Morning Blood Pressure Surge Research Articles

855 AMBULATORY MORNING SURGE - A NEW CONCEPT OF MORNING SURGE IN HYPERTENSIVE PATIENTS

Objectives: ACHIEVE-ONE is a large-scale clinical study designed to evaluate the effects of cilnidipine, a unique L/N-type Ca channel blocker, on blood pressure (BP) measured at the clinic, home, and by ambulatory BP monitoring (ABPM) in Japanese hypertensive patients. We searched a potential morning surge which could be detected only by ABPM, but not self-measured BP monitoring at home. Design and Methods: We analyzed 378-patient data that obtained both self-measured home systolic BP (SBP) at wake-up (SBPself-w) and 2-hour average SBP after wake-up by ABPM (SBPabpm-w). The sleep-trough morning surge (ST-MS) was defined as difference between SBPabpm-w and the lowest 1-hour moving average SBP during sleep period. The top decile of ST-MS and the remaining 90% were subclassified as ST-MS Group and Non-ST-MS Group, respectively. The difference between SBPabpm-w and SBPself-w was defined as ambulatory morning surge (AMS). Results: SBPabpm-w (170.4 ± 15.2 mmHg) was significantly higher than SBPself-w (154.7 ± 17.7 mmHg) in ST-MS Group (n = 38, ≥53.5 mmHg), while there was no difference in SBPself-w between ST-MS Group and Non-ST-MS Group. The ambulatory SBP in ST-MS Group reached a peak at 1-2 hour after wake-up (Fig.1). The AMS was greater in ST-MS Group (15.6 ± 16.2 mmHg) than in Non-ST-MS Group (-1.9 ± 18.4 mmHg). 12-week treatment of cilnidipine reduced SBPabpm-w and SBPself-w in ST-MS Group. Conclusions: Self-measured morning home BP may underscore the risk of morning surge. The ambulatory morning surge, newly defined by combination of ABPM and home BP monitoring, may explain the cardiovascular risk of morning BP surge.

Response to Is the Atherosclerotic Risk of Extreme Dipping in Youth Partly Explained by Exaggerated Morning Surge?

We thank Dr Kario1 for raising the interesting question of whether the exaggerated morning blood pressure (BP) surge might explain the relationship between extreme dipping and future coronary artery calcium. To examine whether this might be the case, we created a morning BP variable defined as the average of the ambulatory BP between the hours of 7:00 am and 9:00 am (we had previously eliminated daytime sleepers by detailed diary analysis). We calculated morning …

Role of Yin and Yang in Diurnal Blood Pressure Variation for Cardiovascular Disease

To the Editor: We read with great interest the work by Verdecchia et al,1 which reported that, in initially untreated subjects with hypertension, a blunted day-night blood pressure (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.1 As compared with previous reports, there are conflicting results regarding the association between morning BP surges and following cardiovascular events, and these results should be interpreted carefully. Here, we use the concept of yin and yang representing …

Is Vascular Morning Blood Pressure Surge in the Elderly Resistant to Antihypertensives and More Risky?

To the Editor: I have read the recent article on morning surge in blood pressure (BP; MSBP) in the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) Study.1 Surprisingly, the suppressed MSBP was a risk factor for poor long-term prognosis of cardiovascular disease (CVD) in hypertensives. In previous studies, including our Jichi Medical University Ambulatory Blood Pressure Monitoring (JMUABPM) Study and the International Database of Ambulatory Blood Pressure in Relation to Cardiovascular Outcome, exaggerated MSBP was found to be an independent risk factor of CVD.2,3 Why were these results so different? I would like to address this question from 3 standpoints. ### Elderly MSBP MSBP may be more risky in elderly than in younger individuals (Table). The mean age of …

Response to Is Vascular Morning Blood Pressure Surge in the Elderly Resistant to Antihypertensives and More Risky?

We thank Dr Kario1 for his interest in our study. Because the age of patients was lower in our study than in the Jichi Medical University Study, we made additional analyses to explore the association between the morning surge in blood pressure (BP) and age in our patients, as well as the potential interaction between age and the morning surge in BP on outcome. Surprisingly, the sleep-trough systolic BP surge did not show any association with age ( r =0.01; P =0.59), whereas the preawakening systolic BP surge showed a weak, albeit …

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 <0.0001) and the preawakening ( r =0.554; P <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.

Nocturnal Blood Pressure, Morning Blood Pressure Surge, and Cerebrovascular Events

Cerebrovascular disease is a common cause of death and major cause of disability worldwide. Even in silent cases (e.g., silent cerebral infarction, white matter lesion), cerebrovascular disease can lead to physical and cognitive impairment, thereby substantially reducing the activities of daily living. Accordingly, the earliest possible action to prevent not only symptomatic but also silent cerebrovascular disease has become a major public health challenge. Hypertension is a potent risk factor for both symptomatic and silent cerebrovascular disease. Twenty-four-hour blood pressure (BP) rather than office BP is closely associated with cerebrovascular disease and/or poor physical and cognitive function. In particular, nocturnal BP and morning BP surge have attracted much attention as risk factors for cerebrovascular diseases independently of 24-h BP level. This review is an attempt to summarize some of the evidence on nocturnal BP level or nocturnal BP dipping status, and morning BP surge as potent risk factors for cerebrovascular disease.

Morning blood pressure surge is associated with arterial stiffness and sympathetic baroreflex sensitivity in elderly hypertensive patients

Morning blood pressure (BP) surge (MS; morning – minimal sleeping systolic BP) is an independent risk factor for cardiovascular diseases. We evaluated whether large artery stiffness and sympathetic baroreflex sensitivity (sBRS) would contribute to MS in elderly hypertensives (HT). MS was assessed by measuring ambulatory BP in 35 untreated mild HT [68 ± 1 (SE) yrs] and 30 normotensives (NT; 68 ± 1 yrs). Beat‐by‐beat finger BP and muscle sympathetic nerve activity (MSNA; microneurography) were recorded in the supine position. We quantified arterial stiffness with central pulse wave velocity (PWV) and sBRS during spontaneous breathing. Ambulatory BP was higher in HT than NT during awake and asleep (systolic/diastolic; 147 ± 2/81 ± 1 vs 124 ± 1/73 ± 1 and 129 ± 2/69 ± 1 vs 110 ± 1/61 ± 1 mmHg, all P < 0.001), and MS was greater in HT than NT (36 ± 2 vs 24 ± 2 mmHg, P < 0.001). MSNA was similar between groups (40 ± 2 vs 40 ± 2 bursts/min; P = 0.998), but PWV was higher in HT than NT (11.0 ± 0.4 vs 9.1 ± 0.3 m/s; P < 0.001). MS was correlated positively with PWV (r = 0.65, P < 0.001) and negatively with sBRS (r = −0.48, P = 0.004), but not with MSNA (r = 0.12, P = 0.476) in HT. Conversely in NT, MS tended to be correlated negatively with PWV (r = −0.35, P = 0.055), but not with MSNA or sBRS (r = −0.29, P = 0.125 or r = 0.03, P = 0.889). Thus, both arterial stiffness and sympathetic baroreflex sensitivity may contribute to the morning blood pressure surge in elderly hypertensives.

Anxiety Disorder Is Associated With Nocturnal and Early Morning Hypertension With or Without Morning Surge

Nocturnal and early morning hypertension are both significant risk factors for cardiovascular events. It remains unclear whether anxiety disorder affects nocturnal blood pressure (BP), early morning BP, or BP pattern in hypertensive patients. One hundred and twenty consecutive hypertensive outpatients (77 men and 43 women; mean age, 66±11 years) were divided into 2 groups based on Hospital Anxiety and Depression Scale (HADS) score: a control group (n=78; HADS ≤10) and an anxiety group (42 patients; HADS ≥11). Nocturnal BP, early morning BP, morning BP surge (defined as BP rise ≥50 mmHg), and BP pattern (extreme-dipper/dipper/non-dipper/riser) were measured on ambulatory BP monitoring. Clinical characteristics and BP were also evaluated at physician check-up. There was no significant difference between the 2 groups for BP check-up, but nocturnal and early morning BP were significantly higher in the anxiety group (142±16 mmHg and 152±21 mmHg) than in the control group (126±14 mmHg and 141±18 mmHg). With regard to patients with morning BP surge, nocturnal and early morning BP were also significantly higher in the anxiety group. The relative risk of existing anxiety disorders in riser-type hypertension was 4.48-fold higher (95% confidence interval: 1.58-12.74; P<0.005) than in dipper-type hypertension. Anxiety disorder is associated with nocturnal and early morning hypertension, and may be a risk factor for cardiovascular events.

Home blood pressure control is low during the critical morning hours in patients with hypertension: the SURGE observational study

The morning blood pressure (BP) surge is associated with a peak increase in vascular events. The aim of this observational study was to evaluate morning BP control in treated hypertensive patients using home BP (HBP) monitoring and to compare these findings with clinic BP control. Clinic BP was measured twice during a 2-week period, prior to medication. Seated HBP was measured, using a BHS-validated device, three times per day over a 2-week period. Assessments included morning (06:00-11:59), lunch time (12:00-14:00) and evening (18:00-22:00) HBP control (all <135/85 mmHg) and clinic BP (<140/90 mmHg) control. A total of 15618 patients were assessed. At baseline (Day 1 and Week 1), clinic BP control (<140/90 mmHg) and morning HBP control (<135/85 mmHg) were low: 23.6% and 21.9%, respectively. The percentage of patients with both clinic BP and morning HBP control was extremely low (8.5%). Similar values were obtained at lunch time (11.3%) and evening (9.9%). There was a slight improvement at the end of the second week, but values remained low. At final visit (Day 4 and Week 2), morning, lunch time and evening HBP control was observed in 31.8%, 42.2% and 36.4% of patients, respectively. Clinic BP control was observed in 41.7%. Morning HBP control was low in this large hypertensive population. The improvement in BP control observed may be associated with inclusion in a study; this could indicate low medication compliance in general practices but may also be attributable to the use of agents that cannot sustain 24-hour BP control.

Efficacy and Safety of Benidipine Therapy of Essential Hypertension in Elderly Chinese Patients

Benidipine (CAS 105979-17-7) is a dihydropyridine calcium channel blocker used in the treatment of hypertension and angina pectoris. To examine the efficacy and safety of therapy with benidipine in elderly hypertensive patients. Chinese patients >60 years of age with mild to moderate essential hypertension were enrolled. The patients were prescribed benidipine at the dose of 8 mg once daily for 12 weeks. Detailed laboratory examinations and 24-h ambulatory blood pressure monitoring were performed before and after the treatment. One hundred and sixty-four of the 180 patients enrolled completed the 12-week active treatment phase. Sitting systolic blood pressure (SBP) and diastolic blood pressure (DBP) reductions at the end of treatment were 21.50 +/- 12.83 and 10.60 +/- 8.04 mmHg, respectively; the proportion of patients showing a good treatment response was 95.1% for SBP and 96.9% for DBP. Benidipine significantly reduced the mean 24-h ambulatory blood pressure (p < 0.001 vs. baseline) exhibiting smooth, sustained effects and high trough-to-peak ratios (T/P ratio) (0.87 for SBP and 0.72 for DBP). Moreover, benidIpine significantly reduced the systolic morning blood pressure surge and urinary albumin, and it was well tolerated. No serious adverse events were noted. Benidipine was welltolerated and effective in elderly Chinese patients with essential hypertension.

The morning blood pressure surge

The morning blood pressure surge

Morning blood pressure surge, morning platelet aggregation, and silent cerebral infarction in older Japanese hypertensive patients

To examine whether or not the extent of morning blood pressure surge (MBPS), defined as a morning SBP increase from sleep SBP, is associated with that of platelet aggregation, coagulation/fibrinolytic activity, and silent cerebral infarction (SCI) in older hypertensive patients. Sixty hypertensive patients aged at least 60 years (mean age 70.6 years; 40% men) underwent measurement of morning spontaneous small-sized platelet aggregation (SPA) detected by a light scattering intensity method, measurement of circulatory levels of von-Willebrand factor (vWF), noradrenalin, and plasma renin activity (PRA), and brain MRI. The extent of MBPS, but not 24-h SBP, was associated with circulatory levels of noradrenalin, PRA, vWF, and spontaneous SPA (all P < 0.05); the association between MBPS and spontaneous SPA remained significant even after adjustment for significant covariates (P < 0.001). The patients with multiple (more than three per person) SCIs had a significantly greater extent of MBPS (43.3 vs. 31.8 mmHg), morning spontaneous SPA (20 471.9 vs. 4850.9 × 10(5) × 2 mV counts 10 min), and higher circulatory vWF (196.6 vs. 150.1%) compared with those without it (all P < 0.01). On multiple regression analysis, the odds ratio for multiple SCIs with a +1 SD increase of MBPS was 2.0, that of morning spontaneous SPA was 3.0, and that of circulatory morning vWF level was 3.3 (all P < 0.05). When MBPS increase and either platelet aggregation or vWF increases were entered into the same model, the latter parameters, but not the MBPS, were associated with multiple SCIs (both P < 0.05). The extent of MBPS was associated with increased activity of morning platelet aggregation in older hypertensive patients.

Resting sympathetic outflow does not predict the morning blood pressure surge in hypertension

The blood pressure (BP) rise on awakening (morning surge) might be a predictor of hypertension-related cardiovascular complications. Previous studies suggest that the autonomic nervous system may contribute to the early morning BP increase. We tested the hypothesis that resting sympathetic outflow [assessed by direct measures of intraneural sympathetic nerve activity (SNA)] may help predict the morning BP surge in hypertension. We measured muscle SNA (MSNA), heart rate (HR) and BP during undisturbed supine rest in 68 newly diagnosed untreated hypertensive patients (53 men and 15 women, age 40 ± 3 years, BMI 27 ± 1 kg/m(2), mean ± SEM). The morning BP surge was defined as the difference between the morning BP and the pre-awake BP. SBP averaged 143 ± 3 mmHg for daytime and 126 ± 2 mmHg for night-time. Mean HR was 81 ± 2 beats/min for daytime and 69 ± 2 beats/min for night-time. Average MSNA was 32 ± 2 bursts/min., SBP morning surge 19 ± 2 mmHg and HR morning surge 14 ± 2 beats/min. In univariate analysis, MSNA correlated with daytime SBP (r = 0.28, P = 0.02); night-time SBP (r = 0.26, P = 0.03); daytime HR (r = 0.28, P = 0.02); and night-time HR (r = 0.26, P = 0.03). Multivariate analysis, taking into consideration age, BMI and sex, revealed that MSNA was independently related to both daytime (P = 0.006) and night-time HR (P = 0.02), but not to ambulatory SBP. The morning surge of SBP and HR was not related to MSNA (r = 0.01 and r = 0.07, respectively, P = NS). In patients with essential hypertension, MSNA is related to both daytime and night-time HR, but not to the morning BP 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.

Ambulatory and Home Blood Pressure Measurement

See related article, pp 22–28 Clinic (office) blood pressure (BP) measurement has a well-established role in medical practice and is the standard on which most of the literature is based. However, clinic BP has several important limitations, including the potential for inadequate or misleading estimates of a patient's true BP status and suboptimal prediction of cardiovascular risk. Particularly relevant is the concern that clinic BP measured with standard techniques may not provide a representative estimate of an individual's usual BP outside the medical setting. Out-of-office BP assessment takes 2 forms at the present time, self (or home) BP measurement (SBPM) and ambulatory BP monitoring (ABPM). These 2 techniques have attracted considerable attention in recent years because of the potential for better classification of hypertensive status compared with office BP. SBPM devices allow for repeated measurements outside the medical environment, and their use has been recommended by several international guidelines.1,2 ABPM is currently considered the gold standard for the correct diagnosis of hypertension on the grounds that the ambulatory BP provides extensive information on several BP parameters other than the average BP, including BP variability, the morning BP surge, BP load, and the nocturnal fall in BP.3 However, it should be noted that all of the clinical guidelines still focus on the importance of the mean ambulatory BP for clinical practice, and all of the other parameters are still considered experimental. ABPM is not widely available in primary care practice and is considered most helpful when self-measured BP is within borderline values. According to most authorities, self-BP measurement should be used as an initial step to evaluate the out-of-office BP1–3 and, thus, used as a screening procedure that should lead to an ABPM for confirmation. However, it is not well known whether this strategy …

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.

Absence of circadian variation of acute coronary syndrome onset in chronic kidney disease patients

Several studies have reported on the circadian variation in acute coronary syndrome (ACS) onset. The influence of morning blood pressure surge, platelet aggregation and sympathetic activity is believed to cause this circadian variation. At the same time, a high frequency of ACS and sympathetic nerve hyperactivity has been reported in chronic kidney disease (CKD). Therefore, we investigated the relationship between CKD and the circadian variation in ACS. This study included 460 consecutive patients undergoing primary percutaneous coronary intervention for ACS between 2003 and 2009. Patients undergoing hemodialysis were excluded. The subjects were divided into two groups according to the value of estimated glomerular filtration rate (eGFR): CKD group [eGFR ≤ 60 ml/min/1.73 m2 by Modification of Diet in Renal Disease (MDRD) equation] and No CKD group (eGFR > 60 ml/min/1.73 m2 by MDRD equation). Clinical and angiographic characteristics, as well as the time distribution of ACS, were compared between the two groups. There were no significant differences in clinical and angiographic characteristics between the two groups. A significant increase in morning coronary events was observed in the No CKD group. This increase was absent in the CKD group. The existence of CKD affected the circadian variation associated with the more frequent ACS onset observed in the No CKD group patients. Probably, these data may suggest the cause of frequent cardiovascular events in CKD patients.

Both morning and evening dosing of nebivolol reduces trough mean blood pressure surge in hypertensive patients

The morning blood pressure surge (MBPS) has been shown to be an independent predictor of cardiovascular events. There is insufficient evidence on the effect of nebivolol, a vasodilating β1-receptor blocker, on the MBPS when given in the morning or the evening. This is a prospective, randomized, double-blind, crossover study designed to test morning vs. evening dosing of nebivolol in nondiabetic, hypertensive patients. Patients received nebivolol 5 mg/day (force-titrated to 10 mg/day after 1 week) in the morning or evening and corresponding placebos. Patients underwent ambulatory BP monitoring at baseline and after each treatment phase. Forty-two patients were randomized, of whom 38 completed both study periods. Both morning and evening dosed nebivolol significantly lowered daytime, nighttime, and 24-hour BP after 3 weeks of treatment. Evening (but not morning) dosing significantly reduced prewaking systolic BP from baseline (8.64 ± 26.46 mm Hg, P = .048). Nebivolol given in the morning or the evening significantly reduces 24-hour BP parameters. Evening dosed nebivolol may confer some advantage over morning dosing in reducing prewaking systolic BP.

The correlation of morning blood pressure peak with cognitive function in elderly masked hypertension patients

Objective To study the current status of morning blood pressure peak in elderly masked hypertension patients and study the correlation between morning blood pressure peak and cognitive function.Methods A total of 72 elderly masked hypertension patients were selected in this study,.Morning blood pressure peak was measured by ABPM examination.The patients were divided into three groups according to the morning blood pressure peak.Morning blood pressure peak ≤ 30 mmHg were divided into non-Morning blood pressure surge group ( NMS group),morning blood pressure peak ＞30 mmHg were divided into Morning blood pressure surge group ( MS group).The cognitive function scale was determined (MMSE and MoCA).T-test and linear regression analysis were performed.Results MMSE score(27.69±2.04) and MoCA scores(24.85 ± 1.52) in MS group were lower than NMS group (28.87 ± 1.34,26.54± 1.53) ( P ＜0.01 ).MMSE and MoCA scores were negatively correlated with the morning blood pressure peak ( r =- 0.308,- 0.447,P ＜ 0.01 ).Conclusions Elderly masked hypertension patients remained the phenomenon of the morning blood pressure peak,the morning blood pressure peak could lead to cognitive impairment. Key words: Blood pressure ; Hypertension/PP/PX; Cognition