title: Prognostic Effect of the Nocturnal Blood Pressure Fall in Hypertensive Patients: The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) Meta-Analysis.
abstract: The prognostic importance of the nocturnal systolic blood pressure (SBP) fall, adjusted for average 24-hour SBP levels, is unclear. The Ambulatory Blood Pressure Collaboration in Patients With Hypertension (ABC-H) examined this issue in a meta-analysis of 17 312 hypertensives from 3 continents. Risks were computed for the systolic night-to-day ratio and for different dipping patterns (extreme, reduced, and reverse dippers) relative to normal dippers. ABC-H investigators provided multivariate adjusted hazard ratios (HRs), with and without adjustment for 24-hour SBP, for total cardiovascular events (CVEs), coronary events, strokes, cardiovascular mortality, and total mortality. Average 24-hour SBP varied from 131 to 140 mm Hg and systolic night-to-day ratio from 0.88 to 0.93. There were 1769 total CVEs, 916 coronary events, 698 strokes, 450 cardiovascular deaths, and 903 total deaths. After adjustment for 24-hour SBP, the systolic night-to-day ratio predicted all outcomes: from a 1-SD increase, summary HRs were 1.12 to 1.23. Reverse dipping also predicted all end points: HRs were 1.57 to 1.89. Reduced dippers, relative to normal dippers, had a significant 27% higher risk for total CVEs. Risks for extreme dippers were significantly influenced by antihypertensive treatment (P<0.001): untreated patients had increased risk of total CVEs (HR, 1.92), whereas treated patients had borderline lower risk (HR, 0.72) than normal dippers. For CVEs, heterogeneity was low for systolic night-to-day ratio and reverse/reduced dipping and moderate for extreme dippers. Quality of included studies was moderate to high, and publication bias was undetectable. In conclusion, in this largest meta-analysis of hypertensive patients, the nocturnal BP fall provided substantial prognostic information, independent of 24-hour SBP levels.
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.). gilsalles@hucff.ufrj.br.
authors.forename: Gil F
authors.initials: GF
authors.lastname: Salles
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Gianpaolo
authors.initials: G
authors.lastname: Reboldi
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Robert H
authors.initials: RH
authors.lastname: Fagard
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Claudia R L
authors.initials: CR
authors.lastname: Cardoso
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Sante D
authors.initials: SD
authors.lastname: Pierdomenico
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Paolo
authors.initials: P
authors.lastname: Verdecchia
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Kazuo
authors.initials: K
authors.lastname: Eguchi
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Kazuomi
authors.initials: K
authors.lastname: Kario
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Satoshi
authors.initials: S
authors.lastname: Hoshide
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Jorge
authors.initials: J
authors.lastname: Polonia
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Alejandro
authors.initials: A
authors.lastname: de la Sierra
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Ramon C
authors.initials: RC
authors.lastname: Hermida
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Eamon
authors.initials: E
authors.lastname: Dolan
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: Eoin
authors.initials: E
authors.lastname: O'Brien
authors.affiliation: From the Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (G.F.S., C.R.L.C.); Department of Medicine, University of Perugia, Perugia, Italy (G.R.); Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium (R.H.F.); Dipartimento di Medicina e Scienze dell'Invecchiamento, Universita Gabriele d'Annunzio, Chieti, Italy (S.D.P.); Department of Medicine, Struttura Complessa di Medicina, Ospedale di Assisi, Assisi, Italy (P.V.); Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan (K.E., K.K., S.H.); Department of Medicine, Faculdade de Medicine da Universidade do Porto, Porto, Portugal (J.P.); Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Terrassa, Spain (A.d.l.S.); Bioengineering and Chronobiology Laboratories, University of Vigo, Vigo, Spain (R.C.H.); Department of Geriatric and Stroke Medicine, Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland (E.D.); Conway Institute, University College Dublin, Belfield, Dublin, Ireland (E.O.); and Department of Medicine, UCONN School of Medicine, Farmington, CT (G.C.R.).
authors.forename: George C
authors.initials: GC
authors.lastname: Roush
mesh_terms: D000328:Adult; D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D018660:Blood Pressure Monitoring, Ambulatory / Q000379:methods* / Q000592:standards*; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D002940:Circadian Rhythm / Q000502:physiology*; D003971:Diastole / Q000187:drug effects / Q000502:physiology; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy / Q000503:physiopathology*; D007022:Hypotension / Q000503:physiopathology; D038622:Internationality; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D018570:Risk Assessment; D013599:Systole / Q000187:drug effects / Q000502:physiology
chemical_list: D000959:Antihypertensive Agents
keywords: blood pressure; blood pressure monitoring, ambulatory; hypertension; meta-analysis; publication bias