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Circadian patterns on ambulatory blood pressure monitoring: Do they really matter in daily clinical practice?
O perfil circadiário de descida noturna da pressão arterial na MAPA é realmente importante na prática clínica diária?
Fernando Pinto
Serviço de Cardiologia, Centro Hospitalar Entre Douro e Vouga, EPE, Presidente-Cessante da Sociedade Portuguesa de Hipertensão, Santa Maria da Feira, Portugal
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "651" "paginaFinal" => "653" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Fernando Pinto" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Fernando" "apellidos" => "Pinto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar Entre Douro e Vouga, EPE, Presidente-Cessante da Sociedade Portuguesa de Hipertensão, Santa Maria da Feira, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "O perfil circadiário de descida noturna da pressão arterial na MAPA é realmente importante na prática clínica diária?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiovascular disease is the leading cause of morbidity and mortality worldwide and hypertension is one of its main risk factors.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,2</span></a> Measurement of blood pressure (BP) is central to the diagnosis, treatment and follow-up of hypertension, and so a reliable and accurate method of measuring BP is vital.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The development of the first sphygmomanometers by Riva-Rocci and the standardization of Korotkoff's auscultatory method in the early 20th century formed the basis of the techniques of office BP measurement, the importance of which in the Framingham studies contributed greatly to the widespread use of this valuable parameter in daily clinical practice. This technique, now over a hundred years old, is by far the most common both in clinical practice and in research, particularly epidemiological studies.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The realization that BP is a hemodynamic variable influenced by multiple factors, including exertion, emotional state, food intake, smoking and weather conditions, confirmed by invasive intra-arterial BP measurements, led to a search for ways to monitor this variable non-invasively. The first non-invasive ambulatory blood pressure monitoring (ABPM) devices appeared in the 1960s, initially for experimental use only,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,5</span></a> and the first paper on the technique, by Kain et al.,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> was published in the journal <span class="elsevierStyleItalic">Circulation</span> in 1964.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The progressive miniaturization of components, complete automation of the equipment, the increasing reliability of measurements and the ability to combine assessment of other clinical parameters such as heart rate, together with lower costs, led to ABPM becoming increasingly widespread in the 1990s and 2000s. It is now considered an essential part of standard clinical practice, both for diagnosis and for assessing response to therapy,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> and its use in clinical practice is expected to expand.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Various studies have shown the advantages of ABPM over office BP measurement, especially the fact that it provides a large number of readings taken in the patient's daily environment (including during sleep), and can help to identify white coat and masked hypertension, two clinical entities that are now recognized to have prognostic significance and clear implications for decision-making. It is also used for assessing response to therapy (pharmacological and non-pharmacological) and 24-h BP variability, as well as for other purposes.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9–12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition, mean BP on ABPM has been amply demonstrated to have superior prognostic value to office BP for subclinical target organ damage and cardiovascular morbidity and mortality in both the general population and in subgroups including men, women, the elderly, the young, and treated and untreated patients.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13–17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As well as mean 24-h BP, several components of the ABPM recording have been studied, including BP variability, morning BP surge, BP load, and various indices derived from these. The most extensively assessed and commonly used are mean systolic and/or diastolic daytime (waking) and nighttime (sleeping) BP and the ratio between them, the circadian BP pattern. As different definitions and terms have been used for the concepts involved, the European Hypertension Society Working Group on Blood Pressure Monitoring recently proposed standard definitions for the different circadian BP patterns on ABPM, classifying the major patterns as nondipping and rising (night/day BP ratio ≥1), reduced dipping (ratio <1 and >0.9), dipping (ratio <0.9 and >0.8), and extreme dipping (ratio <0.8).<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In view of the variation in definitions, it is not surprising that the literature contains conflicting data on the prognostic value of different circadian patterns on ABPM. Moreover, daytime and nighttime periods are not consistently defined, with the patient's diary being used in some cases and predefined times being used in others. All of the above limitations reduce the value that some authors place on different circadian patterns on ABPM as an aid to therapeutic decision-making, particularly when prescribing specific drugs and/or the times when they should be taken.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18–20</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">With the elegance and methodological rigor that we have come to expect from this group, the article by Monte et al. in this issue of the <span class="elsevierStyleItalic">Journal</span>,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> in a large sample of Portuguese subjects at low to moderate cardiovascular risk, confirms the high reproducibility of mean 24-h BP by ABPM in the context of daily clinical practice. This is in agreement with most similar studies and underscores the value of this exam. It also demonstrates that the reproducibility of circadian patterns is low and that they should therefore not be given undue weight in clinical decisions in these patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Besides the limitations mentioned by the authors, it should also be borne in mind that the individuals in the study population were not hypertensive, as can be seen by their mean office BP and ABPM levels, and were at low or moderate cardiovascular risk. Hence, although it may be that the study's findings also apply to hypertensives, this remains to be proven. Another important limitation, and incidentally an indication of the large size of the group's patient database, is that the study population would appear not to be representative of patients that we see in daily clinical practice; it is not usual for patients with these office BP levels, even with low to moderate cardiovascular risk, to undergo two ABPM recordings in less than a year. Another minor point is that the definitions of circadian BP patterns used by the authors, while familiar to us all and therefore easy to understand, do not match those proposed in the European Hypertension Society's position paper cited above.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, the study confirms the importance of ABPM as an essential tool in daily clinical practice in a wide variety of patients,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> providing reliable data that are extremely useful for therapeutic decision-making. It also emphasizes that these data need to be used with caution, and in particular that the importance of circadian patterns identified by ABPM should not be overestimated.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pinto F. O perfil circadiário de descida noturna da PA na MAPA é realmente importante na prática clínica diária?. 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| Year/Month | Html | Total | |
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| 2023 September | 26 | 18 | 44 |
| 2023 August | 24 | 20 | 44 |
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| 2023 May | 31 | 22 | 53 |
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| 2020 December | 40 | 10 | 50 |
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| 2020 October | 21 | 13 | 34 |
| 2020 September | 50 | 10 | 60 |
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| 2020 July | 49 | 15 | 64 |
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| 2020 April | 46 | 11 | 57 |
| 2020 March | 46 | 10 | 56 |
| 2020 February | 68 | 18 | 86 |
| 2020 January | 32 | 7 | 39 |
| 2019 December | 37 | 5 | 42 |
| 2019 November | 29 | 8 | 37 |
| 2019 October | 34 | 2 | 36 |
| 2019 September | 22 | 12 | 34 |
| 2019 August | 43 | 6 | 49 |
| 2019 July | 33 | 7 | 40 |
| 2019 June | 29 | 12 | 41 |
| 2019 May | 40 | 11 | 51 |
| 2019 April | 14 | 10 | 24 |
| 2019 March | 78 | 10 | 88 |
| 2019 February | 32 | 7 | 39 |
| 2019 January | 19 | 6 | 25 |
| 2018 December | 85 | 14 | 99 |
| 2018 November | 88 | 14 | 102 |
| 2018 October | 175 | 16 | 191 |
| 2018 September | 53 | 13 | 66 |
| 2018 August | 50 | 8 | 58 |
| 2018 July | 32 | 2 | 34 |
| 2018 June | 37 | 6 | 43 |
| 2018 May | 70 | 5 | 75 |
| 2018 April | 68 | 10 | 78 |
| 2018 March | 76 | 4 | 80 |
| 2018 February | 57 | 5 | 62 |
| 2018 January | 62 | 3 | 65 |
| 2017 December | 98 | 8 | 106 |
| 2017 November | 37 | 8 | 45 |
| 2017 October | 40 | 7 | 47 |
| 2017 September | 33 | 3 | 36 |
| 2017 August | 34 | 13 | 47 |
| 2017 July | 21 | 8 | 29 |
| 2017 June | 43 | 7 | 50 |
| 2017 May | 34 | 10 | 44 |
| 2017 April | 19 | 6 | 25 |
| 2017 March | 25 | 31 | 56 |
| 2017 February | 29 | 6 | 35 |
| 2017 January | 30 | 1 | 31 |
| 2016 December | 54 | 9 | 63 |
| 2016 November | 23 | 5 | 28 |
| 2016 October | 28 | 6 | 34 |
| 2016 September | 14 | 6 | 20 |
| 2016 July | 19 | 1 | 20 |
| 2016 June | 10 | 3 | 13 |
| 2016 May | 17 | 4 | 21 |
| 2016 April | 24 | 2 | 26 |
| 2016 March | 21 | 19 | 40 |
| 2016 February | 37 | 23 | 60 |
| 2016 January | 49 | 30 | 79 |
| 2015 December | 10 | 6 | 16 |
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