The clinical significance of classifying patients as dippers and non-dippers on the basis of a single period of ambulatory blood pressure monitoring (ABPM) has been questioned. The aim of this study was to evaluate the relationship between nocturnal dipping status, defined on the basis of two periods of ABPM, and cardiac and extracardiac target organ damage in essential hypertension.
A total of 375 never-treated essential hypertensive patients [mean 24-h blood pressure (BP) ≥ 125/80 mmHg; mean ± SD age 45.9 ± 11.9 years] referred for the first time to our outpatient clinic underwent the following procedures: (i) repeated clinic BP measurements; (ii) blood sampling for routine chemistry examinations; (iii) 24-h urine collection for microalbuminuria; (iv) ABPM over two 24-h periods within 4 weeks; (v) echocardiography; and (vi) carotid ultrasonography.
A reproducible nocturnal dipping (decrease in BP > 10% from mean daytime BP in both ABPM periods) and non-dipping profile (decrease in BP ≤ 10% in both ABPM periods) was found in 199 (group I) and 79 patients (group II), respectively; 97 patients (group III) had a variable dipping profile. The three groups did not differ with regard to age, gender, body mass index, clinic BP, 48-h BP and heart rate. Left ventricular mass index, interventricular septum thickness, left atrium and aortic root diameters were significantly higher in group II compared with group I (mean ± SD 108.5 ± 19.5 versus 99.7 ± 19.6 g/m2, P < 0.05; 9.3 ± 0.9 versus 9.1 ± 0.9 mm, P < 0.05; 33.6 ± 3.6 versus 32.2 ± 3.7 mm, P < 0.01; 36.9 ± 4.6 mm versus 35.5 ± 4.6, P < 0.05, respectively). The smaller differences seen between groups II and III and between groups I and III were not statistically significant. The prevalence of left ventricular hypertrophy (defined as a left ventricular mass index > 134 g/m2 in men and > 110 g/m2 in women) was greater in group II (19%) than in group I (6%) (P < 0.05), whereas the differences between groups II and III and between groups I and III did not reach statistical significance. Differences among the three groups in the prevalence of carotid structural alterations (such as carotid plaques or intima–media thickening) were not statistically significant, and microalbuminuria had a similar prevalence in all three groups.
Despite similar clinic and 48-h BP values, never-treated hypertensive patients with a persistent non-dipper pattern showed a significantly greater extent of cardiac structural alterations compared with subjects with a reproducible dipping pattern, but not those with a variable BP nocturnal profile. A non-dipping pattern diagnosed on two concordant ABPM periods instead of a single monitoring therefore represents a clinical trait associated with more pronounced cardiac abnormalities. Finally, in non-dipping middle-aged hypertensives, echocardiography appears to provide a more accurate risk stratification than carotid ultrasonography or microalbuminuria.
aIstituto di Medicina Cardiovascolare and Centro di Fisiologia Clinica e Ipertensione, Università di Milano, Ospedale Maggiore IRCCS, Milan and bIstituto Auxologico Ospedale S Luca, IRCCS, Milan, Italy.
Correspondence and requests for reprints to Cesare Cuspidi, Centro di Fisiologia Clinica e Ipertensione, Via F. Sforza 35, 20122 Milan, Italy. Tel: +39 02 550 33518; fax: +39 02 503 20480; e-mail: email@example.com
Received 23 June 2003 Revised 12 September 2003 Accepted 8 October 2003