Morning blood pressure surge as a predictor of cardiovascular events in patients with hypertension.

Background: The prognostic value of ambulatory blood pressure (BP) monitoring (ABPM) is poorly understood in Latin American populations.

Methods: A prospective observational study was conducted on 1339 patients with hypertension who underwent 24-h BP monitoring between 2015 and 2019. The incidence of serious adverse cardiovascular events (MACE) was analysed using a Cox proportional hazards model adjusted for potential confounders. Three previously reported morning surge definitions were evaluated for SBP and DBP using different ABPM components: sleep-through morning surge, pre-awakening, and morning night-time difference.

Results: The mean age was 62 years, 52% were female, 32.8% had dyslipidaemia, 27.2% were smokers, and 7.8% had diabetes. During a median follow-up period of 32 months, 197 MACE occurred. In men, the adjusted hazard ratio (HR) was 1.84 [95% confidence interval (CI), 1.35-2.49; P  < 0.001). The HR increased to 2.03 (95% CI, 1.89-2.17; P  < 0.001) with a cut-off value of 35 mmHg for a 10 mmHg increase in sleep-through morning surge. The increased adjusted HR associated with the morning rise persisted for each secondary endpoint, including 21 cardiovascular deaths [HR: 2.70 (95% CI, 2.03-3.60; P  < 0.001)], 78 myocardial infarctions [HR: 1.92 (95% CI, 1.72-2.15; P  < 0.001)], 24 hospitalisations for heart failure [HR: 1.77 (95% CI, 1.48-2.12; P  < 0.001)], 22 strokes [HR: 2.32 (95% CI, 1.85-2.91; P  < 0.001)], and 52 atrial fibrillations [HR: 1.94 (95% CI, 1.71-2.20; P  < 0.001)].

Conclusion: The morning BP rise was the most important circadian prognostic factor for MACE in patients with hypertension, which deserves more attention.