Nighttime Blood Pressure Phenotype and CV Prognosis

Quick Takes

  • The nocturnal systolic BP was associated with ASCVD and heart failure and the riser pattern of nocturnal hypertension vs. the dipper was associated with a higher risk of total CV events independent of office and 24-hour systolic BP.
  • The riser pattern was also the most important predictor of heart failure.
  • Considering this very large and several smaller studies demonstrated the importance of nocturnal systolic BP pattern, consideration should be given to extending the indications for 24-hour ambulatory BP monitoring.

Study Questions:

What is the relationship between nocturnal hypertension and nighttime blood pressure (BP) dipping patterns and the occurrence of cardiovascular (CV) events including atherosclerotic CV disease (ASCVD) and heart failure (HF) in patients with hypertension (HTN)?


The JAMP study (Japan Ambulatory Blood Pressure Monitoring Prospective), a practitioner-based Japanese nationwide, multicenter, prospective, observational study, included patients with at least one CV risk factor, mostly HTN, and free of symptomatic CVD at baseline. All patients underwent 24-hour ambulatory BP monitoring at baseline. The primary outcome was total CV events including any ASCVD, fatal and nonfatal stroke, fatal and nonfatal coronary artery disease (CAD), and HF. BP samples were programmed to be every 30 minutes, and for inclusion, recordings had to include at least six daytime and three nighttime readings.


A total of 6,359 patients (68.6 ± 11.7 years of age, 48% men, 93% had HTN, and 77% were taking antihypertensive medication) were included in the final analysis. Mean office BP was 144/84 mm Hg; uncontrolled daytime BP of ≥135/85 mm Hg was present in 59% and uncontrolled nighttime BP of ≥120/70 mm Hg was present in 62%. During a mean follow-up of 4.5 ± 2.4 years, there were 306 CV events (119 stroke, 99 CAD, 88 HF). Nighttime systolic BP was significantly associated with the risk of ASCVD and HF (hazard ratio adjusted for demographic and clinical risk factors per 20 mm Hg increase: 1.18 [95% confidence interval (CI), 1.02–1.37], p = 0.029; and 1.25 [95% CI, 1.00–1.55], p = 0.048, respectively). Disrupted circadian BP rhythm (riser pattern, nighttime BP higher than daytime BP) was associated with higher overall CVD risk (1.48 [95% CI, 1.05–2.08]; p = 0.024), and especially HF (2.45 [95% CI, 1.34–4.48]; p = 0.004) compared with normal circadian rhythm. Daytime systolic BP was associated with a 22% increase in CAD and stroke risk but not HF or CAD.


Nighttime BP levels and a riser pattern were independently associated with the total CV event rate, for HF in particular. These findings suggest the importance of antihypertensive strategies targeting nighttime systolic BP.


The generalizability of the findings in the Japanese cohort needs to be confirmed in other groups. Ideally, a similar moderate sized study needs to be done in a cohort in which the majority are being treated and have well controlled office BP (<130/80 mm Hg). Other smaller studies have shown that nocturnal systolic HTN and the absence of nocturnal dipping are more important than mean daytime and mean 24-hour ambulatory systolic BP. In the clinical setting, nocturnal pressure is considered in four groups with the reference of systolic BP while asleep versus awake: normal dippers (10%–<20%), extreme dippers (>20% or ratio sleep/awake <0.8), nondippers (0%–<10%), and risers (any increase or sleep/awake >1.0). While cost implications are important, this large cohort study supports routine use of 24-hour ambulatory BP monitoring in patients who have what is considered a good systolic BP by home BP monitoring to determine what changes may be necessary to avoid the riser pattern and optimizing both day and night BP based on age and other risk factors.

Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Hypertension, Vascular Medicine

Keywords: Antihypertensive Agents, Atherosclerosis, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Blood Pressure Determination, Circadian Rhythm, Coronary Artery Disease, Geriatrics, Heart Failure, Hypertension, Primary Prevention, Risk Factors, Stroke, Vascular Diseases

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