Current Hypertension Reports

, Volume 12, Issue 6, pp 474–479 | Cite as

Nighttime Blood Pressure: A Target for Therapy?

  • Bernard Waeber
  • Jean-Jacques Mourad
  • Eoin O’Brien


Ambulatory blood pressure (BP) monitoring is increasingly used in the evaluation of hypertensive patients. The ability to monitor BP throughout the day and night allows the detection of abnormal nocturnal BP patterns, the most common being a “nondipping” pattern, which is associated with increased cardiovascular risk; its correction appears to have a positive impact on cardiovascular outcome. Antihypertensive treatment should be individually adjusted to control BP during both daytime and nighttime. However, drug-induced lowering of nocturnal BP, if excessive, could amplify the morning BP surge in patients with daytime BP elevation, increasing the risk of developing a cardiovascular event. Ambulatory BP monitoring therefore represents a unique tool to establish the most appropriate antihypertensive drug regimen for the individual patient.


Ambulatory blood pressure Morning surge Nighttime blood pressure Cardiovascular risk Dipper pattern Nondipping pattern 



Conflicts of Interest: B. Waeber: consultant for Novartis and Menarini; honoraria from Novartis, AstraZeneca, Servier, and Menarini; J-J. Mourad: none; E. O’Brien: none.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Kikuya M, Ohkubo T, Asayama K, et al.: Ambulatory blood pressure and 10-year risk of cardiovascular and noncardiovascular mortality: the Ohasama study. Hypertension 2005, 45:240–245.CrossRefPubMedGoogle Scholar
  2. 2.
    Sega R, Facchetti R, Bombelli M, et al.: Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation 2005, 111:1777–1783.CrossRefPubMedGoogle Scholar
  3. 3.
    Clement DL, De Buyzere ML, De Bacquer DA, et al.: Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension. N Engl J Med 2003, 348:2407–2415.CrossRefPubMedGoogle Scholar
  4. 4.
    Staessen JA, Thijs L, Fagard R, et al.: Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators. JAMA 1999, 282:539–546.CrossRefPubMedGoogle Scholar
  5. 5.
    Redon J, Campos C, Narciso ML, et al.: Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study. Hypertension 1998, 31:712–718.PubMedGoogle Scholar
  6. 6.
    Verdecchia P, Porcellati C, Schillaci G, et al.: Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension. Hypertension 1994, 24:793–801.PubMedGoogle Scholar
  7. 7.
    Dolan E, Stanton A, Thijs L, et al.: Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: The Dublin Outcome Study. Hypertension 2005, 46:156–161.CrossRefPubMedGoogle Scholar
  8. 8.
    O’Brien E: Ambulatory blood pressure measurement is indispensable to good clinical practice. J Hypertens 2003, 21:S11–S18.Google Scholar
  9. 9.
    Pickering TG, Shimbo D, Haas D: Ambulatory blood-pressure monitoring. N Engl J Med 2006, 354:2368–2374.CrossRefPubMedGoogle Scholar
  10. 10.
    Verdecchia P, Angeli F, Gattobigio R, et al.: The clinical significance of white-coat and masked hypertension. Blood Press Monit 2007, 12:387–389.CrossRefPubMedGoogle Scholar
  11. 11.
    Mancia G, Bombelli M, Facchetti R, et al.: Long-term prognostic value of blood pressure variability in the general population: results of the Pressioni Arteriose Monitorate e Loro Associazioni Study. Hypertension 2007, 49:1265–1270.CrossRefPubMedGoogle Scholar
  12. 12.
    Dolan E, O’Brien E: Blood pressure variability: clarity for clinical practice. Hypertension 2010, 56:179–181.CrossRefPubMedGoogle Scholar
  13. 13.
    Fagard RH, Celis H, Thijs L, et al.: Daytime and nighttime blood pressure as predictors of death and cause-specific cardiovascular events in hypertension. Hypertension 2008, 51:55–61.CrossRefPubMedGoogle Scholar
  14. 14.
    Boggia J, Li Y, Thijs L, et al.: Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet 2007, 370:1219–1229.CrossRefPubMedGoogle Scholar
  15. 15.
    Ohkubo T, Hozawa A, Yamaguchi J, et al.: Prognostic significance of the nocturnal decline in blood pressure in individuals with and without high 24-h blood pressure: the Ohasama study. J Hypertens 2002, 20:2183–2189.CrossRefPubMedGoogle Scholar
  16. 16.
    O’Brien E, Asmar R, Beilin L, et al.: Practice guidelines of the European Society of Hypertension for clinic, ambulatory and self blood pressure measurement. J Hypertens 2005, 23:697–701.CrossRefPubMedGoogle Scholar
  17. 17.
    Parati G: Blood pressure reduction at night: sleep and beyond. J Hypertens 2000, 18:1725–1729.CrossRefPubMedGoogle Scholar
  18. 18.
    Kammila S, Campbell NR, Brant R, et al.: Systematic error in the determination of nocturnal blood pressure dipping status by ambulatory blood pressure monitoring. Blood Press Monit 2002, 7:131–134.CrossRefPubMedGoogle Scholar
  19. 19.
    Hermida RC, Calvo C, Ayala DE, et al.: Relationship between physical activity and blood pressure in dipper and non-dipper hypertensive patients. J Hypertens 2002, 20:1097–1104.CrossRefPubMedGoogle Scholar
  20. 20.
    Cavelaars M, Tulen JH, Man in ‘t Veld AJ, et al.: Assessment of body position to quantify its effect on nocturnal blood pressure under ambulatory conditions. J Hypertens 2000, 18:1737–1743.CrossRefPubMedGoogle Scholar
  21. 21.
    James MA, Fotherby MD, Potter JF: Reproducibility of the circadian systolic blood pressure variation in the elderly. J Hypertens 1995, 13:1097–1103.CrossRefPubMedGoogle Scholar
  22. 22.
    van der Steen MS, Lenders JW, Graafsma SJ, et al.: Reproducibility of ambulatory blood pressure monitoring in daily practice. J Hum Hypertens 1999, 13:303–308.CrossRefPubMedGoogle Scholar
  23. 23.
    Mochizuki Y, Okutani M, Donfeng Y, et al.: Limited reproducibility of circadian variation in blood pressure dippers and nondippers. Am J Hypertens 1998, 11:403–409.CrossRefPubMedGoogle Scholar
  24. 24.
    Omboni S, Parati G, Palatini P, et al.: Reproducibility and clinical value of nocturnal hypotension: prospective evidence from the SAMPLE study. Study on Ambulatory Monitoring of Pressure and Lisinopril Evaluation. J Hypertens 1998, 16:733–738.CrossRefPubMedGoogle Scholar
  25. 25.
    Ben-Dov IZ, Ben-Arieh L, Mekler J, Bursztyn M: Blood pressure dipping is reproducible in clinical practice. Blood Press Monit 2005, 10:79–84.CrossRefPubMedGoogle Scholar
  26. 26.
    Chaves H, Campello de Souza FM, Krieger EM: The reproducibility of dipping status: beyond the cutoff points. Blood Press Monit 2005, 10:201–205.CrossRefPubMedGoogle Scholar
  27. 27.
    Pickering T: Recommendations for the use of home (self) and ambulatory blood pressure monitoring. American Society of Hypertension Ad Hoc Panel. Am J Hypertens 1996, 9:1–11.CrossRefPubMedGoogle Scholar
  28. 28.
    Kuwajima I, Shimosawa R, Kanemaru A, et al.: Diminished nocturnal decline in blood pressure in elderly hypertensive patients with left ventricular hypertrophy. Am Heart J 1992, 123:1307–1311.CrossRefPubMedGoogle Scholar
  29. 29.
    White WB, Larocca GM: Improving the utility of the nocturnal hypertension definition by using absolute sleep blood pressure rather than the “dipping” proportion. Am J Cardiol 2003, 92:1439–1441.CrossRefPubMedGoogle Scholar
  30. 30.
    Cavelaars M, Tulen JH, van Bemmel JH, van den Meiracker AH: Physical activity, dipping and haemodynamics. J Hypertens 2004, 22:2303–2309.CrossRefPubMedGoogle Scholar
  31. 31.
    Birkenhager AM, van den Meiracker AH: Causes and consequences of a non-dipping blood pressure profile. Neth J Med 2007, 65:127–131.PubMedGoogle Scholar
  32. 32.
    Uzu T, Ishikawa K, Fujii T, et al.: Sodium restriction shifts circadian rhythm of blood pressure from nondipper to dipper in essential hypertension. Circulation 1997, 96:1859–1862.PubMedGoogle Scholar
  33. 33.
    Uzu T, Kazembe FS, Ishikawa K, et al.: High sodium sensitivity implicates nocturnal hypertension in essential hypertension. Hypertension 1996, 28:139–142.PubMedGoogle Scholar
  34. 34.
    • de la Sierra A, Redon J, Banegas JR, et al.: Prevalence and factors associated with circadian blood pressure patterns in hypertensive patients. Hypertension 2009, 53:466–472. A lot of knowledge has been accumulated owing to this large survey performed in Spain by doctors in everyday practice to compare ABPM and casual office blood pressure.Google Scholar
  35. 35.
    • Hermida RC, Ayala DE, Calvo C, et al.: Chronotherapy of hypertension: administration-time-dependent effects of treatment on the circadian pattern of blood pressure. Adv Drug Deliv Rev 2007, 59:923–939. This extensive review discusses in detail the current knowledge on chronotherapy.Google Scholar
  36. 36.
    Hermida RC, Ayala DE, Mojon A, et al.: Reduction of morning blood pressure surge after treatment with nifedipine GITS at bedtime, but not upon awakening, in essential hypertension. Blood Press Monit 2009, 14:152–159.CrossRefPubMedGoogle Scholar
  37. 37.
    Svensson P, de Faire U, Sleight P, et al.: Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE substudy. Hypertension 2001, 38:E28–E32.CrossRefPubMedGoogle Scholar
  38. 38.
    Dolan E, Stanton AV, Thom S, et al.: Ambulatory blood pressure monitoring predicts cardiovascular events in treated hypertensive patients—an Anglo-Scandinavian Cardiac Outcomes Trial substudy. J Hypertens 2009, 27:876–885.CrossRefPubMedGoogle Scholar
  39. 39.
    Hermida RC, Ayala DE, Mojon A, Fernandez JR: Effects of time of antihypertensive treatment on ambulatory blood pressure and clinical characteristics of subjects with resistant hypertension. Am J Hypertens 2010, 23:432–439.CrossRefPubMedGoogle Scholar
  40. 40.
    • Li Y, Thijs L, Hansen TW, et al.: Prognostic value of the morning blood pressure surge in 5645 subjects from 8 populations. Hypertension 2010, 55:1040–1048. An International Database on Ambulatory Blood Pressure was used to assess the prognostic value of the morning blood pressure surge. This is a very appealing approach to accumulate data and gain new insight into ABPM.Google Scholar
  41. 41.
    Kario K, Pickering TG, Umeda Y, et al.: Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation 2003, 107:1401–1406.CrossRefPubMedGoogle Scholar
  42. 42.
    Kario K: Time for focus on morning hypertension: pitfall of current antihypertensive medication. Am J Hypertens 2005, 18:149–151.CrossRefPubMedGoogle Scholar
  43. 43.
    Metoki H, Ohkubo T, Kikuya M, et al.: Prognostic significance for stroke of a morning pressor surge and a nocturnal blood pressure decline: the Ohasama study. Hypertension 2006, 47:149–154.CrossRefPubMedGoogle Scholar
  44. 44.
    Yano Y, Hoshide S, Inokuchi T, et al.: Association between morning blood pressure surge and cardiovascular remodeling in treated elderly hypertensive subjects. Am J Hypertens 2009, 22:1177–1182.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Bernard Waeber
    • 1
  • Jean-Jacques Mourad
    • 2
  • Eoin O’Brien
    • 3
  1. 1.Division of Clinical PathophysiologyCentre Hospitalier Universitaire VaudoisLausanneSwitzerland
  2. 2.Hôpital AvicenneBobignyFrance
  3. 3.The Conway Institute of Biomolecular and Biomedical ResearchDublin 4Ireland

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