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Extreme dipping

is the cardiovascular risk increased? An unsolved issue

Cuspidi, Cesarea,b; Tadic, Marijanac; Sala, Carlad; Gherbesi, Elisad; Grassi, Guidoa; Mancia, Giuseppea

doi: 10.1097/HJH.0000000000002099

Extreme dipping (i.e. a marked blood pressure fall during night-time period) is an alteration of circadian blood pressure (BP) rhythm frequently observed in the setting of systemic hypertension as well as in the general population. Some reports have suggested that cardiovascular prognosis in extreme dippers (ED) is similar as in dippers, whereas other studies have documented either a better or worse prognosis in ED. Available information on clinical and prognostic implications of ED is scanty and data provided by studies are controversial. Furthermore, a comprehensive report summarizing the key features of this BP pattern is lacking. The present review focuses on a number of issues concerning ED pattern such as the prevalence and clinical correlates, mechanisms underlying this BP phenotype association with hypertension mediated organ damage (HMOD) and prognostic value in predicting cardiovascular events and all-cause mortality. The reported prevalence of this BP rhythm alteration ranges from 5% to 30%, depending on diagnostic criteria, clinical and demographic characteristics of subjects. Most studies targeting the association of this condition with HMOD failed to find consistent findings in support of an adverse impact of ED on vascular, renal of cardiac structure and function. Available data on ED as compared to low risk reference group (i.e. dippers) do not allow to conclude that high BP variability resulting from a marked BP fall at night adversely affects cardiovascular prognosis at the community level and in the general hypertensive population. Thus, further studies aimed to assess the prognostic significance of ED as well as the impact of therapeutic interventions aimed to normalize this circadian BP pattern, are highly needed.

aDepartment of Medicine and Surgery, University of Milano-Bicocca

bIstituto Auxologico Italiano IRCCS, Milano, Italy

cDepartment of Cardiology, Charité-University-Medicine Campus Virchow Klinikum, Berlin, Germany

dDepartment of Clinical Sciences and Community Health, University of Milano and Fondazione IRCCS Policlinico di Milano, Milan, Italy

Correspondence to Cesare Cuspidi, Clinical Research Unit, Istituto Auxologico Italiano, Viale della Resistenza 23, 20036 Meda, Italy. Tel: +39 0362 772433; fax: +39 0362 772416; e-mail:

Abbreviations: ABPM, ambulatory blood pressure monitoring; ACR, albumin/creatinine ratio; BP, blood pressure; CI, confidence interval; CO, cardiac output; HMOD, hypertension mediated organ damage; LVH, left ventricular hypertrophy; LVMI, left ventricular mass index; MSNA, muscle sympathetic nerve activity; SMD, standard means difference

Received 19 January, 2019

Revised 17 February, 2019

Accepted 4 March, 2019

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