Blood Pressure Dipping Pattern Research Articles

Reproducibility of daytime hypertension, night-time hypertension, and nocturnal blood pressure dipping patterns in young to middle age patients with stage 1 hypertension.

To investigate the reproducibility of ambulatory BP sub-periods and nocturnal dipping phenotypes assessed twice 3 months apart in young-to-middle-age untreated individuals screened for stage 1 hypertension. We investigated 1096, 18-to-45-year old participants from the HARVEST. Their office BP was 145.8 ± 10.4/93.7 ± 5.7 mmHg. Office BP and 24 h BP were measured at baseline and after 3 months. Office, 24-h, daytime and night-time hypertensions, and nocturnal dipping patterns were defined according to the 2023 ESH guidelines. Between-recording agreement was evaluated with kappa statistics. Reproducibility evaluated with weighted kappa was moderate for both 24 h hypertension ( K = 0.48) and daytime hypertension ( K = 0.50) and was only fair for night-time hypertension ( K = 0.36). Between-measurement agreement was even worse for isolated night-time hypertension ( K = 0.24), and was poor for office hypertension ( K = 0.14). The better reproducibility of daytime than night-time period was confirmed by the analysis of BP as continuous variable (all between-period differences, P < 0.001). Nondipping was present in 31.8%, and showed a fair agreement ( K = 0.28,). Poorer agreement was shown by extreme dipping ( K = 0.18) and reverse dipping ( K = 0.07). These data show that within the ambulatory sub-periods, daytime hypertension has a better reproducibility than night-time hypertension. This suggests that the better association with adverse outcomes shown by sleep BP compared to wake BP in observational studies is not due to a better reproducibility of the former. The between-measurement agreement is even worse for isolated nocturnal hypertension and dipping patterns, especially for extreme and reverse dipping. Thus, these BP phenotypes should be confirmed with repeat ambulatory BP monitoring.

Efficacy of angiotensin receptor blockers for nocturnal blood pressure reduction: a systematic review and meta-analysis

Background Nocturnal blood pressure (BP) is correlated with an increased risk of cardiovascular events and is an important predictor of cardiovascular death in hypertensive patients. Objective Nocturnal BP control is of great importance for cardiovascular risk reduction. This systematic review and meta-analysis aimed to explore the efficacy of angiotensin receptor blockers (ARBs) for nocturnal BP reduction in patients with mild to moderate hypertension. Methods PICOS design structure was used to formulate the data extraction. All statistical calculations and analyses were performed with R. Results Seventy-seven studies with 13,314 participants were included. The overall analysis indicated that nocturnal BP drop varied considerably among different ARBs. Allisartan (13.04 [95% CI (−18.41, −7.68)] mmHg), olmesartan (11.67 [95% CI (−14.12, −9.21)] mmHg), telmisartan (11.11 [95% CI (−12.12, −10.11)] mmHg) were associated with greater reduction in nocturnal systolic BP. In the aspect of the nocturnal-diurnal BP drop ratio, only allisartan was greater than 1. While, the variation tendency of last 4–6 h ambulatory BP was basically consistent with nocturnal BP. Additionally, allisartan showed improvement effect in the proportion of patients with dipping BP pattern. Conclusions This study demonstrates that for patients with mild to moderate hypertension, allisartan, olmesartan and telmisartan have more advantages in nocturnal BP reduction among the ARBs, while allisartan can reduce nighttime BP more than daytime BP and improve the dipping pattern.

Hypertension in sub-Saharan Africa: the current profile, recent advances, gaps, and priorities.

Recent global and regional reports consistently confirm the high and increasing prevalence of hypertension in sub-Saharan Africa (SSA), with poor detection, treatment, and control rates. This narrative review summarises the burden of hypertension in SSA and recent findings from community-based hypertension management strategies. We further outline prominent risk factors according to recent data and associated underlying mechanisms for hypertension development. An extensive review of literature showed that most countries have reported on the prevalence of hypertension during 2017-2023, despite limitations linked to the lack of nationally representative studies, heterogeneity of sampling and data collection methods. Task-shifting approaches that assign roles to model patients and community health workers reported improved linkage to healthcare services and adherence to medication, with inconsistent findings on blood pressure (BP)-lowering effects over time. The regularly reported risk factors include unhealthy diet, sedentary lifestyle, increased adiposity and underweight, ageing, level of education, and/or income as well as psychosocial factors. Newer data on the pathophysiological mechanisms leading to hypertension and potential areas of intervention are reported from children and adults and include, among others, salt-handling and volume overload, endothelial function, BP dipping patterns and the role of human immunodeficiency virus. To conclude, significant strides have been made in data reporting from SSA on the burden of hypertension in the region as well as biomarker research to improve understanding and identification of areas of intervention. However, gaps remain on linkage between knowledge generation, translation, and implementation research. Coordinated studies addressing both discovery science and public health are crucial to curb hypertension development and improve management in SSA.

RENAL DENERVATION RESULTS IN SUBSTANTIAL NOCTURNAL BP REDUCTION IN PATIENTS WITH A REVERSED DIPPING PATTERN

Objective: We characterized patients with reverse blood pressure (BP) dipping pattern and uncontrolled hypertension (HTN) at baseline referred for radiofrequency renal denervation (RF RDN), and their subsequent BP changes. Design and method: Patients with HTN were enrolled into the Global SYMPLICITY Registry (GSR) DEFINE and underwent RF RDN. Patients were grouped into different BP dipping patterns defined by night/daytime BP ratio: dippers (ratio 0.9 or below), non-dippers (ratio 0.9 to 1.0 or below), reverse dippers (ratio &gt;1.0). Baseline characteristics and BP changes through 3yrs were compared between groups based on dipper patterns. Statistical significance was defined as p&lt;0.05. Results: As of March 2023, 3331 patients with uncontrolled BP were enrolled, 2276 of whom had 24-h BP measures and could be categorized by dipping patterns. Majority of the patients were non-dippers (44.3%), followed by dippers (34.6%) and reverse dippers (21.1%). Reverse dippers (n=480) were the oldest (62±12yrs; p=0.0024), more likely to have cardiac disease (54.2%; p&lt;0.0001), diabetes (48.1%; p&lt;0.0001) and renal disease (38.9%; p&lt;0.0001). Reverse dippers had the highest baseline 24-h ambulatory systolic BP (SBP) (156±19mmHg; p&lt;0.0001) and nighttime SBP (163±21; p&lt;0.0001). In contrast, they had the lowest daytime SBP (153±19mmHg; p&lt;0.0001) and heart rate (66±11bpm; p&lt;0.0001). Reverse dippers were prescribed the most antihypertensive drugs (5.2±1.7; p=0.0058). 3yrs after RF RDN, significant overall 24-h ambulatory SBP reduction from baseline was observed within all dipping patterns, and the largest reduction was observed within reverse dippers (-11.8±25.1mmHg; Figure), particularly in the nighttime (-21.1±23.8mmHg). Conclusions: Reverse dippers with uncontrolled HTN referred for RDN were prescribed more antihypertensive drugs and had more comorbidities compared to patients with other dipping patterns. After RF RDN, significant SBP changes from baseline were observed irrespective of dipping status. The largest BP reduction was observed in nighttime BP in patients with reverse dipping pattern. RF RDN may offer an effective adjunctive therapy to drugs to lower nighttime BP patients with a reverse dipping pattern, who have the highest risk of cardiovascular events.

Postoperative Dipping Patterns of Mean Arterial Pressure and Mortality After Coronary Artery Bypass Grafting.

Blood pressure dipping patterns have long been considered to be associated with adverse events. We aimed to investigate whether dipping patterns of postoperative MAP were related to 90-day and hospital mortality in patients undergoing CABG. Four thousand three hundred ninety-one patients were classified into extreme dippers (night-to-day ratio of MAP ≤ 0.8), dippers (0.8 < night-to-day ratio of MAP ≤ 0.9), non-dippers (0.9 < night-to-day ratio of MAP ≤ 1), and reverse dippers (> 1). Compared with non-dippers, reverse dippers were at a higher risk of 90-day mortality (aHR = 1.58; 95% CI, 1.10-2.27) and hospital mortality (aOR = 1.97; 95% CI, 1.12-3.47). A significant interaction was observed between hypertension and dipping patterns (P for interaction = 0.02), with a significant increased risk of 90-day mortality in non-hypertensive reverse dippers (aHR = 1.90; 95% CI, 1.17-3.07) but not in hypertensive reverse dippers (aHR = 1.26; 95% CI, 0.73-2.19).

Abnormal blood pressure dipping pattern: frequency, determinants, and correlates in Diabetes Mellitus patients in the Cardiovascular Health Risk Assessment in Diabetes Mellitus (CHiD) study.

Non-dipping status is associated with increased total and cardiovascular mortality in many disease conditions including diabetes mellitus. The pattern and its implications are not well described among Africans. This study was done to describe the frequency of abnormal blood pressure (BP) dipping among T2DM subjects, its determinants and correlates in Ogbomoso, Nigeria. This was a cross-sectional study done at the LAUTECH Teaching Hospital, Ogbomoso. One hundred individuals diagnosed with T2DM were recruited and they had 24-hour ambulatory BP monitoring, echocardiography, ECG, and carotid Doppler among other evaluations. Statistical analysis was done using SPSS 27.0 (Chicago Ill, USA). The mean age of the participants was 59.3 ± 10.8 years, mean body mass index 27.7 ± 5.9kg/m2 with a mean duration of diabetes of 7.52 ± 5.54 years. Abnormal BP dipping was present in 89% (consisting of 41% or reverse dippers and 48% non-dippers). T2DM subjects with abnormal dipping pattern were more likely to be females, had higher glycated haemoglobin, lower fractional shortening, higher left atrial volume and left ventricular mass index, and a higher DM duration than those with normal BP dipping status. The major determinants of abnormal dipping pattern were the duration of diabetes and low HDL-C concentration. Abnormal BP dipping pattern is highly prevalent in T2DM subjects, especially among females. Abnormal BP dipping was also associated with markers of increased cardiovascular risk such as impaired kidney function, left ventricular hypertrophy, postural hypotension, history of intermittent claudication, and presence of plaques on carotid Doppler studies. The online version contains supplementary material available at 10.1007/s40200-023-01337-8.

Abstract 13243: Different Efficacy of Angiotensin Receptor Blockers for Nocturnal Blood Pressure Reduction in Patients With Mild to Moderate Hypertension: A Systematic Review and Meta-Analysis

Introduction: High nocturnal blood pressure (BP) is correlated with an increased risk of cardiovascular events and is an important predictor of cardiovascular death in hypertensive patients. Thus, nocturnal BP control is of great importance for cardiovascular risk reduction. Hypothesis: As the most commonly prescribed BP-lowering agents, angiotensin II receptor blockers (ARBs) maybe have different efficacy for nocturnal BP reduction in patients with mild-to-moderate hypertension (MMH). Methods: We conducted a systematic search in PubMed, EMBASE, Cochrane Library and Web of Science from inception to August 8th, 2022, and collected the ambulatory BP study data of different ARBs (allisartan, candesartan, irbesartan, losartan, olmesartan, telmisartan and valsartan) in patients with MMH following PICOs principle. Data was extracted and the risk of bias of the included studies was evaluated accordingly, and R software (version 4.0.0) was used for statistical analysis. Results: Seventy-eight studies with 13,108 patients were included. The results of meta-analysis showed that allisartan, olmesartan, telmisartan were associated with greater reduction in nocturnal systolic BP, while valsartan, olmesartan and telmisartan demonstrated greater efficacy in reducing nocturnal diastolic BP. In the aspect of the nocturnal-diurnal BP drop ratio, only allisartan was greater than 1 (figure). Additionally, allisartan showed more advantages in the last 4-6 hours ambulatory BP drop, the proportion of patients with dipping BP pattern, and the 24 hours ambulatory BP drop as compared to other ARBs. Conclusions: For patients with MMH, allisartan, olmesartan and telmisartan have more advantages in nocturnal BP reduction among the ARBs, while allisartan can reduce nocturnal BP more than daytime BP and improve the dipping pattern, contribute to restore normal BP rhythm.

Obstructive sleep apnea and non-dipper: epiphenomena or risks of Alzheimer's disease?: a review from the HOPE Asia Network.

Obstructive sleep apnea (OSA) and associated nocturnal blood pressure (BP) surges is associated with non-dipper. On the other hand, the relationship between neurodegenerative diseases and non-dipper hypertension has been reported. To date, few studies have evaluated the relationships of nocturnal BP dipping patterns and OSA in relation to neurodegenerative diseases, particularly Alzheimer's disease (AD). This review examines the etiology of the association between OSA and the non-dipper pattern of hypertension and how both are involved in the development of AD. To set the stage for this review, we first focus on the pathophysiology of AD, which is interrelated with sleep apnea and non-dipper through dysregulation of central autonomic network.

Later circadian timing and increased sleep timing variability are associated with attenuations in overnight blood pressure dipping among chronic nightshift workers

ObjectiveDetermine relationships between overnight blood pressure, circadian phase, and sleep variability among dayshift and chronic nightshift nurses. MethodsTwenty participants working dayshift (n = 10) or nightshift (n = 10) schedules participated in a 7-day cross-sectional study. Participants underwent an evening in-laboratory melatonin assessment and wore ambulatory blood pressure devices to assess 24-hour blood pressure patterns. Overnight blood pressure dipping was calculated from sleeping/waking systolic blood pressure ratio and salivary dim-light melatonin onset determined circadian phase. Sleep variability was assessed using the standard deviation of 7-day sleep onset. ResultsNightshift workers had later circadian phase, greater sleep onset variability, and an attenuated overnight blood pressure dipping pattern. Later circadian phase was associated with attenuated dipping patterns and sleep onset variability was negatively correlated with blood pressure dipping magnitude in nightshift, but not dayshift workers. ConclusionsChronic circadian disruption via higher sleep onset variability among nightshift workers may contribute to attenuated blood pressure dipping and cardiovascular risk in this population.

The relationship between the systemic immune-inflammation index and reverse-dipper circadian pattern in newly diagnosed hypertensive patients.

Although hypertension is considered high intravascular pressure, impairing circadian blood pressure (BP) has been shown to potentially contribute to poor clinical outcomes. Systemic immune-inflammation index (SII), based on platelet, neutrophil, and lymphocyte counts, has been established as a strong prognostic marker in cardiovascular disease. The role of inflammation in the pathogenesis of hypertension is a well-known issue and inflammatory markers are associated with BP variability. We aimed to investigate whether there is a relationship between circadian BP changes and SII in newly diagnosed hypertensive patients. The study population consisted of 196 newly diagnosed hypertensive patients without LVH. In total, 76 (38%) patients had a dipper BP pattern, 60 (31%) patients had a non-dipper BP pattern, and 60 (31%) patients had a reverse-dipper BP pattern. SII was calculated according to Multivariate logistic regression analysis revealed SII and HDL-C as an independent predictors of reverse-dipper circadian pattern in newly diagnosed hypertensive patients. The cut-off value of the SII for reverse-dipper hypertension in a ROC curve analysis was>639.73with 63.3% sensitivity and 84.2% specificity. Our study showed that the SII level was higher in the reverse-dipper hypertension patient group than in the dipper and non-dipper hypertension groups. Furthermore, SII was an independent predictor of newly diagnosed reverse-dipper hypertensive patients. The high SII value in newly diagnosed hypertensive patients can be used as an early warning parameter to identify reverse-dipper hypertension patients.

Effect of Home Blood Pressure Telemonitoring Plus Additional Support on Blood Pressure Control: A Randomized Clinical Trial*

ObjectiveCurrent clinical evidence on the effects of home blood pressure telemonitoring (HBPT) on improving blood pressure control comes entirely from developed countries. Thus, we performed this randomized controlled trial to evaluate whether HBPT plus support (patient education and clinician remote hypertension management) improves blood pressure control more than usual care (UC) in the Chinese population. MethodsThis single-center, randomized controlled study was conducted in Beijing, China. Patients aged 30–75 years were eligible for enrolment if they had blood pressure [systolic (SBP) ≥ 140 mmHg and/or diastolic (DBP) ≥ 90 mmHg; or SBP ≥ 130 mmHg and/or DBP ≥ 80 mmHg with diabetes]. We recruited 190 patients randomized to either the HBPT or the UC groups for 12 weeks. The primary endpoints were blood pressure reduction and the proportion of patients achieving the target blood pressure. ResultsTotally, 172 patients completed the study, the HBPT plus support group (n = 84), and the UC group (n = 88). Patients in the plus support group showed a greater reduction in mean ambulatory blood pressure than those in the UC group. The plus support group had a significantly higher proportion of patients who achieved the target blood pressure and maintained a dipper blood pressure pattern at the 12th week of follow-up. Additionally, the patients in the plus support group showed lower blood pressure variability and higher drug adherence than those in the UC group. ConclusionHBPT plus additional support results in greater blood pressure reduction, better blood pressure control, a higher proportion of dipper blood pressure patterns, lower blood pressure variability, and higher drug adherence than UC. The development of telemedicine may be the cornerstone of hypertension management in primary care.

Effects of a high salt diet on blood pressure dipping and the implications on hypertension.

High blood pressure, also known as hypertension, is a major risk factor for cardiovascular disease. Salt intake has been shown to have a significant impact on BP, but the mechanisms by which it influences the blood pressure dipping pattern, and 24-h blood pressure remains controversial. This literature review aims to both summarize the current evidence on high salt diet induced hypertension and discuss the epidemiological aspects including socioeconomic issues in the United States and abroad. Our review indicates that a high salt diet is associated with a blunted nocturnal blood pressure dipping pattern, which is characterized by a reduced decrease in blood pressure during the nighttime hours. The mechanisms by which high salt intake affects blood pressure dipping patterns are not fully understood, but it is suggested that it may be related to changes in the sympathetic nervous system. Further, we looked at the association between major blood pressure and circadian rhythm regulatory centers in the brain, including the paraventricular nucleus (PVN), suprachiasmatic nucleus (SCN) and nucleus tractus solitarius (nTS). We also discuss the underlying social and economic issues in the United States and around the world. In conclusion, the evidence suggests that a high salt diet is associated with a blunted, non-dipping, or reverse dipping blood pressure pattern, which has been shown to increase the risk of cardiovascular disease. Further research is needed to better understand the underlying mechanisms by which high salt intake influences changes within the central nervous system.

5. Nocturnal Dipping Pattern in Hypertensive Patients as a Risk Factor for Cerebral Small Vessel Disease (CSVD): A Systematic Review and Meta-Analysis

Background: Cerebral small vascular disease (CSVD) is one of the most prevalent cerebral vascular pathologies encountered by middle-aged and older people, which can be observed by magnetic resonance imaging (MRI). The most important modifiable risk factor for CSVD is hypertension. Abnormal circadian blood pressure (BP) variability has been reported to significantly damage hypertensive patients’ target organs. Moreover, in many studies, controlling sleep blood pressure has been shown to exert greater protection against stroke and cardiovascular events. Objective: We aim to assess the nocturnal dipping pattern of blood pressure with the findings of cerebral small vessel disease. Method: We performed a comprehensive search on topics that assess nocturnal blood pressure monitoring and cerebral small vessel disease findings through imaging from inception up until November 2022. Result: There were a total of 2674 patients from 5 studies. The outcome of this study reported that reverse dipping and dipping BP patterns were significantly associated with the prevalence of CSVD. Meta-analysis showed that the reverse dipping BP pattern was associated with a higher risk for CSVD (OR 2.18 [1.80, 2.64], p = 0.64; I2: 0%, p &lt; 0.00001), meanwhile dipping pattern had a lower risk for CSVD (OR 0.51 [0.42, 0.63], p = 0.04; I2: 59%, p &lt; 0.00001). There was no association between the non-dipping pattern and CSVD (OR 0.92 [0.77, 1.10], p = 0.70; I2:0%, p = 0.35). Conclusion: Nocturnal BP pattern and CSVD were shown to be associated, with the reverse dipping BP pattern having a higher risk and dipping having a lower risk.

Non-dipping blood pressure pattern is associated with higher risk of new-onset diabetes in hypertensive patients with obstructive sleep apnea: UROSAH data.

Impairment of circadian blood pressure (BP) patterns has been associated with cardiovascular risks and events in individuals with hypertension and in general populations, which are more likely to be found in obstructive sleep apnea (OSA). The aim of this study was to investigate the association of non-dipping BP pattern with new-onset diabetes in hypertensive patients with OSA, based on Urumqi Research on Sleep Apnea and Hypertension (UROSAH) data. This retrospective cohort study included 1841 hypertensive patients at least 18 years of age, who were diagnosed with OSA without baseline diabetes and had adequate ambulatory blood pressure monitoring (ABPM) data at enrollment. The exposure of interest for the present study was the circadian BP patterns, including non-dipping and dipping BP pattern, and the study outcome was defined as the time from baseline to new-onset diabetes. The associations between circadian BP patterns and new-onset diabetes were assessed using Cox proportional hazard models. Among 1841 participants (mean age: 48.8 ± 10.5 years, 69.1% male), during the total follow-up of 12172 person-years with a median follow-up of 6.9 (inter quartile range: 6.0-8.0) years, 217 participants developed new-onset diabetes with an incidence rate of 17.8 per 1000 person-years. The proportion of non-dippers and dippers at enrollment in this cohort was 58.8% and 41.2%, respectively. Non-dippers were associated with higher risk of new-onset diabetes compared with dippers (full adjusted hazard ratio [HR]=1.53, 95% confidence interval [CI]: 1.14-2.06, P=0.005). Multiple subgroup and sensitivity analyses yielded similar results. We further explored the association of systolic and diastolic BP patterns with new-onset diabetes separately, and found that diastolic BP non-dippers were associated with higher risk of new-onset diabetes (full adjusted HR=1.54, 95% CI: 1.12-2.10, P=0.008), whereas for systolic BP non-dippers, the association was nonsignificant after adjusted the confounding covariates (full adjusted HR=1.35, 95% CI: 0.98-1.86, P=0.070). Non-dipping BP pattern is associated with an approximately 1.5-fold higher risk of new-onset diabetes in hypertensive patients with OSA, suggesting that non-dipping BP pattern may be an important clinical implication for the early prevention of diabetes in hypertensive patients with OSA.

Ambulatory Blood Pressure Monitoring Section in Normotensive Type 2 Diabetes Mellitus: An Observational Study

Introduction: Hypertension (HTN) is a major cause of cardiovascular morbidity and mortality, particularly in diabetic people. Because HTN and Type 2 Diabetes Mellitus (T2DM) frequently co-exist, HTN is a significant risk factor for chronic problems masked HTN affects around a one third of T2DM patients who have normal Blood Pressure (BP) readings in the clinic. T2DM patients frequently have normal office BP (BP) and no nocturnal BP falling. The non dipping BP pattern raises the risk of cardiovascular events and damage to target organs. Multiple BP recordings can be obtained with Ambulatory BP Monitoring (ABPM). By providing variability of BP, and diurnal variation in BP, it assists the treating physician in the diagnosis and management of HTN. Aim: To elucidate the prevalence of non dipping pattern in T2DM and the characteristics of diabetics who have non dipping pattern using ambulatory monitoring. Materials and Methods: This was an observational study carried out in the Department of Medicine at JIPMER, Pondicherry, India. Between January 2016 and December 2017, 110 patients with T2DM were visited to Medicine Outpatient Department and the Diabetic Clinic. Out of 110, a total of 62 patients, with an average age of 46.67 years, were included in the study. Sun Tech Oscar 2’ 24 hourR ABPM system was used for the study of ambulatory BP of patients, at specified times. Results: Sixty-two normotensive T2DM patients, mean age of 46.67 years were analysed in the 24 months. A total of 62 patients, the non dipping pattern was seen in 47 (76%) of the 62 individuals evaluated for ABPM, while the dipping pattern was seen in 15 (24%) of the normotensive T2DM patients. A non dipping pattern was associated with a higher Body Mass Index (BMI) (p-value=0.03). A non dipping habit was also substantially associated with high PPBS values (p-value=0.02). Conclusion: Patients with a history of HTN and smoking had a higher chance of non dipping patterns, which may lead to endorgan damage and future cardiovascular events. ABPM can be used as a screening tool to predict cardiovascular events in T2DM.

PS-R01-5: SACUBITRIL/VALSARTAN IMPROVES HYPERTENSION, NIGHTTIME BLOOD PRESSURE AND HEART FAILURE: A CASE-REPORT

Objective: Sacubitril/valsartan, angiotensin receptor blocker (ARB)/neprilysin inhibitor, has been shown to effectively reduce ambulatory 24-h blood pressure in patients with hypertension. Improvements in heart failure have also been reported. This case report highlights the validity of sacubitril/valsartan for the treatment of hypertension, nocturnal blood pressure, and heart failure. Methods: A 75-year-old hypertensive male patient with heart failure was prescribed an ARB and a β;-blocker, along with a mineralocorticoid receptor antagonist (MRA) for diuresis. However, his nighttime blood pressure and central blood pressure remained high, and left ventricular ejection fraction (LVEF) remained low, along with persistent elevation of serum N-terminal pro-brain natriuretic peptide (NT-pro BNP) levels. Hence, we switched the ARB to sacubitril/valsartan. The other drugs were left unchanged. We measured his daytime and nighttime blood pressure by ambulatory blood pressure monitoring (ABPM) before and 6 months after the change of medication. In addition, central systolic blood pressure (cSBP) was measured using an automated tonometry system, LVEF, left ventricular mass index (LVMI), left atrial (LA) diameter and septal ratios of transmitral flow velocity to annular velocity (septal E/e’ ratio) were measured using a Vivid S6 ultrasound system with 3-MHz transducer and serum sample was obtained for NT-pro BNP assessment before and 6 months after the change of medication. Results: Brachial blood pressure (154/71 to 132/72 mmHg), nocturnal blood pressure (average value: 136/65 to 121/67 mmHg), and cSBP (154 to 135 mmHg) improved by changing the treatment. Additionally, the riser pattern was improved to the dipper blood pressure pattern by changing the prescription, along with improvements in EF (39.5 to 51.2%), LVMI (127.3 to 119.6 g/m2), LA diameter (40.1 to 37.8 mm) and septal E/e’ ratio (15.1 to 14.5). Further, although serum levels of NT-pro BNP improved with the change of treatment (656 to 325 pg/mL). Symptoms of heart failure were also reduced from New York Heart Association (NYHA) class 3 to NYHA class 2. There were no noticeable adverse effects after the change. Conclusion: In our patient, changing from an ARB to sacubitril/valsartan resulted in an improvement in nighttime and central blood pressure, and left ventricular hypertrophy and diastolic function, and to recovery of EF, with a change from heart failure with reduced ejection fraction (HFrEF) to heart failure with preserved ejection fraction (HFpEF). His NT-proBNP levels and heart failure symptoms also improved. Our experience suggests that sacubitril/valsartan might be useful in patients with heart failure who have nocturnal hypertension.

JS-HR-7: BLOOD PRESSURE VARIABILITY; THERAPEUTIC TARGET FOR THE PREVENTION OF CARDIOVASCULAR DISEASE

In the past three decades, there have been many reports on the associations of various parameters of blood pressure (BP) variability with increased risk of cardiovascular disease (CVD) events; these parameters include short term BP variability (BPV), i.e., beat-by-beat BPV and ambulatory BPV, abnormality of nocturnal BP dipping pattern, and mid- to long-term BPV, i.e., day-by-day BPV, visit-to-visit BPV, and seasonal variations in BP. Several factors that are associated with abnormal BPV, as well as environmental factors such as cold or warm temperatures and seasonal changes in climate, increase fluctuations in BP. Individual intrinsic factors such as sympathetic nervous tone, arterial stiffness, physical activity, and mental stress also contribute to elevated BPV. According to evaluations of BPV abnormalities, out-of-office BP measurements such as ambulatory and home BP monitoring are needed. Although there are issues regarding measurement accuracy, cuffless BP monitoring devices, for example, those using pulse transit time, may be used to estimate nighttime BP levels. Such cuffless BP devices can also evaluate beat-by-beat BPV. Moreover, by using the multisensor-equipped ambulatory BP monitoring device developed by our research group, it is possible to evaluate BPV associated with changes in temperature, physical activity, and/or atmospheric pressure. Based on the mechanism(s) behind a given patients BPV abnormality, several methods may be considered for the management of that abnormality (Figure). For example, improving excessive sympathetic nervous system activation may be useful in the management of BPV abnormality, and renal denervation has been reported to decrease ambulatory BPV. Abnormal nocturnal BP dipping may be treated by decreasing nighttime BP. Moreover, early adjustment of antihypertensive drugs has been reported to be useful in suppressing seasonal variations in BP, leading to a decreased risk of CVD events. Furthermore, housing conditions and room temperature are closely related to BP levels, and adaptive control of room temperature would be useful to suppress winter increases in BP. In clinical practice, we must not forget that BPV parameters are interrelated. For instance, frequent evaluation of BP levels and adjustment of antihypertensive drugs can suppress visit-to-visit BPV, which in turn leads to the suppression of seasonal variations in BP. Over the next decade, greater data on how to manage and control BPV need to be accumulated. Additionally, future studies should be conducted to verify whether the different types of BVP management are useful in preventing CVD events.

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

Stroke, the most feared complication in patients with atrial fibrillation (AF), is still an important cause of mortality and morbidity. In our study, we aimed to investigate the frequency of stroke and related parameters in patients with atrial fibrillation, for whom 24-h ambulatory blood pressure monitoring (ABPM) was performed. A total of 282 patients with permanent AF were included in this study. 24-h ABPM was performed in all patients. Morning blood pressure surge (MBPS) was defined as the difference between the mean SBP in the first 2 h after awakening and the lowest blood pressure (BP) at night. We evaluated parameters associated with stroke in patients with atrial fibrillation using univariate and multivariate Cox regression analysis. Patients were followed for 19 ± 9.3 months and 22 ischemic strokes were detected during the follow-up period. Also, strokes were significantly lower in atrial fibrillation patients with a dipper BP pattern, whereas strokes were significantly higher in atrial fibrillation patients with a reverse-dipper BP pattern. In multivariate analysis, a history of hypertension ( P = 0.020), BP pattern ( P < 0.001) and MBPS ( P < 0.001) were found to be significantly related to stroke. MBPS levels >32.5 mmHg predicted stroke with a sensitivity of 77% and a specificity of 60% (AUC, 0.741; 95% CI, 0.647-0.834; P < 0.001). MBPS, BP pattern and presence of hypertension as an independent risk factor in predicting stroke in patients with atrial fibrillation. The reduction of the MBPS may be a new therapeutic target for preventing stroke.

Association between nocturnal blood pressure dipping and chronic kidney disease

Abstract Introduction Management of blood pressure (BP) in chronic kidney disease (CKD) is critical for preventing cardio-renal complications. While increasing attention has been given to discrepancies between office and ambulatory BP control in this population, information on nocturnal BP decrease patterns (dipping) in CKD is still scarce. Purpose We aimed at describing nocturnal BP dipping patterns and its predictors in patients with CKD. Methods We analysed data from patients with CKD stages 1 to 5 referred for kidney function testing from September 2006 to January 2022, including 24-hour urine collection, gold-standard measurement of glomerular filtration rate (GFR) using clearance of a radioisotopic tracer, as well as ambulatory BP measurement (ABPM) in a single tertiary hospital in Paris, France. A total of 1177 ABPM were available in 642 participants. The magnitude of dipping was calculated as the difference between day- and night-time systolic BP (SBP), in percentage of daytime SBP. Participants were then categorized as extreme-dippers (≥20%), dippers (10% to &amp;lt;20%), non-dippers (0% to &amp;lt;10%), or reverse-dippers (&amp;lt;0%). Factors associated with a less than 10% dipping were analysed with crude and adjusted logistic regression models including a random intercept to deal with clustering of measurements within patients. Results Participants (mean age 56±15 years; 35% female, mean GFR 49±21 mL/min per 1.73 m2) consisted of 8% extreme-dippers, 37% dippers, 40% non-dippers, and 15% reverse-dippers. The prevalence of non- or reverse-dipping increased with CKD severity, from 36% in CKD stage 1 to 65% in CKD stages 4–5 (Figure). In crude analyses, African origin, a lower measured GFR, a higher daytime SBP, diabetes, a higher number of antihypertensive medications and a higher 24-hour urinary sodium to potassium ratio (24h Na/K) were associated with abnormal dipping status. In the multivariable adjusted regression, non or reverse dipping was independently associated with measured GFR (odds ratio [OR, 95% confidence interval] per 10 ml/min/1.73 m2 decrease = 1.16 [1.06–1.26], p=0.001), daytime ambulatory SBP (OR per 10 mmHg decrease = 1.17 [1.06–1.28], p=0.001), African origin (OR= 1.56 [1.04–2.34], p=0.03) and 24h Na/K (OR per 1-unit increase = 1.20 [1.06–1.37], p=0.006). Conclusions The prevalence of nocturnal non-or reverse dipping BP profiles increases substantially across the spectrum of CKD. Measured GFR, ambulatory daytime SBP, African origin and 24-hour urinary sodium to potassium ratio are independent predictors of abnormal nocturnal BP decrease and thus may help in cardiovascular risk stratification in this population. More research is needed on whether nocturnal dipping may be a treatment target to reduce cardiorenal complications. Funding Acknowledgement Type of funding sources: None.

The Correlation Between ABPM Parameters and Left Ventricular Hypertrophy in Pediatric Essential Hypertension.

ObjectiveTo explore the association of dipping pattern and blood pressure load with left ventricular hypertrophy (LVH) in pediatric essential hypertension.Materials and MethodsThrough an echocardiography monitor and an ambulatory blood pressure monitor of 425 children and adolescents diagnosed with essential hypertension with no treatment received, we identified 140 cases of LVH. Grouping patients according to LVH (LVH, N = 140; n-LVH, N = 285), we further evaluated their ambulatory blood pressure monitoring (ABPM) parameters by comparing dipping patterns between groups. A multivariable logistic regression analysis was used to determine the effect of blood pressure load on LVH.ResultsNo significant difference was found in systolic or diastolic blood pressure dipping patterns between groups (P = 0.161, P = 0.139). However, compared to the n-LVH group, the LVH group presented significant elevated nighttime systolic blood pressure (SBP) (P < 0.05), while nighttime DBP remained stable (P = 0.391), resulting in higher daytime and nighttime SBP loads, higher nighttime DBP load, and higher 24-h SBP load (P < 0.05). Notably, our multivariable logistic regression has shown that this trend of 24-h SBP load acts independently as a critical risk factor for LVH.ConclusionCollectively, we observed a correlation between BP load and LVH in pediatric hypertension. Our data demonstrated that SBP load has a more significant weight in LVH progression, and 24-h SBP load, in particular, acts as a critical early prognostic parameter for LVH in pediatric hypertension.