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. 2018 Dec 7;21(2):324–334. doi: 10.1111/jch.13451

Table 4.

Studies demonstrating the association between early morning blood pressure surge (based on ambulatory blood pressure monitoring) and cardiovascular events

Author Morning surge definition (ABPM) Patients Mean follow‐up CV endpoint Main findings
Kario et al6 (JMS‐ABPM study) Sleep‐trough surge, prewaking surge 519 unmedicated elderly Japanese pts with hypertension (mean 72 y) 3.4 y Stroke Those with sleep‐trough surge >55 mm Hg (highest decile) had a higher stroke incidence than those with a surge <55 mm Hg (19.0% vs 7.3%; P = 0.004). After matching for age and 24‐h BP, the RR in the surge vs nonsurge group was 2.7 (P = 0.04)
Gosse et al5 (Bordeaux cohort) Rising surge 507 untreated pts with hypertension (mean 49 y) 7.7 y CV events The rate of CV events increased in parallel with increasing BP surge quartile (Q1: 4.0%; Q2: 2.3%; Q3: 7.1%; Q4: 11.0%; P = 0.02). In multivariate analysis, the association between rising BP surge and CV events remained a significant independent predictor. Independent of age and 24‐h BP (P = 0.009)
Metoki et al8 (Ohasama study) Prewaking surge, sleep‐trough surge 1430 community‐dwelling subjects aged ≥40 y (mean 61 y) 10.4 y Stroke Those with a prewaking surge >25 mm Hg (highest quintile: Q5) had a higher hemorrhagic stroke risk vs Q2 (surge 3.0‐11.0 mm Hg) (HR 4.0; P = 0.04). Those with a sleep‐trough surge >40 mm Hg (Q5) had a higher hemorrhagic stroke risk vs Q2 (16.0‐23.0 mm Hg surge) (HR 8.9; P < 0.05)
Dolan et al4 (Dublin Outcome Study) Prewaking surge 11 291 referred hypertensive patients off‐medication (mean 55 y) 5.3 y CV mortality, stroke mortality, and cardiac mortality HR values for total CV, stroke, and cardiac mortality associated with a 10‐mm Hg increase in morning surge were 1.38 (95% CI 1.31‐1.45), 1.37 (1.23‐1.51), and 1.39 (1.30‐1.49), respectively. These remained statistically significant after adjusting for covariates including age and 24‐h BP
Amici et al3 Sleep‐trough surge 10 normotensive and 32 well‐controlled hypertensive elderly outputs (mean 66 y) with mean 24‐hour BP <135/85 mm Hg 5.0 y CV events Those with a sleep‐trough surge ≥34 mm Hg (highest tertile: T3) had higher CV risk than those with a surge <34 mm Hg (T1 and T2; 5 events vs 0 events; P = 0.001)
Li et al7 (IDACO) Sleep‐trough surge, prewaking surge 5645 subjects from eight populations (mean 53 y) 11.4 y CV, cardiac, coronary, and cerebrovascular events For all CV, cardiac, coronary and cerebrovascular events, and all‐cause mortality, the HR values for the top decile of the systolic sleep‐trough surge (>37 mm Hg) compared with the average risk in the whole study population were 1.30 (P = 0.01), 1.52 (P = 0.004), 1.45 (P = 0.03), 0.95 (P = 0.74), and 1.32 (P = 0.004), respectively
Israel et al71 Difference between average BP in last hour before waking and first hour after waking 2627 pts with hypertension (mean 22 353 person‐y (median 6.5 y) All‐cause mortality After adjustment for age, sex, hypertension and diabetes treatments, and 24‐h SBP, morning surge above vs below the median (12 mm Hg) was associated with significantly lower mortality (HR 0.61, 95% CI 0.47‐0.79; P < 0.001). This association was significant in dipping (HR 0.49, 95% CI 0.34‐0.73;P < 0.001), but not non‐dipping (HR 0.90, 95% CI 0.60‐1.34) pts
Verdecchia et al48 Sleep‐trough morning surge 3792 pts with initially untreated hypertension (mean 51 y) 8.4 y Major CV events BP surge of ≤9.5 mm Hg was associated with increased risk of CV events (adjusted HR 1.66, 95% CI 1.14‐2.42; P = 0.009). Excessive BP surge did not increase the risk of CV events
Pierdomenico et al17 Prewaking surge 1191 pts with treated hypertension (mean 69 y) 9.1 y Stroke Based on tertiles of morning surge in SBP (≤2.5 mm Hg, >2.5 and ≤11.5 mm Hg, and >11.5 mm Hg), the number of stroke events was 51, 39 and 49, respectively (NS). In dippers, morning surge in SBP of >23 mm was associated with a significantly higher risk of stroke (HR 2.08, 95% CI 1.03‐4.23; P = 0.04)
Pierdomenico et al72 Prewaking surge 1191 pts with treated hypertension (mean 69 y) 9.1 y Coronary events Dippers in the third tertile of morning surge SBP (>23 mm Hg) and nondippers were at higher coronary event risk than dippers with morning SBP surge<23 mm Hg (HR 1.912, 95% CI 1.048‐3.488; P = 0.03 and HR 1.739, 95% CI 1.074‐2.815;P = 0.02)
Abdel‐Khalik et al73 Sleep‐trough morning surge 81 pts with hypertension (mean 56 y) 3 y CV events Pts with a CV event had higher morning surge (P < 0.0001) and a nondipper pattern (P = 0.0171). A morning surge cut‐off of 41 mm Hg has sensitivity/specificity of 100%/80% to predict cardiovascular events, and a cut‐off of 33 mm Hg had sensitivity/specificity of 91%/79% to predict acute coronary syndrome (both P < 0.001).
Cheng et al74 Sleep‐trough morning surge 2020 pts with hypertension (mean 55 y) Median 19.7 y All‐cause and CV mortality The rate of increase (but not the magnitude of the increase) in morning BP was significantly associated with all‐cause (HR 1.7, 95% CI 1.2‐2.3) and CV mortality (HR 2.6, 95% CI 1.6‐4.4).
Pierdomenico et al75 Prewaking surge 391 elderly pts with treated hypertension (mean 69 y) 9.3 y Composite of stroke, coronary events, heart failure and peripheral revascularization Compared to dippers with normal morning surgein adjusted multivariate analysis, dippers with high morning surge (HR 2.52, 95% CI 1.29‐4.93; P = 0.007) and nondippers (HR 2.09, 95% CI 1.19‐3.68; P = 0.01) had significantly higher CV risk

BP, blood pressure; CI, confidence interval; CV, cardiovascular; h, hour; HR, hazard ratio; NS, not statistically significant; pts, patients; Q, quartile or quintile; RR, relative risk; SBP, systolic BP; T, tertile; y, years.