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Sleep-time ambulatory blood pressure as a novel therapeutic target for cardiovascular risk reduction

Journal of Human Hypertension volume 28, pages 567–574 (2014)Cite this article

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Abstract

Diagnosis of hypertension and clinical decisions regarding its treatment are typically based upon daytime clinic blood pressure (BP) measurements, occasionally supplemented by wake-time patient self-assessment. Yet, correlation between BP level and target organ damage, cardiovascular disease (CVD) risk, and long-term prognosis is higher for ambulatory BP monitoring (ABPM) measurements. Numerous studies consistently reveal CVD events are better predicted by the asleep than awake or 24 h BP means. In addition, when the asleep BP mean is adjusted by the awake mean, only the former is a significant independent predictor of outcome. Endogenous circadian rhythms explain statistically and clinically significant ingestion time differences in efficacy, duration of action, safety and/or effects on the daily BP pattern of most hypertension medications and their combinations. Bedtime versus morning-time ingestion of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, independent of drug terminal half-life, both better reduces asleep BP and normalizes the daily BP profile into a more normal dipper pattern. The recently completed prospective outcome MAPEC Study verifies therapeutic restoration of the normal sleep-time BP decline, a novel therapeutic goal most effectively achieved by ingestion of the entire daily dose of ⩾1 conventional hypertension medications at bedtime, best decreases CVD morbidity and mortality. Our findings indicate around-the-clock ABPM is a clinical necessity to accurately detect abnormal sleep-time BP and assess CVD risk, and that hypertension ought to be managed by a bedtime therapeutic strategy, preferably one including medication that antagonizes the activities and actions of the renin–angiotensin–aldosterone system.

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Acknowledgements

This research is supported by unrestricted grants from Ministerio de Ciencia e Innovación (SAF2009-7028-FEDER); Consellería de Economía e Industria, Xunta de Galicia (INCITE07-PXI-322003ES; INCITE08-E1R-322063ES; INCITE09-E2R-322099ES; IN845B-2010/114; 09CSA018322PR); European Research Development Fund and Consellería de Cultura, Educación e Ordenación Universitaria, Xunta de Galicia (CN2012/251 & CN2012/260); and Vicerrectorado de Investigación, University of Vigo (all grants awarded to RC Hermida, DE Ayala, A Mojón and JR Fernández).

Author information

Authors and Affiliations

  1. Bioengineering and Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies, University of Vigo, E.I. Telecomunicación, Campus Universitario, Vigo, Spain

    R C Hermida, D E Ayala, A Mojón & J R Fernández

  2. Department of Biomedical Engineering, Cockrell School of Engineering, University of Texas at Austin, Austin, TX, USA

    M H Smolensky

  3. Hypertension Center, University Hospital S. Anna, Ferrara, Italy

    F Portaluppi

  4. Department of Medical Sciences, University of Ferrara, Ferrara, Italy

    F Portaluppi

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  1. R C Hermida
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  2. D E Ayala
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Correspondence to R C Hermida.

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Hermida, R., Ayala, D., Mojón, A. et al. Sleep-time ambulatory blood pressure as a novel therapeutic target for cardiovascular risk reduction. J Hum Hypertens 28, 567–574 (2014). https://doi.org/10.1038/jhh.2014.1

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