Nighttime Blood Pressure Phenotype and Cardiovascular Prognosis: Practitioner-Based Nationwide JAMP Study

Abstract

Background: Ambulatory and home blood pressure (BP) monitoring parameters are better predictors of cardiovascular events than are office BP monitoring parameters, but there is a lack of robust data and little information on heart failure (HF) risk. The JAMP study (Japan Ambulatory Blood Pressure Monitoring Prospective) used the same ambulatory BP monitoring device, measurement schedule, and diary-based approach to data processing across all study centers and determined the association between both nocturnal hypertension and nighttime BP dipping patterns and the occurrence of cardiovascular events, including HF, in patients with hypertension.

Methods: This practitioner-based, nationwide, multicenter, prospective, observational study included patients with at least 1 cardiovascular risk factor, mostly hypertension, and free of symptomatic cardiovascular disease at baseline. All patients underwent 24-hour ambulatory BP monitoring at baseline. Patients were followed annually to determine the occurrence of primary end point cardiovascular events (atherosclerotic cardiovascular disease and HF).

Results: A total of 6,359 patients (68.6±11.7 years of age, 48% men) were included in the final analysis. During a mean±SD follow-up of 4.5±2.4 years, there were 306 cardiovascular events (119 stroke, 99 coronary artery disease, 88 HF). Nighttime systolic BP was significantly associated with the risk of atherosclerotic cardiovascular disease and HF (hazard ratio adjusted for demographic and clinical risk factors per 20-mm Hg increase: 1.18 [95% 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 significantly associated with higher overall cardiovascular disease 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.

Conclusions: Nighttime BP levels and a riser pattern were independently associated with the total cardiovascular event rate, in particular for HF. These findings suggest the importance of antihypertensive strategies targeting nighttime systolic BP. Registration: URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000020377.

Keywords: cardiovascular disease; diurnal blood pressure variability; heart failure; nighttime blood pressure; nocturnal hypertension.

Figure 1.

Cardiovascular disease risk. A, Cumulative incidence of different cardiovascular disease events by dipping status (adjusted for age, sex, body mass index, smoking, alcohol use, diabetes, dyslipidemia, history of cardiovascular disease, use of antihypertensive drugs, bedtime antihypertensive dosing, office systolic blood pressure, and 24-hour systolic blood pressure, with dipper status as the reference). B, Heat map showing 5-year risk of cardiovascular disease events by nighttime systolic blood pressure and dipping status (adjusted by age, sex, body mass index, smoking, alcohol use, diabetes, dyslipidemia, history of cardiovascular disease, use of antihypertensive drugs, bedtime antihypertensive dosing, and office systolic blood pressure). ASCVD indicates atherosclerotic cardiovascular disease; CAD, coronary artery disease; CHF, congestive heart failure; CVD, cardiovascular disease; and SBP, systolic blood pressure.

Figure 2.

Risk of stroke and heart failure by nocturnal blood pressure dipping status and 24-hour systolic blood pressure control status. Values are adjusted for age, sex, body mass index, smoking, alcohol intake, diabetes, dyslipidemia, prevalent cardiovascular disease, use of antihypertensive drugs, bedtime dosing, and office and 24-hour systolic blood pressure. CHF indicates congestive heart failure; HR, hazard ratio; UC 24hBP, uncontrolled 24-hour blood pressure (24-hour systolic blood pressure >130 mm Hg); and WC 24hBP, well-controlled 24-hour systolic blood pressure (24-hour systolic blood pressure ≤130 mm Hg).