Regression of carotid atherosclerosis by control of morning blood pressure peak in newly diagnosed hypertensive patients.
Marfella Raffaele,Siniscalchi Mario,Nappo Francesco,Gualdiero Pasquale,Esposito Katherine,Sasso Ferdinando Carlo,Cacciapuoti Federico,Di Filippo Clara,Rossi Francesco,D'Amico Michele,Giugliano Dario
American journal of hypertension
BACKGROUND:Morning blood pressure (BP) peak may be a risk factor for cardiovascular disease. Whether morning BP should be a target of hypertension treatment is not known. We investigated the relationship between morning BP variations, carotid internal-medial thickness (CIMT), circulating inflammatory markers, and sympathetic activity in hypertensive patients with different patterns of morning BP increase at baseline and after antihypertensive treatment. METHODS:One hundred twenty-eight hypertensive patients with morning BP peak (MP+) were compared with 196 hypertensive patients without morning BP peak (MP-). All patients performed 24-h ambulatory BP monitoring, assessment of CIMT, circulating concentration of C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-18 (IL-18), and urinary catecholamines. RESULTS:Compared with MP- patients, MP+ patients had higher CIMT and urinary catecholamine output (P < .001), as well as CRP, IL-6, and IL-18 (P < .001). We randomly assigned 128 drug-naive MP+ patients to either metoprolol or carvedilol, two antihypertensive drugs with different effects on sympathetic activity. The primary outcome was change in CIMT and circulating inflammatory markers at 12 months. Morning BP decreased more among patients in the carvedilol group (P < .001), whereas clinic BP showed a similar decrease in both groups. The CIMT (P < .001), IL-6 (P < .001), IL-18 (P < .001), and CRP (P < .001) decreased more in the carvedilol group than in the metoprolol group. The CIMT regression was observed in 49% of patients in the carvedilol group and 18% of patients in the metoprolol group (P < .01). Reduction in CIMT was directly associated with changes in morning BP. CONCLUSIONS:Higher CIMT and circulating inflammatory markers coexist in hypertensive patients with morning BP peak, and might contribute to their increased cardiovascular risk. Carotid atherosclerosis can be prevented by control of morning BP.
Morning blood pressure monitoring in the management of hypertension.
Wang Ji-Guang,Kario Kazuomi,Park Jeong-Bae,Chen Chen-Huan
Journal of hypertension
: The aim of the current article is to review the current evidence on the role of morning blood pressure (BP) in the management of hypertension. Morning BP surge had been and will continue to be a hot topic of hypertension research. However, more evidence is needed to prove its clinical usefulness in the management of hypertension. Masked morning hypertension, as the other forms of masked hypertension, requires more research. The concept of morning BP monitoring could be clinically relevant in the therapeutic management of hypertension and in the prevention of cardiovascular complications by defining and treating morning hypertension. Antihypertensive medication is usually taken in the morning. The presence of uncontrolled morning BP during trough effect hours could be a hallmark of inadequate antihypertensive regimen, such as, for instance, the use of short-acting or intermediate-acting drugs, under dosing of drugs, or no or low use of combination therapy. To improve the management of hypertension in general and morning hypertension in particular, long-acting antihypertensive drugs should be used in appropriate often full dosages and in proper combinations. The clinical usefulness of antihypertensive drugs of specific mechanisms against morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation. In conclusion, there is some evidence that morning BP is critical in the incidence of cardiovascular complications. However, proving its clinical usefulness in the management of hypertension requires further research.
2020 International Society of Hypertension global hypertension practice guidelines.
Unger Thomas,Borghi Claudio,Charchar Fadi,Khan Nadia A,Poulter Neil R,Prabhakaran Dorairaj,Ramirez Agustin,Schlaich Markus,Stergiou George S,Tomaszewski Maciej,Wainford Richard D,Williams Bryan,Schutte Aletta E
Journal of hypertension
DOCUMENT REVIEWERS:Hind Beheiry (Sudan), Irina Chazova (Russia), Albertino Damasceno (Mozambique), Anna Dominiczak (UK), Anastase Dzudie (Cameroon), Stephen Harrap (Australia), Hiroshi Itoh (Japan), Tazeen Jafar (Singapore), Marc Jaffe (USA), Patricio Jaramillo-Lopez (Colombia), Kazuomi Kario (Japan), Giuseppe Mancia (Italy), Ana Mocumbi (Mozambique), Sanjeevi N.Narasingan (India), Elijah Ogola (Kenya), Srinath Reddy (India), Ernesto Schiffrin (Canada), Ann Soenarta (Indonesia), Rhian Touyz (UK), Yudah Turana (Indonesia), Michael Weber (USA), Paul Whelton (USA), Xin Hua Zhang, (Australia), Yuqing Zhang (China).
Morning blood pressure is associated with sleep quality in obese adolescents.
Hannon Tamara S,Tu Wanzhu,Watson Sara E,Jalou Hasnaa,Chakravorty Sangeeta,Arslanian Silva A
The Journal of pediatrics
OBJECTIVE:To examine relationships among blood pressure (BP), adiposity, and sleep quality with the use of overnight polysomnography in obese adolescents. STUDY DESIGN:Overnight polysomnogram and morning BP measurements were performed in obese (body mass index [BMI] >95th percentile) nondiabetic adolescents (eligible age range 12-18 years, n = 49). Subjects were stratified into 2 groups, one with normal BP, and one with elevated BP, and demographic and clinical characteristics were compared between the groups. Multiple linear regression analysis was used to assess the effects of sleep quality on BP. RESULTS:Participants (n = 27) had a normal morning BP, and 22 (44.9%) had elevated morning BP. There were no differences in age (P = .53), sex (P = .44), race (P = .58), or BMI (P = .56) between the 2 BP groups. The group with elevated BP spent shorter percentages of time in rapid eye movement (REM; P = .006) and slow-wave sleep (SWS; P = .024). Multiple linear regression analysis showed that a lower percentage of both REM and SWS was associated with increased morning BP after we adjusted for pubertal stage, sex, race, and BMI. CONCLUSION:Lack of deeper stages of sleep, REM sleep, and SWS is associated with greater morning BP in obese adolescents, independent of BMI. Poor sleep quality should be considered in the work-up of obese youth with hypertension. Intervention studies are needed to evaluate whether improving the quality of sleep will decrease BP elevation.
[Morning rise in home blood pressure and target organ damage in hypertensive patients].
Barochiner Jessica,Aparicio Lucas S,Cuffaro Paula E,Rada Marcelo A,Morales Margarita S,Alfie José,Marin Marcos J,Galarza Carlos R,Waisman Gabriel D
Revista de la Facultad de Ciencias Medicas (Cordoba, Argentina)
UNLABELLED:The morning blood pressure (BP) rise entails a higher cardiovascular risk. Studies evaluating the association between home BP morning rise and target organ damage are scarce and almost exclusively based on Asians. The aim of our study was to characterize hypertensive patients with morning rise in home BP and to establish a possible association with left ventricular hypertrophy (LVH). METHODS:treated hypertensive patients ≥ 18 years underwent home BP measurements (duplicate measurements for 4 days in the morning, afternoon and evening), and completed a questionnaire regarding risk factors and history of cardiovascular disease. Medical records were reviewed to extract data from grams. A morning rise in systolic home BP was defined as a difference between morning and evening systolic BP averages ≥15 mmHg. Subjects were considered to have LVH if the left ventricular mass index was >95 g/m2 in women and >115 g/m2 in men. Variables identified as relevant predictors of home BP morning rise were entered into a multivariable logistic regression analysis model. RESULTS:216 patients were included, mean age 68 (+13.3), 69.4% women and 99.1% Caucasians. The prevalence of BP morning rise was 13.4% and independently associated factors were LVH (OR 3.5; 95%CI 1.1-11.4), age (OR 1.05; 95%CI 1.003-1.1) and a history of cerebrovascular disease (OR 3.9; 95%CI 1.1-14.2). In conclusion, a morning rise in systolic BP detected through home BP monitoring is independently associated with LVH, age and a history of cerebrovascular disease. The therapeutic implications of this observation need to be clarified in large-scale prospective studies.
[Early morning hypertension/morning blood pressure surge].
Hoshide Satoshi,Kario Kazuomi
Nihon rinsho. Japanese journal of clinical medicine
Early morning hypertension and morning blood pressure surge have been reported to be associated with organ damage and cardiovascular events. The concept of early morning hypertension and morning blood pressure surge is sometimes discussed in the same arena, and provides partly overlapping information concerning their mechanism or risk profile. However, what is different between groups is as follows. First, early morning hypertension is blood pressure level, while morning blood pressure surge is variability of blood pressure. Second, the intervention of early morning hypertension is available, which lead to prevent the progression of organ damage or cardiovascular event, but there is not enough evidence whether the reduction of morning blood pressure surge would reduce cardiovascular outcome.
Coexistence of PM2.5 and low temperature is associated with morning hypertension in hypertensives.
Imaizumi Yuki,Eguchi Kazuo,Kario Kazuomi
Clinical and experimental hypertension (New York, N.Y. : 1993)
We tested the hypothesis that concentration of PM2.5 is associated with home BP level. We analyzed home BP data for 91 consecutive days in 40 hypertensives. PM2.5 solely was not correlated with home BP levels, but low temperature was associated with a 1.6-fold increased likelihood of morning hypertension (p < 0.001) under the condition of high PM2.5 concentration. In addition, coexistence of low temperature and high PM2.5 was associated with a 2.3-fold increased likelihood of morning hypertension (p < 0.001) compared with high temperature and low PM2.5 condition. Environmental and meteorological factors could be important causes of enhanced home BP elevation.
Home blood pressure and cardiovascular outcomes in patients during antihypertensive therapy: primary results of HONEST, a large-scale prospective, real-world observational study.
Kario Kazuomi,Saito Ikuo,Kushiro Toshio,Teramukai Satoshi,Ishikawa Yusuke,Mori Yoshihiro,Kobayashi Fumiaki,Shimada Kazuyuki
Hypertension (Dallas, Tex. : 1979)
UNLABELLED:This study aimed to investigate the relationship between on-treatment morning home blood pressure (HBP) and incidence of cardiovascular events using data from the Home Blood Pressure Measurement With Olmesartan Naive Patients to Establish Standard Target Blood Pressure (HONEST) study, a prospective observational study of 21 591 outpatients with essential hypertension (mean age, 64.9 years; women, 50.6%) enrolled between 2009 and 2010 at clinics and hospitals in Japan. They received olmesartan-based treatment throughout. The primary end point was major cardiovascular events. After a mean follow-up period of 2.02 years, cardiovascular events occurred in 280 patients (incidence, 6.46/1000 patient-years). The risk for the primary end point was significantly higher in patients with on-treatment morning HBP ≥145 to <155 mm Hg (hazard ratio [HR], 1.83; 95% confidence interval [CI], 1.12-2.99) and ≥155 mm Hg (HR, 5.03; 95% CI, 3.05-8.31) than <125 mm Hg and with on-treatment clinic blood pressure ≥150 to <160 mm Hg (HR, 1.69; 95% CI, 1.10-2.60) and ≥160 mm Hg (HR, 4.38; 95% CI, 2.84-6.75) than <130 mm Hg. Morning HBP associated with minimum risk was 124 mm Hg by spline regression analysis. Cardiovascular risk was increased in patients with morning HBP ≥145 mm Hg and clinic blood pressure <130 mm Hg (HR, 2.47; 95% CI, 1.20-5.08) compared with morning HBP <125 mm Hg and clinic blood pressure <130 mm Hg. In conclusion, it is essential to control morning HBP to <145 mm Hg, even in patients with controlled clinic blood pressure. CLINICAL TRIAL REGISTRATION URL:http://www.umin.ac.jp/ctr/index.htm. UMIN Clinical Trials Registry, trial No. UMIN000002567.
Morning and Evening Blood Pressures Are Associated With Intima-Media Thickness in a General Population - The Hisayama Study.
Sakata Satoko,Hata Jun,Fukuhara Masayo,Yonemoto Koji,Mukai Naoko,Yoshida Daigo,Kishimoto Hiro,Ohtsubo Toshio,Kitazono Takanari,Kiyohara Yutaka,Ninomiya Toshiharu
Circulation journal : official journal of the Japanese Circulation Society
BACKGROUND:The association of morning and evening home blood pressures (HBPs) with carotid atherosclerosis has been uncertain in general populations, so we aimed to investigate it in a general Japanese population.Methods and Results:We performed a cross-sectional survey of 2,856 community-dwelling individuals aged ≥40 years to examine the association of morning and evening HBPs with carotid mean intima-media thickness (IMT). The age- and sex-adjusted geometric averages of carotid mean IMT increased significantly with increasing morning HBP (optimal: 0.67 mm; normal: 0.69 mm; high normal: 0.72 mm; grade 1 hypertension: 0.74 mm; and grade 2+3 hypertension: 0.76 mm) and with increasing evening HBP (0.68 mm, 0.71 mm, 0.73 mm, 0.76 mm, and 0.78 mm, respectively) (both P for trend <0.001). These associations remained significant even after adjusting for potential confounding factors. Likewise, both isolated morning hypertension (morning HBP ≥135/85 mmHg and evening HBP <135/85 mmHg) and isolated evening hypertension (evening HBP ≥135/85 mmHg and morning HBP <135/85 mmHg) as well as sustained hypertension (both morning and evening HBP ≥135/85 mmHg) were significantly associated with thicker mean IMT. CONCLUSIONS:Our findings suggested that both morning and evening HBPs were significantly associated with carotid atherosclerosis in this general Japanese population.
Diabetes and obesity are significant risk factors for morning hypertension: from Ibaraki Hypertension Assessment Trial (I-HAT).
Toyama Masahiro,Watanabe Shigeyuki,Miyauchi Takashi,Kuroda Yasuhisa,Ojima Eiji,Sato Akira,Seo Yoshihiro,Aonuma Kazutaka
AIMS:Although morning hypertension (HT) has been identified as a major cardiovascular risk, susceptible populations remain unknown. This study aimed to clarify the relationship between morning HT and diabetes or obesity in a large-scale population. MAIN METHODS:Clinic blood pressure (BP) and BP upon awakening were recorded in 2554 outpatients with HT who attended 101 clinics or hospitals for two weeks. Mean clinic and awakening BP>140/90 and >135/85 mmHg, respectively, were considered as HT. The patients were classified according to values for clinic and home BP, into normal BP, white coat HT, masked HT, and sustained HT. KEY FINDINGS:Morning BP (mmHg) significantly and progressively elevated in the order of normal glucose tolerance, impaired glucose tolerance and diabetes (134.1 ± 12.2, 135.4 ± 13.1 and 137.5 ± 11.5; p<0.0001). The incidence of morning HT significantly increased and progressively in the same order (53.4%, 55.6%, 66.4%, p<0.0001). Morning BP was significantly higher among obese patients with diabetes than among non-obese and non-diabetic patients (138.8 ± 10.5, 133.1 ± 11.9, p<0.0001). In addition, the incidence of morning HT was significantly higher in obese diabetic patients than in non-obese and non-diabetic patients (73.0% vs. 49.9%, p<0.0001). SIGNIFICANCE:Diabetic or obese patients frequently have morning HT.
Morning hypertension and night non-dipping in patients with diabetes and chronic kidney disease.
Oh Se Won,Han Sang Youb,Han Kum Hyun,Cha Ran-hui,Kim Sejoong,Yoon Sun Ae,Rhu Dong-Ryeol,Oh Jieun,Lee Eun Young,Kim Dong Ki,Kim Yon Su,
Hypertension research : official journal of the Japanese Society of Hypertension
Morning hypertension (HTN) and nocturnal non-dipping (ND) are closely associated with target organ damage and cardiovascular events. However, their importance in diabetics with advanced renal disease is unclear. We evaluated the relationships of morning HTN and ND with estimated glomerular filtration rate (eGFR) and proteinuria, and determined the risk of morning HTN and ND according to presence of diabetes mellitus (DM) and chronic kidney disease (CKD) stage. A total of 1312 patients, including 439 with diabetes, were prospectively recruited at 21 centers in Korea. All patients had HTN and an eGFR of 15-89 ml min(-1) per 1.73 m(2). Ambulatory 24-h blood pressure was assessed. The rates of morning HTN (25.2% vs. 13.6%, P<0.001) and ND (58.2% vs. 48.2%, P=0.002) were higher in diabetics than in non-diabetics. eGFR was correlated with ND in all patients (P<0.05) and with morning HTN only in non-diabetics (P=0.005). Proteinuria was related to ND in all patients (P<0.05) and to morning HTN only in diabetics (P=0.001). In a regression analysis, the risk of morning HTN was 2.093 (95% confidence interval (95% CI): 1.070-4.094) for the DMCKD2 group, 1.634 (95% CI: 1.044-2.557) for the CKD3-4-only group and 2.236 (95% CI: 1.401-3.570) for the DMCKD3-4 group compared with the CKD2-only group. The risk of ND was high for stage 3-4 CKD: 1.581 (95% CI: 1.180-2.120) for non-diabetics and 1.842 (95% CI: 1.348-2.601) for diabetics. Diabetics showed higher rates of morning HTN, ND and uncontrolled sustained HTN compared with non-diabetics with CKD of the same stages.
Morning Home Blood Pressure and Cardiovascular Events in a Japanese General Practice Population Over 80 Years Old: The J-HOP Study.
Kawauchi Dai,Hoshide Satoshi,Kario Kazuomi
American journal of hypertension
BACKGROUND:Home blood pressure (BP) measurement has been well accepted for use in the diagnosis and treatment of hypertension. However, data regarding the association between home BP levels and cardiovascular events in a general practice population aged ≥80 years are sparse. METHODS:We analyzed the cases of 349 patients ≥80 years old from the Japan Morning Surge-Home Blood Pressure (J-HOP) Study, a nationwide practice-based study of 4,310 Japanese with a history of and/or risk factors for cardiovascular disease. Home BP measurements were performed twice daily (morning and evening) over 14 consecutive days at baseline. RESULTS:During a median follow-up of 3.0 years, 32 composite cardiovascular events (13 strokes and 19 nonstroke events) occurred. Higher morning systolic BP (SBP) was a significant risk factor for composite cardiovascular events (hazard ratio (HR) per 10mm Hg, 1.23; 95% confidence interval (CI): 1.01-1.50) and stroke events (HR per 10mm Hg, 1.47; 95% CI: 1.08-2.00) after adjustment by the 4-year cardiovascular risk scores and clinic SBP. In the adjusted model, morning diastolic BP also tended to be a significant risk factor of stroke events (HR per 5 mm Hg, 1.43; 95% CI: 1.00-2.05). However, these associations were not found for evening BP or clinic BP. CONCLUSIONS:Morning home BP showed a positive linear association with cardiovascular events, especially with stroke. This association was not observed for clinic BP or evening home BP. Based on these results, in very elderly Asian populations, measuring morning home BP might be important in clinical practice regardless of the individual's office BP level.
Morning hypertension is a risk factor of macrovascular events following cerebral infarction: A retrospective study.
Wu Qinhua,Qu Jianfeng,Yin Yong,Wang Aihong,Cheng Wei,Duan Ruikang,Zhang Bin
This study aimed to investigate risk factors (such as morning hypertension, drug compliance, and biochemical parameters) of macrovascular events after cerebral infarction.This was a retrospective study of patients with cerebral infarction admitted between May 2015 and April 2016 at the Fengxian Branch, 6th People's Hospital of Shanghai. They were divided into the macrovascular events and control groups according to the diagnosis of macrovascular events following cerebral infarction.Among the 702 patients included for analysis, 122 patients were with macrovascular events and 580 were without macrovascular events (controls). Morning hypertension (P = .01), dyslipidemia (P = .007), atrial fibrillation (P = .039), carotid artery plaque (P = .014), inflammatory infection (P = .005), high homocysteine (P = .032), antithrombotic compliance (P < .001), statins compliance (P < .001), morning diastolic blood pressure (P < .001), morning systolic blood pressure (P < .001), and morning heart rate (morHR) (P = .033) were associated with macrovascular events. Multivariable analysis showed that morning hypertension (P = .021, odds ratio [OR] = 1.753, 95% confidence interval [CI] [1.088, 2.826]), dyslipidemia (P = .021, OR = 1.708, 95% CI [1.085, 2.687]), and inflammatory infection (P = .031, OR = 2.263, 95% CI [1.078, 4.752]) were independent risk factors for macrovascular events, while antithrombotic compliance (P < .001, OR = 0.488, 95% CI [0.336, 0.709]), statin compliance (P = .02, OR = 0.64, 95% CI [0.44, 0.931]), and morHR (P = .027, OR = 0.977, 95% CI [0.958, 0.997]) were independent protective factors against macrovascular events. Atrial fibrillation showed a tendency to be associated with macrovascular events (P = .077, OR = 1.531, 95% CI [0.955, 2.454]).Morning hypertension, dyslipidemia, and inflammatory infection may increase the risk of macrovascular events following cerebral infarction. Improving morning blood pressure management and drug compliance (antithrombotic drugs and statins) may reduce the risk of macrovascular events following cerebral infarction.
Increased Level of Morning Surge in Blood Pressure in Normotensives: ACross-Sectional Study from Pakistan.
Almas Aysha,Sultan Fatehali Tipoo,Kazmi Khawar
Journal of the College of Physicians and Surgeons--Pakistan : JCPSP
OBJECTIVE:To determine the mean morning surge (MS) in blood pressure, the frequency of increased morning surge in normotensive subjects, and to compare those with morning surge with those without MS. STUDY DESIGN:Across-sectional, comparative study. PLACE AND DURATION OF STUDY:The Department of Medicine, The Aga Khan University Hospital, Karachi, from April 2011 to March 2012. METHODOLOGY:Adult normotensive healthy volunteers aged 35 to 65 years were inducted. Their ambulatory blood pressure (ABP) was measured over a 24-hour period, using digital ambulatory blood pressure monitors. Morning surge was calculated as the average of four readings after waking minus the lowest three nocturnal readings. Increased morning surge was defined as > 11 mm Hg in systolic (SBP) or > 12 mm Hg in diastolic (DBP). Dipping was defined as > 10% dipping in blood pressure. RESULTS:Eighty-two healthy volunteers were recruited. Their mean age was 36.9 ±1.2 years; 74.4 (61%) were men, and 58.5 (48%) woke up for morning prayers. Mean overall SBPwas 113 ±1.6 mm Hg, overall DBPwas 73.9 ±0.7 mm Hg, and overall heart rate was 75 (10) beats/minute. Mean morning surge was 17.6 ±1.0 mm Hg in SBPand 16.0 ±0.8 mm Hg in DBP. The frequency of increased morning surge was 66 (80.5%) in SBP, and 57 (69%) in DBP. On comparison of participants with normal morning surge and increased morning surge in SBP, there was a significant difference in nondipping status (13.4% in normal vs. 18.3% in increased morning surge, p= 0.001). CONCLUSION:Mean morning surge in SBPand DBPare relatively higher in this subset population in a tertiary care center in Pakistan. These values are higher than those reported in the literature.
Morning surge in blood pressure using a random-effects multiple-component cosinor model.
Madden J M,Browne L D,Li X,Kearney P M,Fitzgerald A P
Statistics in medicine
Blood pressure (BP) fluctuates throughout the day. The pattern it follows represents one of the most important circadian rhythms in the human body. For example, morning BP surge has been suggested as a potential risk factor for cardiovascular events occurring in the morning, but the accurate quantification of this phenomenon remains a challenge. Here, we outline a novel method to quantify morning surge. We demonstrate how the most commonly used method to model 24-hour BP, the single cosinor approach, can be extended to a multiple-component cosinor random-effects model. We outline how this model can be used to obtain a measure of morning BP surge by obtaining derivatives of the model fit. The model is compared with a functional principal component analysis that determines the main components of variability in the data. Data from the Mitchelstown Study, a population-based study of Irish adults (n = 2047), were used where a subsample (1207) underwent 24-hour ambulatory blood pressure monitoring. We demonstrate that our 2-component model provided a significant improvement in fit compared with a single model and a similar fit to a more complex model captured by b-splines using functional principal component analysis. The estimate of the average maximum slope was 2.857 mmHg/30 min (bootstrap estimates; 95% CI: 2.855-2.858 mmHg/30 min). Simulation results allowed us to quantify the between-individual SD in maximum slopes, which was 1.02 mmHg/30 min. By obtaining derivatives we have demonstrated a novel approach to quantify morning BP surge and its variation between individuals. This is the first demonstration of cosinor approach to obtain a measure of morning surge.
Augmented venoarteriolar response with ageing is associated with morning blood pressure surge.
Yoo Jeung-Ki,Sun Dan-Dan,Parker Rosemary S,Urey Marcus A,Romero Steven A,Lawley Justin S,Sarma Satyam,Vongpatanasin Wanpen,Crandall Craig G,Fu Qi
NEW FINDINGS:What is the central question of this study? The venoarteriolar response (VAR) contributes substantially to the maintenance of orthostatic tolerance in humans. Despite its importance in haemodynamic homeostasis, the impact of ageing on the VAR remains understudied. What is the main finding and its importance? Older adults exhibit an augmented VAR in response to leg dependency. The age-related augmentation of the VAR might be linked with progressive increases of peripheral vascular resistance with ageing. We found a modest but significant correlation between the leg VAR and the morning blood pressure surge in older adults. Augmented leg VAR might contribute to the blood pressure elevation in the early morning. ABSTRACT:The venoarteriolar response (VAR) is a non-adrenergic, non-baroreflex-mediated mechanism of vasoconstriction, which has been proposed to contribute ∼45% of the increase in total peripheral resistance during orthostasis. Despite its importance in human cardiovascular control during orthostatic stress, there is no information available regarding the impact of age and sex on the VAR or its role in diurnal blood pressure (BP) variation. We studied 33 (15 women) young (mean ± SD; 28 ± 4 years old) and 26 (12 women) older (71 ± 3 years old) healthy individuals. Brachial and femoral blood flow were measured using Doppler ultrasound. The percentage reduction in vascular conductance (blood flow/mean BP) during 4 min of limb dependency (35-40 cm below the heart level) was used to assess the VAR. The morning surge in BP was assessed using 24 h ambulatory BP monitoring. Peak VAR in the lower limb, but not in the upper limb, was significantly higher in the older than the younger adults (33 ± 4 versus 26 ± 6%, older versus young; P < 0.05). There was no sex difference in the VAR in either the young or the older group. A greater leg VAR was related to a greater morning surge in BP in older adults (r = -0.4, P = 0.02) but not in the young adults (r = -0.26, P = 0.1). Thus, advancing age enhances the VAR in the lower limb and is associated with the morning blood pressure surge in older adults. Sex does not affect this local axonal reflex in healthy humans.
Association of morning blood pressure surge with carotid intima-media thickness and cardiac dysfunction in patients with cardiac syndrome-X.
Mahfouz Ragab A,Goda Mohammad,Galal Islam,Ghareb Mohamed S
Background & hypothesis: We hypothesized that exaggerated morning blood pressure surge, may contribute in cardiac dysfunction and arterial stiffness in patients with cardiac syndrome X. Thus we investigated the impact of morning blood pressure surge on cardiac function and carotid intima-media thickness in subjects with cardiac syndrome X. METHODS:We studied patients with cardiac syndrome X using ambulatory blood pressure monitoring and investigated the association of morning blood pressure surge with carotid intima thickness, left atrial volume index and left ventricular filling (E/e'). Seventy patients with cardiac syndrome X were enrolled for the study and compared with 70 age and sex matched controls. RESULTS:Patients with cardiac syndrome X were stratified based on the systolic morning blood pressure surge value of control subjects to patients with exaggerated blood pressure surge (n = 42) and those with normal morning blood pressure surge (n = 28). Basal heart rate (p < .05), high sensitive C-reactive protein (p < .01), left atrial volume index (p < .01), E/e' (p < .01); carotid intima-media thickness (p < .001) and percentage of detected plaque (p < .005) were significantly higher in patients with exaggerated morning blood pressure surge group than those with morning blood pressure surge group. Morning blood pressure surge was significantly correlated with carotid intima-media thickness, high sensitive C-reactive protein, left atrial volume index and E/e' ratio in patients with cardiac syndrome X. In multivariate analysis, exaggerated morning blood pressure surge was the only independent predictor of increased carotid intima-media thickness (OR = 2.379; p < .001), and diastolic dysfunction (OR = 2.464; p < .001) in patients with cardiac syndrome X. CONCLUSION:Our data suggest that excessive morning blood pressure surge is an independent predictor for arterial stiffness and diastolic dysfunction in patients with cardiac syndrome X.
Awaking Blood Pressure Surge and Progression to Microalbuminuria in Type 2 Normotensive Diabetic Patients.
Barbieri Michelangela,Rizzo Maria Rosaria,Fava Ilaria,Sardu Celestino,Angelico Nicola,Paolisso Pasquale,Abbatecola Angela,Paolisso Giuseppe,Marfella Raffaele
Journal of diabetes research
BACKGROUND:We investigated the predictive value of morning blood pressure surge (MBPS) on the development of microalbuminuria in normotensive adults with a recent diagnosis of type 2 diabetes. METHODS:Prospective assessments of 24-hour ambulatory blood pressure monitoring and urinary albumin excretion were performed in 377 adult patients. Multivariate-adjusted Cox regression models were used to assess hazard ratios (HRs) between baseline and changes over follow-up in MBPS and the risk of microalbuminuria. The MBPS was calculated as follows: mean systolic BP during the 2 hours after awakening minus mean systolic BP during the 1 hour that included the lowest sleep BP. RESULTS:After a mean follow-up of 6.5 years, microalbuminuria developed in 102 patients. An increase in MBPB during follow-up was associated with an increased risk of microalbuminuria. Compared to individuals in the lowest tertile (-0.67 ± 1.10 mmHg), the HR and 95% CI for microalbuminuria in those in the highest tertile of change (24.86 ± 6.92 mmHg) during follow-up were 17.41 (95% CI 6.26-48.42); p for trend <0.001. Mean SD MBPS significantly increased in those who developed microalbuminuria from a mean [SD] of 10.6 [1.4] to 36.8 [7.1], p < 0.001. CONCLUSION:An increase in MBPS is associated with the risk of microalbuminuria in normotensive adult patients with type 2 diabetes.
Morning Blood Pressure Surge as a Predictor of Development of Chronic Kidney Disease.
Turak Osman,Afsar Baris,Siriopol Dimitrie,Ozcan Firat,Cagli Kumral,Yayla Cagri,Oksuz Fatih,Mendi Mehmet Ali,Kario Kazuomi,Covic Adrian,Kanbay Mehmet
Journal of clinical hypertension (Greenwich, Conn.)
Blood pressure (BP) usually increases upon awakening--a physiological mechanism called morning BP surge (MBPS). BP values above the MBPS threshold are associated with target organ damage, including left ventricular hypertrophy and proteinuria. Despite these data, there have been no studies that have investigated the association between elevated MBPS and the development of incident chronic kidney disease (CKD). In this study, patients with essential hypertension were included and underwent ambulatory BP measurements and MBPS. Patients were followed for a median of 3.33 years. In total, 622 patients were enrolled. The mean age of patients was 57.6±12.4 years, 54.0% were men, 16.7% had diabetes, and 10.6% had prevalent cardiovascular disease. During follow-up, 32 patients developed CKD. Higher MBPS, analyzed both as continuous and categorical variables, was associated with incident CKD in all models. Elevated MBPS is associated with kidney function deterioration and the development of CKD. Studies are needed to further examine underlying mechanisms regarding MBPS and these renal outcomes.
The relationship between a blunted morning surge and a reversed nocturnal blood pressure dipping or "riser" pattern.
Fujiwara Takeshi,Tomitani Naoko,Sato Keiko,Okura Ayako,Suzuki Noriyuki,Kario Kazuomi
Journal of clinical hypertension (Greenwich, Conn.)
The authors sought to determine the association between the blunted morning blood pressure (BP) surge and nocturnal BP dipping of the "riser" pattern in 501 patients with hypertension enrolled in the ACHIEVE-ONE (Ambulatory Blood Pressure Control and Home Blood Pressure [Morning and Evening] Lowering by the N-Channel Blocker Cilnidipine) trial. The patients' sleep-trough morning BP surge and prewaking surge were calculated and then classified according to their nocturnal systolic BP reduction pattern as extreme dippers, dippers, nondippers, and risers. The prevalence of the riser pattern was significantly higher in both the lowest sleep-trough morning BP surge decile and the prewaking surge decile (blunted surge group) compared with the remaining deciles (56.0% vs 10.4% [P<.0001] and 59.2% vs 10.2% [P<.0001], respectively). The riser pattern was a significant determinant of both blunted sleep-trough morning BP surge (odds ratio, 73.3; P<.0001) and blunted prewaking surge (odds ratio, 14.8; P<.0001). The high prevalence of the riser pattern in patients with blunted morning BP surges may account for the cardiovascular risk previously reported in such patients.
Prognostic Utility of Morning Blood Pressure Surge for 20-Year All-Cause and Cardiovascular Mortalities: Results of a Community-Based Study.
Cheng Hao-Min,Wu Chung-Li,Sung Shih-Hsien,Lee Jia-Chun,Kario Kazuomi,Chiang Chern-En,Huang Chi-Jung,Hsu Pai-Feng,Chuang Shao-Yuan,Lakatta Edward G,Yin Frank C P,Chou Pesus,Chen Chen-Huan
Journal of the American Heart Association
BACKGROUND:Morning blood pressure (BP) surge (MS), defined by the MS amplitude, is an independent prognostic factor of cardiovascular outcomes in some, but not all, populations. METHOD AND RESULTS:We enrolled 2020 participants (1029 men; aged 30-79 years) with 24-hour ambulatory BP data. During a median 19.7-year follow-up, 607 deaths (182 by cardiovascular causes) were confirmed from the National Death Registry. The amplitude of sleep-trough MS (STMS) was derived from the difference between morning systolic BP (SBP) and lowest nighttime SBP. The rate of STMS was derived as the slope of linear regression of sequential SBP measures on time intervals within the STMS period. Thresholds for high STMS amplitude and rate were determined by the 95th percentiles (43.7 mm Hg and 11.3 mm Hg/h, respectively). Multivariable Cox models, adjusting for age, sex, body mass index, smoking, alcohol, low-density lipoprotein cholesterol, 24-hour SBP, night:day SBP ratio, and antihypertensive treatment, revealed that a high STMS rate (hazard ratio, 1.666; 95% confidence interval, 1.185-2.341), but not STMS amplitude (hazard ratio, 1.245; 95% confidence interval, 0.984-1.843), was significantly associated with a greater mortality risk. Similarly, STMS rate (hazard ratio, 2.608; 95% confidence interval, 1.554-4.375), but not STMS amplitude, was significantly associated with the risk of cardiovascular mortality (hazard ratio, 0.966; 95% confidence interval, 0.535-1.747). Moreover, the prognostic values of STMS rate were comparable in subjects with or without morning and nocturnal hypertension (>0.05 for interaction for all). In simulation studies, STMS rate was less susceptible to measurement errors of the sleep-trough SBP than STMS amplitude. CONCLUSIONS:STMS rate could independently help identify subjects with an increased cardiovascular risk.
Morning blood pressure surge and arterial stiffness in newly diagnosed hypertensive patients.
Kıvrak Ali,Özbiçer Süleyman,Kalkan Gülhan Yüksel,Gür Mustafa
OBJECTIVE:We aimed to investigate the relationship between the morning blood pressure (BP) surge and arterial stiffness in patients with newly diagnosed hypertension. SUBJECTS AND METHODS:Three hundred and twenty four (mean age 51.7 ± 11.4 years) patients who had newly diagnosed hypertension with 24 h ambulatory BP monitoring were enrolled. Parameters of arterial stiffness, pulse wave velocity and augmentation index (Aix) were measured by applanation tonometry and aortic distensibility was calculated by echocardiography. RESULTS:Compared with the other groups, pulse wave velocity, day-night systolic BP (SBP) difference (p < 0.001, for all) and hs-CRP (p = 0.005) were higher in morning BP surge high group. Aortic distensibility values were significantly lower in morning BP surge high group compared to the other groups (p < 0.05, for all). Morning BP surge was found to be independently associated with pulse wave velocity (β = 0.286, p < 0.001), aortic distensibility (β= -0.384, p < 0.001) and day-night SBP difference (β = 0.229, p < 0.001) in multivariate linear regression analysis. CONCLUSIONS:We found independent relationship between morning BP surge and arterial stiffness which is a surrogate endpoint for cardiovascular diseases. The inverse relationship between morning BP surge and aortic distensibility and direct relation found in our study is new to the literature.
Nighttime Blood Pressure Measured by Home Blood Pressure Monitoring as an Independent Predictor of Cardiovascular Events in General Practice.
Kario Kazuomi,Kanegae Hiroshi,Tomitani Naoko,Okawara Yukie,Fujiwara Takeshi,Yano Yuichiro,Hoshide Satoshi
Hypertension (Dallas, Tex. : 1979)
We developed an innovative automated home blood pressure (BP) monitoring method that measures BP while asleep repeatedly over several days. Our aim was to assess the predictive ability of nighttime BP obtained using the home BP device for incident cardiovascular disease (CVD) in general practice patients. We used data from the nationwide practice-based J-HOP (Japan Morning Surge-Home Blood Pressure) Nocturnal BP Study, which recruited 2545 Japanese with a history of or risk factors for CVD (mean age 63 years; antihypertensive medication use 83%). The associations between nighttime home BPs (measured at 2:00, 3:00, and 4:00 am using validated, automatic, and oscillometric home BP devices) and incident CVD, including coronary disease and stroke events, were assessed with Cox proportional hazards models. The mean±SD office, morning home, and nighttime home systolic BP (SBP)/diastolic BP were 140±15/82±10, 137±15/79±10, and 121±15/70±9 mm Hg, respectively. During a follow-up of 7.1±3.8 years (18,116 person-years), 152 CVD events occurred. A 10-mm Hg increase of nighttime home SBP was associated with an increased risk of CVD events (hazard ratios [95% CIs]: 1.201 [1.046-1.378]), after adjustments for covariates including office and morning home SBPs. The model fit assessed by the change in Goodness-of-Fit was improved when we added nighttime home SBP into the base models including office and morning home SBPs (Δ6.838 [5.6%]; P=0.009). This is among the first and largest nationwide practice-based study demonstrating that nighttime SBP obtained using a home device is a predictor of incident CVD events, independent of in-office and morning in-home SBP measurement. Clinical Trial Registration- URL: http://www.umin.ac.jp/icdr/index.html . Unique identifier: UMIN000000894.
Research and Development of Information and Communication Technology-based Home Blood Pressure Monitoring from Morning to Nocturnal Hypertension.
Kario Kazuomi,Tomitani Naoko,Matsumoto Yuri,Hamasaki Haruna,Okawara Yukie,Kondo Maiko,Nozue Ryoko,Yamagata Hiromi,Okura Ayako,Hoshide Satoshi
Annals of global health
Asians have specific characteristics of hypertension (HTN) and its relationship with cardiovascular disease. The morning surge in blood pressure (BP) in Asians is more extended, and the association slope between higher BP and the risk for cardiovascular events is steeper in this population than in whites. Thus, 24-hour BP control including at night and in the morning is especially important for Asian patients with HTN. There are 3 components of "perfect 24-hour BP control": the 24-hour BP level, adequate dipping of nocturnal BP (dipper type), and adequate BP variability such as the morning BP surge. The morning BP-guided approach using home BP monitoring (HBPM) is the first step toward perfect 24-hour BP control. After controlling morning HTN, nocturnal HTN is the second target. We have been developing HBPM that can measure nocturnal BP. First, we developed a semiautomatic HBPM device with the function of automatic fixed-interval BP measurement during sleep. In the J-HOP (Japan Morning Surge Home Blood Pressure) study, the largest nationwide home BP cohort, we successfully measured nocturnal home BP using this device with data memory, 3 times during sleep (2, 3, and 4 am), and found that nocturnal home BP is significantly correlated with organ damage independently of office and morning BP values. The second advance was the development of trigger nocturnal BP (TNP) monitoring with an added trigger function that initiates BP measurements when oxygen desaturation falls below a variable threshold continuously monitored by pulse oximetry. TNP can detect the specific nocturnal BP surges triggered by hypoxic episodes in patients with sleep apnea syndrome. We also added the lowest heart rate-trigger function to TNP to detect the "basal nocturnal BP," which is determined by the circulating volume and structural cardiovascular system without any increase in sympathetic tonus. This double TNP is a novel concept for evaluating the pathogenic pressor mechanism of nocturnal BP. These data are now collected using an information and communication technology (ICT)-based monitoring system. The BP variability includes different time-phase variability from the shortest beat-by-beat, positional, diurnal, day-by-day, visit-to-visit, seasonal, and the longest yearly changes. The synergistic resonance of each type of BP variability would produce great dynamic BP surges, which trigger cardiovascular events. Thus, in the future, the management of HTN based on the simultaneous assessment of the resonance of all of the BP variability phenotypes using a wearable "surge" BP monitoring device with an ICT-based data analysis system will contribute to the ultimate individualized medication for cardiovascular disease.
Morning and Evening Home Blood Pressure and Risks of Incident Stroke and Coronary Artery Disease in the Japanese General Practice Population: The Japan Morning Surge-Home Blood Pressure Study.
Hoshide Satoshi,Yano Yuichiro,Haimoto Hajime,Yamagiwa Kayo,Uchiba Kiyoshi,Nagasaka Shoichiro,Matsui Yoshio,Nakamura Akira,Fukutomi Motoki,Eguchi Kazuo,Ishikawa Joji,Kario Kazuomi,
Hypertension (Dallas, Tex. : 1979)
UNLABELLED:Our aim is to determine the optimal time schedule for home blood pressure (BP) monitoring that best predicts stroke and coronary artery disease in general practice. The Japan Morning Surge-Home Blood Pressure (J-HOP) study is a nationwide practice-based study that included 4310 Japanese with a history of or risk factors for cardiovascular disease, or both (mean age, 65 years; 79% used antihypertensive medication). Home BP measures were taken twice daily (morning and evening) over 14 days at baseline. During a mean follow-up of 4 years (16 929 person-years), 74 stroke and 77 coronary artery disease events occurred. Morning systolic BP (SBP) improved the discrimination of incident stroke (C statistics, 0.802; 95% confidence interval, 0.692-0.911) beyond traditional risk factors including office SBP (0.756; 0.646-0.866), whereas the changes were smaller with evening SBP (0.764; 0.653-0.874). The addition of evening SBP to the model (including traditional risk factors plus morning SBP) significantly reduced the discrimination of incident stroke (C statistics difference, -0.008; 95% confidence interval: -0.015 to -0.008; P=0.03). The category-free net reclassification improvement (0.3606; 95% confidence interval, 0.1317-0.5896), absolute integrated discrimination improvement (0.015; SE, 0.005), and relative integrated discrimination improvement (58.3%; all P<0.01) with the addition of morning SBP to the model (including traditional risk factors) were greater than those with evening SBP and with combined morning and evening SBP. Neither morning nor evening SBP improved coronary artery disease risk prediction. Morning home SBP itself should be evaluated to ensure best stroke prediction in clinical practice, at least in Japan. This should be confirmed in the different ethnic groups. CLINICAL TRIAL REGISTRATION:URL: http://www.umin.ac.jp/ctr/. Unique identifier: UMIN000000894.
Prognostic significance of the morning blood pressure surge in clinical practice: a systematic review.
Sheppard James Peter,Hodgkinson James,Riley Richard,Martin Una,Bayliss Susan,McManus Richard J
American journal of hypertension
BACKGROUND:An exaggerated morning blood pressure surge (MBPS) may be associated with stroke and other cardiovascular events, but the threshold at which an MBPS becomes pathological is unclear. This study aimed to systematically review the existing literature and establish the most appropriate definition of pathological MBPS. METHODS:A MEDLINE search strategy was adapted for a range of literature databases to identify all prospective studies relating an exaggerated MBPS to cardiovascular endpoints. Hazard ratios (HRs) were extracted and synthesized using random-effects meta-analysis. RESULTS:The search strategy identified 2,964 unique articles, of which 17 were eligible for the study. Seven different definitions of MBPS were identified; the most common was a prewaking surge (mean blood pressure for 2 hours after wake-up minus mean blood pressure for 2 hours before wake-up; n = 6 studies). Summary meta-analysis gave no clear evidence that prewaking MBPS (defined by a predetermined threshold: >25-55 mm Hg) was associated with all cardiovascular events (n = 2 studies; HR = 0.94, 95% confidence interval (CI) = 0.39-2.28) or stroke (n = 2 studies; HR = 1.26, 95% CI = 0.92-1.71). However, using a continuous scale, which has more power to detect an association, there was evidence that a 10 mm Hg increase in MBPS was related to an increased risk of stroke (n = 3 studies; HR = 1.11, 95% CI = 1.03-1.20). CONCLUSIONS:These findings suggest that when measured and analyzed as a continuous variable, increasing levels of MBPS may be associated with increased risk of stroke. Large, protocol-driven individual patient data analyses are needed to accurately define this relationship further.
Day-by-Day Variability of Home Blood Pressure and Incident Cardiovascular Disease in Clinical Practice: The J-HOP Study (Japan Morning Surge-Home Blood Pressure).
Hoshide Satoshi,Yano Yuichiro,Mizuno Hiroyuki,Kanegae Hiroshi,Kario Kazuomi
Hypertension (Dallas, Tex. : 1979)
We assessed the relationship between day-by-day home blood pressure (BP) variability and incident cardiovascular disease (CVD) in clinical practice. J-HOP study (Japan Morning Surge-Home Blood Pressure) participants underwent home BP monitoring in the morning and evening for a 14-day period, and their BP levels and BP variability independent of the mean (VIM) were assessed. Incident CVD events included coronary heart disease and stroke. Cox models were fitted to assess the home BP variability-CVD risk association. Among 4231 participants (mean±SD age, 64.9±10.9 years; 53.3% women; 79.1% taking antihypertensive medication), mean (SD) home systolic BP (SBP) levels over time and VIM were 134.2 (14.3) and 6.8 (2.5) mm Hg, respectively. During a 4-year follow-up period (16 750.3 person-years), 148 CVD events occurred. VIM was associated with CVD risk (hazard ratio per 1-SD increase, 1.32; 95% confidence interval [CI], 1.15-1.52), independently of mean home SBP levels over time and circulating B-type natriuretic peptide levels or urine albumin-to-creatinine ratio. Adding VIM to the CVD prediction model improved the discrimination (C statistic, 0.785 versus 0.770; C statistic difference, 0.015; 95% CI, 0.003-0.028). Changes in continuous net reclassification improvement (0.259; 95% CI, 0.052-0.537), absolute integrated discrimination improvement (0.010; 95% CI, 0.003-0.016), and relative integrated discrimination improvement (0.104; 95% CI, 0.037-0.166) were also observed with the addition of VIM to the CVD prediction models. In addition to the assessments of mean home SBP levels and cardiovascular end-organ damage, home BP variability measurements may provide a clinically useful distinction between high- and low-risk groups among Japanese outpatients.
Morning Surge and Peak Morning Ambulatory Blood Pressure Versus Automated Office Blood Pressure in Predicting Cardiovascular Disease.
Andreadis Emmanuel A,Geladari Charalampia V,Angelopoulos Epameinondas T,Kolyvas George N,Papademetriou Vasilios
High blood pressure & cardiovascular prevention : the official journal of the Italian Society of Hypertension
INTRODUCTION:Automated office blood pressure (AOBP) has been recently shown to predict equally well to ambulatory blood pressure (ABP), conventional office blood pressure (OBP) and home blood pressure (HBP), cardiovascular (CV) events among hypertensives. AIM:To compare AOBP recording and ABP monitoring in order to evaluate morning blood pressure (BP) peak in predicting CV events and deaths in hypertensives. METHODS:We assessed 236 initially untreated hypertensives, examined between 2009 and 2013. The end points were CV and non-CV death and any CV event including myocardial infarction, evidence of coronary heart disease, heart failure hospitalization, severe arrhythmia, stroke, and symptomatic peripheral artery disease. We fitted proportional hazards models using the different modalities as predictors and evaluated their predictive performance using two metrics: the Akaike's Information Criterion, and Harrell's C-index. RESULTS:After a mean follow-up of 7 years, 23 subjects (39% women) had at least one CV event. In Cox regression models, systolic conventional OBP, AOBP and peak morning BP were predictive of CV events (p < 0.05). The Akaike Information Criterion showed smaller values for AOBP than peak morning BP, indicating a better performance in predicting CV events (227.2736 and 238.7413, respectively). The C-index was 0.6563 for systolic AOBP and 0.6243 for peak morning BP indicating a better predicting ability for AOBP. CONCLUSION:In initially untreated hypertensives, AOBP appears to be at least equally reliable to 24-h monitoring in the evaluation of morning BP peak in order to detect CV disease whereas the sleep-trough and preawakening morning BP surge did not indicate such an effect.
Blood pressure variability in relation to outcome in the International Database of Ambulatory blood pressure in relation to Cardiovascular Outcome.
Stolarz-Skrzypek Katarzyna,Thijs Lutgarde,Richart Tom,Li Yan,Hansen Tine W,Boggia José,Kuznetsova Tatiana,Kikuya Masahiro,Kawecka-Jaszcz Kalina,Staessen Jan A
Hypertension research : official journal of the Japanese Society of Hypertension
Ambulatory blood pressure (BP) monitoring provides information not only on the BP level but also on the diurnal changes in BP. In the present review, we summarized the main findings of the International Database on Ambulatory BP in relation to Cardiovascular Outcome (IDACO) with regard to risk stratification based on BP variability. The predictive accuracy of daytime and nighttime BP and the night-to-day BP ratio depended on the disease outcome under study and treatment status, and differed for fatal outcomes compared with the composite of fatal and nonfatal diseases. An exaggerated morning surge, exceeding the 90th percentile of the population, is an independent risk factor for mortality and cardiovascular and cardiac events. Conversely, a sleep-trough or preawakening morning surge in systolic BP below 20 mm Hg is probably not associated with an increased risk of death or cardiovascular events. BP variability as captured by the average of the daytime and nighttime s.d. weighted for the duration of the daytime and nighttime interval (s.d.(dn)) and the average real variability (ARV(24)) predicted the outcome, but improved the prediction of the composite of all cardiovascular events by only 0.1%. In conclusion, the IDACO observations support the concept that BP variability adds to risk stratification, but above all highlight that 24-h ambulatory BP level remains the main predictor to be considered in clinical practice.