Why is blood pressure high in afternoon and evening

J Clin Hypertens (Greenwich). 2020 Dec; 22(12): 2202–2203.

Hypertension is associated with a high risk of mortality and morbidity due to ensuing cardiovascular and cerebrovascular events and kidney disease. 1 , 2 However, previous studies have shown that blood pressure (BP)‐lowering therapies can reduce this risk in patients with mild hypertension and low risk of cardiovascular disease. Therefore, it is important to diagnose and treat hypertension early to improve the outcomes of such patients. 3 , 4 The SPRINT trial assessed the safety and efficacy of intensively lowering the systolic BP (SBP) to <120 mmHg in comparison with routine lowering to < 140 mmHg in non‐diabetic, stroke‐free hypertensive patients with a risk factor for heart disease. 5 The trial showed that intensive BP control (SBP < 120 mmHg) resulted in a significantly lower incidence of heart failure, cardiovascular mortality, and all‐cause mortality than routine BP control (SBP < 140 mmHg). 5 In response to this study, the recent 2017 US hypertension guidelines (2017 ACC/AHA guideline) changed the threshold BP in the definition of hypertension, from the previous office BP of 140/90 mmHg to 130/80 mmHg. 6 On the other hand, because BP fluctuates due to various factors, including circadian rhythms, physical and mental stress, food intake, and smoking, the time, place, and method of BP measurement are also important issues. 7

Early morning is a high‐risk period in the day for the development of cardiovascular events, including stroke and ischemic heart disease. 8 , 9 Previous studies have reported that morning BP surge is associated with subclinical target organ damage 10 and that the surge is a strong predictor of stroke, coronary artery disease, and all‐cause mortality in hypertensive patients, as well as in the general population. 11 Nocturnal hypertension, defined as a nocturnal BP level of >120/70 mmHg as measured by ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) with a riser and non‐dipper BP pattern, is also associated with higher cardiovascular risk. 8 , 12 The non‐dipper pattern is associated with decreased renal sodium excretion, which is one of the causes of salt‐sensitive hypertension. 13 Non‐dipper nocturnal hypertension is associated with the progression of cardiovascular and renal diseases, which further exacerbates nocturnal hypertension. Therefore, because office BP alone cannot adequately evaluate the cardiovascular risk in hypertensive patients, accurate out‐of‐office BP measurement is imperative. To this end, many guidelines recommend twice‐daily (morning/evening) HBPM while simultaneously stressing the importance of assessing BP variability by ABPM. 6 , 14 , 15 , 16

In this issue of The Journal of Clinical Hypertension, Gong and colleagues claimed that twice‐daily BP measurements may be inadequate for assessing the cardiovascular risk in hypertensive patients and emphasized the need to reclassify the BP variability phenotype. 17 Gong and colleagues showed that nearly 50% of hypertensive patients undergoing no treatment exhibited a more pronounced afternoon peak SBP (ASBP) than morning peak SBP (MSBP) and that ASBP in these patients was more strongly associated with LVH than MSBP. 17 This suggests that traditional morning/evening HBPM might misdiagnose many hypertensive patients (especially patients with ASBP > MSBP) as healthy individuals, fail to achieve BP goals, and underestimate the cardiovascular risk because BP remains unmeasured during its afternoon peaking time. 18 Although a second peak BP in the afternoon is recognized as a possible contributor to target organ damage, 19 the characteristics of the patients who exhibit it and its association with cardiovascular risk are unidentified. Interestingly, Gong and colleagues analyzed that ASBP was independently associated with LVH in patients more pronounced ASBP even after adjusting for 24‐h BP. 17 This suggests that even if the 24‐h mean BP is adequately controlled, a late afternoon BP surge, as well as a morning BP surge, may cause target organ damage.

Gong and colleagues noted that because their study was cross‐sectional, the association between late afternoon peak BP and future cardiovascular risk remained to be elucidated, and this issue should be addressed in the future prospective studies. 17 In addition, as the authors have shown in part, the time of the second peak BP in the afternoon may vary by race, environment, season, and lifestyle, among others; however, it may also vary in the same patient. Therefore, in future studies, the reproducibility of the time of afternoon peak BP in the same patient needs to be examined, because the results would clarify whether afternoon peak BP should be monitored by HBPM or ABPM.

Given that many previous clinical studies, including the present study by Gong and colleagues in this issue, 17 have demonstrated the importance of BP variability, out‐of‐office BP measurements, such as ABPM and nocturnal BP measuring, are increasingly important. However, cuff BP measurement may fail to record BP during daily activities and may cause errors related to patient discomfort due to cuff tightening during sleep, resulting in a barrier to assessing BP variability. 16 Thus, standardizing less‐stressful home BP measurement devices, including wearable BP sensing systems with or without a cuff, is essential for accurately evaluating the cardiovascular risk in hypertensive patients. 20 , 21

CONFLICT OF INTEREST

The authors declare that there are no conflicts of interest or other disclosures concerning this manuscript.

AUTHOR CONTRIBUTIONS

Shinya Taguchi involved in writing the article; kouichi Tamura involved in detailed review with constructive remarks that substantially changed the article.

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