Page 37 - GALENIKA MEDICAL JOURNAL

NOCTURNAL HYPERTENSION

Branislava Ivanović 1, 2
1 Faculty of Medicine, University of Belgrade, Belgrade, Serbia at this time whether routine bedtime dosing is
2 Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia beneficial for reducing cardiovascular outcomes.
Keywords: nocturnal hypertension,
Corresponding author:
dipping and reverse dipping patterns
Prof. dr Branislava Ivanović
Medicinski fakultet Univerziteta u Beogradu, Dr Subotića
starijeg 8, Beograd, Srbija Introduction
branislava.ivanovic.bg@gmail.com Arterial Hypertension (AH) is one of the main modifiable
risk factors responsible for increasing cardiovascular morbi-
dity and mortality . AH is responsible for cardiac, vascular,
1
renal, and retinal complications, as well as consecutive fatal
Abstract outcomes .
2
The importance of nighttime blood pressure The gold standard in diagnosing AH is ambulatory blood
and nighttime blood pressure dipping has been pressure measurement. Ambulatory Blood-Pressure Mo-
demonstrated for decades. Nighttime pressure may be nitoring (ABPM) over 24 hours and home monitoring are
elevated (nocturnal hypertension) in isolation or together widely accepted methods for determining blood pressure
with daytime hypertension. Nocturnal blood pressure values in non-institutional settings and for detecting “white
3
(BP) has been shown to have a significant predictive coat hypertension“ and masked hypertension . The imple-
value for cardiovascular disease. Abnormal circadian mentation of ABPM has also enabled the detection of no-
blood pressure patterns associated with elevated sleep cturnal hypertension, characterized by a mean nighttime
systolic blood pressure ≥ 120 mmHg and/or diastolic ≥ 70
blood pressure include non-dipping and reverse dipping, mmHg, according to the European Society of Hypertension
both of which are associated with increased target- (ESH) guidelines. In the American Heart Association (AHA)
organ damage and adverse cardiovascular outcomes. guidelines, nocturnal hypertension refers to mean blo-
Ambulatory BP monitoring is the recommended od pressure values during the night greater than 110/65
4
method for diagnosis of nocturnal hypertension and mmHg .
abnormal nighttime dipping. Home BP measurement ABPM is irreplaceable in detecting the circadian pattern
is an important technique and a recent study showed of arterial pressure. Intrinsic and extrinsic factors such as
that it is more reliable and more strongly associated physical activity, salt and alcohol intake, and psychological
with LV mass index than office and ambulatory BP stress influence the circadian rhythm of blood pressure. It
measurements. As the efficacy of the BP medications is normal for heart rate and blood pressure, predominan-
wanes during nighttime and early morning, control of tly influenced by these extrinsic factors, to be elevated du-
nocturnal hypertension and morning hypertension can ring the active part of the day and to decrease during sleep
be difficult. As such, chronotherapy, the dosing of BP by 10 to 20%. Based on nocturnal blood pressure values,
O'Brien first divided patients into two groups: those with
medication in the evening, has been an ongoing topic an expected decline in nighttime blood pressure values (di-
of interest in the field of hypertension. Some studies ppers) and those without a decline in nighttime blood pre-
have shown that chronotherapy is effective in reducing ssure values (non-dippers) . This classification has proven to
5
nocturnal BP, improving non-dipping and rising patterns be insufficient because it did not include patients with an
to dipping patterns, and improving cardiovascular extreme reduction in blood pressure values (>20%) during
prognosis. However, criticism and concerns have been the night, referred to as extreme dippers, nor did it include
raised regarding the design of these studies, and the patients with nocturnal values higher than daytime values,
6
implausible clinical benefits in cardiovascular outcomes referred to as reverse dippers .
considering the degree of BP lowering from bedtime The use of ABPM has also aided in defining isolated no-
dosing. Studies have shown that there is no consistent cturnal hypertension (INH). INH was first described by Lin
evidence to suggest that routine administration of and colleagues in 2007 as a new entity characterized by
antihypertensive medications at bedtime can improve an increase in systolic blood pressure ≥ 120 mmHg and/or
nocturnal BP and early morning BP control. It is unclear diastolic blood pressure ≥ 70 mmHg during the night, with

REVIEW PAPER Galenika Medical Journal, 2024; 3(9):35-41. 35