Prognostic Significance for Stroke of a Morning Pressor Surge and a Nocturnal Blood Pressure Decline

Abstract

Abstract-There is continuing controversy over whether the pattern of circadian blood pressure (BP) variation that includes a nocturnal decline in BP and a morning pressor surge has prognostic significance for stroke risk. In this study, we followed the incidence of stroke in 1430 subjects aged Ն40 years in Ohasama, Japan, for an average of 10.4 years. The association between stroke risk and the pattern of circadian BP variation was analyzed with a Cox proportional hazards model after adjustment for possible confounding factors. There was no significant association between total stroke risk and the nocturnal decline in BP (percentage decline from diurnal level) or between total stroke risk and the morning pressor surge. The cerebral infarction risk was significantly higher in subjects with a Ͻ10% nocturnal decline in BP as compared with subjects who had a Ն10% nocturnal decline in BP (Pϭ0.04). The morning pressor surge was not associated with a risk of cerebral infarction. On the other hand, an increased risk of cerebral hemorrhage was observed in subjects with a large morning pressor surge (Ն25 mm Hg; Pϭ0.04). Intracerebral hemorrhage was also observed more frequently in extreme dippers (those with a Ն20% nocturnal decline in BP) than dippers (those with a 10% to 19% decline; Pϭ0.02). A disturbed nocturnal decline in BP is associated with cerebral infarction, whereas a large morning pressor surge and a large nocturnal decline in BP, which are analogous to a large diurnal increase in BP, are both associated with cerebral hemorrhage.

Efficacy of olmesartan/amlodipine combination therapy in reducing ambulatory blood pressure in moderate-to-severe hypertensive patients not controlled by amlodipine alone

“…28 In our study, the combination of amlodipine with the ARB olmesartan decreased not only 24-h BP levels but also early morning and morning BP levels. This finding is important in the light of previous reports suggesting that either morning blood pressure surge 13,29 or morning hypertension 30 may be an independent risk factor for cardiovascular events. As the methodology of morning surge assessment is far from being defined, we focused on assessing the average BP level in two subperiods of the morning hours that is, (1) early morning (0400-0700 hours), which in most subjects lies in the preawake period and is associated with a sympathetic activation Olmesartan/amlodipine: 24-h BP control G Bilo et al related to the higher frequency of Rapid Eye Movement (REM) sleep, and with an increased activity of several hormonal systems (including RAAS or cortisol secretion), 31 which might contribute to the increased rate of cardiovascular events observed in this period; (2) morning (0800 hours to noon) corresponding to the first hours of subjects daily activity and associated commonly with significant BP variations due to changes in posture and physical activity.…”

Non-dipping pattern relates to endothelial dysfunction in patients with uncontrolled resistant hypertension

“…Individuals with a non-dipper pattern (reduction in nighttime SBP o10%) are at increased risk for cerebrovascular and cardiovascular complications Nocturnal dipping and endothelial function in resistant hypertension T Quinaglia et al when compared with individuals with a normal dipper profile. 16,[21][22][23][24][25][26] Previous studies have shown that patients with UCRH and CRH both have blunted nocturnal drops in SBP and DBP. 3,27 In these earlier publications, patients with RHTN have a high prevalence of nondipper pattern which contributes to an increased risk of cardiovascular events, 18 as well as a high prevalence of target organ damage at cardiac, macroand microvascular levels.…”

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

“…In a meta‐analysis of 5645 subjects from 8 cohorts, sleep‐trough MS (STMS) significantly and independently associated with cardiovascular outcomes 5. However, the prognostic value of MS for cardiovascular disease was not confirmed by recent prospective studies 7, 8, 9…”