Morning Surge in Blood Pressure as a Predictor of Silent and Clinical Cerebrovascular Disease in Elderly Hypertensives

Abstract

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

Prognostic Utility of Morning Blood Pressure Surge for 20‐Year All‐Cause and Cardiovascular Mortalities: Results of a Community‐Based Study

“…First, compared with the previous seminal study investigating the prognostic value of STMS in elderly hypertensive outpatients, our population‐based study subjects were relatively younger, with a lower mean 24‐hour SBP level 4. The characteristics of our study population may dilute the impact of the amplitude of STMS on cardiovascular mortality, which may be modulated by age and 24‐hour SBP level.…”

“…Ambulatory BP monitoring (ABPM), by tracking changes in the BP level over 24 hours, provides the opportunity to test the hypothesis that the high incidence of cardiovascular complications in the morning is linked to an exaggerated night‐to‐day BP elevation 3. Indeed, the morning BP surge (MS) has been demonstrated to be an important prognostic factor of cardiovascular end points in Japanese elderly hypertensive patients4 and in many other population‐based cohorts 5, 6. In a meta‐analysis of 5645 subjects from 8 cohorts, sleep‐trough MS (STMS) significantly and independently associated with cardiovascular outcomes 5.…”

Diurnal blood pressure variation and sympathetic activity

“…29,30 The issue has important clinical and therapeutic implications because exaggerated morning blood pressure surge is associated with a greater risk of cerebrovascular and cardiovascular events. [30][31][32][33] Therapeutic implications could include the use of antihypertensive drugs that are capable of reducing adrenergic activation to achieve a better blood pressure control in the early morning hours. 34 Two additional factors may affect sympathetic neural influence on diurnal and early morning blood pressure variation, blood pressure patterns during sleep and sleep apnea.…”

Telmisartan versus angiotension-converting enzyme inhibitors in the treatment of hypertension: a meta-analysis of randomized controlled trials

“…43,44 In addition, the increased BP variability is independently associated with increased target-organ damage and cardiovascular events. 45,46 The ARB telmisartan might be of benefit with smooth and sustained 24-h BP.…”