1. Journal Club ADAM WILCOX, PHARMD 1/22/14

2. Patient Case  DB, 70 yo M  Overall ABPM summary  Avg. BP = 116/62  Daytime = 120/63  Nighttime = 103/58  Systolic load: 9.2%  Night dip: 14.2%  First 3 blood pressures (in office)  161/86  158/82  155/87  9/21 (43%) of nighttime readings have SBP <100  Medications  Lisinopril  Beta-blocker

3. Ambulatory BP Monitoring  Monitor blood pressure over a 24 hour period  Every 20 minutes while awake  Every 30 minutes while sleeping  Indications  Variable office blood pressure readings  Differences between in home and office readings (white coat)  Hypertension resistant to multiple medications

4. What is normal?  150/90 or 140/90?  24 hour: <130/80  Daytime: <135/85  Nighttime: <120/70  SBP load: >30% increases cardiovascular risk  Nighttime dip: 10-20% is normal  Non-dippers: LVH, CHF, microalbuminuria, GFR reduction

5. Question  Does nocturnal blood pressure drop have an effect on cardiovascular mortality?

6. PICO  P: DB, 70yo male  I: Extreme dippers(BP decline ≥ 20% of daytime BP) Non-dippers(BP decline ≥ 0% but < 10% of daytime BP) Inverted dippers(no nighttime BP decline)  C: Dippers(BP decline ≥ 10% but < 20% of daytime BP)  O: Cardiovascular mortality

7. Journal Article  Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline in Blood Pressure and Mortality. American Journal of Hypertension 1997(10)1201-1207.

8. Study Basics  Objective:  To investigate the relationship between nocturnal decline in blood pressure and mortality  Type:  Prospective trial involving 1542 residents of a rural Japanese community  Exclusion:  <40 years old, hospitalized individuals, demented patients, people who worked out of town  Study population:  565 men(62.5 years) and 977 women(61.2 years)  Primarily farmers, retirees, housewives  Outcomes:  Overall mortality, cardiovascular, non-cardiovascular

9. Methods  Needed at least 8 hours of daytime readings and 4 hours of nighttime readings to be included in the analysis  Average duration of monitoring was 22.3 hours  Average # of measurements 44.6  Average 24 hr, daytime, nighttime, and nocturnal decline were calculated for each person  %decline nocBP = (daytime BP – nighttime BP) x 100/daytime BP  Classified into groups(extreme, dippers, non-dippers, inverted)

10. Analysis/Results  Kaplan-Meier life table, SAS LIFETEST procedure, Cox proportional hazards regression model  Mean follow up time 5.1 years(0.1-8.1)  Data adjusted for age, sex, smoking status, history of CVD, BP levels, and use of hypertensive medications

11. Analysis/Results  Sharp declines in the inverted dipper group

14. Limitations  Prospective study  All participants came from a small Japanese community

15. What does this mean to practice?  For DB…  Avg. BP = 116/62  Daytime = 120/63  Nighttime = 103/58  Systolic load: 9.2%  Night dip: 14.2%  In office avg. = 158/85  For extreme dippers…  Prevent the early morning blood pressure surge (stroke, MI)  Switch to short-acting  Timing of medications  For non-dippers/inverted…  Move one of your medications to bedtime

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17. References  1. Ernst M. Ambulatory Blood Pressure Monitoring: Recent Evidence and Clinical Pharmacy Applications. Pharmacotherapy 2013;33(1)69-83.  2. Ernst M. Nighttime Blood Pressure Is the Blood Pressure. Pharmacotherapy 2009;29(1)3-6.  3. Kaplan N. Ambulatory Blood Pressure Monitoring and White Coat Hypertension in Adults. UptoDate Nov. 2013.  4. Ohkubo T, Imai Y, Tsuji I, et al. Relation Between Nocturnal Decline in Blood Pressure and Mortality. American Journal of Hypertension 1997(10)1201-1207.