Circadian variation of blood pressure: The basis for the chronotherapy of hypertension

Ambulatory blood pressure (BP) measurements present a close correlation with target organ damage and cardiovascular events, including myocardial infarction, stroke and cardiovascular mortality. With the use of this measurement technique, a significant circadian variation has been shown to characterize BP. This circadian BP variation, although affected by a variety of external factors, represents the influence of internal factors such as ethnicity, gender, autonomic nervous system tone, vasoactive hormones, and hematologic and renal variables. In most individuals, BP presents a morning increase, a small post-prandial valley, and a deeper descent during nocturnal rest. However, under certain pathophysiological conditions, the nocturnal BP decline may be reduced or even reversed. This cannot be determined by traditional clinical or home BP assessments. Subjects with a diminished nocturnal BP decline (non-dipper pattern) have a significantly worse prognosis than the ones with a normal dipper pattern. In particular, the non-dipper circadian BP pattern represents a risk factor for left ventricular hyperthropy, microalbuminuria, cerebrovascular disease, congestive heart failure, vascular dementia and myocardial infarction. The normalization of the circadian BP pattern to a dipper profile is a novel therapeutic goal, and accumulating medical evidence suggests this can delay the progression towards the renal and cardiovascular pathology known to be a consequence of the non-dipper BP pattern. The features of the circadian BP profile have direct implications for improving the drug-delivery of antihypertensive therapies as well as the qualification of patients for medication trials and assessment.