» The Role Of Nocturnal Blood Pressure And Sleep Quality In Hypertension Management The Role Of Nocturnal Blood Pressure And Sleep Quality In Hypertension Management Francesco P Cappuccio Login or register to view PDF. Order reprints Abstract The accurate measurement, prediction and treatment of high blood pressure (BP) are essential to the management of hypertension and the prevention of its associated cardiovascular (CV) risks. However, even if BP is optimally controlled during the day, nocturnal high blood pressure may still increase the risk of CV events. The pattern of circadian rhythm of BP can be evaluated by ambulatory BP monitoring (ABPM). Nighttime ABPM is more closely associated with fatal and nonfatal CV events than daytime ambulatory BP. However, the use of ABPM is limited by low availability and the fact that it can cause sleep disturbance, therefore may not provide realistic nocturnal measurements. Home blood pressure monitoring (HBPM) offers an inexpensive alternative to ABPM, is preferred by patients and provides a more realistic assessment of BP during an individual’s daily life. However, until recently, HBPM did not offer the possibility to measure nocturnal (sleep time) BP. The development and validation of new BP devices, such as the NightView (OMRON Healthcare, HEM9601T-E3) HBPM device, could overcome these limitations, offering the possibility of daytime and night-time BP measurements with minimal sleep disturbance. Keywords Ambulatory blood pressure monitoring, cardiovascular disease, home blood pressure monitoring, hypertension, nocturnal blood pressure monitoring Disclosure FPC has received fees and refund of expenses from OMRON Healthcare Europe and Asia for educational involvement in the development and delivery of the OMRON Academy Programme. Correspondence Francesco P Cappuccio, WMS – Mental Health and Wellbeing, University of Warwick, Gibbet Hill Rd, Coventry CV4 7AL, UK. E: [email protected] Support The publication of this manuscript was supported by OMRON Healthcare Europe B.V. Received date 21 April 2020 Accepted date 05 June 2020 Citation European Cardiology Review 2020;15:e60. DOI http://sci-hub.tw/10.15420/ecr.2020.13 Open access This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly. Hypertension is a major independent risk factor for cardiovascular (CV) diseases, including cardiac death, coronary heart disease, heart failure, stroke and chronic kidney disease. Therefore, early diagnosis, prevention and optimal management of hypertension is essential.1 Hypertension poses a growing public health burden: the number of adults with elevated blood pressure (BP) increased from 594 million in 1975 to 1.13 billion in 2015, and it is estimated that the number of people with hypertension will be close to 1.5 billion by 2025.2,3 During the past decades, BP measurement has evolved from manual measuring to fully automatic monitoring; ambulatory BP monitoring (ABPM) was first described in 1964.4 Since then, the importance of nocturnal BP has been recognised.5 This article aims to understand the clinical significance, therapeutic implications and optimal measurement of nocturnal hypertension. Nocturnal Hypertension BP variation over 24 hours normally follows a pattern, with a peak in the early morning hours and a decrease at night, known as dipping. This variation is the result of an endogenous circadian rhythm, which exerts its peak at around 9 pm, and behavioural effects that are superimposed on the circadian pattern, causing much of the observed day-night pattern in BP.6 In general, BP starts declining from late evening onwards, reaches a nadir around midnight and rises just after awakening in the morning (Figure 1).7,8 People are defined as dippers if their nocturnal BP falls by >10 % of the daytime average BP value; however, dipping status varies from day to day and the classification of patients into dippers and non-dippers is not reproducible over time.1,5,9 Non-dipping status is associated with sleep disturbance, obstructive sleep apnoea (OSA), obesity, high salt intake in salt-sensitive people, orthostatic hypotension, autonomic dysfunction, chronic kidney disease, diabetic neuropathy and older age.10–16 In recent years, it has been recognised that nocturnal BP is, in general, a better predictor of the risk of fatal and nonfatal CV events (stroke, MI and CV death) and organ damage than daytime BP in hypertensive and renal transplant patients.10,15–19 Night-to-day ratio is also a significant predictor of CV events, and patients defined as non-dippers have an increased CV risk.15 A non-dipping BP pattern has been shown to be predictive of a range of CV events, including total CV death, sudden death, nonfatal CV events and nonfatal stroke, in people with and without carotid atherosclerosis.20 In patients with heart failure with preserved ejection fraction, a non-dipping pattern was found to be an independent risk factor for future CV events, including recurrence of hospitalisation for heart failure and cognitive dysfunction.21,22 People who experience a night-time BP decrease of ≥20% are termed extreme dippers; this may be associated with an increased risk of ischaemic stroke and silent cerebral diseases.23 An exaggerated morning surge in BP is also associated with an increased risk of stroke.24 Therefore, nocturnal hypertension has become an important therapeutic target for the prevention of CV events in patients with hypertension.
