Non-dipping Pattern Research Articles

Clinical Significance and Therapeutic Implication of Nocturnal Hypertension: Relationship between Nighttime Blood Pressure and Quality of Sleep.

Recent global hypertension guidelines recommend an early, strict and 24-hour blood pressure (BP) control for the prevention of target organ damage and cardiovascular events. Out-of-office BP measurement such as ambulatory BP monitoring and home BP monitoring is now widely utilized to rule out white-coat hypertension, to detect masked hypertension, to evaluate the effects of antihypertensive medication, to analyze diurnal BP variation, and to increase drug adherence. Nocturnal hypertension has been neglected in the management of hypertension despite of its clinical significance. Nighttime BP and non-dipping patterns of BP are stronger risk predictors for the future cardiovascular mortality and morbidity than clinic or daytime BP. In addition to ambulatory or home daytime BP and 24-hour mean BP, nocturnal BP should be a new therapeutic target for the optimal treatment of hypertension to improve prognosis in hypertensive patients. This review will provide an overview of epidemiology, characteristics, and pathophysiology of nocturnal hypertension and clinical significance, therapeutic implication and future perspectives of nocturnal hypertension will be discussed.

Normotensive non-dipping blood pressure profile does not predict the risk of chronic kidney disease progression.

The lack of a decrease in nocturnal blood pressure is a risk factor for the progression of chronic kidney disease (CKD); however, it currently remains unknown whether it is a risk factor in normotensive CKD patients. We conducted a retrospective cohort study and enrolled 676 CKD patients who underwent ambulatory blood pressure monitoring (ABPM). According to their nocturnal blood pressure dipping pattern (>10%: dipper or <10%: non-dipper) and average 24-h systolic blood pressure (>130/80 mmHg: hypertension or <130/80 mmHg: normotension), patients were divided into four groups. The estimated glomerular filtration rate (eGFR) decline over 2 years and relevant clinical parameters were analyzed among groups. Among all participants, 82.7% were non-dippers and half of them were normotensive. The eGFR decline was the most rapid in hypertensive non-dipper patients (4.73 ± 0.45 ml/min/1.73 m2/2 years), and was not significantly different between normotensive non-dipper (1.31 ± 0.49 ml/min/1.73 m2/2 years) and dipper patients (1.69 ± 0.80 ml/min/1.73 m2/2 years). A multivariate regression analysis revealed that the amount of urinary protein (95% confidence interval (CI): 1.51-2.63), 24-h systolic blood pressure (95% CI 1.13-1.45), and eGFR (95% CI 1.02-1.44) were associated with a rapid eGFR decline. We conclude that, according to the ABPM-based analysis, a non-dipping blood pressure pattern in normotensive CKD patients does not predict the risk of a rapid decline in eGFR. This suggests that the control of blood pressure, rather than its circadian rhythm, is essential for the preservation of eGFR.

The additive effects of OSA and nondipping status on early markers of subclinical atherosclerosis in normotensive patients: a cross-sectional study.

The additive effect of hypertension on carotid atherosclerosis in patients with obstructive sleep apnea (OSA) is well-established; however, the effect of the nondipping pattern has not yet been evaluated. In this study, we aim to assess the effect of the nondipping pattern on carotid atherosclerosis, which is quantified as carotid intima-media thickness (CIMT), and on the high-risk carotid profile in normotensive patients with OSA. We included 189 patients with OSA in this cross-sectional study. We followed a 2 × 2 factorial design to create groups according to the presence of OSA and nondipping pattern. All patients underwent carotid ultrasonography to quantify their CIMT and presence of plaques. Patients who had CIMT ≥ 0.9 mm and/or carotid plaques were classified as having a high-risk carotid profile. Patients in the OSA/nondipper group had a 26% higher CIMT and five times the prevalence of a high-risk carotid profile compared to patients in the non-OSA/dipper group. CIMT was correlated with age, the apnea-hypopnea index (AHI), minimum oxygen saturation, and nighttime systolic blood pressure (SBP). Independent of age, diabetes, and AHI, a one mmHg increase in nighttime SBP was associated with a 0.22 mm increase in CIMT and a 4% increase in odds for the high-risk carotid profile. Similarly, independent of age and diabetes, being in the OSA/nondipper group was associated with 6.7 times increased odds for a high-risk carotid profile than being in the non-OSA/dipper group. Modeling with both the nondipping status and presence of OSA produced an 8% higher discriminative value than modeling with neither of these parameters. We found an additive effect of the nondipping pattern on carotid atherosclerosis in normotensive patients with OSA. Our findings suggested that in addition to having established hypertension, a nondipping pattern in normotensive patients with OSA may aggravate atherosclerosis.

Diminished circadian blood pressure variability in elderly individuals with nuclear cataracts: cross-sectional analysis in the HEIJO-KYO cohort.

The present study aimed to determine the relationship between cataract subtypes and circadian blood pressure (BP) variability in elderly individuals. In this cross-sectional study of a community-based cohort, we assessed bilateral lens opacity using slit lamp photographs of 458 elderly individuals (mean age, 69.1 years). Cataract status was defined as a bilateral Lens Opacities Classification System III grade of ≥3 for nuclear cataract, ≥2 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Ambulatory BP monitoring was performed at 30-min intervals for 48 h. A nondipper pattern of BP was defined as a <10% decline in the mean nighttime systolic BP relative to the mean daytime systolic BP. The prevalence of nondipper patterns was 42.4% and 25.9% in the groups with nuclear cataracts (n = 66) and without cataracts for both eyes (n = 290), respectively. Multivariable logistic regression analysis adjusted for potential confounders revealed a significantly higher odds ratio (OR) for nondipper pattern in the group with nuclear cataract than in that without cataract (OR, 1.81; 95% confidence interval, 1.01-3.24; P = 0.047) but not in the group with cortical cataract (P = 0.61) or PSC (P = 0.95). In conclusion, circadian BP variability was significantly diminished in elderly individuals with nuclear cataracts but not in those with cortical cataracts or PSCs. These associations were independent of daytime light exposure, physical activity, and known risk factors of cataracts, such as aging, obesity, and diabetes.

Serum pentraxin-3 levels and flow-mediated dilation in dipper and non-dipper hypertension.

Endothelial dysfunction is one of the main pathological processes of hypertension. The association of serum pentraxin-3 (PTX3) levels and endothelial dysfunction becomes a more interesting scientific research issue due to high potential of PTX3 as a diagnostic and prognostic biomarker. We aimed to investigate the relationship between serum PTX3 levels and flow-mediated dilation results in patients with dipper and non-dipper hypertension. This study included 90 hypertensive patients were divided into two groups based on 24hours ambulatory blood pressure monitoring (ABPM): 38 patients with a dipper pattern and 52 patients with non-dipper pattern. Noninvasive evaluation of the endothelial functions was performed using flow-mediated dilation (FMD) method. Serum pentraxin-3 levels were higher in patients with non-dipper HT compared to dipper hypertension (P=0.028). In addition, we found negative correlation between serum PTX3 and FMD basal/FMD hyperemia ratio (r=-0.297, P=0.05 for FMD basal/FMD hyperemia ratio, respectively). Serum PTX3 levels are closely related with the measures of indirect noninvasive evaluation methods (FMD) in both DH and NDH patients.

Nondipping pattern on 24-h ambulatory blood pressure monitoring is associated with left ventricular hypertrophy in chronic kidney disease.

Few studies have assessed the role of 24-h ambulatory blood pressure monitoring (ABPM) in adults with nondialysis chronic kidney disease (CKD). We examined the potential determinants of left ventricular hypertrophy (LVH) and mass index (LVMI) in this population. We carried out a cross-sectional study on 69 stage 3b-5 CKD adults who had ABPM and transthoracic echocardiography performed simultaneously. Hypertension (HT) was defined as 24 h blood pressure (BP) of at least 130/80 mmHg. ABPM parameters considered were BP dipping status, BP load, and the BP night-time/daytime ratio. We performed stepwise backward multivariate linear and logistic regression to assess the determinants of LVH and LVMI. ABPM parameters were considered the main independent variables, whereas HT, angiotensin-converting enzyme inhibitor/angiotensin II receptor antagonist use, glomerular filtration rate of less than 30 ml/min/1.72 m, diabetes, smoking, age, sex, hemoglobin, and parathyroid hormone levels were considered covariates. LVH was present in 22 (31.8%) patients. In linear regression analysis, systolic [β=-13.8, 95% confidence interval (CI)=-26.3 to -1.3, P=0.031] and mean (β=-13.5, 95% CI=-25.7 to -1.2, P=0.031) nondipping status was associated with increased LVMI. BP load and night-time/daytime ABPM ratio were not associated with LVMI. In logistic regression analysis, systolic nondipping status (odds ratio=0.27, 95% CI=0.08-0.91, P=0.036) was associated with LVH. Among covariates, estimated glomerular filtration rate of less than 30 ml/min/1.72 m and HT were associated with LVH and increased LVMI. At 1-year follow-up, mean nondipping status on the initial ABPM remained associated significantly with increased LVMI (β=-19.8, 95% CI=-36.6 to -3.0, P=0.022). These data confirm the high incidence of LVH among nonrenal replacement therapy CKD patients and suggest that the nondipping phenomenon on ABPM is associated independently with LVH and increased LVMI in this population.

Nondipping Blood Pressure Patterns Predict Obstructive Sleep Apnea in Patients Undergoing Ambulatory Blood Pressure Monitoring.

A nondipping blood pressure (BP) pattern is common in patients with obstructive sleep apnea (OSA). However, it is unclear how useful a nondipping BP pattern is in screening for OSA. In this cross-sectional study, we recruited consecutive patients with clinical indications for performing ambulatory BP monitoring evaluating the following dipping patterns: (1) normal: ≥10% but <20%; (2) extreme: ≥20%; (3) reduced: ≥0% but <10%; and (4) reverse (riser): <0%. Sleep questionnaires and sleep studies were performed within 7 days after ambulatory BP monitoring. OSA was defined as an apnea-hypopnea index ≥15 events/h. We evaluated 153 patients (OSA frequency, 50.3%). Patients with OSA had higher BPs during sleep, were taking more antihypertensive drugs, and more frequently used hypertensive drugs during the night than patients without OSA. Considering systolic BP, the frequency of OSA in patients with reverse dippers (73.5%) was higher than normal (37.3%), extreme (46.2%), and reduced dippers (49.1%; P=0.012). For diastolic BP, OSA was more common in reduced (66.7%) and reverse dippers (69.6%) as compared to normal (41.4%) or extreme dippers (33.3%; P=0.007). In the regression analysis, reverse systolic dipper was independently associated with OSA (odds ratio, 3.92; 95% CI, 1.31-11.78). Both reduced and reverse diastolic dippers increased the likelihood of OSA for 2.7-fold and 3.5-fold, respectively. Snoring and positive sleep questionnaire findings were associated with a modest increase in the accuracy of reverse dipping pattern for predicting OSA. In conclusion, reverse systolic, as well as reduced and reverse diastolic dippers are independently associated with OSA.

A4113 The non-dipper pattern is an independent predictor of cardiovascular events in patients with sleep-disordered breathing

A4113 The non-dipper pattern is an independent predictor of cardiovascular events in patients with sleep-disordered breathing

Abstract P380: Inverse Circadian Pattern in the Renal Generation of Tumor Necrosis Factor-Alpha (TNFå) and Angiotensinogen (AGT) in Salt-Sensitive Hypertension (SSH) Induced by Angiotensin II (AngII) in Mice

Individuals with SSH show a non-dipping blood pressure (BP) during the inactive night period, a phenomenon which is significantly associated with enhanced cardiovascular morbidity and mortality. However, the pathophysiological mechanism for this phenomenon is not yet clearly understood. Chronic AngII administration in mice (reversed circadian rhythm) induced SSH with an increase in intra-renal AGT formation, a response that was exaggerated in TNFα receptor type 1 (TNFR1) knockout mice, indicating that renal AGT formation is suppressed by TNFR1 activation by TNFα. The present study examined the hypothesis that AngII-induced TNFα formation follows a circadian pattern with increases during the active period compared to the inactive period, that facilitates less AGT formation during the active period. Experiments were performed in mice chronically treated with or without AngII (25 ng/min; osmotic mini-pump) + high salt (4% NaCl) intake for 4 weeks that increased BP from 90±2 to 108±3 mmHg (tail-cuff method). Circadian rhythm in urinary parameters was assessed by 12 hour collections of urine using metabolic cages during the active night period (7PM to 7AM) and the inactive day period (7 AM to 7 PM). In normal mice (n=6), urinary excretion of TNFα (uTNFα) was higher (0.5±0.2 vs 0.13±0.08 pg/hour) but urinary excretion of AGT (uAGT) was lower (0.28±0.18 vs 0.46±0.14 ng/hour) during the active period compared to that during the inactive period. This inverse relationship between uTNFα and uAGT was exaggerated in AngII+HS treated mice (n=6). From the baseline (0 week) to the 2nd and 4 th week period, there were marked incremental changes in uTNFα during active periods (0.68±0.20 to 14.2±5.4 and 44.6±14.6 pg/hour) which were less during inactive periods (0.73±0.48 to 10.3±3.3 and 12.1±4.7 pg/hour). Interestingly, uAGT changed minimally during active periods (0.21±0.14 to 0.05±0.04 and 1.42±0.97 ng/hour) but increased significantly during inactive periods (0.32±0.14 to 1.57±0.71 and 3.98±1.67 ng/hour). These data suggest that an increase in TNFα generation suppresses intra-renal AGT formation during active periods but this phenomenon is inversed during inactive periods. The increase in AGT during the inactive period could lead to a non-dipping BP pattern in SSH.

Ambulatory blood pressure monitoring and diabetes complications: Targeting morning blood pressure surge and nocturnal dipping.

Ambulatory blood pressure monitoring (ABPM) correlates more closely to organ damages than clinic blood pressure (BP). In the current study we aimed to investigate the association between micro- and macrovascular complications of diabetes and both diurnal and nocturnal variability in BP.A total of 192 patients with type 2 diabetes (T2DM) who had complete data on ABPM were selected. BP categories were defined based on 2017 ACC/American Heart Association BP guideline. The cross-sectional association between different BP phenotypes and diabetes complications including cardiovascular disease (CVD), nephropathy, retinopathy, and neuropathy was assessed using multiple logistic regression models adjusted for age, sex, body mass index, hypertension (HTN), hemoglobin A1c, fasting blood glucose (FBG), triglyceride (TG), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and total cholesterol.Approximately 48.9% of participants with T2DM had 24-hour HTN. The prevalence of daytime, nighttime, and clinic HTN were 35.9%, 96.3%, and 53.1%, respectively. Approximately 54.2% of participants had nondipping nocturnal pattern and 28.6% were risers. Nondipping nocturnal BP was associated with CVD, neuropathy, and retinopathy (P = .05, .05, and .014, respectively). Sleep trough morning blood pressure surge (MBPS) was associated with neuropathy (P = .023). Neuropathy was also associated with other components of MBPS (P < .05).We demonstrated that diabetic neuropathy was associated with all the components of MBPS and abnormal dipping status. Our results indicated loss of nocturnal BP dipping but not MBPS as a risk factor for CVD and retinopathy in patients with T2DM. Our findings once again highlighted the importance of ambulatory BP monitoring and targeted antihypertensive therapy directed toward to restore normal circadian BP in patients with T2DM.

Arterial stiffness but not endothelial dysfunction is associated with multidrug antihypertensive therapy and nondipper blood pressure pattern in kidney transplant recipients.

Vascular injury related to chronic kidney disease results in increased arterial stiffness and endothelial dysfunction which may affect arterial blood pressure (BP) and influence patient and graft survival in kidney transplant recipients (KTRs).This cross-sectional study aims to elucidate the relationship between the above-mentioned measures of vascular damage and effectiveness of antihypertensive treatment in KTR.One hundred forty-five KTRs 7.6 ± 2.7 years after transplantation were enrolled in our study. Pulse wave velocity (PWV), flow-mediated dilation (FMD), and nitroglycerin-mediated dilation (NMD) were measured, and 24-hour ambulatory BP monitoring was performed.Overall, there were 62 patients with well-controlled or borderline BP and 83 subjects who did not achieve target BP despite antihypertensive treatment. Patients with suboptimal BP control were characterized by greater PWV (median 9.6/interquartile range: 3.9 vs 8.0/3.3 m/s, P = .002), but borderline lower FMD (8.4% ± 5.0% vs 9.9% ± 5.7%; P = .09) as compared with the group with better BP control. When patients were allocated to subgroups based on the number of current antihypertensive medications, no differences in FMD and NMD were found. However, a significant trend was observed for higher PWV values and decreased proportion of dippers along with the increasing number of drugs. PWV, diabetes, and total cholesterol level, but not FMD or NMD, were explanatory variables for systolic BP in multivariate analysis.Arterial stiffness but not endothelial dysfunction is associated with suboptimal BP control in stable KTRs. Less efficient antihypertensive treatment appears to be caused by inadequate control of nocturnal BP.

Usefulness of blood pressure monitoring in patients with gestational diabetes mellitus

Background and objectiveGestational diabetes mellitus (GDM) is associated to an increased risk of pregnancy-induced hypertension (PIH). Ambulatory blood pressure monitoring (ABPM) has been used to detect PIH and preeclampsia, but few data are currently available on its use in women with GDM. The aim of this study was to achieve early identification in women with GDM of BP profiles (detected by ABPM) that could define a population at greater risk of developing PIH and preeclampsia. Material and methodsA prospective study of 93 normotensive women with GDM in whom 24-h ABPM was performed (using a Spacelabs 90207 monitor) at 28–32 weeks of pregnancy. Clinical and laboratory variable and obstetric and perinatal outcomes were analyzed. ResultsMean age was 34.8±4.39years, and 5.4% of patients developed PIH. Higher levels of HbA1c (p=0.005) and microalbumin (p=0.001) were seen in patients with PIH. Patients with non-dipper patterns (50.5%) had higher values of night-time systolic BP (106.7 vs. 98.4mmHg) and night-time diastolic BP (64.8 vs. 57.2mmHg) (p<0.001). Lower birth weights (3084.57 vs. 3323.7) (p=0.021) and shorter gestational age at delivery (38.67 vs. 39.27 weeks) (p=0.04) were found in women with non-dipper pattern. High night-time systolic BP significantly increased the chance of developing PIH (OR: 1.18; 95%CI: 1.00–1.39; p=0.043). ConclusionsPatients with GDM have BP changes, with predominance of the non-dipper pattern and higher night-time systolic and diastolic BP, changes that could be useful predictors of PIH. High night-time systolic BP values increase the risk of developing PIH. Further studies are needed to ascertain the relationships between BP changes and obstetric and perinatal complications.

P5726Diabetes mellitus is associated with high sleep-time blood pressure and non-dipping pattern

P5726Diabetes mellitus is associated with high sleep-time blood pressure and non-dipping pattern

Morning blood pressure surge in young black and white adults: The African-PREDICT Study

An exaggerated morning blood pressure surge (MBPS) has independent predictive value for cardiovascular mortality and is suggested to be prevalent in elderly hypertensive patients: men and white populations. To better understand the MBPS profile in a young and normotensive population, we evaluated the MBPS in young adults and explored associations with demographic, cardiovascular and health behaviour measurements. We included 845 black (n = 439) and white (n = 406) men and women aged between 20 and 30 years. We calculated the sleep-trough and dynamic morning surge, and compared demographic data, health behaviours and ambulatory blood pressure according to MBPS quartiles. In the total group, higher waist circumference, socioeconomic score, lean mass, ambulatory blood pressure (24-h, daytime blood pressure) and increased night-time dipping (all p < 0.05) were found in the highest sleep-trough and dynamic morning surge quartiles. In the total white group, particularly men, both sleep-trough and dynamic morning surge were higher than the black group (all p < 0.013). More black participants were non-dippers than whites (44% vs 34%; p = 0.004). In multivariable adjusted regression in the total group, we found no consistent associations of MBPS with demographic and health behaviour measurements. MBPS related independently and positively with night-time percentage dipping in all ethnic groups (all p < 0.01). Ethnic differences in MBPS is evident in young adults, with a higher, but normal MBPS in white men. A non-dipping night-time pattern in young black adults (with reduced MBPS) and a higher MBPS (observed in dippers) may serve as potential risk factors for cardiovascular disease.

Serum hs-CRP, YKL-40 and brain-derived neurotrophic factor (BDNF) associated biomarkers in non-dipper hypertension profile?

Abstract Background: Twenty-four hours dynamic blood pressure (BP) behaviour displays dipper profile defined as nocturnal systolic BP (SBP) reduction&gt;10% compared to daytime. Non-dipper profile, nocturnal absence of SBP fall, associates an increased cardiovascular risk. We investigated the concomitant association of inflammatory bio-markers - high-sensitivity- C-reactive protein (hs-CRP), Human Chitinase3-like1 (YKL-40) and autonomic nervous system (total brain-derived neurotrophic factor, BDNF) with respect to non-dipping blood pressure status. Material and method: Using 24h automatic BP measurements, 80 known hypertensive patients were divided into two groups: dipper group included fifty-one dipper patients (age 55.6 ±13.5 years) and non-dipper group consisted of 29 non-dipper subjects (62.07±12.03 years). Serum levels of hs-CRP were evaluated with enhanced immunoturbidimetric assay. Plasma levels of YKL-40 were measured by commercial sandwich ELISA using microplate coated with a monoclonal antibody for CHI3L1. Plasma levels of total BDNF were determined using quantitative sandwich enzyme-linked immunoassay. Statistical analysis of obtained data was performed. Results: In the non-dipper group, a significant positive association with age over 60 years, hs-CRP values above 1.90 mg/dl was observed along with increased mean values of YKL-40. Non-dipper status is independently and statistically significantly associated with elevated levels of hs-CRP (OR: 3.248, 95% CI: 1.022-10.317, p=0.046) in multivariate odds ratio analysis. No statistically significant positive association between a median total BDNF plasma level of 1430 pg/ml and the non-dipper hypertension profile was identified. Conclusion: Our study demonstrated that patients over 60 years, in particular, have a higher probability to present a non-dipping pattern of hypertension. hs-CRP and YKL-40 values are more likely to increase in the non-dipping hypertensive patients, and hs-CRP values above 1.9 mg/dl can identify the presence of a non-dipper blood pressure profile.

Association between nondipping pattern and EndoPAT signal in patients with mild obstructive sleep apnea

ObjectiveTo compare vascular endothelial function between dipping (D) and nondipping (ND) patterns in patients with and without mild obstructive sleep apnea (OSA) using EndoPAT, a test of reactive hyperemia used to assess peripheral vascular endothelial function. MethodsThe sample consisted of individuals of both genders between 18 and 65 years of age with a body mass index (BMI) of ≤35 kg/m2 and apnea/hypopnea index (AHI) of ≤15. The nondipping pattern was considered present when the dip of nocturnal blood pressure (NBP) was <10%. All of the sample underwent clinical and physical evaluation, full polysomnography, 24-hour ambulatory blood pressure monitoring, and EndoPAT evaluation. A generalized linear model was used for statistical analysis. ResultsThe sample comprised 120 individuals, 35 in the control group and 85 in the mild OSA group. Four groups were formed: Control-ND, Control-D, Mild OSA-ND, and Mild OSA-D according to nocturnal ABPM patterns. The frequency of nondipping was (34.1%) in the Mild OSA group and (17.1%) in the Control group (p = 0.07). The Mild OSA-ND group had a higher augmentation index (AIx) than the Mild OSA-D group. Regression analysis showed that male gender, higher age, and nondipping status were associated with these results, whereas oxygen desaturation index (ODI) and AHI did not. With respect to the reactive hyperemia index (RHI), the Mild OSA-D group had lower values compared to the Control-ND group, but an association with OSA was not confirmed in the regression model. ConclusionNondipping status was associated with a worse augmentation index in both groups independently of AHI or oxygen desaturation index. Male gender, higher age, and nondipping status were associated with augmentation index.ClinicalTrials.gov Identifier: NCT01461486.

Evaluation of atrial electromechanical functions in dipper and nondipper hypertension patients using left atrial strain P-wave dispersion and P terminal force.

Nondippers are known to carry a high risk of cardiovascular morbidity and mortality. The aim of this study was to investigate the effects of dipper and nondipper status of hypertension on left atrial (LA) systolic and diastolic functions using two-dimensional speckle tracking echocardiography (2D-STE), P-wave dispersion (PWD), and P terminal force (PTF) in hypertensive patients. A total of 72 patients and 39 healthy individuals were included in the study. The patients were classified as nondippers if their daytime ambulatory systolic and diastolic blood pressure did not decrease by at least 10% during the night. Atrial electromechanical delay times, LA strain values were obtained by 2D-STE with automated software and compared between the groups. PWD and PTF data were calculated on the electrocardiography. Inter-atrial (dippers: 25.5±3.9, nondippers: 32.2±7.4, P<.001), left-atrial (dippers: 14.9±3.7, nondippers: 18.2±6.0, P=.016), and right atrial (dippers: 10.5±2.1, nondippers: 14.2±5.2, P<.001) electromechanical delay times were significantly longer in nondippers. LA strain S (dippers: 34.2 [29.7-38.7], nondippers: 27.7 [22.7-32.2], P<.001), LA strain E (dippers: 18.2 [16.6-20.1], nondippers: 14.4 [11.6-16.8], P<.001), and LA strain A (dippers: 15.8 [13.5-17.9], nondippers: 12.7 [9.9-14.5], P<.001) were significantly lower in nondippers. Nondippers also had an increased values of maximum P-wave duration (dippers: 0.117 [0.10-0.12], nondippers: 0.126 [0.12-0.14], P<.001), PWD (dippers: 0.062 [0.06-0.07], nondippers: 0.069 [0.06-0.08], P=.004), and PTF (dippers: 0.055±0.02, nondippers: 0.066±0.02, P=.02). Nondipping pattern in hypertensive patients had a worse cardiac remodeling, and impaired mechanical LA function compared with dipping pattern. The PWD and PTF findings support these changes.

ERYTHROPOIETIN THERAPY IS NOT RELATED TO NON-DIPPING PATTERN AND INCREASED CARDIOVASCULAR MORTALITY IN PATIENTS UNDERGOING CHRONIC HEMODIALYSIS

Objective: ABPM is superior to dialysis center measurements in predicting cardiovasular (CV) events in patients undergoing chronic hemodialysis (HD). It was found that non-dipping pattern is assocated with poor prognosis. There is currently no evidence linking erythropoiesis-stimating agents (ESAs)-induced hypertension with increased CV morbidity and mortality. It was proposed that long-acting ESA may have a lower hypertensive effect than short-acting ESAs. Our aim was to analyze association of non-dipping pattern, ESA therapy and CV mortality in patients undergoing chronic HD. Design and method: 164 patients (103 M, 61 F; averaged age 65.2), who had been on intermittent HD treatment for more than 6 months, were enrolled in (88.5% hypertensives, 28.6% diabetics, 19.5% smokers) and followed up for average 25.7 months. Patients received HD treatment 4 hr/session 3 times a week during the study period. Average number of antihypertensive drugs was 2.63 (the most prescribed were CaB followed by beta-blockers, ACEi/ARBs, diuretics, central-acting drugs, urapidil and direct vasodilatators: 60.7%, 54.4%, 38.9%, 34.8%, 30.3%, 26.9% and 6.9%, respectively). There were 43.9% of patients on short- and 56.1% of patients on long-acting ESAs. At basal 24 h ABPM (Spacelab) was performed following the ESH/ESC guidelines on non-dialysis midweek day. Data of subjects with more than 70% successful ABPM readings were analyzed. Nondipping was defined as nighttime BP aver Results: Non-dipping pattern was found in 77.4% patients. No differences were found in age, dialysis parameters, comorbidity, chronic HD therapy and laboratory parameters between dippers and non-dippers. However, CV mortality was significantly higher in non-dippers (28.9% vs.16.0%, p = 0.02). Deceased patients were significantly older, had higher serum calcium and iPTH levels and day-time mean arterial pressure levels. There were no differences in number of antihypertensive drugs, proportion of patients with hypertension, diabetes or smokers.No difference was found between patients treated with short- and long-acting ESAs. Conclusions: Observed increased CV mortality in patients undergoing chronic HD is related to non-dipping pattern and is not associated with the type of used ESAs. Mechanisms of increased non-dipping pattern and associated poor prognosis should be evaluated in larger prospective cohorts.

ASSOCIATION OF NOCTURNAL BLOOD PRESSURE PATTERNS WITH CARDIOVASCULAR RISK IN NEWLY DIAGNOSED, NEVER-TREATED ESSENTIAL HYPERTENSIVE PATIENTS

Objective: Both non-dipping pattern and elevated nighttime systolic blood pressure (SBP) are predictors of adverse cardiovascular outcomes. Despite the fact that these are often related features, research to date has focused on the association of either with cardiovascular risk, as separate features. We assessed whether the combination of a dipping pattern with abnormal nighttime SBP confers increased cardiovascular risk for patients with essential hypertension Design and method: Newly diagnosed, never-treated hypertensive patients free from any known health problems were eligible to participate. Only true hypertensives, based on their office blood pressure measurements and the 24-hour ambulatory blood pressure monitoring, were included. 10-year risk of general cardiovascular disease was determined from the Framingham Heart Study. Results: In a total of 182 patients aged 46.7 ± 8.8 years, nighttime SBP positively correlated with cardiovascular risk (r = 0.190, p = 0.010). Initially, patients were classified according to their dipping status as dippers (n = 117) and non-dippers (n = 65). The groups did not differ in terms of age, gender, body mass index (BMI), office blood pressure, smoking, and lipids (p > 0.05 for all comparisons). Cardiovascular risk [9.8 (6.3–15.9) vs 10.3 (6.5–15.2) %, p = 0.981] was similar between dippers and non-dippers. Participants were then classified in three groups, based on the combination of dipping status with nighttime SBP: dippers with normal nighttime SBP (n = 45), dippers with elevated nighttime SBP (n = 72), and non-dippers (n = 65). Age, gender, BMI, smoking status, and lipids were similar between groups (p > 0.05 for all comparisons). However, dippers with normal nighttime SBP exhibited the lowest levels of office SBP (144.1 ± 13.5 vs 153.0 ± 15.2 vs 151.9 ± 14.9 mmHg, p = 0.004) and, importantly, the lowest cardiovascular risk score [8.4 (5.8–12.9) vs 11.6 (7.7–18.6) vs 10.3 (6.5–15.2) %, p = 0.050], compared to dippers with abnormal nighttime SBP and non-dippers. Conclusions: In a population of relatively young, untreated patients with uncomplicated, early-stage essential hypertension, the combination of a dipping profile with elevated nighttime SBP confers the same cardiovascular risk as the non-dipping pattern. Subsequently, further classification of dippers according to their nighttime SBP levels may improve cardiovascular risk stratification.

PULSE WAVE VELOCITY NON-DIPPING PATTERN IS ASSOCIATED WITH CARDIOVASCULAR MORTALITY IN HYPERTENSIVE PATIENTS UNDERGOING CHRONIC HEMODIALYISIS

Objective: Increased arterial stiffness is established as an independent cardiovascular (CV) risk factor. Although this association was found also in patients undergoing hemodialysis (HD), reports are frequently contradictory largely because measurements were obtained shortly before or after HD. The aim of our study was to analyze circadian variations of aortic stiffness using ABPM device which provides valid measures in ambulatory conditions and association with CV mortality. Design and method: A total of 31 hypertensive patients (19 M, 12 F; averaged age 59.4) who had been on intermittent HD treatment for more than 6 months were enrolled in this study (22.6% diabetic, 16.1% smokers) and followed up for average 18.6 months. Patients received HD treatment 4 hr/session three times a week during the study period. TensioMed Arteriograph which records oscillometric BP and pulse waveforms at the brachial artery and provides valid measures of aortic BP, AIx, and PWV in ambulatory conditions was applied on non-dialysis midweek day. Control group consist of 25 healthy subjects without prior diabetes, CKD, hypertension and hyperlipidemia. Results: Systolic BP, PWV and AIx non-dipping patterns were found in 74.2%, 64.5% and 61.3% of patients. We failed to find difference in AIx dipping pattern between patients and control subjects (38.7% vs. 28.0%; p = 0.4) while PWV non-dipping pattern was significantly more frequently found in HD patients (64.5% vs. 16.0%, p < 0.001). At the end of follow-up period 13 (41.9%) patient died from CV deaths. We have not found any differences in age, dialysis parameters, comorbidity, HD therapy and laboratory parameters between survived and deceased HD patients. Differences in basal systolic and diastolic BP, PWV, AIx between survived and deceased were not statistically significant. There were no differences in number of BP and AIx non-dippers between survived and deceased patients while significantly higher number of deceased patients had PWV nocturnal non-dipping pattern (84.5% vs.50.0%, p = 0.04). Conclusions: A newly introduced ABPM devices for ambulatory recordings provide new insights on importance of arterial stiffnes for CV moratlity in patients undergoing HD. Our results showed that PWV non-dipping pattern is independently associated with CV moratily.