Early Morning Blood Pressure Surge Research Articles

Associations of the nocturnal blood pressure fall and morning surge with cardiovascular events and mortality in individuals with resistant hypertension.

The prognostic importance of the nocturnal blood pressure (BP) fall and early-morning surge were scarcely investigated in patients with resistant hypertension (RHT). We investigated them in a prospective cohort of 1726 RHT individuals. The nocturnal fall and morning surge were calculated from the baseline ambulatory BP monitoring (ABPM) and also as mean cumulative values using all ABPMs performed during follow-up. Dipping patterns (normal, extreme, reduced, and reverse) were defined by classic cut-off values of the night-to-day ratio, while MS (difference between early-morning and night-time BP) was categorized into quartiles and at the extremes of its distribution (5th, 10th, 90th, and 95th percentiles). The primary outcomes were total cardiovascular events (CVEs), major adverse cardiovascular events (MACEs), all-cause and cardiovascular mortalities. Multivariate Cox analyses examined the associations between nocturnal BP fall and morning surge and outcomes. Over a median follow-up of 8.3 years, 417 CVEs occurred (358 MACEs), and 391 individuals died (233 cardiovascular deaths). Reduced and reverse dipping patterns were significant predictors of CVEs and MACEs, with hazard ratios between 1.6 and 2.5, whereas extreme dipping was a protective factor in younger individuals (hazard ratios 0.3--0.4) but a hazardous factor in elderly (hazard ratios 3.7--5.0) and in individuals with previous cardiovascular diseases (hazard ratios 2.6--4.4). No morning surge parameter was predictive of any outcome in fully adjusted analyses. Abnormal dipping patterns but not the early-morning BP surge, were important prognostic markers for future cardiovascular morbidity in RHT patients. The prognosis of extreme dippers depended on age and the presence of cardiovascular diseases.

Evening anti-hypertensive dosing improves blood pressure control and reduce cardiovascular events in hypertensive: a meta-analysis of 40 trials in 44,167 patients

Abstract Introduction Nocturnal blood pressure (BP) and early morning BP surge have consistently been found to be a better prognostic marker of cardiovascular outcome than daytime BP. Most anti-hypertensive show greater blood pressure-lowering effect in the first 12 hours compared to the next 12 hours. Several prospective studies have shown better BP regulation and improved cardiovascular risk when anti-hypertensive are ingested at bedtime versus at awakening. Purpose In patients with hypertension does evening dosing of anti-hypertensive compared to morning dosing led to better reduction in pressure, blood pressure control and reduced cardiovascular morbidity. Methods A meta-analysis was performed based on randomized controlled trials obtained from Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Medline and Medline ahead of print published between 2000 and 2020. Main outcome measures include mean 24 hour systolic and diastolic blood pressure, cardiovascular events as well as prevalence of blood pressure in control. Data synthesis and analysis was done using RevMan 5.3 using a random effects model. Results A total of 40 randomized controlled trials, representing 44,167 patients were included in this meta-analysis. Most studies evaluate the administration of mixed anti-hypertensive with ≥1 medication ingested at bedtime, calcium channel blockers (CCBs) or angiotensin receptor blockers (ARBs) with sample sizes ranging from 30 to 19,084 patients. Evening administration of anti-hypertensive was found to significantly lower 24-hour systolic blood pressure (Mean difference = −1.05, 95% CI: −2.01 to −0.10, p=0.03) and 24-hour diastolic blood pressure (Mean difference = −1.09, 95% CI: −1.68 to −0.50, p=0.0003). Prevalence of controlled blood pressure was found to significantly increase with evening dosing (RR=1.15, 95% CI: 1.03 to 1.28, p=0.01). Significant reduction in cardiovascular events were found in the evening dosing group (RR=0.48, 95% CI: 0.03 to 0.68, p=<0.00001). Discussion Reduction in night-time blood pressure especially among non-dippers as reported in previous studies and higher prevalence of controlled blood pressure may explain the greater than 50% reduction in cardiovascular events in the evening dosing group. This marked benefit from a simple and inexpensive strategy certainly has great potential to benefit patients in practice. Even so, few studies have reported the prevalence of blood pressure in control (9 studies) and cardiovascular events (6 studies). Few has also studied this in geriatric populations where night-time hypotension and hypoperfusion may bring the most impact. Conclusion For patients with hypertension, evening dosing significantly improves blood pressure control and reduces the risk for cardiovascular events. Careful selection of anti-hypertensive administration time in patients is recommended given the possible benefits. Anti Hypertensive Dosing Forest Plot Funding Acknowledgement Type of funding source: None

INTRAVENOUS LASER THERAPY IN A COMPREHENSIVE APPROACH TO THE CORRECTION OF RISK FACTORS OF ARTERIAL HYPERTENSION

Introduction. According to Akl C et al. by 2025, the number of people with arterial hypertension (AH) will increase by 15–20% and reach 1.5 billion people. Since hyperuricemia (HU) is closely related to other AH risk factors, there is a need to study the relationship between HU and other AH risk factors. Objective of this work is to develop rational approaches to modifying individual AH risk factor using intravenous laser therapy (IVLT). Materials and methods. The study included 184 people: Group 1 (n = 30) – normotensive individuals without HU; Group 2 (n = 52) – normotensive patients with HU; Group 3 (n = 48) – patients with essential AH (stage I, 1-2 degree) without HU; Group 4 (n = 54) – patients with essential AH (stage I, 1-2 degree) with HU. Patients in Group 3 and 4 were divided into subgroups according to the treatment regimens: 3A (n = 24), 4A (n = 26) (standard antihypertensive therapy (AHT)) and 3B (n = 24), 4B (n = 28) (combination treatment with AHT and IVLT). The IVLT course was performed with a wavelength of 635 nm, a power of 1.5 mW, a radiation power density of 0.2 W/cm2, a fluence of 0.2 J/cm2, an exposure of 900 seconds, the course – daily, with a total of 10 procedures. Study results. The association between the level of uric acid (UA), systolic blood pressure (SBP), diastolic blood pressure (DBP), endothelial dysfunction (ED), left ventricular myocardial dysfunction, excess increase in arterial wall stiffness, and poikilocytosis in the study groups was established. The use of IVLT in combination with AHT allows to achieve a statistically significant (р < 0.05), compared to AHT reduction in SBPd by 4.2%, DBPd by 2.4%, DBPn by 2.5%, time index (TI) SBPd by 5.1%, TI DBPd by 2.7%, TI SBPn by 19%, rate of morning rise (RMR) SBP by 33.8%, RMR DBP by 31%, early morning blood pressure surge (EMBPS) SBP by 17.3%, EMBPS DBP by 12.8%, puilse wave velosity (PWV) by 4.1%, manifestations of endothelial dysfunction by 1.4%, myocardial dysfunction by 4.5%, poikilocytosis by 2.9%, uric acid level by 3.1% in patients with AH. In AH and HU comorbidity, addition of ILT to AHT allows to achieve an additional reduction in SBPd by 9.3%, DBPd by 7.4%, SBPn by 11,5%, DBPn by 2.7%, TI SBPd by 18.8%, TI DBPd by 18.9%, TI SBPn by 1.8%, TI DBPn by 8,7%, RMR SBP by 25.8%, RMR DBP by 28.5%, EMBPS SBP by 8.2%, EMBPS DBP by 6.0%, PWV by 13.4%, endothelial dysfunction by 3.5%, myocardial dysfunction by 18.8%, poikilocytosis by 5.7%, uric acid level by 11.6% compared to AHT. In patients with normal blood pressure and HU values, the use of IVLT can reduce DBPM, EDVD, poikilocytosis, and UA level parameters (p < 0.05). Conclusions. The presence of direct correlations of average strength between HU and endothelial dysfunction, systolic diastolic dysfunction, excessive increase in arterial wall stiffness, and poikilocytosis was found. The use of IVLT in normotensive and hypertensive patients with AH with an effective method of UA level correction, excessive arterial wall stiffness, myocardial dysfunction, ED and poikilocytosis.

Diversity of and initiatives for hypertension management in Asia-Why we need the HOPE Asia Network.

The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was set up to improve the management of hypertension in Asia with the ultimate goal of achieving "zero" cardiovascular events. Asia is a diverse continent, and the prevalence of hypertension has increased over the last 30years. There are a number of Asia-specific features of hypertension and hypertension-related cardiovascular complications, which means that a region-specific approach is needed. White-coat hypertension will become more of an issue over time as Asian populations age, and masked hypertension is more prevalent in Asian than in Western countries. Identifying and treating masked hypertension is important to reduce cardiovascular risk. Abnormal patterns of blood pressure (BP) variability common in Asia include exaggerated early morning BP surge and nocturnal hypertension. These are also important cardiovascular risk factors that need to be managed. Home blood pressure monitoring (HBPM) is an important tool for detecting white-coat and masked hypertension, and monitoring BP variability, and practices in Asia are variable. Use of HBPM is important given the Asia-specific features of hypertension, and strategies are needed to improve and standardize HBPM usage. Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology-based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. Region-wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices.

Morning surge in blood pressure and blood pressure variability in Asia: Evidence and statement from the HOPE Asia Network.

Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases. To effectively prevent end-organ damage, maintain vascular integrity and reduce morbidity and mortality, it is essential to decrease and adequately control blood pressure (BP) throughout each 24-hour period. Exaggerated early morning BP surge (EMBS) is one component of BP variability (BPV), and has been associated with an increased risk of stroke and cardiovascular events, independently of 24-hour average BP. BPV includes circadian, short-term and long-term components, and can best be documented using out-of-office techniques such as ambulatory and/or home BP monitoring. There is a large body of evidence linking both BPV and EMBS with increased rates of adverse cardio- and cerebrovascular events, and end-organ damage. Differences in hypertension and related cardiovascular disease rates have been reported between Western and Asian populations, including a higher rate of stroke, higher prevalence of metabolic syndrome, greater salt sensitivity and more common high morning and nocturnal BP readings in Asians. This highlights a need for BP management strategies that take into account ethnic differences. In general, long-acting antihypertensives that control BP throughout the 24-hour period are preferred; amlodipine and telmisartan have been shown to control EMBS more effectively than valsartan. Home and ambulatory BP monitoring should form an essential part of hypertension management, with individualized pharmacotherapy to achieve optimal 24-hour BP control particularly the EMBS and provide the best cardio- and cerebrovascular protection. Future research should facilitate better understanding of BPV, allowing optimization of strategies for the detection and treatment of hypertension to reduce adverse outcomes.

EARLY MORNING SURGE BLOOD PRESSURE AND ISOLATED SYSTOLIC HYPERTENSION - A CLINICAL IMPORTANCE IN ELDERLY

Objective: In hypertensive patients treated with antihypertensive medication, even patients whose clinic blood pressure is well controlled, morning blood pressure prior taking medication remains high, and therefore morning hypertension is currently the blind spot in the clinical practice of hypertension. To objective is to asses now again on a wider group of patients whether an increased early morning blood pressure surge is related to more prominent target organ damage. Design and method: 623 treated hypertensive patients randomly attended the out-patient clinic of our hypertension centre from 6 October 2009 to 1 November 2014, and supplemented from 2 November 2014 to 31 October 2016. The Isolated Systolic Hypertension patients (n = 176, 78 ± 11 yrs) were divided into 2 groups (n = 176 {with morning hypertension [sleep > 120mmHg] n = 140 [nondippers] and those without n = 36 [dippers]}). Early Morning Blood Pressure Surge, was defined as peak Blood Pressure during morning period (4–6am, average of 5 values, mean = 124.19 mmHg, SD 21.91 mmHg) minus average BP during the sleep period (average of lowest 3 sleep values, mean = 145.49 mmHg, SD 22.14 mmHg). Early morning surge had a mean of 22.78 mmHg, SD 11.92 mmHg, (P < 0.01). Pulse Pressure was also used in this study as a direct predictor of hypertensive target organ damage. Results: Nondipping pattern is related to metabolic syndrome, masked hypertension and female gender. Pulse pressure mean was higher in Nondippers by 11mmHg. Higher cases of stroke and MI where reported in the Early Morning Surge group. Conclusions: Early Morning Surge is a predictor of hypertensive target organ damage.

Relationship between elevated morning blood pressure surge, uric acid, and cardiovascular outcomes in hypertensive patients.

Early morning blood pressure surge (MBPS) is a risk factor for cardiovascular events (CVEs), but the relationship with uric acid is not well understood. The authors aimed to determine the association between MBPS and increased uric acid and the effect of elevated MBPS and uric acid combination on CVEs. A total of 921 patients underwent 24-hour ambulatory blood pressure monitoring and were followed for a median of 40months. During this period, 103 (11.2%) CVEs occurred. There was a significant relationship between increasing quartiles of serum uric acid level and increasing values of MBPS (P<.0001). Patients in the highest quartile stratified by elevated MBPS and serum uric acid level had a 3.55 odds of major CVE compared with patients in the lowest quartile. Serum uric acid is associated with MBPS and development of new CVEs.

OP-223 Early Morning Blood Pressure Surge is Correlated with Anxiety Level of the Patients in Arterial Hypertension

OP-223 Early Morning Blood Pressure Surge is Correlated with Anxiety Level of the Patients in Arterial Hypertension

Early morning hypertension

Early morning hypertension has attracted more attention because of the close relationship between blood pressure levels in the early morning and cardiovascular risk. However, there are some unsolved issues on early morning hypertension. First, is early morning hypertension more special than other hypertension evaluated by other blood pressure indices? Second, the concept of early morning hypertension and morning blood pressure surge is sometimes discussed in the same context. Finally, is there any benefit in reducing early morning hypertension independent of a reduction in any other blood pressure index? Here, we review the remaining unsolved issues on early morning hypertension.

Non-dipping morning blood pressure and isolated systolic hypertension in elderly

Morning hypertension is currently the blind spot in the clinical practice of hypertension, home 24-hour blood pressure measurement has been recommended in patients with a high clinic blood pressure and patients with target organ damage. To assess whether an increased early morning blood pressure surge, established via a single 24-hour blood pressure monitoring, in treated elderly hypertensive's is related to more prominent target organ damage. 310 treated hypertensive patients randomly attended the out-patient clinic of our hypertension centre. The patients were divided in 2 groups: systolic/diastolic blood pressure hypertension (n = 266) and isolated systolic hypertension (n = 44 76 ± 10 yrs). Equivalent in both males and females, despite the rise in nondippers with an early morning surge (higher in females). Hyperlipidemia arises equally in dippers and nondippers, 45 % of nondippers had diabetes mellitus; 30 % suffered previous renal insufficiency and about 29 % of patients suffered from an endocrine disorder, mostly thyroid. Metabolic syndrome was only found to be associated with a nondipping pattern (3 %). Left ventricular hypertrophy was present in 100 % of patients, heart failure in 60 % nondippers and 56 % dippers, potential renal insufficiency in 34 % nondippers and 22 % dippers, retinopathy in 31 % non dippers and 11 % dippers, aortic aneurysm was only in nondippers. Early morning surge is a predictor of hypertensive target organ damage, being a dipper or nondipper patient with isolated systolic hypertension, might not make a difference depending on one's own degree of target organ damage and diurnal variation (Fig. 2, Ref. 30).

Morning Surge, Dipping, and Sleep-Time Blood Pressure as Prognostic Markers of Cardiovascular Risk

Verdecchia et al1 recently reported lowest cardiovascular disease (CVD) risk in hypertensive patients of the first quartile of the early morning blood pressure (BP) surge (MBPS) determined by a single before-treatment 24-hour ambulatory BP monitoring (ABPM), defining their results as unexpected, novel, and at variance with previous investigations. Nonetheless, findings of prospective MBPS investigations are inconsistent.2–4 On the contrary, numerous studies consistently show, first, an association between blunted sleep-time relative BP decline and increased incidence of fatal and nonfatal CVD events, and, second, the asleep BP mean is a better predictor of CVD events than the awake or 24-hour BP means.2,3 Israel et al4 evaluated the prognostic value of MBPS and …

Body Position and Quality of Sleep Interfere With Day-Night Blood Pressure Dip

We read with interest the study of Verdecchia et al1 on the prognostic significance of the day-night blood pressure (BP) dip and the early morning BP surge. The authors rightfully question the contradicting results of previous reports, suggesting that the early morning BP surge is a risk factor for cardiovascular events, whereas other studies demonstrate that nondipping (and, as such, a lack of surge) is a relevant cardiovascular risk factor.2 The current findings add to the controversy but put more weight on the scale against the …

Response to Body Position and Quality of Sleep Interfere With Day-Night Blood Pressure Dip

We thank Bakx and coworkers1 for their interest in our study. They are right in stating that sleeping on the right or left lateral side can result in different blood pressure (BP) values, with BP differences averaging 15 mm Hg.2 Thus, the absolute nighttime BP levels, the day-night BP dip, and the early morning surge in BP should be corrected for the left or right lateral position. Unfortunately, tracking such information for all BP measurements taken in lying position during night, or even during day, is problematic from a technical point …

Day-Night Dip and Early-Morning Surge in Blood Pressure in Hypertension

We investigated the relationship between the day-night blood pressure (BP) dip and the early morning BP surge in an cohort of 3012 initially untreated subjects with essential hypertension. The day-night reduction in systolic BP showed a direct association with the sleep trough ( r =0.564; P &lt;0.0001) and the preawakening ( r =0.554; P &lt;0.0001) systolic BP surge. Over a mean follow-up period of 8.44 years, 268 subjects developed a major cardiovascular event (composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and heart failure requiring hospitalization) and 220 subjects died. In a Cox model, after adjustment for predictive covariates, including age, sex, diabetes mellitus, cigarette smoking, total cholesterol, left ventricular hypertrophy on ECG, estimated glomerular filtration rate, and average 24-hour systolic BP, a blunted sleep trough (≤19.5 mm Hg; quartile 1) and preawakening (≤9.5 mm Hg; quartile 1) BP surge was associated with an excess risk of events (hazard ratio, 1.66 [95% CI, 1.14–2.42]; P =0.009; hazard ratio, 1.71 [95% CI, 1.12–2.71]; P =0.013). After adjustment for the same covariates, neither the dipping pattern nor the measures of early morning BP surge were independent predictors of mortality. In conclusion, in initially untreated subjects with hypertension, a blunted day-night BP dip was associated with a blunted morning BP surge and vice versa. In these subjects, a blunted morning BP surge was an independent predictor of cardiovascular events, whereas an excessive BP surge did not portend an increased risk of events.

The morning blood pressure surge

The morning blood pressure surge

Abstract 9349: Wave Reflection but Not Arterial Stiffness is Much Highly Correlated with Ambulatory Blood Pressure Parameters Including Blood Pressure Variability and Morning Blood Pressure Surge

Background: With growing evidences that blood pressure (BP) variability, daily BP peak or morning BP surge are independently related to organ damage and future cardiovascular events. We try to invest the role of arterial stiffness and wave reflection, cardiac output in the association of those ambulatory BP parameters. Methods: A sample of 1156 normotensive and untreated hypertensive Taiwanese participants (546 women aged 30-79 years) was drawn from a community-based survey. All participants were recorded with 24 hours ambulatory blood pressure monitors. Besides, serum laboratory data, carotid-femoral pulse wave velocity (PWV, current gold standard for arterial stiffness), amplitude of the backward pressure wave decomposed from a calibrated tonometry-derived carotid pressure waveform (Pb, a transit-time independent index for wave reflections), and hemodynamic data include cardiac output were collected. Results: Mean 24 hours, day, and night systolic blood pressure (SBP), diastolic blood pressure (DBP), SBP standard deviation (SBPsd), DBP standard deviation (DBPsd), are all highly correlated to Pb, PWV, cardiac output (CO) and augmented pressure (r=0.506,0.274, 0.167, 0.419, all p&lt;0.01 with regard to 24 hour SBPsd). At multi-variates regression models, Pb remains the strongest predictor for early morning BP surge, SBPsd, and DBPsd even after adjusting possible confounders include age, sex, cholesterol, triglycerides, creatinine, and body weight index. Conclusion: Reflective wave Pb is the strongest independent factor for predicting daily BP variability, (SBPsd, DBPsd) and even mean-SBP, DBP, morning BP surge but not central arterial stiffness.

P-005 Wave Reflection But Not Arterial Stiffness Is Much Highly Correlated With Ambulatory Blood Pressure Parameters Including Blood Pressure Variability And Morning Blood Pressure Surge

Background With growing evidences that blood pressure (BP) variability, daily BP peak or morning BP surge are independently related to organ damage and future cardiovascular events. We try to invest the role of arterial stiffness and wave reflection, cardiac output in the association of those ambulatory BP parameters. Methods A sample of 1156 normotensive and untreated hypertensive Taiwanese participants (546 women aged 30–79 years) was drawn from a community-based survey. All participants were recorded with 24 hours ambulatory blood pressure monitors. Besides, serum laboratory data, carotid-femoral pulse wave velocity (PWV, current gold standard for arterial stiffness), amplitude of the backward pressure wave decomposed from a calibrated tonometry-derived carotid pressure waveform (Pb, a transit-time independent index for wave reflections), and hemodynamic data include cardiac output were collected. Results Mean 24 hours, day, and night systolic blood pressure (SBP), diastolic blood pressure (DBP), SBP standard deviation (SBPsd), DBP standard deviation (DBPsd), are all highly correlated to Pb, PWV, cardiac output (CO) and augmented pressure (r = 0.506,0.274, 0.167, 0.419, all p < 0.01 with regard to 24 hour SBPsd). At multi-variates regression models, Pb remains the strongest predictor for early morning BP surge, SBPsd, and DBPsd even after adjusting possible confounders include age, sex, cholesterol, triglycerides, creatinine, and body weight index. Conclusions Reflective wave Pb is the strongest independent factor for predicting daily BP variability, (SBPsd, DBPsd) and even mean-SBP, DBP, morning BP surge but not central arterial stiffness.

Antihypertensive efficacy of olmesartan medoxomil and candesartan cilexetil in achieving 24-hour blood pressure reductions and ambulatory blood pressure goals

Background. For patients with hypertension, effective 24-hour blood pressure (BP) control is vital to ensure protection against the early morning surge in BP and the associated increased risk of cardiovascular events. The aim of this analysis was to assess the 24-hour antihypertensive efficacy of olmesartan medoxomil (20 mg once daily) compared with candesartan cilexetil (8 mg once daily), with particular emphasis on BP control during the early morning period.Methods. This is an additional analysis of a previously reported randomised, double-blind study in which 635 patients with mainly mild to moderate hypertension were randomised to 8 weeks of treatment with either olmesartan medoxomil 20 mg/day or candesartan cilexetil 8 mg/day. Changes from baseline during the last 4 and 2 hours of ambulatory BP measurement (ABPM) after 1, 2 and 8 weeks of treatment were compared between the two groups. In addition, the proportions of patients who achieved various ABPM goals, including those suggested by the European Society of Hypertension/European Society of Cardiology (ESH/ESC) [&lt;125/80 mm Hg] and the Japanese Society of Hypertension (JSH) [&lt;135/80 mm Hg], over 24 hours, during the daytime and at the last 4 and 2 hours of ABPM measurement were also compared.Results.After 8 weeks, significantly greater proportions of patients treated with olmesartan medoxomil 20 mg achieved 24-hour and daytime ABPM goals recommended by the guidelines of the ESH/ESC (25,6 % and 18,3 %, respectively) and JSH (37,5 % and 26,6 %, respectively) compared with candesartan cilexetil 8 mg (24-hour ESH/ESC goal 14,9 %,p&lt;0,001; 24-hour JSH goal 26,6 %,p=0,003; daytime ESH/ESC goal 9,6 %,p=0,002; daytime JSH goal 16,4 %,p=0,002). During the last 4 hours of 24-hour ABPM, the proportions of patients who achieved the ESH/ESC and JSH ABPM goals were significantly greater with olmesartan medoxomil (33,3 % and 39,1 %, respectively) than with candesartan cilexetil (22,9 %,p&lt;0,001 and 31,6 %,p=0,047, respectively). Similarly, during the last 2 hours of 24-hour ABPM, the proportions of patients who achieved these BP goals were either significantly greater (JSH) or approached statistical significance (ESH/ESC) with olmesartan medoxomil (26,9 % and 19,9 %, respectively), compared with candesartan cilexetil (19,6 %,p=0,028 and 14,3 %,p=0,061, respectively).Conclusion. Compared with candesartan cilexetil 8 mg, greater proportions of olmesartan medoxomil-treated patients (20 mg) achieved ESH/ESC and JSH ABPM goals over 24 hours. The superior BP control of olmesartan medoxomil was also reflected in the larger proportions of olmesartan medoxomil-treated patients who achieved the ESH/ESC and JSH ABPM goals during the early morning surge period. This not only demonstrates that olmesartan medoxomil 20 mg provides superior 24-hour BP reduction, but also suggests that olmesartan medoxomil may provide greater protection against the increased risk of cardiovascular events associated with the early morning BP surge period.

The Risk of Waking-Up

Through ambulatory blood pressure (BP) monitoring, we know that BP usually follows a distinct circadian rhythm, characterized by a nocturnal decline during sleep of 10% to 30%, followed by a moderate-to-marked increase coinciding with the time of awakening.1 For >2 decades, there has been great interest in the early morning period by preventive cardiologists and hypertension specialists, because it became evident that the onset of acute events, including sudden death, myocardial infarction, and stroke peak in the first 4 to 6 hours postawakening.2,3 Because BP, heart rate, and these cardiovascular events all follow the same temporal pattern, it has been suspected that a pathophysiological relationship exists between hemodynamic aberrations, such as the early morning BP surge and vascular damage.3 Previous researchers have characterized the morning BP surge associated with increased target organ injury.3,4 Risk factors for a profile of excessive early morning hypertension include older age, excessive alcohol and/or smoking, longer sleep times and later awakening times, cold weather climates, and day of the week (primarily Monday!).5,6 Several studies performed in the past decade have found significant relations among the early morning BP surge and vascular disease,7 cardiac hypertrophy,4 and white matter lesions of the brain.6,8 Prospective studies in Japanese individuals8,9 have demonstrated a clinical impact of the early morning BP surge in predicting cardiovascular events. In one such cohort with ≈3.5 years of follow-up, for each 10-mm Hg increase in the early morning systolic BP surge obtained at baseline, the risk of stroke increased by 22%.8 Of note, this change of BP on arising predicted cardiovascular events independently of age, the average 24-hour systolic BP, and antihypertensive therapy. …

Defining blood pressure goals: is it enough to manage total cardiovascular risk?

It is well established that lowering blood pressure (BP) in patients with hypertension is associated with cardiovascular protection. Therefore, BP goals have been defined by international hypertension guidelines (<140/90 mmHg; <130/80 mmHg for patients with type 2 diabetes). However, the relationship of BP with prognosis is complex, and controlling office BP may not be enough to optimally manage total cardiovascular risk. It is becoming clear that out-of-office BP measurements have important prognostic value. In the observational Pressioni Arteriose Monitorate E Loro Associazioni study, the risk of cardiovascular death over 11 years was progressively higher with 10-mmHg increases in office, home, or ambulatory BPs. Smooth control of 24-h BP may be of even greater importance, as the early morning BP surge, nighttime BP, and BP variability are associated with significant risk. A further consideration in managing total cardiovascular risk is the need for multiple antihypertensive agents to control BP.