Morning Rise In Blood Pressure Research Articles

Morning blood pressure surge as a predictor of cardiovascular events in patients with hypertension.

The prognostic value of ambulatory blood pressure (BP) monitoring (ABPM) is poorly understood in Latin American populations. A prospective observational study was conducted on 1339 patients with hypertension who underwent 24-h BP monitoring between 2015 and 2019. The incidence of serious adverse cardiovascular events (MACE) was analysed using a Cox proportional hazards model adjusted for potential confounders. Three previously reported morning surge definitions were evaluated for SBP and DBP using different ABPM components: sleep-through morning surge, pre-awakening, and morning night-time difference. The mean age was 62 years, 52% were female, 32.8% had dyslipidaemia, 27.2% were smokers, and 7.8% had diabetes. During a median follow-up period of 32 months, 197 MACE occurred. In men, the adjusted hazard ratio (HR) was 1.84 [95% confidence interval (CI), 1.35-2.49; P < 0.001). The HR increased to 2.03 (95% CI, 1.89-2.17; P < 0.001) with a cut-off value of 35 mmHg for a 10 mmHg increase in sleep-through morning surge. The increased adjusted HR associated with the morning rise persisted for each secondary endpoint, including 21 cardiovascular deaths [HR: 2.70 (95% CI, 2.03-3.60; P < 0.001)], 78 myocardial infarctions [HR: 1.92 (95% CI, 1.72-2.15; P < 0.001)], 24 hospitalisations for heart failure [HR: 1.77 (95% CI, 1.48-2.12; P < 0.001)], 22 strokes [HR: 2.32 (95% CI, 1.85-2.91; P < 0.001)], and 52 atrial fibrillations [HR: 1.94 (95% CI, 1.71-2.20; P < 0.001)]. The morning BP rise was the most important circadian prognostic factor for MACE in patients with hypertension, which deserves more attention.

EFFECT OF CHOLECALCIFEROL ON RATE OF MORNING BLOOD PRESSURE RISE IN WOMEN WITH ARTERIAL HYPERTENSION IN PREMENOPAUSAL AND EARLY POSTMENOPAUSAL PERIODS

Objective: To assess effect of cholecalciferol on rate of morning blood pressure (BP) rise in women with arterial hypertension (AH) in premenopausal and early postmenopausal periods. Design and method: We investigated 102 women with AH stage II risk 3 aged 50 (48; 53) years: 50 females in premenopausal period – group I and 52 females in early postmenopausal period – group II. Serum level of 25(OH)D was determined by the immunoenzymatic assay. In groups I and II we identified subgroups with the level of 25(OH)D&lt; 30ng/ml: subgroup IB (n = 25) and subgroup IIB (n = 21) respectively, in which antihypertensive therapy was supplemented with cholecalciferol 2,000 IU/day for 3 months. In subgroups IA (n = 25) and IIA (n = 31) cholecalciferol was not administered. The rate of morning BP rise was calculated by the ratio of the BP rise value to its time using daily monitoring of BP. Results: At baseline the level of 25(OH)D was lower (p &lt; 0,05) in subgroups IB (19,3 ± 8,5ng/ml) and IIB (18,2 ± 9,5ng/ml) than in the comparable subgroups IA (26,7 ± 11,5ng/ml) and IIA (27,4 ± 10,5ng/ml). After supplementation the level of 25(OH)D increased (p &lt; 0,001) in subgroup IB (37,28 ± 11,97ng/ml) and in subgroup IIB (36,4 ± 10,0ng/ml), and became higher (p &lt; 0,001) than in the comparable subgroups I and IIA. At baseline, subgroups IA and IB did not differ (p &gt; 0,05) by rate of morning SBP/DBP rise. In subgroup IIB rate of morning DBP rise was higher (p = 0,04) than in subgroup IIA. After therapy in subgroup IB there was a decrease rate of morning SBP/DBP rise (p &lt; 0,05); in subgroup IA, rate of morning SBP/DBP rise did not change (p &gt; 0,05). In subgroup IIA, there was no decrease (p = 0.62) rate of morning DBP rise, while in subgroup IIB, rate of morning DBP rise in the decreased (p &lt; 0,05) compared to the baseline and in comparison with rate of morning DBP rise in subgroup IIA after therapy (p = 0,04). The contribution of cholecalciferol to the dynamics of rate of morning DBP rise was established: F = 4,33, p = 0,04. Conclusions: Correction of 25(OH)D level by intake of cholecalciferol 2000 IU/day for 3 months leads to reduction of rate of morning BP rise in women with AH.

Readings of 24-hour ambulatory blood pressure monitoring (ABPM) in patients with stage II arterial hypertension (HTN) receiving planned antihypertensive therapy

The aim of the study:to analyze ABPM readings in patients with stage II HTN receiving antihypertensive therapy in order to plan a personalized algorithm for managing HTN patients at the stage of the outpatient care. Materials and methods. 60 patients with stage II HTN were examined. ABPM readings were assessed on the background of planned antihypertensive therapy (ARBs and diuretics) and after the adjustment of the therapy (perindopril and amlodipine).Results. The use of long period monitoring provides comprehensive information about the patterns of blood pressure changesthroughout the day. Patients with stage II HTN receiving planned antihypertensive therapy with ARBs and diuretics did not have targeted BP during the day and had a systolic HTN of stage I, while there was a statistically significant increase in BP variability during the day and in the readings indicating a hypertensive load of target organs in comparison with a group of patients receiving a combination of perindopril and amlodipine for 3 months. In addition, there was a statistically significant (ANOVA, p&lt;0.05) difference in the rate of morning BP rise, which can serve as a precursor for the development of cardiovascular events in the morning compared to the group of patients with theadjusted therapy. Among hypertensive patients receiving ARBs and diuretics a disturbed circadian rhythm predominated in the structure of the diurnal BP profilecompared with the patients who received combined therapy with perindopril and amlodipine. In addition, the proportion of night-peakers among patients taking ARBs and diuretics was 2 times higher than among patients whose therapywas adjusted 3 months ago.Conclusion. Thus, in the group of patients whose antihypertensive therapy was timely adjusted, there was an improvement in hemodynamics: due to the achievement of targeteddiurnal blood pressurereadings, a significant decrease in BP variability during the day and the rate of the morning rise in blood pressure, as well as the proportion of patients with a normal diurnal blood pressure profileincreased.

Choosing the optimal antihypertensive therapy

The article considers approaches to the selection of optimal antihypertensive therapy in order to achieve the target blood pressure in patients with hypertension in accordance with the latest Recommendations on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology; ESC), as well as the circadian rhythm of blood pressure. Fixed combinations of renin-angiotensin-aldosterone system blockers, which include angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors, with calcium antagonists should be preferred. Taking such a fixed combination at night can prevent the morning rise in blood pressure, when patients with hypertension usually have cardiovascular accidents.

Calcium metabolism, arterial stiffness and 24-hour blood pressure monitoring data in postmenopausal women with magnesium deficiency, hypertension, and heart failure

Aim. To assess the calcium metabolism, arterial stiffness and 24-hour blood pressure (BP) monitoring data in postmenopausal women with magnesium deficiency, hypertension, and heart failure with preserved ejection fraction (HFpEF) Material and methods . The study involved 140 female patients with hypertension complicated by HFpEF, aged 52 to 76 years. Depending on the results of magnesium-tolerance test, 2 groups were selected. The first group consisted of 72 females with magnesium deficiency, and the second (control) group (n=68) — without magnesium deficiency. Calcium metabolism was assessed using calcium-tolerance test. Twenty-four-hour blood pressure monitoring and arterial stiffness was determined using an automatic blood pressure monitor. Results . Patients with magnesium deficiency had a lower calcium excretion and return to baseline blood calcium levels compared with group 2 (p&lt;0,001). The presence of magnesium deficiency was associated with an increase in 24-hour BP variability (16,9 [13,3; 20,69] mm Hg vs 12,9 [11,7; 17,42] mm Hg; p=0,001), rate of morning BP rise (12,5 [9,7; 13,6] mm Hg/h vs 9,5 [8,1; 10,9] mm Hg/h; p&lt;0,001) and indexed systolic BP (21,2 [19,5; 25,1] mm Hg vs 19,5 [16,5; 23,9] mm Hg; p=0,007). In women with magnesium deficiency, BP pro -files of non-dipper and night-peaker were more common (p&lt;0,05). Pulse wave velocity (11,92 [10,06; 14,47] m/s vs 10,87 [8,41; 13,20] m/s; p=0,005) and central pulse pressure (70,2±13,3 mm Hg vs 63,5±12,5 mm Hg; p=0,003) were also higher in group 1. Also, a correlation ( р=-0,610, p&lt;0,001) was found between the rate of exercise-induced decrease in blood calcium and the pulse wave velocity. Conclusion . In women with hypertension and HFpEF, there were no differences in mean 24-hour BP values, while more unfavorable BP profiles and arterial stiffness indicators were revealed, which is mediated by impaired oalcium metabolism.

Influence of dosed walking on the course of arterial hypertension in patients with chronic obstructive pulmonary disease

Objective: to study the influence of dosed walking on the course of hypertension and quality of life in patients with chronic obstructive pulmonary disease.Materials and methods: the study included 85 patients with a combination of arterial hypertension and chronic obstructive pulmonary disease, with an average age of 60.9 ± 1.06 years. Group A patients were prescribed dosed walking in addition to medication, while group B patients received only antihypertensive medications, statins, and basic treatment for chronic obstructive pulmonary disease. The effectiveness of treatment was determined after 6 weeks based on a standard examination, daily monitoring of blood pressure and ECG, and quality of life indicators. Long-term results were evaluated after 6 months.Results: patients whose treatment plan included physical training, in contrast to patients receiving only medication, noted a decrease in complaints of headache (p=0.034), dizziness (p=0.041), tachycardia (p=0.029), general weakness (p=0.003), head noise and tinnitus (p=0.018), sleep disturbance (p=0.010) and shortness of breath (p=0.004). They had normalization of all indicators of quality of life according to the SF-36 questionnaire: scales physical functioning (p&lt;0.001), role functioning due to physical condition (p&lt;0.001), pain intensity (p&lt;0.001), general health (p=0.002), vital activity (p=0.001), social functioning (p=0.013), role functioning due to emotional state (p&lt;0.001), mental health (p=0.008), physical component of health in general (p&lt;0.001) and the mental health component (p=0.002). Improvement of well-being was accompanied by normalization of lipidogram indicators, daily heart rate and blood pressure: reduction of average daily indicators of blood pressure (p&lt;0.001), pressure load index (p&lt;0.001), blood pressure variability (p&lt;0.05), pulse pressure (p&lt;0.001) and the rate of morning rise in blood pressure (p&lt;0.001).Conclusion: addition to standard medical therapy of dosed walking has a positive effect on the course of arterial hypertension in patients with chronic obstructive pulmonary disease.

Clinical and functional predictors that cause a decrease of indicators of morning blood pressure profile in antihypertensive telmisartan-based therapy

Background: Blood pressure (BP) monitoring is an important aspect in the treatment of arterial hypertension (AH), namely the morning BP increase which is associated with an increased risk of cardiovascular and cerebrovascular incidents as well as sudden death. The study herein revealed clinical and functional predictors which decrease the morning BP rise in the case of optimal antihypertensive therapy with telmisartan, based on results of daily blood pressure monitoring (DBPM).&#x0D; Methods: A single-center open-label study in parallel groups was conducted. The study included 50 patients with AH who had previously received antihypertensive therapy but did not achieve a reduction in BP according to DBPM. Telmisartan (40 - 80 mg per day) was added to the treatment regimen of all patients. All patients underwent a general clinical examination, measurement of glucose and creatinine levels, assessment of lipid profile, ECG recording in 12 leads, echocardiography (EchoCG), and DBPM before treatment and after 12 weeks of treatment. Statistical data analyses were performed.&#x0D; Results: Twelve-week antihypertensive telmisartan-based therapy led to a decrease in mean systolic blood pressure (SBP) from 134.3 ± 5.0 to 126.2 ± 4.3 mm Hg (p = 0.008), and a decrease in mean diastolic blood pressure (DBP) from 79.8 ± 1.5 to 73.0 ± 1.4 mm Hg (p &lt; 0.001). There was a decrease in the index of variability of DBP from 22.4 ± 2.8 to 16 ± 2.4 mm Hg (p &lt; 0.001), and a decrease in the daily index of SBP from 15.7 ± 4.7 to 13.1 ± 4.7 mm Hg (p = 0.014). In the study, a connection was found between the decrease of the average morning index and the following indicators: presence of left ventricular (LV) hypertrophy on ECG, final diastolic size of the LV over 6.0 cm, LV ejection fraction below 52.3%, total cholesterol level over 5.5 mmol/L, LDL level greater than 3.3 mmol/L, and triglyceride level greater than 2.0 mmol/L.&#x0D; Conclusion: These values could be used as predictors of a decrease in the morning index during 12-week telmisartan therapy.

How important is blood pressure variability?

Arterial blood pressure (BP) is a continuous variable, with a physiology characterized by significant variability stemming from the complex interaction among haemodynamic factors, neuronal reflexes, as well as hormonal, behavioural, and environmental stimuli. The homoeostatic response accounts for the physiologic variability in BP in normotensive individuals, which is more evident in hypertensive patients. Blood pressure variability is a complex phenomenon, which could be classified in various types: very short term (beat to beat), short term (during 24 h), mid-term (day by day), long term (<5 years), and very long term (>5 years). Accurate measurement of BP variability represents a complex and often controversial endeavour, despite several methodological approaches are available. Albeit a prognostic significance has been demonstrated for some indicators of BP variability, the clinical significance of this measurement is still uncertain. In fact, none of the indicators presently available for BP variability, including early morning BP rise, substantially affects, and redefines, the cardiovascular risk of the hypertensive patient, over and beyond the mere BP values. Accordingly, in defining the cardiovascular risk, the focus should be on the absolute BP values, which remain the most relevant risk factor, and the one more susceptible to modification with both non-pharmacologic and pharmacologic treatment.

ENDOTHELIAL DYSFUNCTION AND NEUROHUMORAL REGULATION OF BLOOD PRESSURE IN PATIENTS WITH SYSTEMIC SCLEROSIS

Objective: to investigate the effect of endothelial dysfunction, catecholamines, and renin on the diurnal blood pressure (BP) profile in patients with systemic sclerosis (SS).Subjects and methods. Twenty-five patients with SS underwent determination of the blood count of desquamated endotheliocytes by the method described by J. Hladovec (1978), the plasma levels of endothelin-1 (ET-1), adrenaline, norepinephrine, and renin by enzyme immunoassay. All the patients underwent 24-hour BP monitoring with calculating the time index, daily index, the magnitude and rate of a morning rise in BP, as well as its daily variability.Results and discussion. Hypertension was detected in 8 (32%) patients with SS. All the patients with SS showed signs of endothelial dysfunction, as evidenced by considerable differences in endothelial activation measures compared with the control group: the mean level of ET-1 was 5.8±2.3 and 0.48±0.21 fmol/ml (p&lt;0.05); the number of desquamated endotheliocytes was 4.50 [3.00; 7.00] and 2.10 [1.00; 3.20] • 104/l, respectively (p&lt;0.05). The levels of adrenaline and norepinephrine in SS were significantly higher than those in the control. There were positive correlations between endothelial dysfunction and the degree of an increase in BP. Endothelial dysfunction was found to have a negative impact on the diurnal BP profile in the presence of pathological types of night-peaker and non-dipper. Conclusion. Two mechanisms, such as endothelial dysfunction and sympathoadrenal activation, are responsible for the pathogenesis of clinical symptoms of SS, including hypertension.

Moderate morning rise in blood pressure has lowest risk of stroke but only in women.

The morning period which is recognized as the highest risk for cardiovascular events is associated with a surge in blood pressure (BP). However, it is unclear what aspect of this rise is important. To determine whether the rate of rise (RoR), the magnitude (day night difference) or the product [BP power (BPPower)] is associated with increased cardiovascular risk. We developed a logistic equation method to fit individual 24-h patterns of BP to determine RoR, amplitude and BPPower using the ambulatory recordings from the Ohasama study including 564 men and 971 women (16.6 years follow-up). Men had a higher risk of cardiovascular events than women (24, 16%, P < 0.001). Age and night BP were strong linear risk predictors. In men sorting risk by quintiles of BPPower (adjusted for age, night BP, smoking status) revealed no clear linear or nonlinear pattern. However, in women BPPower had a U-shaped relationship with the lowest risk being the 2-3rd quintile for all cardiovascular events (Pquadratic = 0.01) including cardiovascular death (Pquadratic = 0.03) and nonfatal stroke (Pquadratic = 0.02). A similar but less clear trend was observed with the RoR but only stroke (infarct) reached significance (Pquadratic = 0.03) while sorting by range showed a U shaped pattern for combined cardiovascular events (Pquadratic = 0.04). These findings suggest that the morning BPPower is an important independent risk factor for predicting cardiovascular events and stroke but only in women with median levels having the lowest risk.

Cognitive impairment in patients with arterial hypertension: a relationship with the level and daily blood pressure profile and pathogenetic mechanisms

Arterial hypertension (HT) is one of the main recognized risk factors for the development of cognitive impairment and dementia. The results of most studies indicate that the presence of HT in elderly and senile people is associated with a decrease in cognitive functions and an increased risk of dementia in people of this age group, although some studies have identified the so-called U-shaped curve”. The state of cognitive functions in middle-aged patients with HT has been studied to a much lesser extent, but it has been established that the presence of HT in middle age is associated with deterioration of cognitive functions and an increased risk of dementia in the elderly. In middle-aged hypertensive patients, cognitive impairment affected all cognitive domens, but to a greater extent - neurodynamic indicators of cognitive functions (speech activity, ability to concentrate, speed of cognitive processes). There are few data that levels of systolic blood pressure (BP) during the day, during wakefulness and sleep periods, insufficient night BP decrease, increased daily BP variability, and increased magnitude of the morning BP rise are interrelated with deterioration of the control functions/speed of cognitive processes. Pathogenetic aspects of the relationship of cognitive impairment and HT are diverse and include the hyperactivation of neuro-humoral systems (renin-angiotensin-aldosterone and sympathoadrenal, hypothalamic-pituitary-adrenal system dysfunction, reduction of cerebral perfusion, endothelial dysfunction. Anxiety-depressive disorders are of great importance in the occurrence of cognitive impairment in patients with HT, their interrelation is complex, dualistic, possibly due to a decrease in brain perfusion.

Moxonidine in treatment of arterial hypertension in patients with metabolic syndrome

Purpose. To evaluate the efficacy of moxonidine, an imidazoline receptor agonist, in patients with arterial hypertension (AH) and metabolic syndrome compared to enalapril, an ACE inhibitor. Materials and methods. The complex study included 50 patients with AH and metabolic syndrome. Inclusion criteria were abdominal obesity (waist-to-hip ratio (WHR) exceeded 0.95 in men and exceeded 0.80 in women, with BMI ≥25 kg/m 2 , AH of 1st - 2-nd degrees, type 2 diabetes mellitus (DM) in the stage of compensation, dyslipidemia. The mean age of patients was 52 years, duration of AH is 11 years, duration of type 2 DM is 7 years. After examination under conditions of a pure background and obtaining of DM compensation, all patients with AH and metabolic syndrome were randomized into 2 groups. The first group of patients (25 people) received moxonidine, an imidazoline receptor agonist, in individually selected dose of 0.2-0.6 mg per day, an average daily dose of 0.4 mg in twice a day form. The second group (25 people) took enalapril, an ACE inhibitor, in a dose of 5-15 mg per day, an average dose of 10 mg, respectively. A control study was performed after 4 weeks. Results. In patients with AH and metabolic syndrome, the use of moxonidine and enalapril for the correction of blood pressure (BP) showed a comparable effect in changes of office BP, average 24-hour BP, average day-time and night-time BP with the same frequency of achieving target BP. However, only moxonidine showed additional positive effect on the increased BP variability, contributed to the normalization of 24-hour BP profile, reducing the morning rise in BP, reduced the frequency of heart rate and the value of the double product. Moreover, moxonidine had cerebroprotective effects, increasing the cerebrovascular reactivity index. Conclusion. In hypertensive patients with metabolic syndrome, moxonidine provides the best prevention of cardiovascular complications.

Efficiency of perindopril arginine and indapamide retard in patients with nocturnal hypertension: The results of the study “Chronos”

Objective. To assess the antihypertensive efficiency of perindopril arginine and indapamide retard in patients with nocturnal hypertension (HTN). Design and methods. In the regional program “Chronos” of the open, multicenter, observational, non-controlled study, we included 196 patients with nocturnal hypertension (2nd degree — 59,4%; 3rd degree — 40,6%). Upon inclusion, instead of the previous therapy the patients received 10 mg perindopril arginine at night and 1,5 mg indapamide retard in the morning. The follow-up was 3 months, the efficiency and tolerability were assessed in 2 weeks, 1 and 3 months of therapy. Blood pressure (BP) was measured by Korotkoff method. Statistical analysis was performed with the use of the programs Microsoft Excel 2012, Statsoft Statistica 10.0. Results. At baseline, daytime median systolic BP was 165,5 (160; 180) mmHg, diastolic BP was 100 (90; 100) mmHg. After 2 weeks of treatment by perindopril arginine and indapamide retard, both daytime and nocturnal BP decreased (p &lt; 0,05). The positive changes maintained for the whole follow-up period. Seven patients did not achieve target BP 1 month later. In these cases, additional therapy (other drug class medications) was prescribed. Conclusion. All patients demonstrated both daytime and nighttime BP decrease. In 73% patients there was no morning BP rise anymore. In 60% BP was normalized in patients who had been considered resistant. The combination therapy was well-tolerated.

Development of Pulsatile Drug Delivery for Chronotherapeutics of Hypertension

The goal of present work was to investigate the effects of rupturable material ethyl cellulose combines with erodible material Klucel EXF on the pulsatile release pattern of Candesartan cilexetil in order to prevent morning rise in blood pressure. A tablet prepared by compression coating method contains core and coat components. Core consists of active ingredients with its various superdisintegrants where as coat contains different grades of ethyl cellulose and Klucel HXF in various combinations. All these tablets were evaluated for its micromeritics, weight variations, hardness, friability and in vitro dissolution testing. Drug-excipients interactions were carried out by FTIR. Dissolution studies were carried out in simulated gastric fluid followed by phosphate buffer of pH 6.5. The optimized formulation PT6 which give lag time of 6 hrs and released 99.10 % within 7 hr, as well as found to be stable in ICH stability testing guidelines.

CPAP-THERAPY IS A PROTECTIVE CARDIOVASCULAR FACTOR IN PATIENTS WITH SEVERE OBSTRUCTIVE SLEEP APNEA SYNDROME

Objective. To analyze the state of the cardiovascular system in middle-aged patients with severe obstructive sleep apnea syndrome (OSAS), before and 6 months after the use of CPAP therapy. design and methods. The study involved 35 hypertensive patients with verified severe OSAS. All patients underwent comprehensive cardiovascular assessment (blood pressure (BP) and electrocardiogram monitoring, echocardiography), CPAP therapy has been recommended as the primary treatment of obstructive sleep-disordered breathing. After 6 months, all patients underwent a complete re-examination. Patients were divided into 2 groups: the experimental group consisted of 17 people (16 men and 1 woman, mean age 49,6 ± 10,1 years) treated with CPAP therapy throughout the study period, the control group included 18 patients, who refused CPAP-therapy. Results. After 6 months of CPAP therapy, patients with severe OSAS demonstrated favourable changes in the cardiovascular system: reduction of office and average daily BP, reduced BP variability, normalization of BP circadian profile and velocity of morning BP rise. BP reduction in CPAP-users was associated with the decrease of myocardial afterload. As a result, we have witnessed a reverse myocardial remodeling, manifested by a decrease in size of both left and right heart, which also contributed to the increase in exercise tolerance and improvement of quality of life. In CPAP use was associated with the tendency to the decrease in cardiac arrhythmias. conclusions. Six-month CPAP therapy in highly compliant patients leads to the BP reduction and normalization of BP daily profile, reduction in the number of antihypertensive drugs, as well as — to a reverse myocardial remodeling.

Hypertension in Chronic Kidney Disease Part 2: Role of Ambulatory and Home Blood Pressure Monitoring for Assessing Alterations in Blood Pressure Variability and Blood Pressure Profiles.

Blood pressure (BP) is characterized by high variability, including changes beat-to-beat (very short term), within 24 hours (short term), from day to day (midterm), and between visits spaced by weeks, months, seasons, and even years (long term). These variations can be estimated by means of continuous beat-to-beat BP recordings, repeated conventional office BP measures, 24-hour ambulatory BP monitoring (ABPM), or home BP monitoring (HBPM) over longer time windows (Table). A main advantage of ABPM over other BP measurement techniques is represented by its ability to track BP changes occurring in daily life conditions and during 24 hours, thus allowing assessment of overall BP variability (BPV) as well as identification of its specific components, such as nocturnal hypertension and altered day-to-night BP profiles (ie, morning BP rise, nondipping pattern of BP) which become manifest early in the course of chronic kidney disease (CKD). These alterations are even more significant in subjects with end-stage renal disease (ESRD) mainly, but not exclusively, because of the marked reduction in intravascular volume immediately after hemodialysis followed by the progressive increase in volemia throughout the interdialytic period,2 combined with an enhanced sympathetic activity. The higher frequency of alterations in 24-hour BP profiles and BPV in subjects with CKD and in those with ESRD not only makes a proper assessment and achievement of BP control more difficult in these subjects but may be prognostically relevant on the background of the evidence from longitudinal and observational studies indicating that increased BPV may predict the development of cardiovascular and renal disease, over and above the contribution of elevated mean BP levels per se3–11 (Figure 1). The purpose of this review is to address the currently available evidence on the role of ABPM and HBPM for the assessment and management of alterations in circadian BP profiles …

Arterial hypertension and depressive disorders: combination treatment with antihypertensive and psychotropic therapy

Objective. To evaluate the effectiveness of combination treatment with antihypertensive drugs and antidepressant in patients with uncontrolled hypertension (UHTN) and depressive disorders (DD). Design and methods. The study involved 160 patients with UHTN and DD and prescribed a combination therapy including an angiotensin-converting enzyme (ACE) inhibitor (perindopril 10 mg/day) and a thiazide-like diuretic (indapamide SR, 1,5 mg/day). Patients were randomized into 2 groups: 1st group recieved antihypertensive treatment with an antidepressant (selective serotonin reuptake inhibitors, escitalopram 10 mg/day); 2nd group received calcium channel blocker (CCBs, amlodipine 5–10 mg/day). At baseline and after 24 weeks all patients underwent clinical examination, ambulatory blood pressure monitoring (ABPM) (“Petr Telegin”, BPLab Vasotens, Russia) with 25‑minute intervals between the measurements during the day and 50‑minute intervals at night. We assessed the average 24‑hour, daytime and nighttime systolic blood pressure (SBP), diastolic blood pressure (DBP), variability of blood pressure (BP), hypertension time index, the size and speed of morning rise in BP, daily index, pulse pressure. In addition, we evaluated arterial stiffness: the propagation time of the reflected wave (RWTT, ms), the estimated PWV in the aorta (PWVao, m/s) adjusted to systolic BP 100 mm Hg and heart rate 60 beats/min (RWTT ms, PWVao m/s), augmentation index. We also assessed central aortic pressure: systolic aortic pressure, aortic diastolic pressure, mean pressure in the aorta, aortic augmentation index. All the patients filled in the Hospital Anxiety and Depression Scale (HADS), Tsung depression scale, Spielberger’s scale of the anxiety, Wayne questionnaire and the SF‑36 questionnaire for the assessment of quality of life. Results. Combined antihypertensive therapy with escitalopram provided the target BP achievement in half of patients after 4 weeks, while in the control group an increase in the amlodipine dose to 10 mg per day was required to achieve target BP in 75.6 % of patients. After 24 weeks, group 1 showed better ABPM parameters compared to the control group. In addition, daily BP profile was normalized in a larger number of patients than in control group. Antidepressants led to a comparable to the calcium antagonist therapy regression of the indicators of arterial stiffness and the central aortic pressure. After 24 weeks, a positive change in DD was registered in the group treated with escitalopram, while in the group 2 depression indicators remained at a high level. The use of antidepressant resulted in a significant decrease in anxiety disorders and autonomic disturbances, whereas in patients treated with “traditional” antihypertensive therapy, an increase of anxiety level and baseline autonomic dysfunction remained unchanged. Also, the group of antidepressant showed greater improvement of the quality of life assessed by the SF‑36 questionnaire. Conclusions. The use of escitalopram in combination therapy provided a rapid achievement of target BP and more significant improvement in the main ABPM indicators, normalization of daily BP profile, a significant improvement in the emotional status and autonomic function, reduction of the depression and anxiety symptoms, improvement in quality of life compared to the treatment without antidepressant.

Supplement: Cardiology and Therapy

Ambulatory blood pressure monitoring (ABPM) is a tool of great value for the diagnosis and monitoring of hypertensive patients. Its principal advantages are, on the one hand, obtaining a greater number of measures in an environment closer to the individual’s daily life, that better reflect the individual’s real blood pressure, and, on the other hand, a better correlation with organ damage and cardiovascular prognosis [1]. ABPM is envisaged as a complementary tool in all clinical guidelines for treating hypertension and, in some cases, is obligatory for confirmation of the diagnosis [2, 3]. The role of ABPM is not limited to the diagnosis of patients, but also constitutes a useful element in the assessment of treatment and in clinical monitoring [4]. The principal mean estimators during the 24 h over which the monitoring is usually performed, such as the two periods of activity (usually during the daytime) and of rest (usually at night), are prognostically important and enable the impact of the treatment to be targeted more precisely. Furthermore, differences with clinical measurement that result in the phenotypes of white-coat hypertension and masked hypertension enable treatment response to be better defined and allow the identification of patients who will require a different therapeutic approach [5, 6]. In addition to these mean estimators, the so-called “estimators of variability”, which reflect the fluctuations in blood pressure over a 24-h period, are gaining ever greater attention. Among these, the nocturnal drop in blood pressure and the standard deviations during the diurnal and nocturnal periods can be highlighted. There are also indicators that provide information on the effects of medication on monitoring, such as the trough-to-peak ratio, the smoothness index or the treatment-on-variability index [7]. All these variables proposed as diagnostic assessment indexes, and more specifically in assessing treatment, have been evaluated in various controlled studies in which the basis of antihypertensive treatment has been the angiotensin-receptor antagonist olmesartan. It has been observed in these studies that olmesartan and combinations of this drug with the calcium-channel blocker amlodipine, the diuretic hydrochlorothiazide or both, are able to reduce blood pressure over 24 h, diurnal and nocturnal, achieving high levels of ambulatory control [8]. Controlled clinical trials also show that treatment with olmesartan and its combinations has a duration of effect that covers the 24-h period, does not affect the circadian rhythm or nocturnal rest, regardless of whether it is administered in the morning or the evening, and effectively reduces morning blood pressure and the morning rise in blood pressure, parameters that are both related to cardiovascular and cerebrovascular prognosis [9, 10]. Other studies also show a reduction in the day-to-day variability of blood pressure, which is associated with effects such as arterial rigidity [11]. This accumulation of evidence about the pharmacological effects on ambulatory blood pressure, both mean estimators and estimators of variability, is a major step forward in the understanding of the action of antihypertensive drugs or procedures. It is to be expected that, in the future, changes in these estimators as assessed in clinical research will have a fundamental role in the selection of the most appropriate treatment(s) for hypertensive patients.

Chronic obstructive pulmonary disease concurrent with hypertension: Evaluation of the therapeutic effect of prolonged-release indapamide

To provide a rationale for the clinical efficacy and safety of prolonged-release indapamide used in the combination therapy of patients with chronic obstructive pulmonary disease concurrent (COPD) concurrent with hypertension. Sixty-five patients (50 men and 15 women) with Stages I-IV COPD and grades 1-3 elevated blood pressure (BP) in whom prior antihypertensive therapy had proved insufficiently effective were examined. Prolonged-release indapamide demonstrated a high efficacy in achieving and maintaining goal BP, in normalizing its daily profile, and in reducing increased variability and the rate of morning rise in BP, without negatively affecting the clinical manifestations of COPD, pulmonary ventilatory function, and serum potassium levels. The drug was shown to have additional pleiotropic effects in lowering the activity of inflammatory markers (high-sensitivity C-reactive protein, intercellular adhesion molecules-1) and the level of endothelial dysfunction markers (endothelin-1, sP-selectin). Another commonly clinically used diuretic hydrochlorothiazide was chosen as a compared drug. The high antihypertensive efficacy and additional pleiotropic properties of prolonged-release indapamide that exerts no negative effect on the clinical manifestations of COPD, bronchial patency, and serum potassium levels demonstrate that it is expedient to incorporate prolonged-release indapamide into the combination therapy of patients with COPD concurrent with hypertension.

Candesartan in treating hypertension

Candesartan is a selective angiotensin II receptor blocker type 1. The distinctive features of its pharmacokinetics and pharmacodynamics are long duration of antihypertensive action, high selectivity and good bioavailability. In the treatment of hypertension, candesartan can effectively prevent morning rise in blood pressure. For preparation peculiar cerebro-and cardioprotective effects, the ability to reduce the risk of new cases of diabetes. The drug is effective in the treatment of nephropathy different genesis, including in patients with a marked reduction in renal function. Metabolic neutrality, the ability to prevent the development of micro-and macroangiopathy can recommend this angiotensin receptor blocker in the treatment of diabetic patients. Favorable profile of the pharmacokinetic properties of an advantage in efficacy of candesartan in comparison with other drugs of the same group.