Page 41 - GALENIKA MEDICAL JOURNAL

before bedtime were monitored for 5.7 years. It was shown The fact that renin activity is increased during the night
that evening administration of therapy was associated with led Giles et al. to speculate that the combination of aliskiren
a significant reduction in the risk of cardiovascular events (a direct renin inhibitor) and valsartan could be exceptio-
(HR 0.39; 95% CI 0.29-0.51) . Using a similar methodological nally beneficial. They demonstrated that the combination is
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approach to the MAPEC study, the Hygia study, which inclu- more effective than valsartan monotherapy only in non-di-
ded 19.000 patients, confirmed that bedtime therapy led to ppers with nocturnal hypertension, but not in dippers .
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a significant reduction in the risk of adverse cardiovascular
events (HR 0.55; 95% CI 0.50-0.61) . The role of calcium channel blockers in the treatment
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of nocturnal hypertension is exemplified by cilnidipine and
Both studies have faced sharp criticism due to imprecise its effect on the circadian rhythm. This medication has led
randomization protocols and unreliable treatment adhe- to successful reduction of systolic blood pressure in reverse
rence data, especially in monitoring. In the MAPEC study, dippers . The effectiveness of beta-blockers in this domain
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a significant reduction in the risk of cardiovascular events has not been investigated. In modulating autonomic dys-
was recorded without any differences in systolic blood pre- function in nocturnal hypertension, the use of alpha-bloc-
ssure levels between the observed patient groups, while kers, such as doxazosin, has proven to be beneficial .
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minor differences were recorded in the Hygia study. The
results of the TIME study involving 20.000 participants have In the SACRA study, the effectiveness of empagliflozin in
cast doubt on the findings of the MAPEC and Hygia studies. regulating 24-hour blood pressure values was investigated.
Specifically, after five years of monitoring different chronot- The medication significantly reduced 24-hour systolic blo-
herapeutic modalities (morning vs. bedtime medication), no od pressure values (-7.7 mmHg; p=0.002) in patients with
differences were found in major cardiovascular outcomes diabetes mellitus and uncontrolled nocturnal hypertension,
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or hospitalizations . Considering the controversial results, but not nocturnal values (-4.3 mmHg; p=0.159) .
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it is difficult to draw any conclusion other than that the chro- It has been noted that there is a connection between
notherapeutic modality should be tailored to each patient nocturnal hypertension and sleep apnea. The application
individually. of continuous positive airway pressure improves the con-
Even the data on which class, or which combinations of trol of both daytime and nighttime blood pressure values.
drugs, are preferable for nocturnal hypertension are not CPAP leads to a significant reduction in sympathetic activi-
consistent. Considering the mechanisms that lead to no- ty during the night and results in a decrease in nocturnal
cturnal hypertension, it was assumed that the combination systolic blood pressure by 3.8 mmHg, with the caveat that
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of renin-angiotensin-aldosterone system blockers and diu- the effects are greater in more severe cases of the disease .
retics would be preferred. However, Kario et al. have shown It has been shown that renal denervation leads to a signifi-
that the combination of AT1 receptor blockers and calcium cant reduction in nocturnal systolic blood pressure values in
channel blockers was superior to the combination of AT1 patients with obstructive sleep apnea) and resistant hyper-
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receptor blockers and diuretics in patients with uncontro- tension .
lled nocturnal hypertension under conditions of the same Optimal sleep duration contributes to reducing the risk
salt intake and salt sensitivity . In one study, it was shown of developing arterial hypertension. Optimal sleep duration
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that the combination of amlodipine and olmesartan given is considered to be sleeping for more than 6 but less than
before sleep successfully reduced not only blood pressure 9 hours. One way to achieve optimal sleep duration is, in
values but also the albumin-creatinine ratio in patients with addition to correcting poor environmental conditions, the
nocturnal hypertension . use of melatonin. Melatonin reduces nocturnal systolic blo-
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od pressure by 5 mmHg .
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Conclusion

Numerous evidence point to the unfavorable impact of nocturnal hypertension, with or without
dipping pattern disturbance, on increasing cardiovascular risk. The mechanisms underlying
nocturnal hypertension are not fully elucidated. Diagnosis is based on the application of 24-hour
ABPM or advanced home monitoring. The finding of nocturnal hypertension necessitates lifestyle
modifications and therapy. Due to inconsistencies in the results of evening therapy application,
therapy, like in the treatment of hypertension in general, needs to be tailored to each patient

individually.

REVIEW PAPER Galenika Medical Journal, 2024; 3(9):35-41. 39