TABLE 1.

The HOPE Asia Network 2022 update to the consensus on morning hypertension management

1. Definition
‐Morning hypertension is diagnosed by HBPM, ABPM, or WBPM as the average of the measured morning BPs ≥135/85 mmHg, regardless of office BP and BP levels measured at the other time periods.
‐Masked morning hypertension is defined as morning hypertension with office BP < 140/90 mmHg.
‐Masked uncontrolled morning hypertension is masked morning hypertension on medication.
‐There are two types of morning hypertension. One is the morning surge type, and the other is sustained nocturnal and morning hypertension type.
2. Device and assessment
‐Validated upper‐arm HBPM and ABPM devices are essentially recommended to measure morning BP.
‐Morning home BP is the average of the BPs self‐measured after 2 min‐rest in seated position, twice with 1 min‐interval after urination, before taking morning pills, and within 1 h after arising in the morning, with > 5 days of measurements (> 10 measures).
‐Morning ambulatory BP is the average of BPs automatically measured for 2‐h (four measures with 30 min‐interval by ABPM) after arising. If the arising time is not available, morning ambulatory BP (fixed‐time) is defined as the average of BPs during 7:00–8:59 a.m.
‐ABPM is recommended to evaluate nocturnal hypertension and simultaneously to differentiate between “morning surge” and “sustained nocturnal and morning hypertension” types. Wrist and upper‐arm nighttime HBPM devices (oscillometric) may be available to measure nighttime BP.
‐ WBPM (oscillometric device) could be used to measure morning BPs, when it is used under similar conditions as HBPM (measured in the sitting condition, within 1‐h after arising). Wearable morning home BP, could also be used when it is used under similar conditions as ABPM (measured during 2‐h after arising in the ambulatory situation). Upper‐arm WBPM is recommended, but wrist WBPM may alternatively be used, when individual wrist‐brachial systolic BP difference is confirmed < 5 mmHg.
‐Cuff‐less device is not recommended to obtain morning BP values for the diagnosis and treatment of hypertension in clinical practice.
3. Treatment flow
1) Target morning BP is < 135/85 mmHg in general, and < 125/75 mmHg for high‐risk group.
2) Strict salt reduction < 6 g per day, body weight reduction, and exercise are recommended first, and together with antihypertensives dugs when required.
3) Medication
a. Long acting CCB or RASi
b. If morning BP is not controlled, change timing of morning dosing to twice per day (or bedtime dosing could be considered case‐by‐case)
c. Single pill combination (SPC) is recommended when needed (combine CCB, RASi, Diuretics, or MR antagonist).
d. ARNI and SGLT2 inhibitors are also available to reduce morning BP.
e. If BP is still not controlled, beta‐blocker or alpha‐blocker could be added
4) Renal denervation is useful for morning BP reduction.

Abbreviations: ABPM, ambulatory BP monitoring; HBPM, home BP monitoring; WBPM, wearable BP monitoring.