Role of ambulatory blood pressure monitoring for the management of hypertension in Asian populations

Out‐of‐clinic blood pressure (BP) measurement, eg, ambulatory BP monitoring, has a strong association with target organ damage and is a powerful predictor of cardiovascular events compared with clinic BP measurement. Ambulatory BP monitoring can detect masked hypertension or various BP parameters in addition to average 24‐hour BP level. Short‐term BP variability assessed by standard deviation or average real variability, diminished nocturnal BP fall, nocturnal hypertension, and morning BP surge assessed by ambulatory BP monitoring have all been associated with target organ damage and cardiovascular prognosis. Recently, the authors compared the degree of sleep‐trough morning BP surge between a group of Japanese and a group of Western European untreated patients with hypertension and found that sleep‐trough morning BP surge in Japanese persons was significantly higher than that in Europeans. Although Asian persons have been known to have a higher incidence of stroke than heart disease, the difference in characteristics of BP indices assessed by ambulatory BP monitoring might be the cause of racial differences in stroke incidence between Asian and Western populations. This review focuses on Asian characteristics for the management of hypertension using ambulatory BP monitoring.     

Clinical significance of nocturnal home blood pressure monitoring and nocturnal hypertension in Asia

Nocturnal home blood pressure (BP) monitoring has been used in clinical practice for ~20 years. The authors recently showed that nocturnal systolic BP (SBP) measured by a home BP monitoring (HBPM) device in a Japanese general practice population was a significant predictor of incident cardiovascular disease (CVD) events, independent of office and morning home SBP levels, and that masked nocturnal hypertension obtained by HBPM (defined as nocturnal home BP ≥ 120/70 mmHg and average morning and evening BP < 135/85 mmHg) was associated with an increased risk of CVD events compared with controlled BP (nocturnal home BP < 120/70 mmHg and average morning and evening BP < 135/85 mmHg). This evidence revealed that (a) it is feasible to use a nocturnal HBPM device for monitoring nocturnal BP levels, and (b) such a device may offer an alternative to ambulatory BP monitoring, which has been the gold standard for the measurement of nocturnal BP. However, many unresolved clinical problems remain, such as the measurement schedule and conditions for the use of nocturnal HBPM. Further investigation of the measurement of nocturnal BP using an HBPM device and assessments of the prognostic value are thus warranted. Asians are at high risk of developing nocturnal hypertension due to high salt sensitivity and salt intake, and the precise management of their nocturnal BP levels is important. Information and communication technology‐based monitoring devices are expected to facilitate the management of nocturnal hypertension in Asian populations.     

Immediate post‐exercise blood pressure and arterial stiffness in hypertensive and normotensive older females

Although it has been suggested that increased arterial stiffness is linked to exaggerated blood pressure (BP) from brief moderate exercise, it is not clear whether this occurs in older adults with and without hypertension. This study investigates whether the immediate post‐exercise systolic BP following brief moderate exercise is associated with arterial stiffness in older females with different BP status. This cross‐sectional study included 191 older females aged 60–80 years without known cardiovascular disease (CVD). Arterial stiffness was determined by aortic pulse wave velocity (aPWV). Systolic BP was measured before and immediately following a 3‐min moderate walking test (stage 1 Bruce protocol). Specific quartile‐based thresholds were used to define an exaggerated immediate post‐exercise systolic BP for hypertensive and normotensive older females (quartile 4 as an exaggerated response). Traditional CVD risk factors were assessed (covariates). Older females from the highest quartile of immediate post‐exercise absolute systolic BP showed higher aPWV compared to their peers from the lowest quartile (β = .22 m/s, p = .018). The quartile‐based threshold to define the exaggerated post‐exercise systolic BP was higher in hypertensive than in normotensive older females (174 vs. 172 mmHg). In summary, exaggerated immediate post‐exercise systolic BP following a brief moderate exercise is associated with higher arterial stiffness in older females with different BP status.     

Impact of home blood pressure variability on cardiovascular outcome in patients with arterial stiffness: Results of the J‐HOP study

This study sought to investigate whether the relation between increased blood pressure (BP) variability and increased arterial stiffness confers a risk for cardiovascular disease (CVD) events. We analyzed 2648 patients from a practitioner‐based population (mean ± SD age 64.9 ± 11.4 years: 75.8% taking antihypertensive medication) with at least one cardiovascular risk factor who underwent home BP monitoring in the Japan Morning Surge‐Home Blood Pressure Study. The standard deviation (SD_SBP), coefficient of variation (CV_SBP), and average real variability (ARV_SBP) were assessed as indexes of day‐by‐day home systolic BP (SBP) variability. The authors assessed arterial stiffness by brachial‐ankle pulse wave velocity (baPWV) and divided patients into lower (< 1800 cm/s, n = 1837) and higher (≥1800 cm/s, n = 811) baPWV groups. During a mean follow‐up of 4.4 years, 95 cardiovascular events occurred (8.1 per 1000 person‐years). In Cox proportional hazard models adjusted for traditional cardiovascular risk factors including average home SBP, the highest quartiles of SD_SBP (hazard ratio [HR], 2.30; 95% confidence interval [CI], 1.23‐4.32), CV_SBP (HR, 2.89; 95%CI, 1.59‐5.26) and ARV_SBP (HR, 2.55; 95%CI, 1.37‐4.75) were predictive of CVD events compared to the other quartiles in the higher baPWV group. Moreover, 1SD increases in SD_SBP (HR, 1.44; 95%CI, 1.13‐1.82), CV_SBP (HR, 1.49; 95%CI, 1.16‐1.90) and ARV_SBP (HR, 1.37; 95%CI, 1.09‐1.73) were also predictive of CVD events. These associations remained even after N‐terminal pro‐brain natriuretic peptide was added to the models. However, these associations were not observed in the lower baPWV group. We conclude that arterial stiffness contributes to the association between home BP variability and CVD incidence.     

Characteristics of hypertension and arterial stiffness in obstructive sleep apnea: A Scandinavian experience from a prospective study of 6408 normotensive and hypertensive patients

The impact of obstructive sleep apnea (OSA) on arterial stiffness is less studied. We aimed to investigate the prevalence and covariates of increased pulse pressure (PP), a surrogate marker of arterial stiffness, in the entire study population as well as in separate analyses in normotensive and hypertensive patients. Further, we also explored the impact of smoking on brachial BP in hypertensive patients. Between 2012 and 2019, a total of 6408 participants with suspected OSA underwent a standard out‐of‐center respiratory polygraphy. OSA was defined by an apnea‐hypopnea index (AHI) ≥15/h regardless of symptoms. PP ≥60 mmHg was used as a surrogate marker of increased arterial stiffness. Mean age was 49.3±13.7 years, 69.4% were male, and 34.5% had OSA. The prevalence of hypertension was 70.8% in OSA and 46.7% in No‐OSA (AHI < 15/h) controls (P < .0001). Hypertension was controlled (clinic BP < 140/90 mmHg) in 45.5% and uncontrolled in 54.5% (P < .001). Mean PP was 50±12 mmHg in smokers and 52±12 mmHg in non‐smokers (P = .001). Increased PP was found in 24.2% of the entire study population and was higher in patients with OSA compared to No‐OSA group (27.5% vs 22.4%, P < .0001). In an unadjusted logistic regression model, OSA was associated with a 1.3‐fold higher risk of having increased PP (95% CI 1.16‐1.48, P < .001). In a multivariable‐adjusted model, higher age, male sex, and history of hypertension, but not OSA (OR 0.89; 95% CI 0.77‐1.02, P = .104) were associated with increased PP. In this large study of nearly 6500 participants who were referred with suspected OSA, one‐third were diagnosed with OSA and a quarter had increased arterial stiffness by elevated brachial PP. Hypertension but not OSA per se was associated with increased arterial stiffness. Hypertension was highly prevalent and poorly controlled.     

Characteristics and control of the 24‐hour ambulatory blood pressure in patients with metabolic syndrome

Asian countries are facing an increasing prevalence of metabolic syndrome (MetS), which may aggravate the burden of cardiovascular diseases in this region. MetS is closely associated with ambulatory blood pressure (BP). Patients with MetS, compared to those without, had a twofold higher risk of new‐onset office, home, or ambulatory hypertension. Furthermore, the risk of new‐onset MetS in patients with white‐coat, masked and sustained hypertension was also doubled compared to normotensives. High‐risk masked hypertension and blunted nighttime BP dipping are common in patients with MetS, suggesting perfect 24‐hour BP control with long‐acting antihypertensive drugs and early initiation of combination therapy might be especially important for patients with MetS.     

Long sleep duration and cardiovascular disease: Associations with arterial stiffness and blood pressure variability

Although short and long sleep duration are both risk factors of cardiovascular disease (CVD), the recent meta‐analyses have been shown that long sleep duration was closely associated with CVD mortality. While the specific mechanism underlying the association between long sleep duration and CVD remains unclear, long sleep duration was shown to be associated with arterial stiffness and blood pressure variability (BPV) in many Asian populations. This review article will focus on the pathophysiology of long sleep duration, arterial stiffness, BPV and their effects on CVD. To set the stage for this review, we first summarize the current insights for the relationship between long sleep duration and CVD in relation to arterial stiffness and BPV.     

Home blood pressure control status in 2017‐2018 for hypertension specialist centers in Asia: Results of the Asia BP@Home study

A self‐measured home blood pressure (BP)‐guided strategy is an effective practical approach to hypertension management. The Asia BP@Home study is the first designed to investigate current home BP control status in different Asian countries/regions using standardized home BP measurements taken with the same validated home BP monitoring device with data memory. We enrolled 1443 medicated hypertensive patients from 15 Asian specialist centers in 11 countries/regions between April 2017 and March 2018. BP was relatively well controlled in 68.2% of patients using a morning home systolic BP (SBP) cutoff of <135 mm Hg, and in 55.1% of patients using a clinic SBP cutoff of <140 mm Hg. When cutoff values were changed to the 2017 AHA/ACC threshold (SBP <130 mm Hg), 53.6% of patients were well controlled for morning home SBP. Using clinic 140 mm Hg and morning home 135 mm Hg SBP thresholds, the proportion of patients with well‐controlled hypertension (46%) was higher than for uncontrolled sustained (22%), white‐coat (23%), and masked uncontrolled (9%) hypertension, with significant country/regional differences. Home BP variability in Asian countries was high, and varied by country/region. In conclusion, the Asia BP@Home study demonstrated that home BP is relatively well controlled at hypertension specialist centers in Asia. However, almost half of patients remain uncontrolled for morning BP according to new guidelines, with significant country/regional differences. Strict home BP control should be beneficial in Asian populations. The findings of this study are important to facilitate development of health policies focused on reducing cardiovascular complications in Asia.     

Visit‑to‑visit blood pressure variability is associated with arterial stiffness in Chinese adults: A prospective analysis

Blood pressure (BP) variability may have its effect on the development of vascular disease. The authors aimed to examine the association between the visit‐to‐visit variability (VVV) of BP and arterial stiffness in Chinese adults. The authors included 1407 participants from a prospective cohort study of community residents who were ≥40 years, without a history of myocardial infarction or stroke, and with data at the baseline, the second and the third visits in 2008, 2009, and 2013. The VVV of BP was defined as the standard deviation (SD), the coefficient of variation (CV), the average successive variability (ASV), and the variability independent of the mean (VIM) in BP levels at the 3 visits. Arterial stiffness was measured by brachial‐ankle pulse wave velocity (ba‐PWV) at the 2nd and the 3rd visits. Levels of ba‐PWV change and the occurrence of an elevated ba‐PWV increased significantly in the highest tertile of VVV measures of systolic BP (SBP) and pulse pressure (PP) compared with the lowest tertile, respectively. The multivariable regression analysis revealed that VVV measures of SBP and PP were significantly associated with levels of ba‐PWV change and the risks of developing an elevated ba‐PWV. The odds ratios (ORs) and 95% confidence intervals (CIs) for the risk were 2.12 (1.57–3.12) and 1.92 (1.38–2.68) in participants with the highest versus the lowest tertile of SBP‐SD and PP‐SD, respectively. No significant association was found for diastolic BP variability measures. The increased long‐term variabilities of SBP and PP were associated with an increased risk of arterial stiffness.     

Differences in ambulatory blood pressure profiles between Japanese and Thai patients with hypertension /suspected hypertension

Ethnic differences in the profiles of hypertension and cardiovascular risk have been reported between Asians and Westerners. However, blood pressure (BP) profiles and the risk factors for cardiovascular disease might differ even among different Asian populations because of the diversity of cultures, foods, and environments. We retrospectively examined differences in 24‐h BP profiles between 1051 Japanese (mean age, 62.5 ± 12.4 years; medicated hypertension, 75.7%) and 804 Thai (mean age, 56.9 ± 18.5 years; medicated hypertension, 65.6%) by using the Japanese and Thai ambulatory BP monitoring (ABPM) databases, in order to check the BP control status in treated hypertensives and to inform the clinical diagnosis of hypertension. The two populations had similar office systolic BP (SBP) (142.7 ± 20.0 vs 142.3 ± 20.6 mm Hg, p = .679). However, the Japanese population had higher 24‐hr average and daytime SBP, and the Thai population had higher nighttime SBP even after adjusting for cardiovascular risk factors (all p < .05). Greater morning BP surge was observed in Japanese (31.2 vs 22.8 mm Hg, p < .001). Regarding nocturnal BP dipping status, the prevalence of riser status (higher nighttime than daytime SBP) was higher in the Thai population (30.5% vs 10.9%). These findings suggest that a substantial difference in 24‐hr BP profiles exists between even neighboring countries in Asia.     

Nocturnal blood pressure surge in seconds is associated with arterial stiffness independently of conventional nocturnal blood pressure variability in suspected obstructive sleep apnea patients

Nocturnal blood pressure (BP) surge in seconds (sec-surge), which is characterized as acute transient BP elevation over several tens of seconds is induced by obstructive sleep apnea (OSA) and OSA-related sympathetic hyperactivity. The authors assessed the relationship between sec-surge and arterial stiffness in 34 nocturnal hypertensive patients with suspected OSA (mean age 63.9 ± 12.6 years, 32.4% female). During the night, they had beat-by-beat (BbB) BP and cuff-oscillometric BP measurements, and brachial-ankle pulse wave velocity (baPWV) was assessed as an arterial stiffness index. Multiple linear regression analysis revealed that the upward duration (UD) of sec-surge was significantly associated with baPWV independently of nocturnal oscillometric systolic BP variability (β = .365, p = .046). This study suggests that the UD of sec-surge, which can only be measured using a BbB BP monitoring device, may be worth monitoring in addition to nocturnal BP level.     

Prognostic value of daytime and nighttime blood pressure in treated hypertensive patients according to age and sex

The authors assessed the prognostic value of daytime and nighttime blood pressure (BP) in adult (≤65 years) or old (> 65 years) women or men with treated hypertension. Cardiovascular outcomes were evaluated in 2264 patients. During the follow‐up (mean 10 years), 523 cardiovascular events occurred. After adjustment for covariates, both daytime and nighttime systolic BP were always associated with outcomes, that is, hazard ratio (95% confidence interval per 10 mm Hg increment) 1.22 (1.04‐1.43) and 1.20 (1.04‐1.37), respectively, in adult women, 1.30 (1.18‐1.43) and 1.21 (1.10‐1.33), respectively, in adult men, 1.21 (1.10‐1.33) and 1.18 (1.07‐1.31), respectively, in old women, and 1.16 (1.01‐1.33) and 1.28 (1.14‐1.44), respectively, in old men. When daytime and nighttime systolic BP were further and mutually adjusted, daytime and nighttime BP had comparable prognostic value in adult and old women, daytime BP remained associated with outcomes in adult men (hazard ratio 1.40, 95% confidence interval 1.13‐1.74 per 10 mm Hg increment), and nighttime BP remained associated with outcomes in old men (hazard ratio 1.35, 95% confidence interval 1.11‐1.64 per 10 mm Hg increment). Daytime and nighttime systolic BP have similar prognostic impact in adult and old women with treated hypertension, whereas daytime BP is a stronger predictor of risk in adult men and nighttime BP is a stronger predictor of risk in old men.     

Current status of ambulatory blood pressure monitoring in Asian countries: A report from the HOPE Asia Network

Ambulatory blood pressure monitoring (ABPM) can measure 24‐hour blood pressure (BP), including nocturnal BP and diurnal variations. This feature of ABPM could be of value in Asian populations for preventing cardiovascular events. However, no study has yet investigated regarding the use of ABPM in actual clinical settings in Asian countries/regions. In this study, 11 experts from 11 countries/regions were asked to answer questionnaires regarding the use of ABPM. We found that its use was very limited in primary care settings and almost exclusively available in referral settings. The indications of ABPM in actual clinical settings were largely similar to those of home BP monitoring (HBPM), that is, diagnosis of white‐coat or masked hypertension and more accurate BP measurement for borderline clinic BP. Other interesting indications, such as nighttime BP patterns, including non‐dipper BP, morning BP surge, and BP variability, were hardly adopted in daily clinical practice. The use of ABPM as treatment guidance for detecting treated but uncontrolled hypertension in the Asian countries/regions didn't seem to be common. The barrier to the use of ABPM was primarily its availability; in referral centers, patient reluctance owing to discomfort or sleep disturbance was the most frequent barrier. ABPM use was significantly more economical when it was reimbursed by public insurance. To facilitate ABPM use, more simplified indications and protocols to minimize discomfort should be sought. For the time being, HBPM could be a reasonable alternative.     

Association of morning blood pressure surge with chronic kidney disease progression in patients with chronic kidney disease and hypertension

Blood pressure (BP) usually rise from being asleep to awake, which is named the morning blood pressure surge (MBPS). Researches have reported that elevated MBPS was related with CV events, incident CKD in hypertensive patients. However, there have been no studies that have investigated the association between MBPS and renal or heart outcomes in patients with CKD and hypertension, in these patients, the MBPS is much lower because of high prevalence of night hypertension and reduced BP dipping. In this prospective two‐center observational study, we enrolled patients with CKD and hypertension and the 24 h ambulatory blood pressure monitoring (ABPM) was conducted in all patients. Time to total mortality, CKD progression and CV events was recorded; Finally, a total of 304 patients were enrolled and 94 (30.9%) of them had elevated MBPS. After a follow‐up for median 30 months, 23 (7.6%), 34 (11.2%), and 95 (31.3%) patients occurred death, CKD progression and new‐onset CV events, respectively. The Cox regression analysis suggested the elevated MBPS was a strong predictor of CKD progression (HR 2.35, 95%CI 1.2 ‐4.63, p = .013), independent of morning BP, while no associations were found between elevated MBPS and CV events (HR 1.02, 95%CI 0.66 ‐1.57), as well as death (HR 1.08, 95%CI 0.46 ‐2.55). In conclusion, we provided the first evidence that elevated MBPS was an important risk factor of CKD progression in patients with CKD and hypertension. Appropriate evaluation and management of MBPS may be helpful to postpone CKD progression.     

Morning surge in blood pressure and blood pressure variability in Asia: Evidence and statement from the HOPE Asia Network

Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases. To effectively prevent end‐organ damage, maintain vascular integrity and reduce morbidity and mortality, it is essential to decrease and adequately control blood pressure (BP) throughout each 24‐hour period. Exaggerated early morning BP surge (EMBS) is one component of BP variability (BPV), and has been associated with an increased risk of stroke and cardiovascular events, independently of 24‐hour average BP. BPV includes circadian, short‐term and long‐term components, and can best be documented using out‐of‐office techniques such as ambulatory and/or home BP monitoring. There is a large body of evidence linking both BPV and EMBS with increased rates of adverse cardio‐ and cerebrovascular events, and end‐organ damage. Differences in hypertension and related cardiovascular disease rates have been reported between Western and Asian populations, including a higher rate of stroke, higher prevalence of metabolic syndrome, greater salt sensitivity and more common high morning and nocturnal BP readings in Asians. This highlights a need for BP management strategies that take into account ethnic differences. In general, long‐acting antihypertensives that control BP throughout the 24‐hour period are preferred; amlodipine and telmisartan have been shown to control EMBS more effectively than valsartan. Home and ambulatory BP monitoring should form an essential part of hypertension management, with individualized pharmacotherapy to achieve optimal 24‐hour BP control particularly the EMBS and provide the best cardio‐ and cerebrovascular protection. Future research should facilitate better understanding of BPV, allowing optimization of strategies for the detection and treatment of hypertension to reduce adverse outcomes.     

The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation provides a better definition of cardiovascular burden associated with CKD than the Modification of Diet in Renal Disease (MDRD) Study formula in subjects with type 2 diabetes

Differences in 24 h blood pressure (BP) monitoring parameters such as average 24 h BP, day to night BP ratio and BP variability could have an impact in arterial stiffness. The study hypothesis was that despite similar average BP values in ambulatory blood pressure monitoring subjects with increased 24 h BP variability may have increased arterial stiffness. The study population consisted of 115 consecutive young healthy volunteers. Carotid-femoral PWV was measured in all subjects. Clinic BP was measured and an appropriate cuff was fitted on the non-dominant arm of each subject for a 24 h ambulatory blood pressure monitoring session. Waist to hip ratio as well as BMI was measured. Family history and smoking habits were recorded. In univariate analysis, estimated carotid-femoral PWV showed a significant correlation with age, weight, waist circumference, height, clinic systolic and diastolic BP, 24-h systolic and diastolic BP, 24-h pulse pressure, 24-h systolic and diastolic BP variability, daytime systolic and diastolic BP, daytime pulse pressure, daytime systolic and diastolic BP variability, nighttime systolic BP, nighttime pulse pressure and nighttime systolic BP variability. In multivariate regression analysis, age (B=0.95, P<0.001) and 24 h systolic BP variability (B=0.28, P<0.001) were independent determinanats of arterial stiffness. In conclusions, increased 24 h systolic BP variability is associated with arterial stiffness in young healthy volunteers. Pulse wave velocity in a young healthy population is useful to identify determinants of premature arterial stiffness, thus further elucidating the aspects of early vascular ageing.     

Rationale and design for the Asia BP@Home study on home blood pressure control status in 12 Asian countries and regions

Home blood pressure (BP) monitoring is endorsed in multiple guidelines as a valuable adjunct to office BP measurements for the diagnosis and management of hypertension. In many countries throughout Asia, physicians are yet to appreciate the significant contribution of BP variability to cardiovascular events. Furthermore, data from Japanese cohort studies have shown that there is a strong association between morning BP surge and cardiovascular events, suggesting that Asians in general may benefit from more effective control of morning BP. We designed the Asia BP@Home study to investigate the distribution of hypertension subtypes, including white‐coat hypertension, masked morning hypertension, and well‐controlled and uncontrolled hypertension. The study will also investigate the determinants of home BP control status evaluated by the same validated home BP monitoring device and the same standardized method of home BP measurement among 1600 or more medicated patients with hypertension from 12 countries/regions across Asia.     

Association of lower nighttime diastolic blood pressure and hypoxia with silent myocardial injury: The Japan Morning Surge‐Home Blood Pressure study

Whether marked nocturnal blood pressure (BP) reduction is associated with cardiovascular disease (CVD) is still controversial. In addition, no report has yet discussed the relationship between lower nocturnal BP and CVD, involving modification by nighttime hypoxia. We evaluated 840 patients who had one or more cardiovascular risk factors by measuring their high‐sensitivity cardiac troponin T (Hs‐cTnT), N‐terminal pro‐B‐type natriuretic peptide (NT‐pro BNP), and nighttime saturation levels and performing ambulatory BP monitoring. The lowest tertile in nighttime diastolic BP (DBP) (≤66 mmHg) had increased likelihood of the presence of ≥0.014 ng/ml of Hs‐cTnT compared with the second tertile (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.01–3.63), and the lowest tertile of minimum blood oxygen saturation (≤81%) had increased likelihood of the presence of ≥0.014 ng/ml of Hs‐cTnT compared with the third tertile (OR 2.15, 95% CI 1.13–4.10). Additionally, the patients with both lowest tertile of nighttime DBP and minimum SpO2 showed increased likelihood of the presence of ≥0.014 ng/ml of Hs‐cTnT compared with those without this combination (OR 2.93, 95% CI 1.40–6.16). On the other hand, these associations were not found in the presence of ≥125 pg/ml of NT‐pro BNP. In the clinical population, each of lower nocturnal DBP and nighttime hypoxia was associated with asymptomatic myocardial injury, which was represented as higher Hs‐cTnT, and coexisting lower nocturnal DBP and nighttime hypoxia had an additive effect on the risk of myocardial injury.     

Identifying patterns of diurnal blood pressure variation among ELSA‐Brasil participants

Ambulatory blood pressure monitoring (ABPM) is the gold standard method for the diagnosis of hypertension. ABPM provides a set of repeated measurements for blood pressure (BP), usually over 24 h. Traditional approaches characterize diurnal BP variation by single ABPM parameters such as average and standard deviation, regardless of the temporal nature of the data. In this way, information about the pattern of diurnal BP variation and relationship between parameters is lost. The objective of this study was to identify and characterize daily BP patterns considering the set of repeated measures from 24‐h ABPM. A total of 859 adult participants of the Brazilian Longitudinal Study of Adult Health (ELSA‐Brasil) performed a 24‐h ABPM record. Hypertension, sex, age, race/color, education, marital status, smoking, alcohol, physical activity, and BMI were the covariables analyzed. Techniques for longitudinal clustering, multinomial models, and models with mixed effects were used. Three daily BP patterns were identified. Daily BP patterns with high BP presented higher standard deviation and morning surge and lower nocturnal dipping. They showed greater systolic BP variability and faster rise than fall in diastolic BP during sleep. Hypertensive, “pardos,” and men had greater odds to present these patterns. Daily BP patterns with high BP presented the worst profile concerning ABPM parameters associated with cardiovascular risk. The daily BP patterns identified contribute to the characterization of diurnal BP variation.     

Early morning hypertension: what does it contribute to overall cardiovascular risk assessment?

The early morning surge in blood pressure (BP) in patients with hypertension is associated with an increased risk of cardiovascular events, such as myocardial infarction and stroke, especially in the presence of comorbidities of diabetes, cardiac and renal disease. A variety of nonhemodynamic factors contribute to the early morning prothrombotic state, including increased atherothrombotic plaque vulnerability and endovascular shear stress, increased coagulability, platelet aggregation, and blood viscosity, and reduced fibrinolysis. In addition, there is a strong association between morning hypertension and vascular damage throughout the circulation, which may involve the myocardium, large arteries, and other target organs. Because morning hypertension is often unrecognized, the resultant target-organ damage may progress relentlessly. With recent advances in ambulatory BP monitoring and BP self-measurement and the inclusion of antihypertensive agents that target the underlying pathophysiological mechanisms related to the morning BP surge (ie, the sympathetic nervous system and the renin-angiotensin-aldosterone system), control of morning hypertension is clinically feasible and should be an important therapeutic target.