Reverse Dipping Pattern Research Articles

Blood Pressure Regulation in Post-COVID POTS: Beyond Sinus Tachycardia.

Postural orthostatic tachycardia syndrome (POTS) is a frequently diagnosed cardiovascular disorder after COVID-19 infection. POTS is characterized by the presence of excessive sinus tachycardia on standing without a fall in blood pressure (BP). We investigated the BP profile using 24-hour ambulatory BP monitoring in patients with new-onset POTS after COVID-19 compared with prepandemic population-based controls. We performed a case-control study in 100 patients (mean age, 40.0±12.9 years; 85% women) with verified post-COVID-19 new-onset POTS diagnosed by a positive head-up tilt testing versus 100 controls from a population-based cohort with a negative active standing test, no history of syncope, POTS, or endocrine disease (mean age, 42.3±14.0 years; 78% women). Twenty-four-hour BP profile was assessed for circadian BP variation including hypotensive systolic BP (SBP) episodes (<80, <90, and <100 mm Hg). Patients with post-COVID-19 POTS had significantly higher nighttime SBP, but not daytime SBP, and more daytime SBP hypotensive episodes compared with controls. Nondipping (34% versus 19%; P<0.001) and reverse dipping patterns (9% versus 0%; P<0.001) were more frequent in post-COVID-19 POTS. In the logistic regression, patients with post-COVID-19 POTS had significantly higher mean 24-hour SBP (odds ratio, 1.08 [95% CI, 1.04-1.11]; P<0.001) and nighttime SBP (odds ratio, 1.07 [95% CI, 1.04-1.10]; P<0.001), independent of age and sex. Patients with post-COVID-19 POTS demonstrate higher mean 24-hour and nighttime SBP and show disruptions of circadian BP rhythm regulation compared with population-based controls, as well as more daytime hypotensive episodes. Future studies are needed to test whether patients with post-COVID-19 POTS may benefit from tailored BP therapy.

Characteristics of 24-h ambulatory blood pressure monitoring in elderly hypertensive males: An observational study of 85 year older patients.

Although hypertension is highly prevalent among the elderly and significantly contributes to cardiovascular disease risk, studies focusing on male elderly individuals over 85 years old are relatively scarce. This study aimed to investigate ambulatory blood pressure monitoring (ABPM) characteristics in male hypertensive patients aged over 85 years. These included demographic characteristics, antihypertensive drug use, 24-h ABPM values, diabetes, coronary heart disease, sleep disorders, smoking history, and drinking history, and the differences in ABPM between the age groups over and under 85 years old were analyzed. A total of 585 elderly hypertensive patients were included. The mean systolic blood pressure in individuals aged over 85 years was significantly greater throughout the day (131.57±12.52mmHg vs. 123.75±2.74mmHg, p<.001). In the 85 years older age group, the nighttime variability coefficient of SBP was lower at 7.84±2.9 than the under 85 years age group 8.92±3.13 (p<.001). The 85 years older age group age group presented a significantly greater whole-day systolic blood pressure standard deviation of ABPM (13.2±3.19vs. 12.47±3.05, p=.005) compared with those under the age of 85 years. In the 85 years older age group, the proportion of individuals with the reverse dipper pattern was higher (48.15%vs. 38.31%, p=.017) than under 85 years age group. This study revealed that elderly male hypertensive patients aged over 85 years presented elevated average blood pressure levels. The research investigated ABPM characteristics. Older hypertensive individuals are more likely to have a reverse-dipper blood pressure pattern.

O57 NOCTURNAL BLOOD PRESSURE FLUCTUATION AND DIPPING PATTERNS IN PATIENTS WITH SEVERE OBSTRUCTIVE SLEEP APNOEA

Background and Objective: Nighttime blood pressure (BP) is important for diagnosis of hypertension and for cardiovascular risk stratification. Remarkably, a reverse dipping pattern is a strong and independent predictor of overall mortality and major adverse cardiovascular events. Therefore, the further clarification of the underlying mechanisms of non- and reverse dipping is crucial to improve the treatment of patients with nighttime hypertension. Methods: We investigated 97 patients with suspected obstructive sleep apnoea (OSA, AHI &gt;30) using standard polysomnography and continuous BP measurement based on the pulse-transit-time method (SOMNOscreen Plus®, SOMNOmedics). Frequency and amplitude of fluctuations in systolic BP following sleep disturbances (OSA) were investigated. Results: Apnoeic events went along with transient increases of BP. In some cases, systolic BP did not reach the value before the apnoea but increased over time. We defined elevations of the systolic BP baseline by &gt;10 mmHg with a duration of &gt;10 min as BP superpositions. The superposition periods were also characterized by increased BP amplitudes with peak values of BP up to 220 mmHg. Superposition occurred in 48 patients. Further, 65% of the OSA patients were identified as non-dippers. However, nearly all the patients with superposition (98%) were identified to have non-dipper or reverse dipper patterns. Conclusions: Our study strongly suggests that non-dipping and reverse dipping in patients with severe OSA are causally linked to OSA related BP fluctuations. Further, continuous elevations in SBP baseline (superpositions) result in extreme BP values. This behaviour with high BP peaks may be contributing to the increased mortality in patients with reverse dipping. Therefore, identification and adequate treatment of patients with reverse dipping reduces the cardiovascular risk and may prolong their life.

Impact of blood pressure variability and cerebral small vessel disease: A systematic review and meta-analysis

ImportanceAbnormal blood pressure pattern is an independent risk factor for vascular events. Blood pressure variability can predict cardiovascular and cerebrovascular disease outcomes and is closely associated with the risk of cognitive impairment. However, the relationship between blood pressure variability and cerebral small vessel disease neuroimaging markers remains unclear. This study aimed to evaluate the relationship between blood pressure variability and cerebral small vessel disease neuroimaging markers. Data sourcesWe searched multiple databases, including Embase, Web of Science, PubMed, Cochrane Library, UpToDate, and World of Science, from their inception until November 27, 2023.Main Outcomes and Measures: A meta-analysis of 19 observational studies involving 14519 participants was performed. Findings: ①Systolic blood pressure variability was correlated with the cerebral small vessel disease total burden, white matter hyperintensities and lacunar infarction; ② Diastolic blood pressure variability was correlated with the cerebral small vessel disease total burden, white matter hyperintensities and cerebral microbleeds; ③ Non-dipping patterns were correlated with white matter hyperintensities and lacunar infarction. ④ Reverse-dipping patterns were significantly correlated with white matter hyperintensities and cerebral microbleeds. Conclusionsand Relevance: Blood pressure variability correlates with neuroimaging markers of cerebral small vessel disease and its burden. Hence, early monitoring and intervention of blood pressure variability may be essential for the early diagnosis, prevention and treatment of cerebral small vessel disease.

RENAL DENERVATION RESULTS IN SUBSTANTIAL NOCTURNAL BP REDUCTION IN PATIENTS WITH A REVERSED DIPPING PATTERN

Objective: We characterized patients with reverse blood pressure (BP) dipping pattern and uncontrolled hypertension (HTN) at baseline referred for radiofrequency renal denervation (RF RDN), and their subsequent BP changes. Design and method: Patients with HTN were enrolled into the Global SYMPLICITY Registry (GSR) DEFINE and underwent RF RDN. Patients were grouped into different BP dipping patterns defined by night/daytime BP ratio: dippers (ratio 0.9 or below), non-dippers (ratio 0.9 to 1.0 or below), reverse dippers (ratio &gt;1.0). Baseline characteristics and BP changes through 3yrs were compared between groups based on dipper patterns. Statistical significance was defined as p&lt;0.05. Results: As of March 2023, 3331 patients with uncontrolled BP were enrolled, 2276 of whom had 24-h BP measures and could be categorized by dipping patterns. Majority of the patients were non-dippers (44.3%), followed by dippers (34.6%) and reverse dippers (21.1%). Reverse dippers (n=480) were the oldest (62±12yrs; p=0.0024), more likely to have cardiac disease (54.2%; p&lt;0.0001), diabetes (48.1%; p&lt;0.0001) and renal disease (38.9%; p&lt;0.0001). Reverse dippers had the highest baseline 24-h ambulatory systolic BP (SBP) (156±19mmHg; p&lt;0.0001) and nighttime SBP (163±21; p&lt;0.0001). In contrast, they had the lowest daytime SBP (153±19mmHg; p&lt;0.0001) and heart rate (66±11bpm; p&lt;0.0001). Reverse dippers were prescribed the most antihypertensive drugs (5.2±1.7; p=0.0058). 3yrs after RF RDN, significant overall 24-h ambulatory SBP reduction from baseline was observed within all dipping patterns, and the largest reduction was observed within reverse dippers (-11.8±25.1mmHg; Figure), particularly in the nighttime (-21.1±23.8mmHg). Conclusions: Reverse dippers with uncontrolled HTN referred for RDN were prescribed more antihypertensive drugs and had more comorbidities compared to patients with other dipping patterns. After RF RDN, significant SBP changes from baseline were observed irrespective of dipping status. The largest BP reduction was observed in nighttime BP in patients with reverse dipping pattern. RF RDN may offer an effective adjunctive therapy to drugs to lower nighttime BP patients with a reverse dipping pattern, who have the highest risk of cardiovascular events.

RELATIONSHIP BETWEEN CLINIC AND AMBULATORY BLOOD PRESSURE AND MORTALITY IN PATIENTS WITH PREVIOUS STROKE

Objective: The aim of this study was to evaluate the association between clinic and ambulatory BP and mortality in patients with a previous stroke Design and method: Observational cohort study from the Spanish Ambulatory Blood Pressure Registry. Mortality data (date and cause) were ascertained by a computerized search of the vital registry of the Spanish National Institute of Statistics. For each study participant, follow-up was from the date of his or her recruitment to the date of death, or December 31st, 2019, whichever occurred first. Cox models were used to estimate associations between clinic and ambulatory BP and mortality, adjusted for clinical confounders (age, sex, BMI, smoking, diabetes, and dyslipidemia), and additionally for alternative measures of BP. Results: From the 59 124 individuals included in the Registry, we selected 2,183 with a previous stroke. Mean age was 67.5 ± 11.8 years, 43.6% were female. During a median follow-up of 9.7 years (IQR 7.7–11.3), 632 (29.5%) participants died, including 236 from cardiovascular causes (62 ischemic heart disease deaths, 83 stroke deaths, and 28 heart failure deaths). In the confounder-adjusted model, clinic systolic BP was not associated with the risk of all-cause or cardiovascular mortality. In contrast, systolic BP indices obtained through ABPM (24h, day and night) were all associated with all-cause and cardiovascular mortality. In the simultaneous adjustment of daytime and night-time systolic BP, only night-time systolic BP remained significantly associated with all cause and cardiovascular death: OR 1.36 (1.21-1.52) and 1.45 (1.21-1.73), respectively. For diastolic BP, only night-time BP was associated with all-cause and cardiovascular mortality: OR 1.33 (1.18-1.49) and 1.58 (1.32-1.89), respectively. Reverse dipper pattern (risers) was also associated with all-cause mortality: OR 1.56 (1.18-1.86) and cardiovascular mortality: OR 1.81 (1.27-2.57). Conclusions: In patients who have suffered a previous stroke, night-time blood pressure is the BP estimate most closely associated with all-cause and cardiovascular mortality.

Long-term and short-term cardiovascular disease mortality among patients of 21 non-metastatic cancers

IntroductionPrevious studies on cardiovascular disease (CVD) death risk in cancer patients mostly focused on overall cancer, age subgroups and single cancers. ObjectivesTo assess the CVD death risk in non-metastatic cancer patients at 21 cancer sites. MethodsA total of 1,672,561 non-metastatic cancer patients from Surveillance, Epidemiology, and End Results (SEER) datebase (1975–2018) were included in this population-based study, with a median follow-up of 12·7 years. The risk of CVD deaths was assessed using proportions, competing-risk regression, absolute excess risks (AERs), and standardized mortality ratios (SMRs). ResultsIn patients with localized cancers, the proportion of CVD death and cumulative mortality from CVD in the high-competing risk group (14 of 21 unique cancers) surpassed that of primary neoplasm after cancer diagnosis. The SMRs and AERs of CVD were found higher in patients with non-metastatic cancer than the general US population (SMR 1·96 [95 %CI, 1·95-1·97]–19·85[95 %CI, 16·69-23·44]; AER 5·77–210·48), heart disease (SMR 1·94[95 %CI, 1·93-1·95]–19·25[95 %CI, 15·76-23·29]; AER 4·36–159·10) and cerebrovascular disease (SMR 2·05[95 %CI, 2·02-2·08]–24·71[95 %CI, 16·28-35·96]; AER 1·01–37·44) deaths. In the high-competing risk group, CVD-related SMR in patients with localized stage cancer increased with survival time but followed a reverse-dipper pattern in the low-competing risk group (7 of 21 cancers). The high-competing risk group had higher CVD-related death risks than the low-competing risk group. ConclusionThe CVD death risk in patients with non-metastatic cancer varied by cancer stage, site and survival time. The risk of CVD mortality is higher in 14 out of 21 localized cancers (high-competing cancers). Targeted strategies for CVD management in non-metastatic cancer patients are needed.

Associations of sleep-related variables with reverse dipping patterns of blood pressure in α-synucleinopathies

IntroductionThe reverse dipping blood pressure (BP) pattern is very common in α-synucleinopathies. We aimed to explore the associations of sleep-related variables with abnormal BP circadian rhythms in Parkinson's disease (PD) and multiple system atrophy (MSA). MethodsA total of 126 patients, 76 with PD and 50 with MSA, were included. All participants underwent ambulatory BP monitoring and full-night polysomnography (PSG). We analyzed abnormal dipping patterns and sleep-related parameters, including moderate to severe obstructive sleep apnea (OSA), rapid eye movement behavior disorder (RBD), average oxygen saturation (SaO2%), lowest SaO2%, duration of SaO2% <90%, and apnea-hypopnea index (AHI). Binary logistic regression was performed to explore the associations between paraclinical variables, sleep-related variables, and reverse dipping patterns. ResultsReverse dipping patterns were predominant in patients with PD (58.5 %) and MSA (68.0 %). Patients with MSA had higher AHI, RBD, and lower average SaO2% than those with PD. Taking both diseases together as a whole group of α-synucleinopathies, logistic regression analysis indicates the Hoehn-Yahr stage (odds ratio [OR] = 2.00 for reverse systolic and 2.34 for reverse diastolic dipping patterns), moderate to severe OSA (OR = 2.71 for reverse systolic and 2.53 for reverse diastolic dipping patterns), average SaO2% (OR = 1.35 for reverse systolic dipping patterns), and male sex (OR = 2.70 for reverse diastolic dipping patterns) were independently associated with reverse dipping patterns. ConclusionsReverse dipping patterns were common in patients with PD and MSA. Hoehn-Yahr stage, moderate to severe OSA, average SaO2%, and male sex were associated with reverse dipping patterns in α-synucleinopathy.

Nocturnal Blood Pressure Patterns in Hypertensive patients with Obstructive Sleep Apnea Syndrome in Angola

The main cardiovascular consequence of Obstructive Sleep Apnea Syndrome (OSAS) is arterial hypertension (AH), considered since 2003 a second cause of AH. This study aimed to evaluate nocturnal blood pressure patterns (BPP) in hypertensive patients with OSAS in Angola. A descriptive, cross-sectional observational study was carried out in a private clinic in Angola. Demographic and clinical variables, polysomnography, and ABPM parameters were included. Patients were classified as a dippers, non-dippers, and reverse dippers. One-way ANOVA test, Kruskal-Walli’s test, and chi-square test were used as appropriate. The sample consisted of 70 individuals: 39(55.7%) were male. The mean age was 53.63±9.14 years and the BMI was 35.82 ± 6.57 kg/m2. An association between patients with a past medical history of hypertension and BPP was found (p&lt;0.05). Mean O2 saturation was significantly lower in the reverse dippers (p=0.25). Although insignificantly, the dippers were younger and less obese. In contrast, the proportion of smokers and diabetics was higher in the reverse dippers. No correlation was found between the apnea-hypopnea index, the mean blood pressure, and the Epworth sleepiness scale. In the present study, the prevalence of non-dipping and reverse dipping patterns was high. It needs to be confirmed with future prospective studies.

Monocyte-to-high-density lipoprotein ratio: an independent predictor of reverse dipper pattern in hypertensive patients.

In healthy individuals, blood pressure (BP) levels are expected to decrease by 10-20% during sleep hours, which is defined as the dipping pattern. On the other hand, the presence of a BP rise at night in hypertensive patients is defined as a reverse dipper hypertensive pattern (RDHT). RDHT has been associated with stroke and cardiovascular mortality. Similarly, the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) has been associated with the prognosis of cardiovascular disease. We, therefore, aimed to assess the relationship between MHR and RDHT in patients with hypertension. A total of 363 patients were enrolled in the study, all of whom had undergone 24-hour ambulatory BP monitoring. The patients were analyzed in three groups: RDHT (n: 92), dipper hypertensive (DHT) (n: 124), and normotensive controls (n: 147). Univariable and multivariable analyses were performed to identify factors that could be used to predict RDHT presence. The RDHT group was compared with the DHT and normotensive groups. A high MHR (p = 0.014, OR: 1.110, CIs: 1.021-1.206) and low daytime diastolic BP (p = 0.026, OR: 0.951, CIs: 0.910-0.994) were found to be independent factors that differentiated RDHT from DHT. Additionally, high MHR (p < 0.001, OR: 1.244, CIs: 1.140-1.357), body mass index (p = 0.005, OR: 1.143, CIs: 1.042-1.255), and C-reactive protein (p = 0.009, OR: 1.166, CIs: 1.039-1.308) were found to be independent factors that could differentiate patients with RDHT from controls. We demonstrated that MHR, a novel inflammatory marker, independently predicts RDHT. This easily applicable and inexpensive marker can be used to predict RDHT in patients with hypertension.

The Importance of Out-of-Office Blood Pressure Measurement, as Highlighted by the Correlation with Left Ventricular Hypertrophy in an Untreated Hypertensive Population.

Background and Objectives: Hypertensive heart disease, especially left ventricular hypertrophy (LVH), is considered to be one of the main types hypertension-mediated organ damage. Hence, the purpose of this study was to examine which method of measuring BP (office BP measurement (OBPM), 24 h ambulatory BP monitoring (ABPM), or home BP monitoring (HBPM)), can be better correlated with echocardiographic LVH in the untreated hypertensive population. Materials and Methods: This study's population consisted of 202 patients 58 ± 15 years old (40.8% males). All patients reported elevated home BP measurements for at least 3 months, but they had never been treated before for hypertension. Office and out-of-office BP measurements, including ABPM on a usual working day and seven-day HBPM, as well as 2D echocardiography, were performed. Results: In the univariate analysis, LVH was associated (p < 0.05) with a mean 24 h systolic BP (OR: 1.93, CI: 1.29-2.91), a mean 24 h diastolic BP (OR: 1.30, CI: 1.16-1.80), ambulatory daytime systolic (OR: 1.11, CI:1.01-1.82) and diastolic BP (OR: 1.13, CI:1.09-1.17), ambulatory nighttime systolic BP (OR: 2.11, CI: 1.04-4.31), and mean home systolic BP (OR: 1.05, CI:1.01-1.12). Pearson's correlation analysis showed a significant correlation between the LV mass index and the mean 24 h systolic BP (r = 0.58, p < 0.05), daytime systolic BP (r = 0.59, p < 0.05), and nighttime systolic BP (r = 0.57, p < 0.05). Most of the population with confirmed LVH presented confirmed hypertension (based on ABPM, 48.1% or HBPM, 40%). The second most dominant phenotype was masked hypertension (ABPM, 32.7% and HBPM, 23.7%). The majority (59.3%) had non-dipping status, 20.4% had a reverse dipping pattern, 13% had a dipping pattern, and only 7.3% had extreme dipping BP. Conclusions: Out-of-office BP measurement devices seemed to be superior compared to in-office. This advantage is highlighted by better correlations in the identification of LVH as well as the diagnosis of masked hypertension, a condition also highly correlated with LVH.

Clinical and life style factors related to the nighttime blood pressure, nighttime dipping and their phenotypes in Korean hypertensive patients

BackgroundNon-dipping or reverse dipping patterns are known to be associated with adverse cardiovascular prognosis among the general population and clinical cohort. Few large sized studies have explored factors including sleep duration and sleep quality related to nighttime blood pressure (BP) and nocturnal dipping patterns.MethodsAmong 5,360 patients enrolled in Korean multicenter nationwide prospective Registry of ambulatory BP monitoring (KORABP), 981 subjects with complete data on sleep duration, sleep quality assessed using a 4-point Likert scale, and clinical variables were included in the analysis. Phenotypes of nighttime BP pattern were categorized as extreme dipper, dipper, non-dipper, and reverse dipper. Hypertension was defined as a 24-h ambulatory BPs were 130/80 mmHg or higher.ResultsAmong 981 subjects, 221 were normotensive, 359 were untreated hypertensive, and 401 were treated hypertensive. Age of the participants were 53.87 ± 14.02 years and 47.1% were female. In overall patients, sleep duration was 431.99 ± 107.61 min, and one to four points of sleep quality were observed in 15.5%, 30.0%, 30.4%, and 24.2%, respectively. Of the 760 hypertensive patients, extreme dipper, dipper, non-dipper, and reverse dipper were observed in 58 (7.63%), 277 (36.45%), 325 (42.76%), and 100 (13.16%), respectively. In multiple linear regression analysis, sleep duration (β = 0.0105, p < 0.001) and sleep quality (β = -0.8093, p < 0.001) were associated with nighttime systolic BP and sleep quality was associated with extent of nighttime systolic BP dipping (β = 0.7622, p < 0.001) in hypertensive patients. In addition, sleep quality showed positive association with dipper pattern (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.03–1.30) and showed negative association with reverse dipper pattern (OR = 0.73, 95% CI = 0.62–0.86) in multiple logistic regression analyses.ConclusionWhen adjusted covariates, less sleep duration and poor sleep quality were positively associated with nighttime systolic BP. Additionally, sleep quality was the independent associated factor for dipper and reverse dipper phenotypes. The study also found that male sex, low estimated glomerular filtration rate, high ambulatory BP, low office BP, and poor sleep quality were associated with blunted nighttime SBP dipping.

Nocturnal systolic blood pressure dipping and progression of chronic kidney disease.

The relationship between declining nocturnal blood pressure (BP) and adverse cardiovascular outcomes is well-recognized. However, the relationship between diurnal BP profile and the risk of chronic kidney disease (CKD) progression is unclear. Herein, we examined the association between nocturnal systolic SBP (SBP) dipping and CKD progression in 1061 participants at the Cardiovascular and Metabolic Disease Etiology Research Center-High Risk (CMERC-HI). The main exposure was diurnal systolic BP (SBP) profile and diurnal SBP difference ([nighttime SBP-daytime SBP] × 100/daytime SBP). The primary outcome was CKD progression, defined as a composite of ≥ a 50% decline in the estimated glomerular filtration rate from baseline or the initiation of kidney replacement therapy. During 4749 person-years of follow-up (median, 4.8 years), the composite outcome occurred in 380 (35.8%) participants. Compared to dippers, the hazard ratios (HRs) for the risk of adverse kidney outcomes were 1.02 (95% confidence interval [CI], 0.64-1.62), 1.30 (95% CI, 1.02-1.66), and 1.40 (95% CI, 1.03-1.90) for extreme dipper, non-dipper, and reverse dipper, respectively. In a continuous modeling, a 10% increase in diurnal SBP difference was associated with a 1.21-fold (95% CI, 1.07-1.37) higher risk of CKD progression. Thus, decreased nocturnal SBP decline was associated with adverse kidney outcomes in patients with CKD. Particularly, patients with non-dipping and reverse dipping patterns were at higher risk for CKD progression than those with a dipping pattern.

ASSOCIATION BETWEEN NOCTURNAL VARIATION IN BLOOD PRESSURE AND RISK OF ACUTE ISCHEMIC STROKE: A SYSTEMATIC REVIEW

Objective: Blood pressure (BP) is a dynamic parameter characterized by fluctuations during the 24-hour period. Variability of BP has been associated with cardiovascular risk and the occurrence of acute ischemic stroke (AIS). Circadian variation in BP during the night shows some basic patterns. The purpose of this study is to to correlate deviations from baseline patterns of circadian BP variation with the risk of AIS to select the optimal therapeutic intervention. Design and method: To complete our study, we systematically reviewed the literature from 1990-2022 through electronic medical databases (MEDLINE, Scopus and Cochrane). Results: During the nighttime hours, BP drops 10 - 20% in normotensive and untreated hypertensive patients - a dipping phenomenon, followed by a rapid and gradual increase during waking hours. In the studies being reviewed, patients were classified according to the rate of fall in systolic BP during 24-hour recording into four categories: the extreme-dippers drop &gt;20%, dippers drop &gt;10% and &lt;20%, non-dippers drop &lt;10% and &gt;0%, and reverse-dippers or risers drop &lt;0%. Deviating from standard dipping patterns is associated with an increased risk of AIS and highlights the value of chronotherapy, whereas no significant difference is observed in stroke prognosis. The extreme-dipping phenomenon is associated with the occurrence of ischemic stroke (IS), either due to under-treatment or due to subsequent morning hypertensive spike, whereas aggressive antihypertensive treatment seems to be significantly responsible. Interestingly, the occurrence of microbleeds in IS territory has been strongly associated with the reverse-dipping pattern. Conclusions: Overnight BP variation is an independent and robust predictor of cardiovascular risk, including AIS. Nocturnal BP may constitute a therapeutic target for the prevention of AIS. However, the available data on the effect of antihypertensive drugs and the implementation of chronotherapy with pre-sleep medication are conflicting in terms of improving cardiovascular risk. Therefore, at present, current guidelines for the treatment of BP do not recommend the aforementioned therapeutic approach as the best treatment in day-to-day clinical practice. More extensive and targeted studies are needed in the future to confirm the potential benefits of the application of chronotherapy in the prevention of AIS.

Correlation of diabetes complications with blood pressure variability

ABSTRACT Introduction: India is suffering from an epidemic of noncommunicable diseases. Type 2 diabetes and hypertension are two lifestyle diseases which are often coexistent. The present study aimed to assess whether blood pressure (BP) variability has any correlation with the prevalence of chronic complications of diabetes. Materials and Methods: In a hospital-based cross-sectional study, 116 patients of newly diagnosed type 2 diabetes were enrolled. Ambulatory BP monitoring (ABPM) for 24 h duration was performed in all the study participants. The abnormal patterns of BP were analyzed. Results: Out of 100 patients with valid ABPM data, 62% of patients had masked hypertension, 45% had nondipping pattern, and 13% had reverse dipping pattern. The prevalence of diabetes complications both macrovascular and microvascular was significantly higher in patients who had abnormal dipping patterns. Conclusion: Our findings highlight the importance of ABPM which detects masked hypertension, white-coat hypertension, and abnormal BP patterns which are related to complications of diabetes.

Hypertension as Cardiovascular Risk Factor in Chronic Kidney Disease

Hypertension is the leading modifiable cause of premature death and hence one of the global targets of World Health Organization for prevention. Hypertension also affects the great majority of patients with chronic kidney disease (CKD). Both hypertension and CKD are intrinsically related, as hypertension is a strong determinant of worse renal and cardiovascular outcomes and renal function decline aggravates hypertension. This bidirectional relationship is well documented by the high prevalence of hypertension across CKD stages and the dual benefits of effective antihypertensive treatments on renal and cardiovascular risk reduction. Achieving an optimal blood pressure (BP) target is mandatory and requires several pharmacological and lifestyle measures. However, it also requires a correct diagnosis based on reliable BP measurements (eg, 24-hour ambulatory BP monitoring, home BP), especially for populations like patients with CKD where reduced or reverse dipping patterns or masked and resistant hypertension are frequent and associated with a poor cardiovascular and renal prognosis. Even after achieving BP targets, which remain debated in CKD, the residual cardiovascular risk remains high. Current antihypertensive options have been enriched with novel agents that enable to lower the existing renal and cardiovascular risks, such as SGLT2 (sodium-glucose cotransporter-2) inhibitors and novel nonsteroidal mineralocorticoid receptor antagonists. Although their beneficial effects may be driven mostly from actions beyond BP control, recent evidence underline potential improvements on abnormal 24-hour BP phenotypes such as nondipping. Other promising novelties are still to come for the management of hypertension in CKD. In the present review, we shall discuss the existing evidence of hypertension as a cardiovascular risk factor in CKD, the importance of identifying hypertension phenotypes among patients with CKD, and the traditional and novel aspects of the management of hypertensives with CKD.

The Relationship Between the Dipping Pattern and Coronary Artery Disease Severity Assessed by the SYNTAX Score in Patients With Hypertension.

Background The morbidity and mortality rates related to hypertension (HT) are still high despite the developments in this area. Nondipper hypertension (NDHT) is related to worse clinical outcomes. But the dipping pattern of HT is not still used for treatment targets. In this study, we investigated the effect of dipping patterns on coronary artery disease (CAD) complexity evaluated by the SYNTAX score (SS). Methodology Patients with stable CAD and HT were included in the study. All patients were monitored with 24-hour ambulatory monitoring, and dipping patterns were evaluated. Coronary artery complexity was determined by SS for all patients and compared along with different dipping patterns. Results A total of 331 patients with HT and stable CAD were evaluated in the study. The mean age of the patients was 62.6 ± 9.9 years, and 172 (52%) were male. The number and percentage of patients with dipper HT (DHT), NDHT, over-dipper HT (ODHT), and reverse-dipper HT (RDHT) were 89 (26%), 143 (43%), 11 (3%), and 88 (26%), respectively. When the groups were compared according to SS, the SS of the patients with RDHT were significantly higher (the SS were 6.33, 4.99, 3.09, and 2.7 for RDHT, ODHT, NDHT, and DHT, respectively, P = 0.003). The mean SS between the DHT group and the NDHT group (P = 0.03) and between the DHT group and the RDHT group (P = 0.01) was significantly different. The less decrease or increase in mean blood pressure (MnBP) values was significantly correlated with high SS. Conclusions NDHT, especially the reverse dipping pattern, is closely related to complex CAD. Meticulous consideration of dipping patterns can identify high-risk patients and improve clinical outcomes.

Prediction of atrial fibrillation in patients with hypertension: A comprehensive comparison of office and ambulatory blood pressure measurements.

Hypertension is associated with the development of atrial fibrillation (AF). Evidence has shown that reverse dipping pattern, an abnormal increase of night‐time blood pressure (BP) comparing to daytime BP, is associated with cardiovascular events. However, the relationship between diurnal changes in BP and AF has not been sufficiently explored. This paper aims to cross‐sectionally explore the relationship between AF and ambulatory BP parameters, especially reverse dippers to the others, and further longitudinally analyze how BP patterns are associated to the risk of developing new‐onset AF. Between February 2012 and March 2021, five out of 412 patients were identified of AF at baseline; four were reverse dippers (3.7%) and one was from the others (.3%). Cross‐sectionally, the multivariate logistic regression analysis showed that reverse dippers were significantly more likely to have AF (odds ratio: 12.39, p = .030). After excluding patients with baseline AF, during the mean follow‐up of 4.6 ± 3.0 years, seven patients developed AF. Longitudinally, the multivariate Cox regression analysis revealed that 24‐h systolic BP (hazard ratio per 10 mmHg: 2.12, p = .015), night‐time systolic BP (hazard ratio per 10 mmHg: 2.27, p = .002), and presentation of reverse dipping (hazard ratio: 5.25, p = .042) were independently associated with new‐onset AF. None of the office BP measurements were associated with new‐onset AF. While ambulatory BP measurements were better predictors for the incidence of AF, careful management is necessary for reverse dippers as they are at high risk of developing AF.

Association of Office and Ambulatory Blood Pressure with Left Ventricular Structure and Function in Hypertensive Patients.

ObjectiveThe current study was to evaluate the association of office blood pressure (OBP) and 24h ambulatory blood pressure (ABP) with left ventricular (LV) structure and function in hypertensive patients. Whether the association was modified by sex was also evaluated.MethodsA total of 694 hypertensive patients without cardiovascular disease were retrospectively included from the inpatient clinic. Regression analysis was performed to evaluate the association of OBP and 24h ABP parameters with LV mass index (LVMi), e’ velocity and left ventricular hypertrophy (LVH) with adjustment for covariates including age, obesity, diabetes mellitus, obstructive sleep apnea, estimated glomerular filtration rate and antihypertensive drugs.ResultsThere was no difference in OBP by sex. Compared to women, men had a higher 24h (132.6 ± 11.3 vs 129.3 ± 10.0 mm Hg), daytime (136.6 ± 12.9 vs 132.8 ± 9.5 mm Hg) and nighttime (130.3 ± 9.2 vs 125.1 ± 6.6 mm Hg) SBP. The proportion of patients with non-dipping pattern and reverse dipper pattern was also higher in men. In the overall participants, 24h, daytime and nighttime SBP, non-dipping and reverse dipper pattern were associated with LVMi, e’ velocity and LVH, which were not observed in OBP. The magnitude of the association between 24h, daytime and nighttime SBP, non-dipping and reverse dipper pattern with LVMi, e’ velocity and LVH was stronger in men than in women (P-value for interaction <0.05).ConclusionTwenty-four-hour ABP appears to be better than OBP in association with LV structural and functional alterations, and this association was modified by sex.

Frontal QRS-T angle may predict reverse dipping pattern in masked hypertensives

ABSTRACT Aims The frontal QRS-T (fQRST) angle is associated with worse cardiovascular outcome. The study aimed to assess the effect of reverse dipping pattern on f(QRST) angle in newly diagnosed masked hypertensive (MH) patients. Materials and methods Newly diagnosed 244 consecutive MH patients were included. According to dipping pattern, patients were grouped into three: dipper (n = 114), non-dipper (n = 106), and reverse dipper (n = 24) patterns. The f(QRST) angle, QT and corrected QT interval, and QT dispersion were measured from the 12-lead surface electrocardiogram and compared between groups. Results Of all, 51.2% (n = 125) were male. No gender difference was observed. Reverse dipper MH group had a significantly higher f(QRST) angle than the non-dipper and dipper MH groups (77.9 ± 8.6 vs. 32.4 ± 18.8 and 26.0 ± 18.5, respectively, p < .001). The cutoff value for f(QRST) angle of 51 predicts reverse dipping pattern (AUC: 0.84; 95% CI: 0.77–0.90; p < .001), with a sensitivity of 83% and a specificity of 78%. Conclusion This study revealed that f(QRST) angle is gradually increased starting from the dipper, non-dipper to reverse dipper masked hypertensives. The f(QRST) angle appears as an easy marker for the detection and risk stratification of hypertensive patients.