Morning hypertension for stroke and cardiovascular: clinical pearls for primary care

Hypertension is the world’s leading cause of mortality and morbidity. One of the phenomena that commonly occur in hypertensive as well as normotensive patients, is morning hypertension. Blood pressure (BP) follows a diurnal rhythm, reaching its highest level during the morning hours and dropping to the lowest level at midnight. Transient increases in BP in morning hypertension plus persistent stressors within 24 hours are thought to increase target organ damage and trigger cardiovascular events. Therefore, ambulatory BP monitoring or morning home BP monitoring is recommended as a strong predictor of cardiovascular events. There are two types of morning hypertension according to its underlying mechanisms; the first one is called nocturnal hypertensive morning hypertension, and the other one is morning-surge hypertension. Numerous studies have proved that this phenomenon often leads to several acute cardiovascular events, such as stroke, coronary artery disease, and peripheral artery disease. To prevent these complications, cost-effective management is needed, especially for identifying accurate diagnostic tools, as well as creating specific regimens. Therefore, to achieve appropriate management of hypertension, including morning hypertension, long-acting antihypertensive drugs should be used, at full doses and in the form of combination therapy. The clinical usefulness of antihypertensive drugs with specific mechanisms for morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation. More studies are needed, especially looking for other clinical evidence of the benefits of lowering BP in the morning. Home BP monitoring is recommended as a good choice for BP measurements, especially in the primary care setting.

The Association of Morning Hypertension With Target Organ Damage in Patients With Chronic Kidney Disease and Hypertension

Objectives: To determine the association between morning hypertension and target organ damage (TOD) in patients with chronic kidney disease (CKD) and hypertension.Methods: In this cross-sectional study, 447 patients with CKD and hypertension from two centers were enrolled. Ambulatory blood pressure monitoring was conducted in all patients. Linear regression and logistic regression analysis were used to determine the association between morning hypertension and TOD in patients with CKD and hypertension, including assessments of estimated glomerular filtration rate (eGFR), left ventricular mass index (LVMI), urine protein/creatinine ratio (UPCR), and left ventricular hypertrophy (LVH).Results: Overall, 194 (43.4%) participants had morning hypertension. Morning hypertension was strongly correlated with LVH [odds ratio (OR), 2.14; 95% confidence interval (CI), 1.3–3.51; p < 0.01], lower level of eGFR (β = −0.51; 95%CI, −0.95–−0.08; p < 0.05), higher LVMI (β = 0.06; 95%CI, 0.04–0.08, p < 0.001), and UPCR (β = 0.22; 95%CI, 0.06–0.38, p < 0.01), independent of nocturnal hypertension and elevated morning blood pressure surge. As a continuous variable, both morning systolic blood pressure (SBP) and diastolic blood pressure (DBP) were found to be associated with LVH and higher level of UPCR and LVMI (p < 0.05), whereas only morning SBP was negatively correlated with eGFR (p < 0.01).Conclusion: Morning hypertension was strongly correlated with cardiac damage and impaired kidney function in CKD patients with hypertension, independent of nocturnal hypertension and morning surge in blood pressure. Morning hypertension in CKD patients warrants further attention.

Renal Denervation in Asia

The Asia Renal Denervation Consortium consensus conference of Asian physicians actively performing renal denervation (RDN) was recently convened to share up-to-date information and regional perspectives, with the goal of consensus on RDN in Asia. First- and second-generation trials of RDN have demonstrated the efficacy and safety of this treatment modality for lowering blood pressure in patients with resistant hypertension. Considering the ethnic differences of the hypertension profile and demographics of cardiovascular disease demonstrated in the SYMPLICITY HTN (Renal Denervation in Patients With Uncontrolled Hypertension)-Japan study and Global SYMPLICITY registry data from Korea and Taiwan, RDN might be an effective hypertension management strategy in Asia. Patient preference for device-based therapy should be considered as part of a shared patient-physician decision process. A practical population for RDN treatment could consist of Asian patients with uncontrolled essential hypertension, including resistant hypertension. Opportunities to refine the procedure, expand the therapy to other sympathetically mediated diseases, and explore the specific effects on nocturnal and morning hypertension offer a promising future for RDN. Based on available evidence, RDN should not be considered a therapy of last resort but as an initial therapy option that may be applied alone or as a complementary therapy to antihypertensive medication.

Intervention Effect of Sequential Blood Purification on Early Morning Hypertension in Hemodialysis Patients

Objective: To investigate the effect of sequential blood purification on early morning hypertension in hemodialysis patients. Methods: A total of 76 hemodialysis patients who were admitted in the University of Chinese Academy of Sciences Shenzhen Hospital from June 2017 to August 2019 were selected and recruited in the present study. These patients were randomly divided into two groups, namely the control group and observation group. Each group consisted of 38 patients. The patients in the control group were treated with hemodialysis, while the patients in the observation group were treated with sequential blood purification. Early morning blood pressure was compared between the control group and observation group after 12 weeks of treatment. Results: There was no significant difference in blood pressure between the two groups of patients before treatment (P > 0.05), whereas the blood pressure in the observation group was lower than that in the control group after the treatment, and the difference was statistically significant (P < 0.05). Conclusion: The use of sequential blood purification treatment for hemodialysis patients can significantly reduce the blood pressure in the morning and is worthy of clinical use.

HUBUNGAN PENGENDALIAN GLUKOSA DARAH DAN MORNING BLOOD PRESSURE SURGE DENGAN KEJADIAN PENYAKIT JANTUNG KORONER PADA PASIEN DIABETES MELITUS TIPE 2 DI RUMAH SAKIT UMUM CUT MEUTIA

Pasien diabetes melitus (DM) cenderung menujukkan percepatan proses aterosklerotik dan akibatnya risiko penyakit kardiovaskular lebih tinggi seperti penyakit jantung koroner.DM sering dipersulit dangan komorbiditas lainnya yang berkontribusi terhadap peningkatan risiko penyakit kardiovaskular (seperti, hipertensi, penyakit ginjal kronis, dan dislipidemia). Kontrol glikemik yang tidak adekuat atau terjadinya resistensi insulin mengaktifkan saraf simpatis, yang memicu MBPS berlebihan pada pasien DM.MBPS berlebihan terlibat dalam patogenesis kejadian kardiovaskular pada pagi hari dengan mencetuskan stres hemodinamik. Tujuan umum dari penelitian ini adalah untuk mengetahui hubungan antara pengendalian glukosa darah dan MBPS, serta hubungan antara MBPS dan kejadian penyakit jantung koroner pada pasien diabetes melitus di Rumah Sakit Umum Cut Meutia. Penelitian ini merupakan penelitian observasional analitik dengan rancangan potong lintang (cross sectional). Sumber data dalam penelitian ini diperoleh dari data primer berdasarkan hasil identifikasi karakteristik pasien, pengukuran morning blood pressure surge, kadar gula darah puasa dan pemeriksaan EKG. Hasil penelitian menunjukkan sebesar 75% responden pada penelitian ini (n = 32) memiliki kadar gula darah puasa yang tidak terkontrol, 53,1% responden dengan morning hypertension dan 62,5% responden mengalami Penyakit Jantung Koroner (PJK). Pada analisis bivariat, hasil menunjukkan terdapat hubungan antara kontrol gula darah puasa dengan morning hypertension (p value = 0.024%). Secara umum terdapat hubungan timbal balik antara DM dengan hipertensi.