The need for 24-hour blood pressure control

The current focus of our efforts in treating hypertension is to ‘treat to target’ using combination therapy. However, 24-hour control of blood pressure (BP) is of crucial importance in reducing cardiovascular risk. There is a circadian rhythm for such risk, with morning peaks in sudden cardiac death, myocardial infarction, unstable angina and ischaemic stroke. There is also a natural circadian rhythm in BP. Lack of a significant nocturnal dip worsens prognosis: patients tend to have increased left ventricular hypertrophy, cardiovascular mortality and cerebrovascular disease. Risk is related to the patient’s total BP load.
The implications are that truly long-acting once-daily antihypertensives are needed, with a trough/peak ratio > 50%. Patient compliance is very important. Ambulatory BP monitoring should be used in selected patients. Patients should be advised to take their antihypertensive medication on waking rather than waiting until after breakfast.