Clinical impact of dipping and nocturnal blood pressure patterns in newly diagnosed,never-treated patients with essential hypertension

The significance of nondipping and increased nighttime systolic blood pressure (SBP) in established hypertension is well defined. We investigated whether these factors alone or combined correlate with vascular damage in early-stage hypertension. Newly diagnosed, untreated hypertensives were classified as dippers and nondippers according to ambulatory blood pressure (BP). Twenty-four–hour urinary albumin excretion and markers of arterial stiffness (pulse wave velocity, augmentation index, central and peripheral pulse pressure, central BP) and atherosclerosis (carotid intima-media thickness) were assessed. Serum asymmetric dimethylarginine, an index of endothelial dysfunction, was measured in a study subgroup; 10-year cardiovascular risk was calculated. Among 222 hypertensives, only urinary albumin excretion was increased in nondippers, compared to dippers (P = .026). When dippers were further stratified according to nighttime SBP (<120 or ≥120 mm Hg), the first group demonstrated the lowest levels of office, aortic, 24-hour, daytime and nighttime BP, compared to dippers with elevated nighttime SBP and nondippers. Although vascular measurements and asymmetric dimethylarginine were comparable between these groups, dippers with normal nighttime SBP exhibited the lowest cardiovascular risk score (P = .050). In early-stage hypertension, nondipping was accompanied by microvascular, yet not macrovascular and endothelial dysfunction. Dippers with elevated nighttime SBP appear as a distinct group with increased hemodynamic pressure load and cardiovascular risk.     

Effects of the long-acting calcium channel blocker barnidipine hydrochloride on 24-h ambulatory blood pressure

The effect of the long acting calcium channel blocker, barnidipine hydrochloride (barnidipine) on 24-h ambulatory blood pressure (ABP) was evaluated in J-MUBA (Japanese Multicentre Study on Barnidipine with Ambulatory Blood Pressure Monitoring). Following an observation period of two weeks, antihypertensive treatment with barnidipine was continued for at least six months. At the end of each period, ABP were measured. The patients were divided into high- and low-range groups based on ABP measurement. Throughout the 24 h, barnidipine exerted an excellent antihypertensive effect in the high-range group, but not in the low-range group. Barnidipine had comparable effects in the daytime and nighttime in inverted dippers and non-dippers, but it was more effective on daytime ABP than on nighttime ABP in dippers and in extreme dippers. Morning blood pressure before and after waking was evaluated before and after barnidipine administration in 233 patients. Barnidipine inhibited increases in blood pressure before and after waking, especially in surge-type patients whose blood pressure increased rapidly after waking. A positive correlation among 24-h ABP, daytime and night time ABP, morning blood pressure, and clinic blood pressure during the observation period and the antihypertensive effect of barnidipine was observed, with barnidipine exhibiting stronger antihypertensive effects in patients with persistently high blood pressure. It was concluded that the antihypertensive effects of barnidipine are maintained for 24 h but it has no excessive hypotensive effects on lower blood pressure and is thus a safe antihypertensive agent.     

Nocturnal blood pressure patterns and cardiovascular outcomes in patients with masked hypertension

Masked hypertension (MHT) is characterized by normal clinic and above normal 24‐hour ambulatory blood pressure (BP) levels. We evaluated clinical characteristics and CV outcomes of different nocturnal patterns of MHT. We analyzed data derived from a large cohort of adult individuals, who consecutively underwent home, clinic, and ambulatory BP monitoring at our Hypertension Unit between January 2007 and December 2016. MHT was defined as clinic BP <140/90 mm Hg and 24‐hour BP ≥ 130/80 mm Hg, and stratified into three groups according to dipping status: (a) dippers, (b) nondippers, and (c) reverse dippers. From an overall sample of 6695 individuals, we selected 2628 (46.2%) adult untreated individuals, among whom 153 (5.0%) had MHT. In this group, 67 (43.8%) were nondippers, 65 (42.5%) dippers, and 21 (13.7%) reverse dippers. No significant differences were found among groups regarding demographics, clinical characteristics, and prevalence of risk factors, excluding older age in reverse dippers compared to other groups (P < 0.001). Systolic BP levels were significantly higher in reverse dippers than in other groups at both 24‐hour (135.6 ± 8.5 vs 130.4 ± 6.0 vs 128.2 ± 6.8 mm Hg, respectively; P < 0.001) and nighttime periods (138.2 ± 9.1 vs 125.0 ± 6.3 vs 114.5 ± 7.7 mm Hg; P < 0.001). Reverse dipping was associated with a significantly higher risk of stroke, even after correction for age, gender, BMI, dyslipidemia, and diabetes (OR 18.660; 95% IC [1.056‐33.813]; P = 0.046). MHT with reverse dipping status was associated with higher burden of BP and relatively high risk of stroke compared to both dipping and nondipping profiles, although a limited number of CV outcomes have been recorded during the follow‐up.     

Changes of nocturnal blood pressure dipping status in hypertensives by nighttime dosing of alpha-adrenergic blocker, doxazosin : results from the HALT study

Abnormal nocturnal blood pressure (BP) dipping status may be partly determined by nocturnal sympathetic activity. We studied the effect of nighttime dosing of an alpha(1)-adrenergic blocker, doxazosin, on the BP dipping status of 118 hypertensives, all of whom underwent 24-hour ambulatory BP monitoring before and after treatment. The mean nighttime/daytime ratio of systolic BP was increased (0.91 after therapy versus 0.89 at baseline, P<0.05). The patients were initially divided into 4 groups on the basis of their dipping status at the baseline assessment: 18 (15%) were extreme dippers, with a nighttime systolic BP fall of at least 20% of daytime BP; 46 (39%) were dippers (fall between 10% and 20%); 48 (41%) were nondippers (fall between 0% and 10%); and 6 (5%) were risers (nocturnal increase of systolic BP). A shift in dipping status toward less nocturnal BP dipping was observed after doxazosin therapy (P<0.05). Dipping status was determined by nighttime more than by daytime BP, and this was not explained by differences in the number of daytime and nighttime readings. The effects of doxazosin on the mean nocturnal systolic BP changes were an increase of 4.3 mm Hg in extreme dippers and decreases of 0.7 mm Hg in dippers, 12 mm Hg in nondippers, and 18 mm Hg in risers; the reduction was only significant in the latter 2 groups (both P<0.01). To estimate the effects of regression to the mean on the changes in dipping status, we also defined dipping status with the average of the BPs before and after doxazosin and found no difference in the degree of nighttime BP reduction among each group. The reduction of daytime BP was now significantly greater in the subgroups with less dipping: 6. 4 mm Hg for extreme dippers and 16 mm Hg for risers (P<0.05). In conclusion, nighttime dosing with doxazosin markedly affects the nocturnal BP dipping status of hypertensives, but the apparently greater reduction in nighttime pressure in nondippers and risers may be, at least partly, due to the effect of regression to the mean. The most important determinants of the effect of doxazosin were the absolute BP levels, both day and night, rather than dipping status per se.     

INSULIN RESISTANCE IS ASSOCIATED WITH REDUCED NOCTURNAL FALLS OF BLOOD PRESSURE IN NORMOTENSIVE,NONOBESE TYPE 2 DIABETIC SUBJECTS

To assess the relationship between insulin resistance and ambulatory blood pressure (BP) pattern, we determined glucose infusion rate (GIR) as a marker of insulin resistance using a glucose clamp method, and measured 24-h BPs in 25 normotensive, nonobese type 2 diabetic subjects. They were divided into two groups: 11 dippers and 14 nondippers. Clinical characteristics were similar in the two groups except for orthostatic fall in systolic BP. The median GIR level was significantly lower in nondippers than in dippers (P < 0.05). Spearman's rank correlation revealed that the GIRs were negatively correlated with the systolic, diastolic and mean BPs during nighttime (P < 0.05 or less), but not with daytime or whole day BPs. Moreover, based on a logistic regression analysis, the GIR as well as orthostatic fall in systolic BP discriminated independently between dippers and nondippers. Thus, our results suggest that insulin resistance is associated with decreased nocturnal BP fall in type 2 diabetic subjects.     

Low Diastolic Ambulatory Blood Pressure Is Associated with Greater All-Cause Mortality in Older Patients with Hypertension

OBJECTIVES: To assess the relationship between office and ambulatory systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) and total mortality in elderly patients with hypertension.
DESIGN: Observational prospective cohort study.
SETTING: Hypertension outpatient clinic in a geriatric academic hospital.
PATIENTS AND METHODS: Eight hundred five older (≥60) subjects with hypertension underwent office and ambulatory BP measurement. Mortality was assessed after a mean follow-up of 3.8 years.
RESULTS: In a total of 3,090 person-years of follow-up, 107 participants died (average mortality rate 3.5% per year). With bivariate analysis, participants who died had higher SBP and PP and lower DBP, with office and ambulatory measurements. Mortality rates were greater with higher SBP and lower with higher DBP. As a combined effect of these trends, PP was associated with the widest death rate gradients, from 12 to 66, 13 to 63, and 9 to 70 per 1,000 person-years across office, 24-hour, daytime, and nighttime PP quartiles, respectively. Multivariate Cox analysis confirmed these trends; the adjusted hazard of death increased linearly with increasing ambulatory SBP and PP, whereas it decreased significantly with increasing ambulatory DBP. A five times greater risk of death was detected when comparing night-time PP quartile 4 (median PP value 78 mmHg) with quartile 1 (median PP value 46 mmHg).
CONCLUSION: In older patients with hypertension, low DBP and high PP, particularly when measured using ambulatory BP monitoring, are associated with greater risk of death. The achievement of an SBP treatment goal should not be obtained at the expense of an excessive DBP reduction.     

Differential Effects of Amlodipine on Ambulatory Blood Pressure in Elderly Hypertensive Patients With Different Nocturnal Reductions in Blood Pressure

Previous studies have discovered that amlodipine given once daily can reduce blood pressure (BP) throughout the day and night. The effects of amlodipine on day and night BP have not been fully investigated in groups of hypertensives with different diurnal variations. In a prospective study, we performed 24-h ambulatory BP monitoring before and after once-daily use of amlodipine in three groups of asymptomatic elderly hypertensive patients with different nocturnal BP reductions, as follows: 10 extreme dippers with nocturnal reduction of systolic BP ≥ 20% of daytime systolic BP, 17 dippers (reduction by ≥ 10% to < 20%), and 23 nondippers (reduction by < 10%). At baseline, the office and the awake BP were similar in all three groups, whereas the nighttime BP was significantly higher in the nondippers than in the dippers and in the dippers than in the extreme dippers. After treatment, the office and the daytime BP were both equally reduced in all three groups. On the other hand, the nighttime BP was significantly reduced both in the nondippers and, to a lesser extent, in the dippers. In the extreme dippers, however, no further reductions of nocturnal BP were found. Significant positive correlations were found between baseline BP levels and the BP reduction after amlodipine therapy was begun. No BP reduction > 10 mm Hg was observed when the baseline systolic/diastolic BP was < 120/70 mm Hg. Multiple linear regression analysis disclosed that the nighttime BP reduction afforded by amlodipine was dependent on the baseline nighttime BP levels, but not on the baseline nocturnal fall of BP. Once-daily use of amlodipine reduced BP levels throughout the day and night in hypertensive patients who show minimal or mild nocturnal BP fall, but it had no effects on nocturnal BP in those who show a substantial nighttime BP reduction. Thus, when we controlled using daytime office BP, amlodipine might not further reduce nocturnal BP to the extent that it accelerates the brain ischemia in some hypertensive patients with marked nocturnal BP reduction.     

Effect of weight loss on blood pressure changes in overweight patients: A systematic review and meta-analysis

To determine quantitative differences between weight loss and changes in clinic blood pressure (BP) and ambulatory BP in patients with obesity or overweight, the authors performed a meta-analysis. PubMed, Embase, and Scopus databases were searched up to June 2022. Studies that compared clinic or ambulatory BP with weight loss were included. A random effect model was applied to pool the differences between clinic BP and ambulatory BP. Thirty-five studies, for a total of 3219 patients were included in this meta-analysis. The clinic systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly reduced by 5.79 mmHg (95% CI, 3.54–8.05) and 3.36 mmHg (95% CI, 1.93–4.75) after a mean body mass index (BMI) reduction of 2.27 kg/m², and the SBP and DBP were significantly reduced by 6.65 mmHg (95% CI, 5.16–8.14) and 3.63 mmHg (95% CI, 2.03–5.24) after a mean BMI reduction of 4.12 kg/m². The BP reductions were much larger in patients with a BMI decrease ≥3 kg/m² than in patients with less BMI decrease, both for clinic SBP [8.54 mmHg (95% CI, 4.62–12.47)] versus [3.83 mmHg (95% CI, 1.22–6.45)] and clinic DBP [3.45 mmHg (95% CI, 1.59–5.30)] versus [3.15 mmHg (95% CI, 1.21–5.10)]. The significant reduction of the clinic and ambulatory BP followed the weight loss, and this phenomenon could be more notable after medical intervention and a larger weight loss.     

高血压病患者运动血压与动态血压关系的研究

目的　探讨高血压病患者运动血压与动态血压的关系。方法　分别以活动平板运动试验中最大运动量时收缩压 (peakSBP)和舒张压 (peakDBP)过度升高和反应正常分组 ,以运动后收缩压(recSBP)和舒张压 (recDBP)恢复慢和恢复正常分组 ,对比分析 30 3例 1、2级高血压病患者的动态血压变化。结果　peakSBP、peakDBP过度升高组动态血压各检测值均显著高于反应正常组 (P <0 0 5或0 0 1) ;recSBP恢复慢组的夜间平均收缩压、舒张压显著高于恢复正常组 (P <0 0 1) ;recDBP恢复慢组白昼舒张压负荷显著高于恢复正常组 (P <0 0 1)。多元逐步回归分析显示 ,对peakSBP、peakDBP、recSBP最具影响的共同参数为夜间平均舒张压。结论　高血压病患者运动试验中 74 2 6 %～ 81 85 %存在运动中血压过度升高和运动后收缩压恢复慢并与动态血压检测值有显著统计意义。     

肾血管性与原发性高血压患者24h动态血压的比较

目的 比较肾血管性高血压(RVH)与原发性高血压(EH)患者24 h动态血压的差别.方法 应用动态血压监测仪观察51例RVH患者的24 h动态血压,并与年龄、性别与之相匹配的51例EH患者的24 h动态血压进行比较.结果 RVH组24 h、白天及夜间动态收缩压、舒张压及脉压均值都比EH组有不同程度的升高(P<0.05),尤以夜间收缩压升高明显;血压负荷增加明显,24 h收缩压、舒张压负荷分别达到58.96%和35.98%,而EH组血压负荷均在20.00%左右,两组比较差异有统计学意义(P<0.05).EH组夜间血压下降率为10.36%,血压曲线呈勺型(60.8%的患者夜间血压下降率>10%);而RVH组夜间血压下降率为5.39%,血压曲线呈非勺型(仅有27.50%的患者夜间血压下降率>10%).结论 RVH患者动态血压均值、脉压和血压负荷明显增加,昼夜节律减弱.

Abstract：

Objective To compare 24 h ambulatory blood pressure changes between patients with renovascular hypertension and essential hypertension.Methods The 24 h ambulatory blood pressure of patients with age and gender matched renovascular hypertension (RVH, n=51) was compared with that of patients with essential hypertension (EH, n=51).Results The 24 h, daytime and nighttime systolic blood pressures(SBP),diastolic blood pressures(DBP) and pulse pressures (PP) in RVH were significantly higher than in EH (all P<0.05), especially the nocturnal SBP (P<0.05). The SBP and DBP loads in RVH were 58.96% and 35.98% respectively, while blood pressure loads were around 20.00% in EH (P<0.05). In patients with RVH, The nocturnal blood pressure fall was 5.39%, and only 27.50% patients were dippers, while the nocturnal blood pressure fall was 10.36% and 60.8% patients were dippers in EH.Conclusion RVH patients have higher dynamic BP, PP, BP loads and blunted diurnal rhythm compared to those with EH.     

高血压合并阻塞性睡眠呼吸暂停低通气综合征患者短时血压变异性的影响因素研究

目的:探讨高血压合并阻塞性睡眠呼吸暂停低通气综合征(OSAS)患者短时血压变异性(BPV)的影响因素。方法:选择2017年6月至2019年5月在宁波市第一医院心血管科诊治的153例高血压患者,给予多导睡眠呼吸监测及动态血压监测,根据睡眠呼吸暂停低通气指数(AHI)将患者分四组:单纯高血压作为对照组(41例)、高血压合并轻度OSAS组(36例)、高血压合并中度OSAS组(36例)、高血压合并重度OSAS组(40例)。采用因子分析方法提取影响高血压合并OSAS患者短时血压变异性的公因子,进行多元线性回归分析影响高血压合并OSAS患者短时血压变异性的因素。结果:因子分析纳入可能影响高血压合并OSAS患者短时血压变异性的因素,共提取4个公因子:体重指数、OSAS严重程度相关参数、生活行为习惯、年龄及高血压病程;多元线性回归分析显示OSAS严重程度与高血压合并OSAS患者夜间收缩压短时血压变异性(nSBPARV)及夜间舒张压短时血压变异性(nDBPARV)均存在相关性(β=0.277,P<0.05;β=0.360,P<0.05),对于高血压合并OSAS患者nSBPARV的影响因素依次为OSAS严重程度>年龄及高血压病程(分别为β=0.277,P<0.05;β=0.225,P<0.05),对于nDBPARV的影响因素依次为OSAS严重程度>体重指数(分别为β=0.360,P<0.05;β=0.187,P<0.05)。高血压合并轻度、中度、重度OSAS组的nSBPARV、nDBPARV均较对照组大;且高血压合并重度OSAS组的nSBPARV、nDBPARV、日间收缩压短时血压变异性均大于对照组、高血压合并轻度、中度OSAS组,差异均具有统计学意义(P<0.05)。结论:高血压患者合并OSAS时容易出现夜间短时血压变异性增加,OSAS严重程度是高血压合并OSAS患者夜间血压短时变异性增加的主要因素,肥胖、年龄及高血压病程也是重要影响因素。     

Clinical trial of arotinolol in the treatment of hypertension: dippers vs. non-dippers.

To compare the effects of an alpha, beta blocker, arotinolol, in the treatment of essential hypertension between patients with a dipper and those with a non-dipper profile by means of 24-h ambulatory blood pressure monitoring (ABPM), a multicenter single blind parallel trial was carried out in five clinical centers. After a one-week single blind placebo run-in period, the patients underwent ABPM if their clinic diastolic blood pressure (DBP) ranged from 90-109 mmHg and their clinic systolic blood pressure (SBP) was <180 mmHg. They were divided into two groups according to the absence (non-dipper group, 24 cases) or presence (dipper group, 23 cases) of nocturnal BP reduction > or =10% of daytime BP. ABPM was measured again at the end of the active treatment phase. All patients were given Arotinolol 10-20 mg twice daily for 4 weeks. Twenty four-hour systolic and diastolic average BPs (MSBP, MDBP), 24-h systolic and diastolic blood pressure load (LS BP, LDBP), daytime systolic and diastolic average BPs (dMSBP, dMDBP), daytime systolic and diastolic blood pressure load (dLSBP, dLDBP), nighttime systolic and diastolic average BPs (nMSBP, nMDBP) and nighttime systolic and diastolic blood pressure load (nLSBP, nLDBP) were calculated. Arotinolol was effective in 78.2% of dippers and 54.2% of non-dippers, but the difference in effectiveness between these groups was not statistically significant. After treatment, SBP and DBP-including 24-h, daytime and nighttime systolic and diastolic BPs- were significantly reduced in both groups. During the daytime period, the systolic and diastolic blood pressures were significantly reduced in both dippers and non-dippers, while nighttime systolic and diastolic blood pressures were significantly reduced only in the non-dipper group. No significant changes were found in the dipper group over this period. In conclusion, Arotinolol, which can be dosed twice daily, is an effective antihypertensive agent which effectively lowers blood pressure during the day while reducing nighttime blood pressure more in non-dippers than in dippers, without excessive lowering blood pressure in the latter.     

Racial differences in nocturnal dipping status in diabetic kidney disease: Results from the STOP‐DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) study

While racial variation in ambulatory blood pressure (BP) is known, patterns of diurnal dipping in the context of diabetic kidney disease have not been well defined. The authors sought to determine the association of race with nocturnal dipping status among participants with diabetic kidney disease enrolled in the STOP‐DKD (Simultaneous Risk Factor Control Using Telehealth to Slow Progression of Diabetic Kidney Disease) trial. The primary outcome was nocturnal dipping—percent decrease in average systolic BP from wake to sleep—with categories defined as reverse dippers (decrease <0%), nondippers (0%–<10%), and dippers (≥10%). Twenty‐four‐hour ambulatory BP monitoring was completed by 108 participants (54% were nondippers, 24% were dippers, and 22% were reverse dippers). In adjusted models, the common odds of reverse dippers vs nondippers/dippers and reverse dippers/nondippers vs dippers was 2.6 (95% confidence interval, 1.2–5.8) times higher in blacks than in whites. Without ambulatory BP monitoring data, interventions that target BP in black patients may be unable to improve outcomes in this high‐risk group.     

Captopril Administered at Night Restores the Diurnal Blood Pessure Rhythm in Adequately Controlled,Nondipping Hypertensives

The aim of our study was to evaluate whether captopril administered at night, can shift the circadian blood pressure (BP) from a nondipper to a dipper pattern in adequately controlled hypertensive patients, who continued their antihypertensive therapy. In a prospective, randomized, double blind, placebo-controlled designed study, we enrolled 121 treated, adequately controlled nondipping hypertensive patients. All patients were randomly assigned to 12.5 mg captopril or placebo treatment administered at night. In case of nondippers, the dosage of captopril or placebo was doubled after two weeks of treatment, while for dippers antihypertensive regimens were not changed. After another two weeks, all patients underwent ambulatory BP monitoring. Our results show that at the end of the active treatment period, the prevalence of a dipping diurnal BP pattern in the captopril group (70%) was significantly higher than that in the placebo group (9.8%, P < 0.001). Nighttime BP, night/day BP ratio, nighttime BP load and 24-h systolic BP were significantly lower after 4 weeks nighttime captopril treatment compared to baseline. In conclusion, the present study demonstrates for the first time that captopril administered at night can restore the diurnal BP rhythm and decrease the elevated night/day BP ratio in appropriately controlled, nondipper hypertensive patients. These results were mainly due to the decrease of nighttime BP.     

老老年人群动态血压参数与动脉僵硬度的相关性

目的探讨老老年人群动态血压参数与动脉僵硬度的相关性。方法筛选年龄≥80岁的老老年人238例,以血压≥160/95 mm Hg(1 mm Hg=0.133 kPa)为标准,分为高血压组(134例)和对照组(104例),并进行臂-踝脉搏传导速度(baPWV)和24 h动态血压监测。用Pearson分析动态血压各参数与动脉僵硬度的相关性。结果高血压组baPWV高于对照组(P<0.05)。高血压组偶测收缩压,24 h、昼间和夜间收缩压、舒张压、脉压,收缩压负荷及舒张压负荷均高于对照组.夜间收缩压下降率、舒张压下降率低于对照组,差异有统计学意义(P<0.05,P<0.01)。baPWV与偶测血压;24 h收缩压、舒张压、脉压;昼间收缩压、舒张压、脉压、心率;夜间收缩压、舒张压、脉压;收缩压负荷、舒张压负荷呈正相关(P<0.05,P<0.01),而与夜间收缩压下降率呈负相关(P<0.01)。结论高血压是老老年人群动脉僵硬度增加的一个重要因素,动脉僵硬度与动态血压、脉压、心率及血压负荷相关。     

80例老年高血压病人的动态血压监测及康复干预的效果

目的：探讨老年高血压患的动态血压监测特点及康复治疗意义。方法：使用英国产MEDILOG ABP MONIFORING SYSTEM（无创伤性动态血压监测仪），对80例老年高血压患进行24小时动态血压监测，采用固定时间段记录（日间每15分钟1次，晚间每30分钟1次）。38例轻，中度老年高血压患接受了8周的综合康复干预疗法。结果：老年高血压患的24小时平均SBP及DBP，日间及夜间SBP及DBP，血压负荷值，24小时mBP及mPP等参数值均明显高于正常参照值（P＜0．05）。康复组在接受8周康复治疗后血压各参数水平显下降（P＜0．05－P＜0．05）。：ABPM的常用参数是诊断高血压，指导临床用药，观察评估康复疗效，预测并发症的重要指标。     

Ambulatory blood pressure in the dash diet trial: Effects of race and albuminuria

We evaluated whether low‐grade albuminuria or black race modulates ambulatory blood pressure (BP) or nocturnal BP response to the DASH diet. Among 202 adults enrolled in the DASH multicenter trial who were fed the DASH or control diet for 8 weeks, reductions in 24‐hour daytime and nighttime SBP and DBP were significantly larger for DASH compared to control. Median changes in nocturnal BP dipping were not significant. Compared to urine albumin excretion of <7 mg/d, ≥7 mg/d was associated with larger significant median reductions in 24‐hour SBP (?7.3 vs ?3.1 mm Hg), all measures of DBP (24‐hour: ?5.9 vs ?1.8 mm Hg; daytime: ?9.9 vs ?4.0 mm Hg; nighttime ?9.0 vs ?2.0 mm Hg), and with increased nocturnal SBP dipping (2.3% vs ?0.5%). Black race was associated with larger median reduction in 24‐hour SBP only (?5.5 vs ?2.4 mm Hg). This analysis suggests greater effect of DASH on ambulatory BP in the presence of low‐grade albuminuria.     

Relationships between new risk factors and circadian blood pressure variation in untreated subjects with essential hypertension

Recently a growing amount of interest has been focused on new risk factors for cardiovascular disease, such as insulin, leptin, homocysteine, and urinary albumin excretion (UAE). Furthermore, the absence of a nocturnal blood pressure (BP) decrease is emerging as an index for future target organ damage. In the present study we aimed to determine the relationship between these risk factors and circadian BP variations in essential hypertensive subjects.One hundred six patients, aged 54 ± 7 years, with stage I–II untreated hypertension were classified as dippers and nondippers according to the diurnal variation of >10% between mean daytime and nighttime systolic BP (SBP) and diastolic BP (DBP) in 24-h noninvasive ambulatory BP monitoring. Venous blood samples were drawn for determination of insulin, leptin, and homocysteine plasma levels, whereas UAE was evaluated in three consecutive 24-h urine samples. Nondippers compared to dippers had significantly greater hemodynamic load and higher UAE (by 17 mg/24 h, P < .05). The two groups did not differ regarding serum insulin, plasma leptin, and homocysteine levels. In the entire population, leptin was positively correlated with age, body mass index, 24-h DBP, fasting serum insulin, and plasma homocysteine levels, whereas homocysteine levels were significantly related to 24-h SBP and DBP values. Multiple linear regression analyses revealed that only UAE was significantly related with nocturnal SBP and DBP decrease (P < .05 for both). These findings suggest that the increased UAE observed in nondipper hypertensive subjects possibly represents a useful indicator for future target organ damage.     

Circadian Blood Pressure Changes and Myocardial Ischemia in Hypertensive Patients With Coronary Artery Disease

Objectives. We sought to evaluate whether different circadian blood pressure (BP) changes could influence the occurrence of ischemic episodes in untreated and treated hypertensive patients with stable coronary artery disease (CAD).

Background. In hypertensive patients with CAD the occurrence of myocardial ischemia could be influenced by either high or low BP values. Ambulatory monitoring has shown that circadian BP profile is not uniform in hypertensive patients.

Methods. Twenty-one patients with a nighttime BP fall <10% (“nondippers”), 35 with a nighttime BP fall between >10% and <20% (“dippers”) and 14 with a nighttime BP fall >20% (“overdippers”) with CAD underwent simultaneous ambulatory BP and electrocardiographic monitoring before and during drug therapy with nitrates and atenolol or verapamil in a prospective, randomized, open, blinded end point design.

Results. Daytime BP was not significantly different among the groups both before and during therapy. Nighttime BP was different by definition. Treatment significantly reduced BP values in each group (p < 0.05). Daytime ischemic episodes did not differ among the groups either before or during therapy. Drug therapy significantly reduced daytime ischemia (p < 0.05). In untreated patients, nighttime ischemia was more frequent in nondippers than in dippers and overdippers (p < 0.05). Drug therapy significantly reduced nocturnal ischemia in nondippers (p < 0.05), had no significant effect in dippers and significantly increased nighttime ischemia in overdippers (p < 0.05). During treatment, nighttime ischemia was more frequent in overdippers than in dippers and nondippers (p < 0.05). The same results were achieved when ischemic episodes were defined with more restrictive criteria (ST segment depression ≥2 mm).

Conclusions. Circadian BP changes can influence the occurrence of myocardial ischemia in untreated and treated hypertensive patients with CAD. Nocturnal ischemia was found to be more frequent in nondippers among untreated patients and in overdippers among treated patients, potentially suggesting different therapeutic approaches based on circadian BP profile.     

Clinical predictors and impact of ambulatory blood pressure monitoring in pediatric hypertension referrals

Elevated blood pressure (BP) is rising in children. Significant proportions of children have reactive hypertension or masked hypertension, making ambulatory BP monitoring (ABPM) a valuable tool, although with potential economic implications. In youth referred for elevated BP, we sought clinic BP combinations that obviated the need for ABPM and to specify the economic role of ABPM. In a retrospective pediatric referral cohort (N = 170), we examine clinic systolic BP (SBP) predictors of components of ABPM hypertension and their combination. In economic analyses, we compared effectiveness and charges of three diagnostic pathways: (1) clinic BP alone; (2) abnormal clinic BP prompting ABPM; or (3) universal ABPM. ABPM hypertension occurred in 55 (32.4%) and reactive hypertension in 37 (21.8%), average automated (β = 0.208; 95% confidence interval, 0.027, 0.389; P = .03) and maximum auscultatory clinic SBP (β = 0.160; 95% confidence interval 0.022, 0.299; P = .02) were associated with ABPM SBP mean, but none predicted SBP load. No clinic SBP combination was associated with ABPM hypertension. Universal ABPM accrued the lowest average charge per hypertensive youth identified ($10,948). We did not identify a clinic SBP combination that predicted ABPM hypertension in youth referred for elevated BP. Universal ABPM, in this context, may be the most economically and clinically efficient diagnostic strategy.