Bedtime hypertension treatment and improving cardiovascular outcomes
Overview
The debate continues on whether taking blood pressure medications at bedtime can improve cardiovascular outcomes. This approach, known as “chronotherapy,” aims to counteract the morning blood pressure surge and support patients whose blood pressure doesn’t drop at night as expected.
Recent studies suggest cardiovascular risk may be lower when patients take at least one of their once-daily antihypertensive medications at bedtime. However, some experts question the results, finding the cardiovascular benefits reported to be unexpectedly large, potentially exceeding those of simply lowering blood pressure. Notably, previous studies have shown mixed effects on blood pressure. Also, lowering blood pressure too much at night can increase the risk of nocturnal hypotension, orthostatic hypotension, and falls.
Practical recommendations
Encourage medication adherence
Ask patients to take their antihypertensive medications at a time that best suits their lifestyle. Emphasize that adherence is key to effective blood pressure control.
- For patients on multiple antihypertensive drugs, it may be beneficial to administer at least one at bedtime, especially if their morning readings are elevated. This strategy could help them reach target blood pressure goals.
Consider “Non-Dipper” patients for bedtime dosing
For patients suspected of being “non-dippers” at night—commonly those with resistant hypertension, sleep apnea, diabetes, or kidney disease—consider scheduling at least one antihypertensive at bedtime. ACE inhibitors, ARBs, and calcium channel blockers are suitable options for evening administration, though avoid diuretics at night due to the risk of nocturia.
- Ambulatory blood pressure monitoring can provide valuable insights into blood pressure variations, though it may be challenging to coordinate and reimbursement is variable.
- For additional guidance, refer to “Overview of hypertension”.
References
- Hermida RC, Crespo JJ, DomÃnguez-Sardiña M, et al. Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. Eur Heart J. 2020;41(48):4565-4576.
- Hermida RC, Ayala DE, Mojón A, Fernández JR. Decreasing sleep-time blood pressure determined by ambulatory monitoring reduces cardiovascular risk. J Am Coll Cardiol. 2011;58(11):1165-1173.
- Poulter NR, Savopoulos C, Anjum A, et al. Randomized Crossover Trial of the Impact of Morning or Evening Dosing of Antihypertensive Agents on 24-Hour Ambulatory Blood Pressure. Hypertension. 2018;72(4):870-873.
- Fujiwara T, Hoshide S, Yano Y, Kanegae H, Kario K. Comparison of morning vs bedtime administration of the combination of valsartan/amlodipine on nocturnal brachial and central blood pressure in patients with hypertension. J Clin Hypertens (Greenwich). 2017;19(12):1319-1326.
