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High Morning Systolic Blood Pressure Linked to Cerebrovascular Events


Presented by Kazuomi Kario, Japan

Morning systolic blood pressure (SBP) is associated with increased risk of cerebrovascular events, even if clinic SBP is low. Kazuomi Kario, MD, PhD, Jichi Medical University School of Medicine, Shimotsuke, Japan, presented data from the Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure Study [HONEST; UMIN000002567; Saito I et al. Hypertens Res 2013].

Home BP monitoring is the first step in achieving 24-hour BP control [Shimamoto K et al. Hypertens Res 2014]. Morning hypertension, defined as a BP ≥135/85 mmHg in the morning, is recommended to be targeted in clinical practice by suggesting that patients take their antihypertensive medication in the morning [Kario K. Am J Hypertens 2005]. The purpose of the HONEST study was to determine the effect of home BP, clinic BP, and the occurrence of cardiovascular events.

In the large, prospective, observational HONEST study, 21591 olmesartan-naïve patients with essential hypertension who had data for 2 days of morning home and clinic BP were followed for 2 years. At baseline, the mean age was 65 years, the body mass index was 24 kg/m2, and 50% of participants had previously used antihypertensive therapy. All patients received olmesartan at baseline with a mean dose of 18.2 mg and 83% continued its use by the end of the study, with a mean dose of 20 mg. The primary endpoints included cerebrovascular event, cardiac event, and sudden death.

Morning home and clinic SBP were significantly associated with reaching the primary endpoint at 18 (p=0.015 and p=0.0005, respectively) and 24 months (p≤0.0001 for both). According to a spline regression analysis, the minimum risk for morning home and clinic SBP was 124 mmHg and 131 mmHg, respectively. Patients with a morning home SBP of ≥145 mmHg and a clinic SBP of ≥150 mmHg had the greatest risk of reaching the primary endpoint (HR, 3.92; p<0.0001), with patients having a morning home SBP of ≥145 mmHg and a clinic SBP <130 mmHg also demonstrating significant risk for reaching the primary endpoint (HR, 2.47; p=0.014).

There were no significant differences between morning home systolic BP (SBP) and clinic SBP, and morning home diastolic BP (DBP) and clinic DBP, over the 2 years of follow-up. In addition, morning home and clinic BPs decreased by 20 and 10 mmHg, respectively, at 2 years. The incidence of the primary endpoint was 6.46 (95% CI, 5.75 to 7.27), with a stroke incidence of 2.92 (95% CI, 2.46 to 3.48). In addition, the incidence of cardiac events was 3.85 (95% CI, 3.30 to 4.48), including a myocardial infarction incidence of 1.03 (95% CI, 0.77 to 1.38). The incidence for sudden death was 0.80 (95% CI, 0.58 to 1.12).

Dr. Kario concluded that data from the HONEST study suggest that on-treatment morning home SBP >145 mmHg is associated with an increase in risk of cardiovascular events at 2 years. In addition, the risk is also high in patients who have masked hypertension (ie, those patients who have a high home BP but a low BP in the clinic).



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