Extreme Dippers Research Articles

AMBULATORY BLOOD PRESSURE MEASURMENT INTEREST IN GENERAL PRACTICE

Objective: International societies recommend out of office blood pressure (BP) measurement to confirm and follow hypertension (HT). In France Ambulatory blood pressure monitoring (ABPM) is usually used only by cardiologists or hypertensive specialists. However a majority of hypertensive patients are seen by general practitioners GP’s. The objective of our study was to evaluate ABPM interest in GP’s daily practice. Design and method: This is a retrospective, monocentric, observational study including all consecutive patients undergoing ABPM in a GP’s surgery in Grenoble. The study groups were divided in three depending on ABPM indications: - Screening of normal clinical blood pressure patients with high cardiovascular risk factors (SNBPP) - Diagnosis in unknown hypertensive patients with elevated clinical BP (DHBPP) Follow up of known treated hypertensive patients (HPP). Results: 422 subjects ABPM were analysed. ABPM changed 43% patient BP status. - Among SNBPP (35 subjects) 49% presented masked HT. - Among DHBPP (158 subjects) 41% presented white coat HT. Systolic and diastolic office BP were significantly higher in confirmed hypertensive patients (p = 0.01 and < 10–4 respectively). - Among HPP (229 subjects) 16% presented controlled BP, 33% presented white coat HTN, 11% masked HTN, 40% uncontrolled HT. Number and type of medications were not statistically correlated with BP control. Dipping profil: 40.4% of patients were dippers, 40.2% were non dippers, 9.9% were reverse dippers, and 9.4% extreme dippers. Dipping variations were statistically different over the 3 groups (p < 10–4). Conclusions: ABPM is a great tool for GP’s to characterise accurately BP profil, and improve follow up and monitoring of patients.

CIRCADIAN BLOOD PRESSURE PROFILE IN PEDIATRIC PATIENTS WITH PRIMARY HYPERTENSION

Objective: Disturbed circadian blood pressure (BP) profile is a risk factor for cardiovascular complications in adults. The study aimed to evaluate factors affecting circadian BP profile and its association with hypertension-mediated organ damage (HMOD) in pediatric patients with primary hypertension (PH). Design and method: The study included 112 children (79 boys, 33 girls, 14.7 ± 2.7 years) with untreated PH. Circadian BP profile was assessed by 24-hour ABPM. Disturbed circadian BP profile (non-dipping) was defined as a nocturnal drop in systolic or diastolic BP (SBP, DBP) < 10%. A nocturnal drop in SBP or DBP > 20% was defined as extreme dipping. Patients were evaluated for central BP, HMOD (left ventricular mass index - LVMI, aortic pulse wave velocity, augmentation index (AIx75HR), intima-media thickness, albuminuria), and clinical and biochemical parameters, including sodium-potassium balance. Results: In the study group, the mean nocturnal drop in SBP was 10.9 ± 5.9 [%] and in DBP - 16.2 ± 8.5 [%]. Non-dipping was found in 50 (44.6%) children and extreme-dipping in 29 (25.9%) patients. The nocturnal drop in SBP correlated negatively with Z-scores of body weight (r = -0.191, p = 0.043) and BMI (r = -0.242, p = 0.010) and with LVMI [g/m2.7] (r = -0.395, p = 0.006). The nocturnal drop in SBP and DBP correlated positively with urinary potassium excretion [mmol/kg/24 h] (r = 0.656, p = 0.001 and r = 0.540, p = 0.011, respectively). Patients with disturbed circadian blood pressure profile were characterized by higher LVMI (44.5 ± 12.5 vs. 36.8 ± 8.8 [g/m2.7]) and albuminuria (median: 10.8, IQR: 5.3–53.3 vs. median: 8.1, IQR: 5.5–16.4 [mg/24 h], p = 0.043) and lower urinary potassium excretion (0.6 ± 0.2 vs. 1.1 ± 0.3 [mmol/kg/24 h]). Extreme-dipping patients had a higher AIx75HR than the other patients (median: + 3.3, IQR: -6.3- + 17.7 vs. -4.6, IQR: -17.3- + 4.0 [%], p = 0.048). Conclusions: 1. Disturbed circadian BP profile is common in children with PH and should not be considered a marker of secondary hypertension. 2. Disturbed circadian BP profile may be associated with higher body weight and lower dietary potassium intake. 3. Pediatric patients with PH and disturbed BP profile are at risk for HMOD: left ventricular hypertrophy and microalbuminuria. 4. Extreme-dipping may be associated with increased arterial stiffness in children with PH.

NOCTURNAL DIPPING PATTERN IN 24-HOUR AMBULATORY BLOOD PRESSURE RECORDINGS OF HYPERTENSIVE INDIVIDUALS IN THE BAY OF PLENTY (BOP)

Objective: 24-Hour Ambulatory blood pressure monitoring (ABPM) is gold standard for diagnosis/management of hypertension (HT). Untreated and poorly controlled HT leads to increased rates of cerebrovascular, cardiovascular, and renal disease. Data is lacking on dipping patterns in different ethnicities of New Zealand (NZ). The primary aim was to compare nocturnal dipping pattern between Maori and Non-Maori ethnicities. Secondary aims included comparison of nocturnal HT, morning surge index (MSI) and ambulatory arterial stiffness index (AASI) amongst them and comparison as per socio-economic deprivation index (NZDep 2018). Design and method: ABPM data of hypertensive adults > 18 years of age (on antihypertensives) in EBOP was collected retrospectively from Midland Clinical Portal from 1st December 2018 to 31st July 2021. Duplicates or unsuccessful ABPM results were excluded from the analysis. Normal dipping was defined as 10–20%, non-dipping being 0- < 10%, reverse dipping < 0% and extreme dipping > 20%. Statistics were processed using Excel. Results: Of 213 ABPMs nalysed, 20% were of Maori individuals. 39.5% of Maori were non-dippers and 9.3% were reverse dippers. Amongst Non-Maori, 34.1% were non-dippers and 13.5% were reverse dippers (p = 0.840). Uncontrolled nocturnal HT was more likely in Maori (60.5%) as compared to Non-Maori (54.1%), though not significant (p = 0.454). AASI was significantly higher (p = 0.001) in Non-Maoris, though MSI was not different (p = 0.865). Lower socio-economic demographic individuals or Maori are less likely to receive ABPM. Conclusions: There was no statistical difference between dipping status of Maori and Non-Maori. However, it is evident up to 55% of patients in this data set have uncontrolled nocturnal HT suggesting that EBOP is receiving subtherapeutic management of their HT. Therefore, all hypertensives should have ABPM in NZ to manage HT. As HT is more prevalent in Maori, researchers recommend a commitment from Bay of Plenty District Health Board to address this inequity to improve cardiac, cerebrovascular and renal health.

Utility of ambulatory blood pressure monitoring in detection of masked hypertension and risk of hypertension mediated organ damage in normotensive patients with type 2 diabetes mellitus

Purpose In patients with diabetes, unrecognised hypertension is a serious problem risk factor for the development and progression of chronic complications. The study aimed to determine the prevalence of masked hypertension in normotensive diabetic patients, the factors affecting it, and its association with diabetes complications using ambulatory blood pressure monitoring (ABPM). Materials and methods A cross-sectional observational study was conducted on 150 normotensive diabetic patients. Patients were subjected to an interview and clinical examination to record demographic data, epidemiological data, and significant past history. ABPM was performed for each patient. Urine samples, echocardiogram, and ophthalmologic fundoscopy were done to check for diabetes-related complications. Results The mean age of all participants was 56.7 ± 7.8 years. A total of 93 patients (62%) were males. 99 (66%) patients had masked hypertension. A total of 85 (56.7%) were non-dippers, 49 (32.7%) were dippers, 1 (0.7%) was extreme dipper and 15 (10%) were reverse dippers. Non-dipping and reverse dipping were associated with concentric left ventricular hypertrophy LVH (p < .001). Masked hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.008) whereas, nocturnal hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.003). Conclusions A single office blood pressure (BP) reading cannot rule out hypertension in patients with diabetes. Regardless of hypertension, clinicians should have all patients, especially patients with diabetes, undergo ABPM at least once. Masked hypertension, changes in nocturnal dipping and other phenomena that raise the risk of diabetes complications but cannot be measured by office BP can be measured by ABPM, and thus ABPM can provide a good prognostic benefit.

Arterial hypotension in patients with essential hypertension II–III: unresolved issues and ambulatory blood pressure monitoring diagnostic criteria

The aim was to study the prevalence of sustained arterial hypotension in high cardiovascular risk patients with II–III stage essential hypertension and associated factors. Materials and methods. Patients with II–II stage essential hypertension and sinus rhythm (n = 179, mean age 61 (95 % CI: 59.6‒62.5) years, 57.0 % were males) underwent ambulatory blood pressure monitoring (ABPM). Arterial hypotension episodes were evaluated according to the blood pressure (BP) office measurement (&lt;110/70 mm Hg) and ABPM over 24 hours (&lt;100/60 mm Hg), daytime (&lt;105/65 mm Hg) and nighttime (&lt;90/50 mm Hg). To determine the covariates associated with the probability of arterial hypotension, models were constructed using binary logistic regression analysis. Results. There was an almost threefold increase in the prevalence of arterial hypotension according to ABPM (6.2 %, 11/179), compared with the results of office measurement (2.2 %, 4/179). The prevalence of masked arterial hypotension was 63.6 %. Hypotension episodes (n = 22) were detected in 11 patients mainly during the daytime (13/22). Hypotension was represented by a significant percentage of people with isolated diastolic (81.8 %) and lower – with systo-diastolic fall in BP (18.2 %). Hypotension associated risk factors were reaching the target level of intensive BP control, lower mean arterial pressure (24-hour time, daytime, nighttime analysis), its extreme dipping pattern, and female sex. Conclusions. The method of ABPM has advantages over office BP measurement in detecting episodes of sustained arterial hypotension. The risk of developing hypotension is increased in intensive BP control. The sustained hypotension is associated with lower mean arterial pressure values, its extreme dipping pattern and female sex.

A Study Comparing Office Blood Pressure with Ambulatory Blood Pressure in Successful Adult Kidney-Transplant Recipients at a Tertiary Care Center in North India

Introduction: Hypertension is common following successful renal transplantation and has adverse effects on cardio-vascular and graft health. Blood pressure (BP) readings obtained during clinical visits can be misleading and ambulatory blood pressure monitoring (ABPM) is a more reliable and accurate non-invasive method of BP monitoring. Aims and Objectives: To compare office BP with ambulatory BP recordings in successful adult kidney transplant recipients (KTRs). Material and Methods: Office BP (OBP) was measured with mercury sphygmomanometer according to standardized procedure as the mean of two readings taken 1 minute apart; thereafter, 24 hour ABPM was done using automated oscillometric device (Meditech device) in 56 KTRs. Results: OBP missed hypertension in 68% of KTRs who had normal OBP (masked phenomenon) and OBP overestimated hypertension in 11% of KTRs with uncontrolled OBP (white coat phenomenon). Thirty-four percent of patients were normal dippers, 32% non-dippers, 25% reverse dippers and 9% were extreme dippers. Conclusions: ABPM is a valuable tool in detecting dipping status, white coat and masked phenomena which are frequent problems among KTRs and should be considered as part of routine management of hypertension in KTRs.

Chronic Kidney Disease and Left Ventricular Hypertrophy. Potent Modifiers of the Prognostic Impact of Circadian Blood Pressure Changes.

It is unclear whether the prognostic value of blood pressure (BP) changes from day to night is modified by concomitant risk factors and organ damage. We studied 3247 clinically hypertensive patients who underwent off-therapy 24-hour ambulatory BP monitoring during their initial diagnostic work-up. Over a mean 9.9-year follow-up, 292 patients developed a first primary outcome event (composite of nonfatal myocardial infarction, nonfatal stroke, cardiovascular death, hospitalization for heart failure) and 281 died. The day-night BP changes were analyzed as night-to-day systolic BP ratio and included in semiparametric Cox models. After allowance for age, sex, diabetes, cigarette smoking, low-density lipoprotein cholesterol, serum uric acid and average 24-hour systolic BP, the night-to-day systolic BP ratio maintained an independent association with outcome (hazard ratio, 1.17 [1.01-1.35]; P=0.041). When 2 markers of organ damage, chronic kidney disease and left ventricular hypertrophy, were added to the model, the night-to-day systolic BP ratio failed to maintain an independent association with outcome (hazard ratio, 1.19 [0.97-1.31]). The Akaike Information Criterion and the Schwarz-Bayes Information Criterion showed that, after allowance for other covariables, the night-to-day systolic BP ratio: (1) provided less information when compared with chronic kidney disease and left ventricular hypertrophy and (2) did not improve information provided by chronic kidney disease and left ventricular hypertrophy. Results were comparable on all-cause death as well as using categories of the night-day systolic BP ratio (extreme dippers, dippers, nondippers, reverse dippers). Chronic kidney disease and left ventricular hypertrophy are potent modifiers of the prognostic value of the circadian BP changes.

Cardiac Remodeling According to the Nocturnal Fall of Blood Pressure in Hypertensive Subjects: The Whole Assessment of Cardiac Abnormalities in Non-Dipper Subjects with Arterial Hypertension (Wacanda) Study.

Objective: Several epidemiological studies suggest that the preservation of the physiological circadian rhythm of blood pressure or its disruption affects the extent of the organ damage developed by the patient. If we classify the circadian rhythm of blood pressure into four nocturnal profiles, significant differences emerge in terms of organ damage burden and prognosis: reverse dippers have the worst prognosis while dippers and mild dippers fall into an intermediate risk range. The risk profile of extreme dippers is still debated, and the available data are very conflicting and inconclusive. Starting from this gap of knowledge, we aimed to evaluate, retrospectively, in a cohort of hypertensive subjects, the degree of cardiac involvement in relation to the different nocturnal blood pressure profiles. Methods: We retrospectively evaluated 900 patients with essential hypertension, of whom 510 met our study criteria. We graded the 510 patients in relation to the percentage of reduction in mean systolic blood pressure (SBP) at night-time compared with day-time, considering this as a continuous variable, and then compared the extreme quintiles with each other and with the middle quintile (considered as reference). Results: Patients with less (or no) reduction in nocturnal SBP (reverse dipper) showed a higher level of organ damage and comorbidities. With regard to echocardiographic indexes, patients with maximum nocturnal pressure reduction (extreme dipper) showed a lower level of remodeling and/or impairment of E/e’ ratio, Right Atrium Area, Basal Right Ventricular Diameter, Inferior Vena Cava Average Diameter, and Tricuspidal Anular Plane Systolic Excursion compared also with hypertensive patients with a physiological nocturnal pressure reduction, even after correction for the main confounders. Conclusions: These data suggest that extreme dippers may constitute the subgroup of hypertensive patients with the lowest 24-h pressure load and, therefore, less cardiac remodeling.

Abstract 9837: A Blunted Nocturnal Blood Pressure Decline is Associated with Total and Cardiovascular Mortality

Introduction: A blunted nocturnal BP decline is associated with an increased cardiovascular risk. Nevertheless, patients with a blunted BP dip usually have high levels of nighttime BP, being both parameters clearly related. Thus, it is unclear if an abnormal dipping is deleterious per se or it merely reflects an elevated BP during sleep. Hypothesis: We aimed to assess the prognostic value of nocturnal BP decline, independently of the presence or not of nocturnal BP elevation. Methods: Vital status and death due to cardiovascular causes were obtained from death certificates in 59110 hypertensives, enrolled in the Spanish ABPM Registry between 2004 and 2014, and having a valid 24-h ABPM at entry. On the basis of BP data, patients were classified into 4 groups: Normal (&lt;120 mmHg) night systolic BP (SBP) and normal (&lt;0.9) systolic night-to-day ratio (NDR). Normal night SBP with elevated (≥0.9) NDR. Elevated (≥120 mmHg) night SBP with normal NDR and both elevated night SBP and NDR. Association between NDR, dipping status and groups combining night SBP and NDR with total and cardiovascular mortality were assessed by Cox models, adjusted for clinical confounders. Results: The total number of deaths were 2866 (978 of cardiovascular causes) during a median follow-up of 5 years. NDR predicted total mortality (HR for 1 SD change: 1.19; 95%CI: 1.15-1.23). Both patients with reduced dipping (HR: 1.28; 1.17-1.41) and risers (HR: 1.59; 1.42-1.77) had increased risk of total mortality, whereas extreme dippers (NDR&lt;0.8) did not. With respect to patients with both normal night SBP and NDR, those with elevated NDR in the absence of elevated night SBP had increased risk of death (HR: 1.36; 1.19-1.55), as well as those with elevated night SBP and normal NDR (HR; 1.40; 1.21-1.62). Those combining both abnormalities had the highest risk (HR: 1.78; 1.60-1.98). Similar results were obtained for cardiovascular mortality. Conclusions: Abnormalities in the circadian dipping pattern are responsible for an increased risk of mortality, both total and cardiovascular. Increased mortality rates are observed in patients with a reduced nocturnal dip and, even more intensively, in those with a riser pattern. This abnormal dipping increases the risk of mortality even in the absence of BP elevation.

Is there a difference between normotensive and hypertensive patients in terms of blood parameters and cardiovascular diseases?

Objectives: It has been stated in various studies that there is a difference in some blood parameters between hypertensive and normotensive patients for a long time. Mean platelet volume (MPV), and red blood cell distribution width (RDW), have been studied in hypertensive patient groups in many studies. Hypertension is a classic risk factor for ischemic stroke and myocardial ischemia, as known. In our study, we examined whether there was a difference between hypertensive patient groups and normotensive patients in terms of blood parameters such as MPV and RDW, and the incidence of stroke and myocardial infarction. Methods: Blood samples and twenty-four-hour ambulatory blood pressure monitoring (ABPM) results of 552 patients admitted to our outpatient clinic with a pre-diagnosis of hypertension were retrospectively analyzed. According to ABPM results, we divided the study participants into four groups; dippers, non-dippers, extreme dippers, and normotansives. Complete blood count and biochemical test results were found in the database of our hospital for all patients and differences between groups were investigated. Results: One hundred seventy three normotensives (Group 1) (mean age, 47.4 ± 15.4 years), 210 non-dippers (Group 2) (mean age, 53.8 ± 15.8 years), 67 extreme dippers (Group 3) (mean age, 49.1 ± 15.9 years) and 102 dippers (Group 4) (mean age, 52.2 ± 12.5 years). Daytime mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) and night-time mean SBP and DBP were significantly different in groups (Group 1: 117 [90-193] mmHg and 71 [55-87] mmHg; Group 2: 137 [107-188] mmHg and 83 [107-188] mmHg; Group 3: 143 [115-193] mmHg and 88 [56-122] mmHg; and Group 4: 140.5 [116-173] mmHg and 76 [55-124] mmHg), p &amp;lt; 0.001; respectively. MPV and RDW levels were different in all four groups (p &amp;lt; 0.001). We found a significant difference in the rates of stroke and coronary artery disease between the four groups (p = 0.018 and p = 0.002, respectively). In the ROC curve analysis MPV had sensitivity of %77. 8 and specificity of 78. 1% for stroke when the cut-off value MPV was 9.25 (Area under curve: 0.808, 95% confidence interval: 0.726-0.889, p &amp;lt; 0.001). Conclusions: In our study, MPV and RDW levels and the rates of stroke and cardiovascular disease were significantly higher in non-dipper patients compared to other groups.

Effect of esaxerenone on nocturnal blood pressure and natriuretic peptide in different dipping phenotypes.

There are limited data on the nighttime blood pressure (BP)-lowering effect of esaxerenone and its effect on N-terminal pro b-type natriuretic peptide (NT-proBNP), a predictor of cardiovascular risk, according to different dipping patterns of nocturnal BP. This was a post hoc analysis of a multicenter, open-label, long-term phase 3 study of esaxerenone, a new highly selective mineralocorticoid receptor blocker, in patients with essential hypertension. Patients were classified by dipping pattern (extreme dippers, dippers, non-dippers, risers). Mean changes in BP, changes in dipping pattern, mean NT-proBNP levels, and percentage of patients with normal NT-proBNP levels (<55 pg/mL) at baseline and Weeks 12 and 28 were evaluated. Nighttime systolic BP decreased in all dipping pattern groups at Week 28, with the riser group showing the greatest change (−25.5 mmHg). A significant shift in dipping pattern and riser/non-dipper pattern changes to dipper/extreme dipper pattern were found from baseline to Week 28 (p < 0.0001). The prevalence of the riser pattern decreased from 14.4% to 9.8%, and that of the non-dipper pattern from 44.7% to 39.2%. The decrease in NT-proBNP from baseline to Week 28 was statistically significant in risers, non-dippers, dippers, and extreme dippers (p < 0.001, respectively). At baseline, the proportion of patients with NT-proBNP <55 pg/mL was lowest in risers versus the other dipping pattern types, but after reductions in NT-proBNP in all groups to Week 28, these differences disappeared. Long-term administration of esaxerenone may be a useful treatment option for nocturnal hypertension, especially in patients with a riser pattern.

Ambulatory Blood Pressure Monitoring: Our Experience in Routine Clinical Practice.

Objective: To evaluate feasibility and usefulness of ambulatory blood pressure monitoring (ABPM) in outpatient setting.Material and methods: In this prospective study, data of 58 patients who were evaluated with ABPM for diagnosis or therapeutic efficacy purpose were collected from their records. Demographic details of these were recorded. Patients were categorized into different categories based on 24 hours BP pattern. Dipping pattern was compared based on the gender, age, and presence of diabetes or hypertension. Number of patients diagnosed as hypertensive with ABPM reports was compared with office and home BP measurement.Results: Fifty-eight patients (mean age 57.8 years; 70.69% males) were included of whom 22 (37.93%) underwent ABPM for diagnostic purposes. There was gender-wise significant difference in terms of purpose of performing ABPM (p=0.040). Diabetes was present in 22 (37.93%) patients. Out of 36 known hypertensive patients, 17 (47.22%) patients were receiving dual therapy. Out of 45 patients whose records for active BP variability were available, 26 (57.78%) had high variability. The number and percentage of dippers, extreme dippers and reverse dippers as 23 (42.79%), three (5.56%), and six (11.11%), respectively. Depending on the age, there was significant difference in the dipping pattern (p=0.013). On office blood pressure measurement, 35 (64.81%) patients were found to have hypertension. ABPM revealed hypertension in 32 (59.26%). Masked hypertension and white-coat hypertension was observed in nine (16.17%) and 12 (22.22%) patients, respectively.Conclusion: ABPM is feasible and useful in routine outpatient clinical practice for diagnosis of essential hypertension, pattern of dipping, masked hypertension, and white-coat hypertension and also for the therapeutic evaluation of patients in clinical practice.

Association between blood pressure dipping patterns and hypertension-mediated organ damage among Nigerians with newlydiagnosed hypertension

Introduction: Abnormal blood pressure (BP) dipping patterns are associated with increased cardiovascular risk among Africans. This study determined the association between BP dipping patterns and hypertension-mediated organ damage among patients with newly-diagnosed hypertension.Methods: Ambulatory BP monitoring and echocardiography were carried out on 120 participants. Participants were categorized based on the ratio of night-time to day-time systolic BP into 4 patterns: Normal dipper (≥ 10% but &lt; 20%), non-dippers (≥ 0% but &lt; 10%), reverse dippers (&lt;0%) and extreme dippers (≥ 20%).Result: Fifty-one (42.5%) were males, the mean age and body mass index were 44.2±9.8years and 27.1±4.4kg/m2 respectively. The non-dipping pattern was the most prevalent while the reverse dipping had the lowest mitral E/A ratio. Office systolic blood pressure was the only predictor of left ventricular hypertrophy (OR=1.050, 95% CI=1.004-1.098; p-value = 0.034).Conclusions: The non-dipping pattern was the most prevalent abnormal dipping pattern while the reverse dippers had the highest risk of hypertension-mediated organ damage. Office blood pressure was the only predictor of left ventricular hypertrophy. Hence, office BP measurement as well as ambulatory blood pressure measurements are potentially important tools in risk stratification in resource-poor settings of sub-Saharan Africa.

Prognostic value of nocturnal blood pressure dipping on cardiovascular outcomes in Chinese patients with hypertension in primary care.

Meta‐analyses showed that non‐dipping of nocturnal blood pressure on ambulatory blood pressure monitoring (ABPM) was associated with adverse cardiovascular prognosis. However, these prognostic studies were mainly conducted in Caucasian and Japanese populations. Whether this association applies to Chinese patients remained uninvestigated. A total of 1199 Chinese patients with hypertension undergoing ABPM between January 2012 and December 2014 were recruited retrospectively from five public hypertension referral clinics in Hong Kong. Patients were followed up for a mean 6.42 years for cardiovascular morbidity and mortality and all‐cause mortality. Time to event of different dipping patterns was compared by Kaplan‐Meier curves. Hazard ratios (HR) were obtained by Cox proportional hazard models with patient demographics and confounding factors adjusted in multivariate regression. A total of 163 end point events occurred in the period. Normal dipping was observed in 446 patients (37.2%), non‐dipping in 490 (40.9%), reverse dipping in 161 (13.4%), and extreme dipping in 102 (8.5%). Kaplan‐Meier analyses showed inferior survival in non‐dippers and reverse dippers for total cardiovascular events and coronary events but not cerebrovascular events. After adjusting for confounding factors, Cox regressions showed HRs 1.166 (CI 0.770‐1.764) and 1.173 (CI 0.681‐2.021) in non‐dippers and reverse dippers for total cardiovascular events, and HRs 1.320 (CI 0.814‐2.141) and 1.476 (CI 0.783‐2.784) for coronary events. Nocturnal blood pressure non‐dipping, and to a greater extent reverse dipping, demonstrated adverse cardiovascular prognosis in a cohort of Chinese patients with hypertension in Hong Kong. Further focused studies on cerebrovascular events and reverse dippers were warranted to refine risk stratification.

Twenty-four-hour and office blood pressure measurement in a comprehensive assessment of the effectiveness of 12-week therapy with a triple fixed-dose combination of amlodipine/indapamide/perindopril in hypertensive patients in actual clinical practice

Aim. To study the efficacy and safety of the triple fixed-dose combination (FDC) of amlodipine/indapamide/perindopril on blood pressure (BP) profile in patients with grade I-II hypertension (HTN) in actual clinical practice.Material and methods. Data from 54 patients with paired 24-hour ambulatory BP monitoring (ABPM) data were included in the TRICOLOR subanalysis (ClinicalTrials. gov study ID — NCT03722524). The mean 24-hour, daytime, and nighttime BP were calculated at baseline and after 12-week follow-up. We determined the proportion of patients with nocturnal HTN (≥120/70 mm Hg) and nocturnal hypotension (&lt;100/60 and &lt;90/50 mm Hg) initially and after 12 weeks of triple FDC therapy. Patients with nocturnal BP decrease included dippers (D; 10-20%), reduced dippers (RD; 0-10%) and extreme dippers (ED; &gt;20%), as well as those without nocturnal BP decrease (&gt;0%, non-dipper (ND)). The smoothness index (SI) was analyzed as the ratio of the mean hourly SBP fall to its mean standard deviation in paired ABPM. To assess the BP phenotypes, two methods were used with reference values of &lt;130/80 and &lt;140/90 mm Hg for ABPM and office BP, respectively. Controlled hypertension (CHT), uncontrolled hypertension (UHT), white coat hypertension (WHT) and masked ineffectiveness of antihypertensive therapy were distinguished.Results. Among 1247 participants of the TRICOLOR study, 54 patients with valid paired ABPM were selected (men, 46%; mean age, 57,7 [12,1] years; mean office BP, 150,4 [16,6]/93,3 [10,7] mm Hg; HTN duration, 8,3 [7,5] years). Initially, the mean 24-hour, daytime and nighttime BP was 141,1 [15,4]/85,9 [9,9], 144,2 [15,5]/88,8 [10,5] and 132,6 [18,0]/78,1 [9,9] mm Hg, respectively. After 12-week follow-up, the mean 24-hour, daytime and nighttime BP was 123,1 [10,5]/75,6 [8,5], 125,7 [10,9]/77,9 [8,7] and 115,4 [10,2]/68,6 [8,8] mm Hg, respectively (p&lt;0,001). After 12-week follow-up, the proportion of patients with nocturnal hypertension decreased from 64,8% to 25,0% (2,6 times) (p&lt;0,001). The proportion of NDs and EDs decreased from 16,7% and 7,4% to 5,8% and 0%, respectively (p=0,048); the proportion of patients with RD and D patterns increased from 42,6% and 33,3 to 57,7% and 36,5%, respectively (p=0,048). With triple FDC therapy, the SI during the day was higher than 0,73 in half of the cases. According to the two methods, the proportion of patients with UHT decreased from 81,6% to 4,4%, WHT from 12,2% to 0%. The prevalence of CHT increased from 4,1% to 57,8%, while masked ineffectiveness of antihypertensive therapy — from 2,0% to 37,8%.Conclusion. Twelve-week FDC therapy of amlodipine/indapamide/perindopril led to a significant fall in the mean 24-hour, daytime and nighttime BP values. Comprehensive analysis of two techniques (24-hour and office BP measurement) identified patients requiring further triple FGC titration.

Dipper pattern in arterial hypertension: is there a correlation with ageing?

Abstract Funding Acknowledgements Type of funding sources: None. Dipper pattern in arterial hypertension is there a correlation with aging? Background Systemic arterial hypertension is an important cardiovascular risk factor. Non-dipper hypertension is associated with increased cardiovascular morbidity and mortality. Purpose Study the effect of aging in the dipper pattern, in patients submitted at 24-Hour Ambulatory Blood Pressure Monitoring. Methods Retrospective study based on patients submitted at 24-Hour Ambulatory Blood Pressure Monitoring on the first trimester of 2020. Patients were divided into categories based on percentage of nighttime blood pressure drop: 0% Reverse Dipper, 0-10% Non-Dipper, 10-20% Dipper e &amp;gt;20% Extreme Dipper. The sample was dived into two groups: group A (GA) with age between 18- and 60-years vs group B (GB) with age between 60- and 90-years. Results This study included 91 hypertensive patients, whom 46.2% were male and with a mean age of 56 ± 15 years. GA represented 60.4% of study sample, whom 43.6% were male and with a mean age of 46 ± 10 years. In the group B, 50% were male with a mean age of 71 ± 6 years. GB patients had more history of diabetes (7.8% vs 26.5%, p = 0.022). No significant difference was found between the two groups in history of kidney chronic disease, obesity or sleep apnea syndrome. In terms of medical treatment, GB had more prescription of loop diuretics (3.9% vs 22.9%, p = 0.010) and angiotensin-converting enzyme (ACE) inhibitors (58.8% vs 88.6%, p = 0.028). No significant differences were found in the prescription of other hypertension therapies or the use of drug combinations. No significant difference was found in the number of Dippers in both groups (63.6% vs 58.3%, p = 0.386). GB had more reverse dippers (1.8% vs 16.7%, p = 0.014). GA had more extreme dippers (12.7% vs 2.8%, p = 0.024). Conclusion There is no difference in the rate of dipper pattern accordingly to age. The prevalence of reverse dippers in older patients was superior, leading to increased risk of cardiovascular events in this group. The younger group had more prevalence of extreme dippers, which, by some authors, can lead to increased risk of a silent cerebrovascular event.

NOCTURNAL NON-DIPPING STATUS AND LEFT VENTRICULAR HYPERTROPHY IN HYPERTENSIVE PATIENTS

Objective: Ambulatory Blood Pressure Monitoring (ABPM) is used to assess the dipping status in hypertensive patients according to the nocturnal blood pressure (NBP) decline: extreme dippers, dippers, non-dippers and inverted dippers. Increased NBP is currently regarded as a risk factor for cardiovascular (CV) events and hypertension-mediated organ damage (HMOD). One of the most common HMOD include left ventricular (LV) remodelling as chronic BP elevation may progressively increase LV thickness. The aim of this study is to determine if there is a higher prevalence of LVH in echocardiographic (ECHO) parameters in patients with increased NBP. Design and method: Prospective observational study. Inclusion criteria: subjects with treated hypertension undergoing ABPM performed in our Primary Health Care Unit and with ECHO in the last 3 years. Fisher's exact test was used whenever appropriate to assess independence and statistical significance of reported factors. Logistic regression analysis was performed to assess the effects and its statistical significance between established parameters. Statistical differences were indicated as p &lt; 0.05 and p &lt; 0.01. Statistical analysis was performed using R version 4.0.3. Results: For this study, 67 patients were screened, from which 44 were male and 23 females, average age of 55 years old. We obtained a distinct distribution of dipper and non-dipper profiles in a LVH dependent manner. The non-dipper presented higher significant effect with LVH (p &lt; 0.01) and the results obtained from the fisher test showcase a statistically significant relation between non-dippers and LVH (annex 1) Conclusions: The limitations of this study included the small sample size and the usage of a questionable diagnose of dipping status in a 24 h period since it is often highly variable. Based on the results, there seems to be an impact of NBP on LV structure since there is a statistically significant relation between non-dipper status and LVH. Hypertensive patients should be submitted to ECHO and other forms of HMOD screening, especially non-dippers, considering their increased CV risk, in order to improve CV risk stratification therapeutic strategies.

AMBULATORY BLOOD PRESSURE MONITORING: ADVANTAGES AND OPPORTUNITIES

Objective: Ambulatory Blood Pressure Monitoring (ABPM) is a procedure used to diagnose hypertension, detect white-coat effect, masked hypertension and monitor blood pressure (BP) control. It offers additional and important data in opposite to office BP, such as the dipping status and circadian variability of ambulatory BP, and it is a better predictor of cardiovascular outcomes and morbid or fatal events. In our country, ABPM has limited availability in Primary Health Care. With that in mind, the health care team of our Primary Health Care Unit created an ABPM protocol in August 2017 in order to provide this procedure to its patients. Design and method: Descriptive, cross-sectional and observational study. Data collected from August 2017 to December 2019 regarding the results of ABPM and patient data. The ABPM protocol was designed following the most recent European Society of Hypertension guidelines. Results: In the described period, our unit performed 136 ABPM exams. The average age of patients submitted to ABPM was 53 years and 54% were of the male gender. The majority (67%) were referred for diagnosis purposes and 33% to monitor BP control. With the ABPM protocol we were able to diagnose 60 patients with sustained hypertension and 36 patients with uncontrolled hypertension, from which 10 presented resistant hypertension. Regarding the dipping status, 55% were dipper, 23% extreme dipper, 19% non-dipper and 3% reverse dipper. In 63% of cases, the ABPM results led to direct clinical decision-making by the family physician, such as pharmacology intervention, clinical investigation and lifestyle advice. Conclusions: Overall the ABPM is an accurate, cost-effective protocol that provides important information for the prediction of cardiovascular risk. Consequently, ABPM protocol implementation has been observed to have a direct positive impact in the diagnosis, monitoring and clinical decision-making ability of the physician regarding hypertension. With this presentation we wish to share the positive impact of ABPM usage on our Health Care Unit and to inspire and motivate others to create a similar protocol.

NON-DIPPING ASSOCIATED PARAMETERS IN SINUS RHYTHM INDIVIDUALS

Objective: The aim of the study was to evaluate the association between non-dipping pattern of systolic BP (SBP) in sinus rhythm individuals. Design and method: We studied 145 individuals (mean age, 60 [95% CI, 59–62] years, 54% men), 92% was essential hypertension patients, who underwent 24-h ABPM and 24-h ECG. Averages were measured for SBP, diastolic (DBP), pulse pressure (PP), mean arterial pressure (MAP) and 24-h ambulatory arterial stiffness index (AASI) calculated. According to the degree of nocturnal SBP fall (according to the 24-hour-clock-based definition of night from 1 am to 6 am), patients were sub-classified as dippers (39%) and non-dippers (61%), which included mild dippers (60/89), extreme dippers (6/89), reverse dippers (23/89). A bivariate multivariate logistic regression analysis (Stata 15) was performed to evaluate the value of ABPM parameters for non-dipping status. Results: Comparisons between groups showed no differences in age, sex, as well as in SBP, DBP, PP, MAP. The best fitting model for explanatory non-dipping pattern (log likelihood = -97.82; AUC ROC = 0.6372) after adjustment for age, sex (male vs female), SBP, DBP, PP, MAP with ORs included AASI (11.57 [CI 95%, 1.02–130.47], p = 0.048). Conclusions: 24-h AASI is the only one ABPM parameter that associated with non-dipping pattern in individuals with sinus rhythm.

RELATIONSHIP BETWEEN PSCK9 PLASMA LEVELS AND BLOOD PRESSURE LEVELS REGISTERED BY AMBULATORY BLOOD PRESSURE MONITORING (ABPM)

Objective: Establish a correlation between values and circadian patterns of 24-hour BP measured by ABPM and serum PCSK9 values to try identify an early CVR biomarker. Design and method: In a sample of 166 patients (without treatment with statins) followed in an HBP medical office, 24-hour BP was evaluated by ABPM and correlated with the plasma analytical values of PCSK9. The mean age of the participants was 59.5 years The mean values of daytime and nocturnal systolic and diastolic BP and its relationship with the circulating values of PSCK9 were analyzed. For all variables, the mean, median, standard deviation and coefficient of variation were calculated, as well as their minimum and maximum values and their asymmetry coefficient. Results: There is a significant correlation of PCSK9 values with daytime SBP (r = 0.240; p = 0.002; R2 = 0.06), and also weaker with nocturnal SBP (r = 0.153; p = 0.049), in both cases with positive correlation. No positive correlation of PCSK9 values was observed with the mean values of DBP (p = 0.587 and p = 0.081), although it should be taken into account that at the sample level the sign of the coefficient is negative. When grouping the sample by type of AT, it is observed that in general, the positive relationship between daytime systolic BP and PSCK9 remains both in patients with a standard dipper (r = 0.206) and in those with a non-dipper (r = 0.387). On the contrary, for nocturnal systolic BP, it is only observed in dippers (r = 0.420) and in extreme dippers but with a negative sign (r = -0.515). The correlation is not significant among the dippers (p = 0.191). Conclusions: In our study, we found a positive correlation between serum PSCK9 levels and 24-hour BP values with different degrees of positivity according to the circadian pattern and type of HBP. This assumes that the plasma level of PSCK9 could be a possible early biomarker of CVR in these hypertensive patients. More studies are needed to confirm our preliminary results.