150621 introduction and pathophysiology nocturnal hypertension

8/20/2019 150621 Introduction and Pathophysiology Nocturnal Hypertension

http://slidepdf.com/reader/full/150621-introduction-and-pathophysiology-nocturnal-hypertension 1/4

Nocturnal Hypertension: Neglected Issue in Comprehensive Hypertension Management

.........., Rensa/Yudis2

1. Faculty of Medicine, Atmajaya Catholic University of ndonesia, !a"arta, ndonesia.

2. #e$artment of nternal Medicine, Faculty of Medicine, Atmajaya Catholic University of

ndonesia, !a"arta, ndonesia.

Corres$ondence author%

Faculty of Medicine, Atmajaya Catholic University of ndonesia, !a"arta, ndonesia.

Email:

Introduction

&y$ertension had 'een lon( time )ell studied as one of main cardiovascular disease *C+#

ris" factor, that made every $hysicians routinely $rescri'ed anti hy$ertensive dru( to

maintain normal 'lood $ressure.1 &o)ever, the dia(nosis of nocturnal hy$ertension tend to 'e

missed althou(h it )as im$ortant $redictor of all cause mortality and/or cardiovascular

mortality.2 -ac" of a)areness )ith hy$ertension made the $atients measure their 'lood

$ressure only in hos$ital visit. his factor contri'uted to the limited use of am'ulatory 'lood

$ressure measurement, and the $ossi'ility of nocturnal hy$ertension 'ecame overloo"ed. n

this revie), )e descri'ed the definition, e$idemiolo(y, $atho$hysiolo(y, clinical si(nificance,

dia(nosis, and anti hy$ertension mana(ement of isolated hy$ertension.



Pathophysiology of Nocturnal Hypertension

Many factors )ere $ostulated can disru$t the circadian rhythm, )hich in turn lead to

attenuation of nocturnal 'lood $ressure lo)erin( $henomenon. he causes of a'normal

circadian rhythm of 'lood $ressure can 'e divided to hormonal meta'olic factors and e0ternal

factors such as smo"in( or a(in(. ome disease are im$licated in the disru$tion, such as

dia'etes mellitus, meta'olic syndrome, chronic "idney disease, and o'structive slee$ a$nea

*A.3 n this $a$er, )e descri'ed the t)o most re$orted mechanism of nocturnal

hy$ertension, )hich )ere im'alance of nocturnal autonomic nervous system and limited

sodium meta'olism 'y "idneys.

Imbalance of nocturnal autonomic nervous system activation

4ormally, 'lood $ressure level is fluctuated alon( the day )ith $ea" rise in early mornin( and

lo) )hile slee$in(. Circadian rhythm is one of the contri'utor of the fluctuation )hich

controlled from su$rachiasmatic nuclei *C4 of the anterior hy$othalamus. Circadian

rhythm mainly influenced 'y autonomic nervous system.a n (eneral, Autonomic nervous

system com$osed of sym$athetic and $arasym$athetic nerves, )hich "ee$ in 'alance to

maintain $hysiolo(ic state. ver dominant of sym$athetic activation )ere $ostulated as the

cause of nocturnal hy$ertension and attenuated the 'lood $ressure di$$in(. +ardhan et al

re$orted that, $atients )ith o'structive slee$ a$nea *A )ere havin( hi(her catecholamines

$lasma and urinary level com$ared )ith control. his findin(s )ere correlated )ith

hy$ertension in $atient )ith A. ' 4ielsen et al, found that lo) de(ree of 'lood $ressure

di$$in( )ere related to sustained adrener(ic activity )hich reflected 'y hi(her noradrenaline

level and lead to decreased the $eri$heral vasodilatation ca$acity.c #o0a5osin, an al$ha61

adre(enic, )ill effectively 'loc" the sym$atethic activity )hich in turn lo)er the 'lood

$ressure )hile slee$in(.d

Limited sodium metabolism

7idneys are havin( role for maintainin( 'lood $ressure, re(ulated 'y renin6an(iotensin6

aldosteron system and influenced 'y circadian rhythm. 4on di$$in( $atient are thou(ht to 'e

related )ith im$aired ca$acity of "idneys to e0crete sodium durin( daytime or ncreased

tu'ular sodium rea'sor$tion )hich )as commonly caused 'y hy$eraldosteronisme,f

histheory )as su$$orted 'y data that the $revalence of nondi$$er increased in $atient )ith lo)



(lomerular filtration rate *8FR.( Farmar et al, found there )as direct correlation 'et)een

$lasma creatinine level and $ercent of 'lood $ressure declinin( at ni(ht. From their 9:

$atients retros$ective data, non6di$$in( $henomenon )ere more $revalent in C7# $atients

*;< than in $atients )ith essential hy$ertension *:<.h =an( et al re$orted amon( ;3:

Chinese C7# $atients, total of 21,>< $atients had ni(httime 'lood $ressure increased

*reversed di$$er, ?,1 < $atients )ere di$$er, and 32< of $atients )ere non6di$$er.i

&o)ever, increased daily salt inta"e also found to 'e related )ith nocturnal hy$ertension

7idneys )ill com$ensate hi(h sodium inta"e 'y enhancin( natriuresis durin( the ni(ht,

resultin( in elevated ni(httime 'lood $ressure. @lood $ressure )ill remain elevated until

"idneys succeed in reducin( e0cess sodium."

1. ad)al R, traus B, McAlister FA. Cardiovascular ris" factors and their effects on the

decision to treat hy$ertension% evidence 'ased revie). @M!. 2::1 A$r 2122*D2>2%>DDE9:.

2. Friedman , -o(an A8. Can nocturnal hy$ertension $redict cardiovascular ris" nte(r

@lood ress Control. 2::> e$ 32%2;ED.

. -i Y, =an( !68. solated 4octurnal &y$ertension A #isease Mas"ed in the #ar".

&y$ertension. 2:1 Fe' 1?1*2%2D9E9.

3. 7an'ay M, ur(ut F, Uyar MB, A"cay A, Covic A. Causes and mechanisms of nondi$$in(

hy$ertension. Clin B0$ &y$ertens. 2::9 ct:*D%;9;E>D.

a. @ia((ioni . Circadian Cloc"s, Autonomic Rhythms, and @lood ressure #i$$in(.

&y$ertension. 2::9 4ov 1;2*;%D>DE9. '. +ardhan +, hanmu(anandan 7. &y$ertension and catecholamine levels in slee$ a$noea.

Med ! Armed Forces ndia. 2:12 !an?9*1%E9.c. 4ielsen F, &ansen &, !aco'sen , Rossin( , midt UM, Christensen 4!, et al. ncreased

sym$athetic activity durin( slee$ and nocturnal hy$ertension in y$e 2 dia'etic $atients )ith

dia'etic ne$hro$athy. #ia'et Med. 1>>> !ul1?*D%;;;E?2.



d. Yasuda 8, &ase(a)a 7, 7uji , (a)a 4, himura 8, Umemura , et al. Bffects of

do0a5osin on am'ulatory 'lood $ressure and sym$athetic nervous activity in hy$ertensive

y$e 2 dia'etic $atients )ith overt ne$hro$athy. #ia'et Med. 2::; ct22*1:%1>3E3::.e. @an"ir -, @ochud M, Maillard M, @ovet , 8a'riel A, @urnier M. 4i(httime @lood ressure

and 4octurnal #i$$in( Are Associated =ith #aytime Urinary odium B0cretion in African

u'jects. &y$ertension. 2::9 A$r 1;1*3%9>1E9.f. Gelin"a , Htrauch @, ecen -, =idims"I !. #iurnal 'lood $ressure variationin

$heochromocytoma, $rimary aldosteronism and Cushin(Js syndrome. ! &um &y$ertens.

2::319*2%1:DE11.(. so'e , hashi 4, Fuji"ura , suji , a"ao Y, Yasuda &, et al. #istur'ed circadian rhythm

of the intrarenal renin6an(iotensin system% relevant to nocturnal hy$ertension and renal

dama(e. Clin B0$ 4e$hrol. 2:13 A$r 121>*2%21E>.

h. h. Farmer C7, 8oldsmith #!, Co0 !, #allyn , 7in(s)ood !C, har$stone . An investi(ation

of the effect of advancin( uraemia, renal re$lacement thera$y and renal trans$lantation on

'lood $ressure diurnal varia'ility. 4e$hrol #ial rans$lant. 1>>D 4ov 112*11%2:1ED.i. =an( C, Ghan( !, -iu K, -i C, Ye G, en( &, et al. Reversed #i$$er @lood6ressure attern

s Closely Related to evere Renal and Cardiovascular #ama(e in atients )ith Chronic

7idney #isease. -o 4B. 2:1 Fe' ;9*2%e;;31>. j. hin !, Ku B, -im Y&, Choi @Y, 7im @7, -ee Y8, et al. Relationshi$ 'et)een nocturnal

'lood $ressure and 236h urinary sodium e0cretion in a rural $o$ulation in 7orea. Clinical

&y$ertension. 2:13 e$ 2;2:*1%>.". 7imura 8, #ohi Y, Fu"uda M. alt sensitivity and circadian rhythm of 'lood $ressure% the

"eys to connect C7# )ith cardiovasucular events. &y$ertens Res. 2:1: !un*?%;1;E2:.

150621 introduction and pathophysiology nocturnal hypertension

Documents