Reverse Dipping Research Articles

POS-260 ASSOCIATION OF BLOOD PRESSURE VARIABILITY AND NON-DIPPING WITH THE PROGRESSION OF CHRONIC KIDNEY DISEASE AND CARDIOVASCULAR OUTCOMES- A SINGLE-CENTRE PROSPECTIVE OBSERVATIONAL STUDY

Hypertension is seen in almost seventy percent of patients with chronic kidney disease (CKD). The association of blood pressure variability and non-dipping with the progression of chronic kidney disease (CKD) and cardiovascular events is unclear. We aimed to study if blood pressure variability and non-dipping were associated with the progression of chronic kidney disease and cardiovascular events. This was a single-centre, prospective observational study, conducted at a tertiary care centre in South India over eighteen months. Patients with CKD with estimated glomerular filtration rate (eGFR) between 59 and 15 ml/minute per1.73 m2, and aged between 18 and 70years were included in the study. Standardized clinic blood pressure (BP) and 24-hour ambulatory BP were recorded in all enrolled patients. All study participants had follow-up visits every three months for one year. Office BP and serum creatinine were recorded during the visit and the history of occurrence of cardiovascular events were noted. The association of ambulatory blood pressure monitoring (ABPM) parameters with cardiovascular and renal outcomes was analyzed. The cardiovascular outcome was defined as a composite of nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death. The renal outcome was defined as a composite of end-stage renal disease (eGFR<15ml/minute/1.73m2) or the initiation of renal replacement therapy. The correlation of BP variability and non-dipping with decline in glomerular filtration rate was also analyzed. Of the seventy-six study participants, 49(64.5%) were male and the mean age was 54±12 years. When the index of dipping was analyzed we found that 15(19.7%) were dippers, 40 (52.6%) were non-dippers and 21(27.6%) were reverse dippers. The percentage decline in eGFR over one year was significantly more in non-dippers (35.49 ± 19.29 ml/minute/1.73m2) compared to dippers (23.24 ± 12.19ml/minute/1.73m2) (p = 0.022). The baseline characteristics of dippers and non-dippers given in Table 1. At one year, out of the seventy-six study participants, 29(38.2%) had the defined cardiovascular outcome. Cardiovascular outcome was significantly associated with number of anti-hypertensives used (p=0.035), dipping status(p=0.029), 24-hour systolic BP(p=0.038), night systolic BP(p=0.014), index of BP dipping(p=0.014), and BP variability(p=0.036). On multivariate analysis, non-dipping was independently associated with cardiovascular events. The composite renal outcome was seen in 22(28.9%) patients. The renal outcome was found to be significantly associated with diabetes(p=0.053), 24-hour systolic BP(p=0.000), day systolic BP(p=0.001), night systolic BP(p=0.000), index of BP dipping(p=0.000), and BP variability(p=0.071). On multivariate analysis, non-dipping (p=0.030) was independently associated with significant decline in eGFR. The index of nocturnal dipping (r=-0.522, p<0.001) and blood pressure variability (r=0.324, p=0.004) showed a significant correlation with the decline in glomerular filtration rate over one year. In chronic kidney disease ABPM parameters like non-dipping and short-term blood pressure variability were associated with poor renal and cardiovascular outcomes. Although ABPM is time-consuming our study demonstrated that information from ABPM can potentially impact future CV and renal outcomes in patients with CKD.

AMBULATORY BLOOD PRESSURE MONITORING: ADVANTAGES AND OPPORTUNITIES

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

NON-DIPPING ASSOCIATED PARAMETERS IN SINUS RHYTHM INDIVIDUALS

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

THE RELATIONSHIP BETWEEN CIRCADIAN RHYTHM OF BLOOD PRESSURE AND LEFT ATRIAL PHASIC FUNCTION IN HYPERTENSION

Objective: Objective: We used two dimensional speckle tracking echocardiography (2DSTE)-based strain and strain rate imaging to evaluate left atrial (LA) mechanics and investigated its correlation with circadian rhythm of blood pressure in essential hypertension (HT). Design and method: Design and Methods: We enrolled 249 HT patients. All subjects were evaluated by ambulatory 24-hour blood pressure monitoring and 2D-STE. According to blood pressure (BP) patterns, these patients were divided into three groups. Group I (dipper, n = 91), patients with a 10%-20% reduction in BP at nighttime; Group II (non-dipper, n = 129), patients with a &lt; 10% reduction in BP at nighttime; Group III (reverse dipper, n = 29), patients with higher BP at nighttime compared with daytime. The strain and strain rate images were studied, and the following parameters were measured: LA reservoir strain and strain rate (LAS-S, LASR-S), LA conduit strain and strain rate (LAS-E and LASR-E), LA booster strain and strain rate (LAS-A and LASR-A). LA stiffness index (LASI) was defined as the ratio of E/e‘ to LAS-S. In the present study, we also explored the correlation between LASI and cardiovascular risk factors as well as ambulatory blood pressure indexes. The factors related to LASI were evaluated by multivariate regression analysis to find the independent factors. Results: Results: LASI was significantly higher in Group III than Group I (p &lt; 0.05). LAS-E and LASR-E were significantly lower in Group III than Group I and II (p &lt; 0.05 for both). However, there were no significant differences between the Group I and II (p &gt; 0.05). Otherwise, LAS-S, LASR-S, LAS-A and LASR-A were not significantly different among these three groups. We also found LASI was correlated with ages, diabetes, courses of HT, 24-hour mean systolic blood pressure (24h-mSBP), 24-hour mean diastolic blood pressure (24h-mDBP), daytime mean SBP (d-SBP), nighttime mean SBP (n-SBP) and nighttime mean DBP (n-DBP). Multivariate regression analysis revealed that age, n-SBP and n-DBP were independent factors related to LASI. Conclusions: Conclusions: Left atrial function is associated with circadian rhythm of blood pressure. Nocturnal blood pressure may have more influence on left atrial stiffness and conduit function.

POS-280 CORRELATION OF AMBULATORY BLOOD PRESSURE MEASUREMENT (ABPM) WITH OFFICE BLOOD PRESSURE MEASUREMENT IN PATIENTS OF CHRONIC KIDNEY DISEASE (CKD)

CKD is major risk factor for end-stage kidney disease, cardiovascular disease and premature death. Hypertension affects an estimated 20% of the adult population. ABPM recognized gold standard for the assessment of hypertension and is superior to office BP for prediction of clinical outcomes. It is useful and provides a better guide for monitoring adequacy of antihypertensive therapy in patient with CKD. ABPM patterns have prognostic importance in hypertensive population. White coat hypertension and masked hypertension are also picked up better by ABPM. ABPM provides superior BP measurements compared to office measurement in CKD patients. We planned this study as there is paucity of data from our country on ABPM in patients with CKD. We carried out this study to compare prevalence of hypertension by ABPM and by office measurement and to assess the prevalence of white coat hypertension and masked hypertension in CKD patients. Prospective, observational study, 102 patients were included. Hypertensive adults >18 of age and CKD patients were included. Patients were excluded if they denied consent, were diabetic CKD or if they were on dialysis and if ABPM measurements were valid in less than 65% of measurements. Detailed history and physical examination along with standard lab tests including hemogram, urine routine, electrolytes, renal function test was performed in all patients .eGFR was calculated according to CKD-EPI equation. Patients were categorized according to various stages of CKD. One hundred and two (57M, 45F) patients with CKD and hypertension were included. There were 4, 22, 76 patients of CKD in stage 3, 4, 5 respectively. Hypertension was present in 61 out of 102 (59.8%) patients enrolled in the study. The ratio of hypertensive and normotensive was 1.5. The prevalence of hypertension was 57.9%, 63.7%, 75% in patients of CKD stage 3,4,5 respectively. Cut of value of hypertension according to ABPM day time was taken as prehypertension if record was ≥ 130/80; stage 1 HTN ≥ 135/80 and stage 2 HTN >145/ 90. Taking ABPM as the gold standard the sensitivity of office BP in picking up hypertension was 52.3% and specificity was 53.9%. Positive predictive value was 61.6% and negative predictive value was 52.9%. ABPM picked 6 additional patients of hypertension as compared to office BP. White coat hypertension (WCHT) was present in 16 out of 57 males 19 females out of 45 enrolled in study. Masked hypertension (MHT) was present in 8 out of 57 males and 9 females out of 45 enrolled in study. Out of 102 patients there were 12, 55 and 35 dippers, non-dippers and reverse dippers respectively. Prevalence of non-dippers increased as the CKD stage progressed with 76.4% in patients with ESRD In our study ABPM was an important tool to detect hypertensive CKD patients and picked up 6 more patients who needed intensification of treatment who would have been missed if only office BP was taken.Sensitivity of office BP in picking up hypertension was 52.3% and specificity was 53.9%Early detection and management will help ameliorate hypertension and its associated complications.ABPM is important to identify non-dipping patients who would benefit from treatment and thereby reduce cardiovascular complications.ABPM also helped in identifying WCH and masked hypertension.

DOES OFFICE BLOOD PRESSURE STILL RELIABLE IN TYPE 2 DIABETES MELLITUS TO ASSESS BLOOD PRESSURE CONTROL?

Objective: Ambulatory blood pressure (ABP) monitoring in type 2 diabetes (T2DM) is not yet routine in clinical practice. We aimed to quantify abnormal ABP patterns and their associations with diabetic complications and to assess the reliability of office blood pressure (OBP) for assessing BP control in T2DM. Design and method: In a cross-sectional study, eligible patients with T2DM underwent OBP and 24- hour ABP measurements under standardized conditions and screening for diabetic complications. Results: Eighty patients (mean age 58 + 10 years, males 30%) completed assessment. All patients had a known history of hypertension. Non-dipping and nocturnal systolic hypertension (SHT) were prevalent in 54 (67,5%) and 30(37,5%) patients, respectively. Non-dipping had a significant association with microvascular complications (p = 0,001). There was no association between other abnormal ABP patterns and diabetic complications. The sensitivity and specificity of OBP for assessing BP control were 52% and 63% respectively. The positive and negative predictive values were 31% and 81% respectively. Conclusions: Non-dipping, reverse dipping and nocturnal SHT are highly prevalent in patients with T2DM with a known history of hypertension. Compared with nocturnal SHT, non-dipping may be a stronger predictor of end-organ damage. The reliability of OBP for assessing BP in T2DM is only modest. Patients with T2DM are likely to benefit from routine ABP monitoring.

PREVALENCE AND PREDICTORS OF HYPOTENSION IN NURSING HOME RESIDENTS UNDERGOING AMBULATORY BLOOD PRESSURE MONITORING

Objective: In nursing home (NH) residents, hypotension may predispose to adverse events including falls, fractures and mortality. Yet, evidence on hypotension detected by ambulatory blood pressure monitoring (ABPM) is scarce in this setting. This study aimed to determine the prevalence and the clinical predictors of ambulatory hypotension in NH residents and to analyze its related ABPM profile. Design and method: We retrospectively analysed data from a sample of 100 NH residents undergoing a comprehensive geriatric assessment and ABPM. Ambulatory hypotension was defined as a systolic blood pressure (SBP) drop of 20 mmHg or greater between two consecutive measurements to a minimum SBP &lt; 100 mmHg. Participants with nocturnal hypotension were excluded from the analysis. Predictors of ambulatory hypotension were investigated using multivariate logistic regression adjusted for comorbidities, functional status and hypotensive medications. Results: Among 91 residents (mean age 83, 56% female), 50 showed ambulatory hypotension. They had a higher prevalence of heart failure (p = 0.02) and atrial fibrillation (p = 0.007) and more commonly received digoxin (p = 0.001) and benzodiazepines (p = 0.015). At ABPM they had lower 24 h, daytime and nighttime SBP (p &lt; 0.001) and more frequently showed a white coat effect (p &lt; 0.001) and a reverse-dipping profile (p = 0.013). At multivariate analysis, benzodiazepines (OR 4.040), digoxin (OR 19.987) and creatinine &lt; 1 mg/dl (OR 3.939) were independently associated with ambulatory hypotension. Conclusions: Hypotension is common in NH residents undergoing ABPM and more frequently occurs in subjects with lower ambulatory SBP, a reverse dipping profile and a white coat effect. Benzodiazepines, digoxin and low creatinine are predictors of ambulatory hypotension in NH residents.

Blood pressure monitoring in kidney transplantation: a systematic review on hypertension and target organ damage.

Sparse studies show that ambulatory blood pressure monitoring (ABPM) is superior to office BP (oBP) measurements to predict target organ damage and cardiovascular (CV) events in kidney transplant recipients (KTRs). We performed a systematic review aimed at determining the potential associations between BP recordings by different methods and renal and CV outcomes in this population. Major medical databases were searched for studies enrolling adult KTRs undergoing 24h ABPM compared to office or home BP measurements. Main outcomes were: associations between different BP recordings and renal and CV outcomes. Additionally, any association between the circadian BP pattern (dipping/non-dipping status) and outcomes was assessed. Twenty-two studies (2078 participants) were reviewed. Amongst 12 studies collecting data on renal endpoints, ten studies found that BP assessed by ABPM was a stronger predictor of renal function decline, assessed by serum creatinine (SCr) and/or creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR), than traditional office measurements. Twelve studies analyzed the relation between different BP recordings and CV target organ damages and reported robust correlations between echocardiographic abnormalities [i.e. left ventricular mass index (LVM/LVMI)] and 24h ABPM, but not with office BPs. Furthermore, 24h ABPM correlated better than oBP with markers of vascular damage, such as carotid intima-media thickness (IMT), diffuse thickening, and endothelial dysfunction. Additionally, abnormal circadian BP pattern (non-dippers and reverse dippers) identified a group of kidney recipients at risk for kidney function loss and CV abnormalities. In our systematic review, ABPM reflected target organ damage more closely than oBP in KTRs. Furthermore, altered circadian BP profile associated with renal and CV target organ damages.

Short- and Long-Term Reproducibility of Nighttime Blood Pressure Phenotypes and Nocturnal Blood Pressure Reduction.

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Reverse dipping and subclinical cardiac organ damage: a meta-analysis of echocardiographic studies.

Available evidence on the association between reverse dipping pattern and subclinical cardiac damage is scanty. We performed a systematic meta-analysis of echocardiographic studies in order to provide an updated and comprehensive information on this issue. The PubMed, OVID-MEDLINE, and Cochrane library databases were analyzed to search English-language articles published from January from the inception up to 31 July 2020. Studies were identified by using MeSH terms and crossing the following search items: 'reverse dipping', 'nondipping', 'inverted dipping', 'ambulatory blood pressure', 'cardiac damage', 'hypertensive heart disease', 'left ventricular mass', 'left ventricular hypertrophy', and 'echocardiography'. Data from 14 studies including 1429 patients with reverse dipping, 2584 dippers and 3508 nondippers were considered. Left ventricular (LV) mass index and relative wall thickness were greater in reverse dippers than in dippers (SMD: 0.40 ± 0.04 g/m2, P < 0.0001; 0.31 ± 0.07, P < 0.0001) and nondippers (SMD: 0.25 ± 0.04 g/m2, P < 0.0001; 0.21 ± 0.07, P = 0.004). The reverse dipping group had an increased risk of LV hypertrophy compared with dipping (OR = 1.85, CI 1.47-2.32, P < 0.0001) and nondipping group (OR = 1.45, CI 1.19-1.78, P < 0.0001). A significant progressive reduction in the E/A ratio, paralleled by an increase in left atrium diameter occurred from dippers, to nondippers and reverse dippers. The present meta-analysis provides a novel piece of information about the unfavourable association between the reverse dipping pattern and subclinical cardiac alterations and suggests that the detection of this blood pressure phenotype may identify individuals at increased risk for subclinical organ damage.

Diurnal Blood Pressure and Heart Rate Variability in Hypertensive Patients with Cerebral Small Vessel Disease: A Case-Control Study

BackgroundWhether autonomic dysfunction contributes to cerebral small vessel disease (CSVD) remains unclear. This study aimed to explore the relationship between CSVD and blood pressure variability (BPV) and heart rate variability (HRV). MethodsThis case-control study recruited 50 patients with CSVD and 50 non-CSVD hypertensive age- and gender-matched controls. All participants completed a 24-h ambulatory electrocardiogram recording and ambulatory BP monitoring (ABPM). Differences in HRV and BPV between the two groups were examined. BPV indices assessed by ABPM included mean systolic BP (SBP), mean diastolic BP (DBP), coefficient of variation and weighted standard deviation of SBP and DBP. ResultsCSVD patients had significant higher 24-h mean systolic BP (SBP), 24-h mean diastolic BP (DBP), daytime mean SBP, nocturnal mean SBP, and nocturnal mean DBP (P < .05 for all). CSVD patients had a significant lower nocturnal SBP fall rate compared with controls (median: 1.0 versus 6.2, respectively; P < .001) and were more likely to be non-dippers and reverse dippers. There were no differences in HRV variables between the two groups. Five logistic models were built to explore the correlations between BPV indices and CSVD. BPV indices were separately entered into the logistic regression models, together with hyperlipidemia, ischemic stroke history, current use of anti-hypertensive agents, and serum blood urea nitrogen. In models 1−3, 24-h mean SBP and nocturnal mean SBP and DBP were significantly correlated with CSVD (r2 = 0.308−0.340). In model 4, the nocturnal SBP fall rate was negatively correlated with CSVD (odds ratio [OR] = 0.871, 95% confidence interval [CI] = 0.804−0.943; P = .001), with r2 = 0.415 fitting the model. In model 5, the pattern of SBP dipping was significantly associated with CSVD, with non-dipper (OR = 8.389, 95%CI = 1.489−47.254; P = .016) and reverse dipper (OR = 27.008, 95%CI = 3.709−196.660; P = .001) having the highest risks of CSVD (r2 = 0.413). ConclusionsLower nocturnal SBP fall rate is associated with CSVD. Non-dipper and reverse dipper hypertensive patients have a higher risk of CSVD.

The relevance of performing 24-hour ambulatory blood pressure and pulse waveanalysis in kidney transplant recipients.

Hypertension guidelines recommend out-of-office blood pressure (BP) measurement especially 24-hour ambulatory measurement (ABPM), to diagnose and manage hypertension but this is not routinely performed in kidney transplant units. This study was to determine if 24-hour ABPM, compared with office BP in kidney transplant recipients, would be more informative regarding BP management, and if pulse wave analysis (PWA) would assist in risk stratification. This study included patients older than 18 years, with working graft kidney for &gt;12months, and without problems affecting BP measurement and interpretation. After performing office BP measurements, a 24-hour ABPM with additional capability of calculating pulse wave velocity (PWV), augmentation index and central BP was undertaken. Patients were assessed for controlled hypertension, uncontrolled hypertension, masked hypertension, nocturnal hypertension, white coat hypertension, and dipping BP status. Data were analyzed using standard statistical tests. Of 30 patients, 15 were Black Africans and 15 were of Mixed Ancestry with a mean age of 48.9 years. 17 patients were males and 36.7% had controlled hypertension, 30% uncontrolled hypertension, 6.7% white coat hypertension, and 33.3% masked hypertension, of whom 70% had isolated nocturnal hypertension. 70% had a non-dipping, 26.7% a reverse dipping and only 3.3% had a normal dipping BP pattern. The mean difference between brachial systolic BP and central systolic BP was 10.4mmHg, whereas PWV and augmentation index were similar to healthy populations. Conclusion: In kidney transplant recipients, 24-hour ABPM was superior to office BP in defining hypertensive status that qualified for modification of therapy, but PWA did not contribute to risk assessment.

Blood Pressure Patterns in Patients with Parkinson's Disease: A Systematic Review.

(1) Background: Cardiovascular autonomic dysfunction is a non-motor feature in Parkinson’s disease with negative impact on functionality and life expectancy, prompting early detection and proper management. We aimed to describe the blood pressure patterns reported in patients with Parkinson’s disease, as measured by 24-h ambulatory blood pressure monitoring. (2) Methods: We conducted a systematic search on the PubMed database. Studies enrolling patients with Parkinson’s disease undergoing 24-h ambulatory blood pressure monitoring were included. Data regarding study population, Parkinson’s disease course, vasoactive drugs, blood pressure profiles, and measurements were recorded. (3) Results: The search identified 172 studies. Forty studies eventually fulfilled the inclusion criteria, with 3090 patients enrolled. Abnormal blood pressure profiles were commonly encountered: high blood pressure in 38.13% of patients (938/2460), orthostatic hypotension in 38.68% (941/2433), supine hypertension in 27.76% (445/1603) and nocturnal hypertension in 38.91% (737/1894). Dipping status was also altered often, 40.46% of patients (477/1179) being reverse dippers and 35.67% (310/869) reduced dippers. All these patterns were correlated with negative clinical and imaging outcomes. (4) Conclusion: Patients with Parkinson’s disease have significantly altered blood pressure patterns that carry a negative prognosis. Ambulatory blood pressure monitoring should be validated as a biomarker of PD-associated cardiovascular dysautonomia and a tool for assisting therapeutic interventions.

Reverse Dipping of Systolic Blood Pressure Is Associated With Increased Dementia Risk in Older Men: A Longitudinal Study Over 24 Years.

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

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

Clinical Utility of 24-h Ambulatory Blood Pressure Monitoring in Hospitalized Patients with Chronic Kidney Disease.

Introduction:Hypertension leads to rapid progression of kidney disease. Hypertension (HTN) is the second most common cause for CKD after diabetes. Ambulatory blood pressure monitoring (ABPM) helps in accurate and early diagnosis of HTN along with measurements of other variables, namely nondippers, reverse dippers, hyperbaric index (HBI), percentage time elevation (PTE), and early morning surge.Methodology:After obtaining the institution ethics committee approval total 192 cases, of 12–80 years age group, who were diagnosed with CKD were included in the study. ABPM was done for patients using Meditech ABPM-05 machine.Results:Study showed male predominance. Maximum patients were in the age group of 41–60 years. Prevalence of Hypertension in patients with CKD was 88.02%. The systolic BP, diastolic BP, and mean arterial pressure (MAP) were significantly higher by clinic BP measurement than ABPM in all stages of patients with CKD especially in stage IV than stage V CKD. Systolic, diastolic, MAP, HBI and PTE at nighttime were significantly higher than daytime in all patients with CKD, especially in patients with resistant hypertension. Prevalence of whitecoat HTN (4.1%), whitecoat effect (16.1%), resistant hypertension (39.6%), masked HTN (1%), and masked uncontrolled HTN (10.4%) was noted. Systolic and diastolic HBI was lower in patients on hemodialysis as compared to those not on hemodialysis. Non-dippers were more than dippers.Conclusion:Apart from mean systolic and diastolic BP, ABPM gives the extent of end-organ damage and insights into the need for control of 24 h BP in patients of CKD.

Evaluation of Ambulatory blood pressure monitoring in chronic renal failure (CRF)

Around 20 million individuals in the United States are affected by chronic kidney disease (CKD). A higher risk of cardiovascular (CV) disease is observed in individuals with CKD. In contrast with the workplace, BP assessments in patients with normotensive, hypertensive and CKD, ambulatory blood pressure monitoring (ABPM) offers superior BP measurements. Measures of ABPM in CKD are always unusual, with CKD Sufferers who consistently exhibit an abnormal circadian pattern An improved non-dipping and reverse dipping rate. The incidence of non-dippers and reverse-dippers steadily increases as the CKD stage progresses. ABPM's been displayed to be a better method than office-based pressure for forecasting CV risk, progression of CKD, end-stage renal disease (ESRD) or death. ABPM is also exponential and offers forecasting Value for predicting results of CKD and CV when applied to Glomerular filtration rate estimate (eGFR). Even though ABPM is time-consuming, it should be taken into account, as the information shows that ABPM information will potentially affect CV and renal outcomes for the future of CKD patients.

Soluble Urokinase-Type Plasminogen Activator Receptor, Changes of 24-Hour Blood Pressure, and Progression of Chronic Kidney Disease.

BackgroundSoluble urokinase‐type plasminogen activator receptor (suPAR) is associated with cardiovascular risks and poor renal outcomes. However, whether elevated suPAR levels are associated with 24‐hour blood pressure patterns or kidney disease progression in patients with chronic kidney disease (CKD) is unclear.Methods and ResultsA total of 751 patients with CKD stage 1 to 5 were recruited from CMERC‐HI (Cardiovascular and Metabolic Disease Etiology Research Center–High Risk) cohort study (2013–2018). The relationship of serum suPAR levels to 24‐hour blood pressure parameters and CKD progression was analyzed. The median serum suPAR level was 1439.0 (interquartile range, 1026.2–2150.1) pg/mL, and the mean estimated glomerular filtration rate was 52.8±28.5 mL/min per 1.73 m2 at baseline. Patients with higher suPAR levels had significantly higher levels of office, 24‐hour, daytime, and nighttime systolic blood pressure and nighttime diastolic blood pressure than those with lower suPAR levels. The highest suPAR tertile was associated with an increased risk of a reverse dipping pattern (odds ratio, 2.93; 95% CI, 1.27–6.76; P=0.01). During a follow‐up of 43.2 (interquartile range, 27.0–55.6) months, the CKD progression occurred in 271 (36.1%) patients. The highest suPAR tertile was significantly associated with higher risk of CKD progression than the lowest tertile (hazard ratio [HR], 2.09; 95% CI, 1.37–3.21; P=0.001). When the relationship was reevaluated with respect to each dipping pattern (dipper, extreme dipper, nondipper, and reverse dipper), this association was consistent only in reverse dippers in whom the risk of CKD progression increased (HR, 1.43; 95% CI, 1.02–2.01; P=0.03) with every 1‐unit increase in serum suPAR levels.ConclusionsElevated suPAR levels are independently associated with CKD progression, and this association is prominent in reverse dippers.

Nighttime dipping status and risk of cardiovascular events in patients with untreated hypertension: A systematic review and meta-analysis.

The objective of this systematic review and meta-analysis is to determine whether nocturnal blood pressure fall, expressed by dipping patterns according to ambulatory blood pressure monitoring (ABPM), is a risk factor for cardiovascular events (CVEs) in untreated hypertensives. Α thorough systematic literature search at MEDLINE, Embase, Cochrane Library, and gray literature was conducted through March 2020. Two reviewers screened studies and assessed dipping patterns of untreated hypertensives using ABPM with a follow-up >6months. Newcastle-Ottawa scale was used for risk of bias assessment. We initially identified 463 reports; of which, seven cohort studies were eligible for meta-analysis enrolling 10438 untreated hypertensives. Untreated patients classified as dippers at baseline (n=7081) had significant lower risk of CVEs and total mortality compared to non-dippers (n=3,357) [RR=0.67, 95% CI (0.49, 0.92); RR=0.71, 95% CI (0.59, 0.86)]. However, when patients were further classified into four dipping groups, only reverse dippers, yet not extreme dippers or non-dippers, were at increased risk for CVEs compared to dippers [RR=0.47, 95% CI (0.33, 0.66)]. Likewise, only reverse dippers had a higher stroke risk than dippers [RR=0.39, 95% CI (0.22, 0.72)]. When compared with the whole group of dippers (including extreme dippers), non-dipping alone (excluding reverse dipping) was not a significant risk factor for CVEs [RR=0.84, 95% CI (0.61, 1.16)] or total mortality [RR=0.84, 95% CI (0.61, 1.16); RR=0.78, 95% CI (0.53, 1.13), respectively]. Untreated hypertensives may benefit more from the evaluation of reverse dipping rather than the non-dipping phenomenon in general.

Effect of short-term exposure to indoor particulate matter on noctunal blood pressure dipping among hypertensive adults in ibadan: a pilot study

Abstract Introduction While blunted nocturnal blood pressure is a major risk factor for cardiovascular events, limited information exist on the association between indoor particulate and circadian blood pressure variation. We report the association of short-time exposure to PM2.5 and PM10 with blunted nocturnal blood pressure among hypertensive adults in Ibadan. Purpose This study was to determine the association between short time exposure to air particulates and blunted nocturnal blood pressure among people of African descent. Methods We conducted a cross-sectional study among fifty hypertensive cases attending our University College Hospital. A 24-hours blood pressure (BP) monitoring was carried out at the same time as indoor particulate matter monitoring in their homes. Exposure to indoor fine particles (PM2.5) and thoracic particles (PM10) was estimated using a real-time particle counter and compared to the World Health Organization (WHO) 24-hours threshold of 25 μg/m3 and 50 μg/m3 for PM2.5 and PM10 respectively. All monitoring was carried out over a 24-hours period during the wet season. Linear regression model was fitted to determine predictors of non-dipping hypertension. Results Of the 50 hypertensive patients studied, 5 (10.0%), 39 (78.0%), 6 (12.0%) were reverse dippers, non-dippers and dippers respectively. The mean indoor PM2.5 (44.17±19.18 μg/m3) and PM10 (60.10±27.13 μg/m3) among the non-dippers were significantly higher than values obtained among dippers (PM2.5 = 22.97±10.19 μg/m3; PM10 = 29.51±12.74 μg/m3); p&amp;lt;0.0001, and the WHO threshold limit. More non-dippers than dippers (54.5% vs 37.8%) used unimproved fuel such as firewood for cooking. PM10 was an independent predictors of non-dipping status in our regression analysis. Conclusion Short-term exposure to indoor PM air pollution was associated with blunted nocturnal blood pressure. Therefore air pollution reduction strategies through improved cooking pattern is advocated in order to prevent future cardiovascular events. Funding Acknowledgement Type of funding source: None