insulin-glucose metabolism from the performed frequently sampled intravenous glucose-tolerance test and from fasting blood samples. Overnight sleep polygraph recordings were performed to assess sleep-disordered breathing. Forty-two percent of the children were systolic non-dippers, and 17% were diastolic non-dippers. There were no associations between systolic or diastolic dipping and measures of insulin-glucose metabolism after adjustments for BMI Z-score, gender and pubertal status. There were no associations between dipping and measures of sleep-disordered breathing. Nocturnal non-dipping was two times higher among severely obese, prepubertal and early pubertal children, compared to previous reports among children in general. There were no associations between nocturnal dipping and insulin-glucose metabolism or measures of sleep-disordered breathing in this group.

Response to The Pattern of Nondipping and Urinary Albumin Excretion

We thank Afsar1 for his interest in our article2 and for raising an important question about the relationships between urinary albumin excretion and different circadian blood pressure profiles in subjects with hypertension. We found Afsar's suggestion interesting that, if urinary albumin excretion is independently associated with increased nighttime systolic blood pressure, a likely correlation with dipping blood pressure profiles could be expected. We, therefore, performed additional analyses to check this possible relationship. The distribution of dipping blood pressure patterns in our cohort was as follows: 22.3% dippers (n=74), 21.7% isolated systolic nondippers (n=72), 2.7% isolated diastolic nondippers (n=9), and 53.3% patients with both systolic and diastolic nondipping profiles (n=177). We then determined urinary …

The Dominant Role of the Systolic Component of Nondipping Status on Target-Organ Damage in Never-Treated Hypertensives

Blood pressure (BP) nondipping has been associated with target-organ damage (TOD) and adverse outcomes in hypertension. Diverse definitions of nondipping status appear in the literature, regarding the BP components taken into account. Aim of this study was to compare the effects of isolated nondipping of systolic, diastolic and combined systolic and diastolic BP on various indices of TOD. From 630 consecutive subjects with never-treated essential hypertension stage I-II, we selected 279 subjects who were consistently isolated systolic nondippers (SND, n=76) isolated diastolic nondippers (DND, n=64) and combined systolic and diastolic nondippers (SDND, n=139) in two ambulatory BP monitoring sessions. All three subgroups were subjected to echocardiographic examination, carotid-femoral pulse wave velocity (PWV(c-f)) and albumin-to-creatinine ratio (ACR) determination. Metabolic profile was determined in a morning blood sample. SND compared to DND and SDND exhibited higher left ventricular mass/height(2.7) (42.4 ± 9.9 vs. 38.0 ± 9.1 vs. 40.9 ± 11.0 g/m(2.7), P < 0.05), higher log(10)(PWV(c-f)) (0.94 ± 0.07 vs. 0.86 ± 0.05 vs. 0.91 ± 0.07 m/s, P < 0.005), and higher log(10)(ACR) (1.2 ± 0.5 vs. 0.9 ± 0.3 vs. 1.1 ± 0.4 mg/g, P < 0.05). Isolated systolic BP nondipping was an independent determinant of all the studied indices of TOD whereas isolated diastolic BP nondipping was not. Isolated systolic as compared to diastolic and to combined systolic/diastolic BP nondipping is associated with higher left ventricular mass, stiffer arteries, and pronounced urinary albumin excretion.

Urinary albumin excretion among nondipper hypertensive patients is closely related with the pattern of nondipping

The relationship between 24-hour urinary albumin excretion (UAE) rate and the pattern of nondipping (isolated systolic nondipping, isolated diastolic nondipping, and both systolic and diastolic nondipping) is not known. Medical history, physical examination, laboratory analysis, and office and ambulatory blood pressure measurements were performed. Twenty-four hour urine specimens were collected to determine creatinine clearance and UAE. In total, 158 essential hypertensive patients (104 dippers, 54 nondippers) were included. Fourteen patients were isolated systolic nondippers, 7 patients were isolated diastolic nondippers, and 33 patients were both systolic and diastolic nondippers. Among nondipper patients, 17 had microalbuminuria and, among dipper patients, 9 had microalbuminuria ( P < .0001). The median UAE of dippers was lower when compared with nondippers (5.25 mg/day vs.23 mg/day, P < .0001). The median UAE of isolated systolic nondippers, isolated diastolic nondippers, and both systolic and diastolic nondippers were 8.45 mg/day, 7.7 mg/day, and 25.5 mg/day, respectively ( P = .001). Subgroup comparison of patients revealed that UAE was higher in patients with both systolic and diastolic nondippers when compared with dippers ( P < .0001), isolated systolic nondippers ( P = .001), and isolated diastolic nondippers ( P = .017). Not only nondipping itself, but nondipping profile may be related with UAE in essential hypertensive patients.

Ambulatory Blood Pressure Monitoring (ABPM) in Children with Thalassemia Major (TM).

In TM chronic anemia, blood transfusions and iron over load result in impairments in many organs. Little is known about the changes in blood pressure (BP) patterns of children with TM. To evaluate ABPM changes and associated laboratory and clinical features in children with TM. ABPM was performed in 20 TM patients with no cardiac or renal dysfunction (12M, 8F; 11.3+/−3.8 years), and 20 healthy children (11M, 9F; 11.6+/−2.4 years). Blood and timed urine samples were collected for hematological and biochemical tests. [Dipping: a fall in the mean systolic (diastolic) BP during nighttime of more than 10% of the mean daytime systolic (diastolic) BP]. Mean daytime (8AM–8PM) and nighttime (midnight to 6AM) systolic (SBP) and diastolic (DBP) blood pressures were comparable. No patient in TM and control group had mean 24-h, day time, nighttime SBP or DBP above 90th percentile. SBP and DBP- loads were always less than 20% in control group. In TM group: SBP-load was more than 20% in 1, and 1 patient during daytime and nighttime, respectively; and DBP- load was more than 20% in 1, and 2 patients during daytime and nighttime, respectively. The percentage of systolic (60% vs 35%; p:0.102) and diastolic (30% vs 20%; p:0.118) non-dippers among TM patients were higher, compared to control group. In TM group: the percentage of systolic (80% vs 40%; p:0.063) and diastolic (50% vs 10%; p:0.044) non-dippers among older (12–16 years) patients were higher, compared to younger (5–11 years) patients. There was no association between non-dipping pattern and hemoglobin, ferritin or albuminuria level. Our preliminary results suggest that BP anomalies in TM occur before the development of cardiac or renal dysfunction. There is an association between non-dipping and the age of the patient. Long-term follow-up will make clear whether abnormalities in ABPM patterns have a predictive value in the development of renal and cardiac dysfunction in TM patients.

Nondipping and its relation to glomerulopathy and hyperfiltration in adolescents with type 1 diabetes.

To determine whether there is a relation between dipping/nondipping status and end-organ damage (measured as renal glomerulopathy) and long-term renal function in order to predict the development of nephropathy in normoalbuminuric patients with type 1 diabetes. Analysis of renal biopsy and ambulatory blood pressure measurements was done in relation to renal function tests performed during a 10-year period. Forty unselected patients (16 girls), with a mean age of 17.7 years and a mean duration of 10.7 years, were studied. The renal biopsies were examined by electron microscopy. Ambulatory blood pressure was monitored (Space Labs 90 207). Systolic nondippers were defined as a <7%, diastolic nondippers as a <14%, and mean arterial blood pressure (MAP) nondippers as a <12% fall in blood pressure during the night. Renal function was evaluated every other year by clearances of inulin (glomerular filtration rate [GFR]) and para-amino hippurate (effective renal plasma flow [ERPF]), and filtration fraction (GFR/ERPF) was calculated. Overnight urinary albumin excretion rate and long-term mean HbA(1c) were measured. MAP (27% of the patients) and diastolic nondippers (12%) had a significantly thicker basement membrane; larger mesangial matrix volume fraction; and higher long-term GFR, nighttime heart rate, and mean HbA(1c) than dippers. Nondipping status was related to more renal morphological changes and long-term hyperfiltration in normoalbuminuric adolescents and young adults, despite a short duration of type 1 diabetes. Nondipping status may be an early predictor of later nephropathy.