Background-Cardiovascular events occur most frequently in the morning hours. We prospectively studied the association between the morning blood pressure (BP) surge and stroke in elderly hypertensives. Methods and Results-We studied stroke prognosis in 519 older hypertensives in whom ambulatory BP monitoring was performed and silent cerebral infarct was assessed by brain MRI and who were followed up prospectively. The morning BP surge (MS) was calculated as follows: mean systolic BP during the 2 hours after awakening minus mean systolic BP during the 1 hour that included the lowest sleep BP. During an average duration of 41 months (range 1 to 68 months), 44 stroke events occurred. When the patients were divided into 2 groups according to MS, those in the top decile (MS group; MS Ն55 mm Hg, nϭ53) had a higher baseline prevalence of multiple infarcts (57% versus 33%, Pϭ0.001) and a higher stroke incidence (19% versus 7.3%, Pϭ0.004) during the follow-up period than the others (non-MS group; MS Ͻ55 mm Hg, nϭ466). After they were matched for age and 24-hour BP, the relative risk of the MS group versus the non-MS group remained significant (relative riskϭ2.7, Pϭ0.04). The MS was associated with stroke events independently of 24-hour BP, nocturnal BP dipping status, and baseline prevalence of silent infarct (Pϭ0.008). Conclusions-In older hypertensives, a higher morning BP surge is associated with stroke risk independently of ambulatory BP, nocturnal BP falls, and silent infarct. Reduction of the MS could thus be a new therapeutic target for preventing target organ damage and subsequent cardiovascular events in

Stroke occurs most frequently in the morning hours, but the impact of the morning blood pressure (BP) level on stroke risk has not been fully investigated in hypertensives. We studied stroke prognosis in 519 older hypertensives in whom ambulatory BP monitoring was performed, and who were followed prospectively. During an average duration of 41 months (range: 1-68 months), 44 stroke events occurred. The morning systolic BP (SBP) was the strongest independent predictor for stroke events among clinic, 24-h, awake, sleep, evening, and pre-awake BPs, with a 10 mmHg increase in morning SBP corresponding to a relative risk (RR) of 1.44 (p <0.0001). The average of the morning and evening SBP (Av-ME-SBP; 10 mmHg increase: RR =1.41, p =0.0001), and the difference between the morning and evening SBP (Di-ME-SBP; 10 mmHg increase: RR =1.24, p =0.0025) were associated with stroke risks independently of each other. The RR of morning hypertension (Av-ME-SBP ≥ 135 mmHg and Di-ME-SBP≥20 mmHg) vs. sustained hypertension (Av-ME-SBP ≥135 mmHg and Di-ME-SBP <20 mmHg) for stoke events was 3.1 after controlling for other risk factors (p =0.01). In conclusion, morning hypertension is the strongest independent predictor for future clinical stroke events in elderly hypertensive patients, and morning and evening BPs should be monitored in the home as a first step in the treatment of hypertensive patients. (Hypertens Res 2006; 29: 581-587)

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Older age, beta-blocker use, and regular alcohol drinking were significant determinants of the exaggerated ME difference in medicated hypertensive patients.

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Amlodipine monotherapy was more effective than valsartan monotherapy in controlling 24-h ambulatory BP and morning BP in hypertensive patients.

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Based on the study results, SDB assessed by overnight pulse oximetry was associated with silent cerebral disease in a high-risk, community-dwelling Japanese population.