Abstract
Our objective was to assess the prognostic significance of the night-time dipping pattern and the night–day blood pressure (BP) ratio for mortality and cardiovascular events in hypertensive patients without major cardiovascular disease at baseline. We performed a meta-analysis on individual data of 3468 patients from four prospective studies performed in Europe. Age of the subjects averaged 61±13 years; 45% were men and 61% were under antihypertensive treatment at the time of ambulatory BP monitoring. The night–day BP ratio and 24-h BP averaged, respectively, 0.907±0.085/0.866±0.095 and 138.1±16.4/82.3±11.0 mm Hg. Total follow-up time amounted to 23 164 patient-years. We used multivariable Cox regression analysis to assess the outcome of reverse dippers, non-dippers and extreme dippers vs dippers, and to assess the hazard ratios associated with 1 standard deviation higher night–day BP ratio. In comparison with dippers, and with adjustment for confounders and 24-h BP, the incidence of cardiovascular events was worse in reverse dippers (P⩽0.05), whereas mortality was lower in extreme dippers (P⩽0.01); outcome was similar in non-dippers and dippers. The systolic night–day BP ratio independently predicted all-cause mortality and cardiovascular events (P⩽0.001), which persisted after additional adjustment for 24-h BP (P⩽0.05); appropriate interaction terms indicated that the results were similar in men and women, in younger and older patients and in treated and untreated patients. In conclusion, the dipping pattern and the night–day BP ratio significantly and independently predict mortality and cardiovascular events in hypertensive patients without history of major cardiovascular disease, even after adjustment for 24-h BP.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 digital issues and online access to articles
$119.00 per year
only $9.92 per issue
Rent or buy this article
Prices vary by article type
from$1.95
to$39.95
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality. Hypertension 2005; 46: 156–161.
Ben-Dov IZ, Kark JD, Ben-Ishay D, Mekler J, Ben-Arie L, Bursztyn M . Predictors of all-cause mortality in clinical ambulatory monitoring. Hypertension 2007; 49: 1235–1241.
Staessen JA, Thijs L, Fagard R, O’Brien ET, Clement D, de Leeuw PW et al. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. JAMA 1999; 282: 539–546.
Celis H, Staessen JA, Thijs L, Buntinx F, De Buyzere M, Den Hond E et al. Cardiovascular risk in white-coat and sustained hypertensive patients. Blood Press 2002; 11: 352–356.
Clement DL, De Buyzere ML, De Bacquer DA, de Leeuw PW, Duprez DA, Fagard RH et al. Prognostic value of ambulatory blood pressure recordings in patients with treated hypertension. N Engl J Med 2003; 348: 2407–2415.
Fagard RH, Van Den Broeke C, Decort P . Prognostic significance of blood pressure measured in the office, at home and during ambulatory monitoring in older patients in general practice. J Hum Hypertens 2005; 19: 801–807.
Fagard RH, Celis H, Thijs L, Staessen JA, Clement DL, De Buyzere M et al. Daytime and night-time blood pressure as predictors of death and cause-specific cardiovascular events in hypertension. Hypertension 2008; 51: 55–61.
Verdecchia P, Porcellati C, Schillaci G, Borgioni C, Ciucci A, Battistelli M et al. Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension. Hypertension 1994; 24: 793–801.
Khattar RS, Swales JD, Dore C, Senior R, Lahiri A . Effect of aging on the prognostic significance of ambulatory, systolic, diastolic and pulse pressure in essential hypertension. Circulation 2001; 104: 783–789.
Kario K, Pickering TG, Matsuo T, Hoshide S, Schwartz JE, Shimada K . Stroke prognosis and abnormal nocturnal fall in older hypertensives. Hypertension 2001; 38: 852–857.
Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhäger WH et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet 1997; 350: 757–764.
Staessen JA, Byttebier G, Buntinx F, Celis H, O’Brien ET, Fagard R . Antihypertensive treatment based on conventional or ambulatory blood pressure measurement. JAMA 1997; 278: 1065–1072.
Fagard RH, Staessen JA, Thijs L, Gasowski J, Bulpitt CJ, Clement D et al. Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Circulation 2000; 102: 1139–1144.
Staessen JA, Thijs L, Fagard R, Celis H, Birkenhäger WH, Bulpitt CJ et al. Effects of immediate versus delayed antihypertensive therapy on outcome in the Systolic Hypertension in Europe Trial. J Hypertens 2004; 22: 847–857.
Fagard R, Brguljan J, Thijs L, Staessen J . Prediction of the actual awake and asleep blood pressures by various methods of 24-h pressure analysis. J Hypertens 1996; 14: 557–563.
Khattar RS, Swales JD, Baufield A, Dore C, Senior R, Lahiri A . Prediction of coronary and cerebrovascular morbidity and mortality by direct continuous ambulatory blood pressure monitoring in essential hypertension. Circulation 1999; 100: 1071–1076.
Hansen TW, Jeppesen J, Rasmussen S, Ibsen H, Torp-Pedersen C . Ambulatory blood pressure monitoring and risk of cardiovascular disease: a population based study. Am J Hypertens 2006; 19: 243–250.
Ohkubo T, Imai Y, Tsuji I, Nagai K, Watanabe N, Minami N et al. Relation between nocturnal decline in blood pressure and mortality. The Ohasama study. Am J Hypertens 1997; 10: 1201–1207.
Boggia J, Li Y, Thijs L, Hansen TW, Kikuya M, Björklund K et al. Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet 2007; 370: 1219–1229.
Björklund K, Lind L, Zethelius B, Berglund L, Lithell H . Prognostic significance of 24-h ambulatory blood pressure characteristics for cardiovascular morbidity in a population of elderly men. J Hypertens 2004; 22: 1691–1697.
Redon J, Lurbe E . Nocturnal blood pressure versus nondipping pattern. What do they mean? Hypertension 2008; 51: 41–42.
Kario K, Eguchi K, Nakagawa Y, Motai K, Shimada K . Relationship between extreme dippers and orthostatic hypertension in elderly hypertensive patients. Hypertension 1998; 31 (part 1): 77–82.
Ejaz AA, Kazory A, Heinig ME . 24-h blood pressure monitoring in the evaluation of supine hypertension and orthostatic hypotension. J Clin Hypertens 2007; 9: 952–955.
Mansoor GA . Orthostatic hypotension due to autonomic disorders in the hypertension clinic. Am J Hypertens 2006; 19: 319–326.
The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension and of the European Society of Cardiology. 2007 Guidelines for the Management of Arterial Hypertension. J Hypertens 2007; 25: 1105–1187.
Acknowledgements
We gratefully acknowledge the assistance of N Ausseloos en V Cornelissen for the preparation of the article.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Fagard, R., Thijs, L., Staessen, J. et al. Night–day blood pressure ratio and dipping pattern as predictors of death and cardiovascular events in hypertension. J Hum Hypertens 23, 645–653 (2009). https://doi.org/10.1038/jhh.2009.9
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/jhh.2009.9
Keywords
This article is cited by
-
Non-Dipping Blood Pressure or Nocturnal Hypertension: Does One Matter More?
Current Hypertension Reports (2024)
-
Arterial Hypertension—clinical trials update 2023
Hypertension Research (2023)
-
Hypertension and cardiomyopathy associated with chronic kidney disease: epidemiology, pathogenesis and treatment considerations
Journal of Human Hypertension (2023)
-
Association between ambulatory blood pressure monitoring patterns with cognitive function and risk of dementia: a systematic review and meta-analysis
Aging Clinical and Experimental Research (2023)
-
Time-Restricted Eating in Metabolic Syndrome–Focus on Blood Pressure Outcomes
Current Hypertension Reports (2022)