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Nocturnal Hypertension: Neglected Issue in Comprehensive Hypertension Management

.........., Rensa/Yudis2
1. Faculty of Medicine, Atmajaya Catholic University of Indonesia, Jakarta, Indonesia.
2. Department of Internal Medicine, Faculty of Medicine, Atmajaya Catholic University of
Indonesia, Jakarta, Indonesia.
Correspondence author:
Faculty of Medicine, Atmajaya Catholic University of Indonesia, Jakarta, Indonesia.
Hypertension had been long time well studied as one of main cardiovascular disease (CVD)
risk factor, that made every physicians routinely prescribed anti hypertensive drug to
maintain normal blood pressure.1 However, the diagnosis of nocturnal hypertension tend to be
missed although it was important predictor of all cause mortality and/or cardiovascular
mortality.2 Lack of awareness with hypertension made the patients measure their blood
pressure only in hospital visit. This factor contributed to the limited use of ambulatory blood
pressure measurement, and the possibility of nocturnal hypertension became overlooked.3 In
this review, we described the definition, epidemiology, pathophysiology, clinical significance,
diagnosis, and anti hypertension management of isolated hypertension.

Pathophysiology of Nocturnal Hypertension

Many factors were postulated can disrupt the circadian rhythm, which in turn lead to
attenuation of nocturnal blood pressure lowering phenomenon. The causes of abnormal
circadian rhythm of blood pressure can be divided to hormonal metabolic factors and external
factors such as smoking or aging. Some disease are implicated in the disruption, such as
diabetes mellitus, metabolic syndrome, chronic kidney disease, and obstructive sleep apnea
(OSA).4 In this paper, we described the two most reported mechanism of nocturnal
hypertension, which were imbalance of nocturnal autonomic nervous system and limited
sodium metabolism by kidneys.
Imbalance of nocturnal autonomic nervous system activation
Normally, blood pressure level is fluctuated along the day with peak rise in early morning and
low while sleeping. Circadian rhythm is one of the contributor of the fluctuation which
controlled from suprachiasmatic nuclei (SCN) of the anterior hypothalamus. Circadian
rhythm mainly influenced by autonomic nervous system.a In general, Autonomic nervous
system composed of sympathetic and parasympathetic nerves, which keep in balance to
maintain physiologic state. Over dominant of sympathetic activation were postulated as the
cause of nocturnal hypertension and attenuated the blood pressure dipping. Vardhan et al
reported that, patients with obstructive sleep apnea (OSA) were having higher catecholamines
plasma and urinary level compared with control. This findings were correlated with
hypertension in patient with OSA.b Nielsen et al, found that low degree of blood pressure
dipping were related to sustained adrenergic activity which reflected by higher noradrenaline
level and lead to decreased the peripheral vasodilatation capacity.c Doxazosin, an alpha-1
adregenic, will effectively block the sympatethic activity which in turn lower the blood
pressure while sleeping.d
Limited sodium metabolism
Kidneys are having role for maintaining blood pressure, regulated by renin-angiotensinaldosteron system and influenced by circadian rhythm. Non dipping patient are thought to be
related with impaired capacity of kidneys to excrete sodium during daytime or Increased
tubular sodium reabsorption which was commonly caused by hyperaldosteronisme,f This
theory was supported by data that the prevalence of nondipper increased in patient with low

glomerular filtration rate (GFR).g Farmar et al, found there was direct correlation between
plasma creatinine level and percent of blood pressure declining at night. From their 380
patients retrospective data, non-dipping phenomenon were more prevalent in CKD patients
(53%) than in patients with essential hypertension (30%).h Wang et al reported among 540
Chinese CKD patients, total of 21,9% patients had nighttime blood pressure increased
(reversed dipper), 36,1 % patients were dipper, and 42% of patients were non-dipper.i
However, increased daily salt intake also found to be related with nocturnal hypertension
Kidneys will compensate high sodium intake by enhancing natriuresis during the night,
resulting in elevated nighttime blood pressure. Blood pressure will remain elevated until
kidneys succeed in reducing excess sodium.k

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