An expert consensus to refine treatment strategies on morning hypertension. It is an overlooked condition linked to underlying cardiovascular risks and various diseases.
The Silent Morning Menace
Through blood pressure monitoring, we know that blood pressure follows a circadian rhythm characterised by a drop of 10-30% during night sleep followed by an increase aligned with the moment of awakening. However, morning hypertension is a condition where the average blood pressure rises to or above 135/85 mmHg between 6 and 10 am, assessed by home or ambulatory monitoring. This phenomenon may occur in people with diagnosed or undiagnosed hypertension and is a serious indication of the increased risk of developing various diseases. Therefore, it is crucial for healthcare professionals to encourage at-risk patients to monitor their blood pressure and help those suffering from this condition to manage it effectively to mitigate any potential health risk.
Current guidelines highlight the importance of morning blood pressure or morning hypertension. However, none of these guidelines provide specific directives for its treatment. Consequently, an Asian expert panel of cardiologists has convened to discuss and reach a consensus on the strategies for effectively treating and managing morning hypertension in patients. In this article, we explore the risk factors and associated risks of morning hypertension, and the consensus guidelines suggested by the expert panel. We aim to equip healthcare professionals with a comprehensive understanding of the condition and actionable strategies to improve patient management and clinical outcomes.
A Concern in Asia
Research has indicated that there are ethnic differences in morning blood pressure, and Asians tend to have higher morning blood pressure surge and morning blood pressure compared to Caucasians. There is even some, albeit limited evidence of untreated persons with masked morning hypertension. In two separate Japanese studies, the prevalence of masked morning hypertension was 7% in Ohasama and 21.9% in Hisayama, respectively. Among patients with treated hypertension, the prevalence of morning hypertension ranges between 17.5% to 60.7% in Korean and Japanese studies.
Risk Factors Behind Morning Hypertension
There are many risk factors associated with morning hypertension which are similar to those of general hypertension. Both conditions share common risk factors such as age, genetics, obesity, high salt intake, high fat intake, a sedentary lifestyle, smoking, and excessive alcohol consumption. However, there are some nuances. Morning hypertension can also be influenced by:
- Sleep quality: Longer sleep times and later wake times which are common in shift work, and sleep apnea may result in lower sleep quality and impact circadian rhythm, which contribute to morning hypertension.
- Endocrine Factors: Conditions that influence hormone levels, such as adrenal disorders like pheochromocytoma or Cushing’s syndrome, can exacerbate morning hypertension.
- Medication Timing: In patients treated for hypertension, the inadequate use of antihypertensive medications may be a cause of uncontrolled morning hypertension. If the medications wear off by the morning, it increases the likelihood of a spike in morning blood pressure.
Associated Health Complications
Morning hypertension is a serious indication of other possible underlying conditions. It also has significant impacts on risks of other diseases or are often comorbid with these conditions:
- Cardiovascular risks: Including left ventricular hypertrophy, increased carotid intima-media thickness, arterial stiffness, and reduced coronary flow reserve. These conditions can heighten the likelihood of severe events such as heart attack and stroke.
- Neurological impacts: White matter lesions of the brain that can affect cognitive function and may lead to silent cerebrovascular disease and hemorrhagic stroke.
- Renal impact: Albuminuria, the presence of albumin in the urine, indicates kidney damage or disease and also serves as an early marker for kidney dysfunction.
Expert Recommendations for Effective Management of Morning Hypertension
Given the serious health implications associated with morning hypertension, effective management strategies are critical. These are some consensus statements and the corresponding clinical evidence put forth by the expert panel in the management of morning hypertension in hypertensive patients. They mainly involve the use of long-acting drugs, full dose or maximum dose of medications, combination therapy, and multiple dosing or timed dosing of short-acting drugs.
Long-acting drugs
When comparing a long-acting drug (amlodipine) and a short—or intermediate-acting drug (nifedipine), the most significant difference in blood pressure reduction is observed in the early morning hours between 5 and 10 a.m. During this period, amlodipine has a larger reduction than nifedipine. Drugs like perindopril, telmisartan, bisoprolol, amlodipine, and chlorthalidone are recommended for their long biological half-lives and sustained blood pressure-lowering effects.
Full dose or maximum dose of medications
Recent studies suggest that increasing dosages even for short-acting drugs, like the renin-angiotensin system inhibitors, can enhance control of morning hypertension and be as effective as long-acting drugs. In one study, doubling the dose of valsartan from 80 mg/d to 160 mg/d increases its efficacy to almost that of telmisartan. There was only a 2.4/1.8 mm Hg difference in the last six hours of a 24-hour ambulatory blood pressure monitoring.
Combination therapy
Combining an angiotensin receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor with a calcium channel blocker or diuretic can significantly enhance 24-hour blood pressure control. A study in Japan demonstrated that a combination of losartan/hydrochlorothiazide (50/12.5 mg) significantly improved blood pressure control in the morning and evening in 54.5% of patients. In contrast, only 29.1% of patients receiving a monotherapy dose of 100 mg/d of losartan experienced similar improvements. In particular, for patients with isolated morning hypertension, the combination controlled blood pressure in 81.8% of these patients versus just 21.4% with losartan alone. Further, another study involving 626 participants found that the combination of olmesartan/amlodipine was more effective over 24 hours, compared to those not adequately controlled with amlodipine alone.
Short- or Intermediate-acting drugs
To ensure the sustained duration of action or effect at a specific time, it is recommended to have multiple split dosing (e.g. two or three times a day) or dosing at a specific time, like before bedtime, for short- or intermediate-acting drugs. However, some researchers suggested that morning hypertension could be a consequence of the activation of the sympathetic nervous system. In particular, the action of getting up from bed. Therefore, they proposed the use of drugs that specifically inhibit the sympathetic nervous system, such as the alpha1-blocker doxazosin. When doxazosin is taken at bedtime, they found that it significantly lowers blood pressure in the morning and maintains reduced blood pressure throughout the day.
Conclusion
The link between morning hypertension and severe health risks to the cardiovascular, neurological, and renal systems underscores the necessity of effective management. Particularly prevalent in Asia, this condition requires proper therapeutic strategies. Based on expert consensus and clinical evidence, the recommended approaches include long-acting drugs, full or maximum doses of medications, or combination therapy for comprehensive 24-hour blood pressure control, with a focus on mitigating early morning spikes. Additionally, adjusting the timing of drug administration can significantly enhance treatment effectiveness. By tailoring these strategies to address the unique challenges of morning hypertension, healthcare professionals can improve patient outcomes and mitigate associated health risks.
References
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- Hoshide, S., Kario, K., de la Sierra, A., Bilo, G., Schillaci, G., Banegas, J. R., Gorostidi, M., Segura, J., Lombardi, C., Omboni, S., Ruilope, L., Mancia, G., & Parati, G. (2015). Ethnic differences in the degree of morning blood pressure surge and in its determinants between Japanese and European hypertensive subjects. Hypertension, 66(4), 750–756. https://doi.org/10.1161/HYPERTENSIONAHA.115.05958
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- Wang, J.-G., Kario, K., Chen, C.-H., et al. (2018). Management of morning hypertension: a consensus statement of an Asian expert panel. Journal of Clinical Hypertension, 20, 39–44. https://doi.org/10.1111/jch.13140
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