Bedtime hypertension treatment and improving cardiovascular outcomes

There will be renewed debate about whether taking blood pressure medications at bedtime improves CV outcomes. The idea behind this “chronotherapy” is to combat the morning blood pressure rise or help patients whose blood pressure doesn’t “dip” at night like it should.

Now evidence suggests that cardiovascular risk is lower if patients take at least one of their once-daily antihypertensive medications at bedtime. But many experts think these results are too good to be true, since the study implies a greater magnitude of cardiovascular benefit than simply treating hypertension. Plus prior studies show mixed effects on blood pressure. And be mindful that lowering blood pressure too much at night can lead to nocturnal hypotension and possibly orthostatic hypotension and falls.

Ask patients when it’s most convenient to take their antihypertensive medications. Stress that medication ADHERENCE is the best predictor of blood pressure control. If patients are on multiple antihypertensive drugs, it’s okay to give at least one at bedtime, especially if some blood pressure readings are high in the morning. This may do the trick to reach blood pressure goals.

Also consider prescribing at least one antihypertensive medication at bedtime if you suspect the patient’s a “non-dipper” at night. These are often patients with resistant hypertension, sleep apnea, diabetes, or kidney disease. Feel comfortable giving an ACEI, ARB, or calcium channel blocker at bedtime. But taking diuretics at bedtime may cause nocturia. Keep in mind, ambulatory blood pressure monitoring can reveal blood pressure fluctuations, but can be cumbersome to coordinate and reimbursement is spotty. For further information, see note on "Overview of hypertension".

References

• Hermida, R.C., Crespo, J.J., Domínguez-Sardiña, and Hygia Project Investigators (2019). Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. European heart journal, [online] p.ehz754. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31641769

  Hermida, R.C., Ayala, D.E., Mojón, A. and Fernández, J.R. (2011). Decreasing sleep-time blood pressure determined by ambulatory monitoring reduces cardiovascular risk. Journal of the American College of Cardiology, [online] 58(11), pp.1165–1173. Available at: https://pubmed.ncbi.nlm.nih.gov/21884956

  Poulter, N.R., Savopoulos, and others (2018). Randomized Crossover Trial of the Impact of Morning or Evening Dosing of Antihypertensive Agents on 24-Hour Ambulatory Blood Pressure. Hypertension (Dallas, Tex. : 1979), [online] 72(4), pp.870–873. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30354703

  Fujiwara, T., Hoshide, S., Yano, Y., Kanegae, H. and Kario, K. (2017). Comparison of morning vs bedtime administration of the combination of valsartan/amlodipine on nocturnal brachial and central blood pressure in patients with hypertension. The Journal of Clinical Hypertension, [online] 19(12), pp.1319–1326. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/jch.13128