A Review of the Complexities of Morning Hypertension

DECEMBER 01, 2008
Robert Lee Page II, PharmD, FCCP, FAHA, BCPS, CGP

Dr. Page is an associate professor of clinical pharmacy and physical medicine and a clinical specialist, Division of Cardiology, University of Colorado Health Sciences Center, Schools of Pharmacy and Medicine.

As with most biologic processes, blood pressure (BP) demonstrates a distinct circadian rhythm, characterized by a substantial reduction during sleep (the nocturnal dip) followed by a moderate to marked increase around the time of awakening (the morning surge). It is not surprising that the onset of acute cardiovascular (CV) events (eg, myocardial infarction, sudden cardiac death, and stroke) also shows a circadian pattern, with peak occurrence during the early morning hours.1,2 In patients with hypertension, this surge in BP (eg, above 135/85 mm Hg) during the first 2 hours after waking, but not in the evening (the last 2 hours before going to bed) has been defined as morning hypertension.3 This morning BP surge has pathological significance as it is positively related to degree of target-organ damage, such as carotid intima-media thickness and left ventricular hypertrophy.4-6 The magnitude of the morning surge also is an independent predictor of cerebrovascular and cardiac events.7

Nondippers Versus Extreme Dippers

Two types of morning hypertension exist.8-10 The patients who demonstrate a nocturnal decrease in BP that is <10% of their daytime BP are known as nondippers. The other type of patients are the extreme dippers who exhibit a 20% or more decrease in nocturnal BP, compared with daytime BP. Finally, a patient can be an inverted dipper/riser in which their BP does not decrease or actually may increase at night. Nondippers and risers typically do not show a surge in BP on awakening but usually have sustained early morning hypertension. An excessive morning surge is common in extreme dippers.8-10

What Causes Morning Hypertension?

The morning surge in BP is influenced by many pathophysiological factors, such as activity of the autonomic and renin-angiotensin- aldosterone systems and dietary sodium intake. Other alterations that occur during the early morning that can have a significant impact on increasing CV risk in this population include increased heart rate, vascular tone, blood viscosity, and platelet aggregability. With the advent of ambulatory blood pressure monitoring (ABPM), this technology has improved identification of patients with excessive morning surges and has facilitated assessment of antihypertensive agents that may be particularly effective in this subgroup of the hypertensive population.11,12

In the Japan Morning Surge-1 study, Ishikawa and colleagues used ABPM in 611 patients with morning hypertension to determine important patient-specific characteristics.13 The analysis showed that patients with morning hypertension are more likely to be of older age, as well as have a longer duration of hypertension and antihypertensive medication use, display a higher prevalence of left ventricular hypertrophy with an elevated B-type natriuretic peptide concentration, and exhibit a lower glomerular filtration rate.

As for pharmacotherapy, choice of an agent is dependent upon the pharmacokinetics and formulation of the drug, published evidence, and timing of administration. Medications with long half-lives, such as telmisartan, amlodipine, chlorthalidone, and bisoprolol, have demonstrated efficacy in controlling early morning BP. Bedtime administration of chronotherapeutic preparations as well as alphablockers such as doxazosin have also been effective, particularly when used in combination with ABPM.14-24

This communication on the importance of home blood pressure monitoring is supported by Omron Healthcare, Inc. It is intended to help pharmacists and their staff understand the importance of home blood pressure monitoring.


  1. Cohen MC, Rohtla KM, Lavery CE, Muller JE, Mittleman MA. Meta-analysis of the morning excess of acute myocardial infarction and sudden cardiac death. Am J Cardiol. 1997;79(11):1512-1516.
  2. Muller JE, Ludmer PL, Willich SN, et al. Circadian variation in the frequency of sudden cardiac death. Circulation. 1987;75(1):131-138.
  3. Pickering TG. Morning hypertension. J Clin Hypertens (Greenwich). 2007;9(3):224-228.
  4. Giles TD. Circadian rhythm of blood pressure and the relation to cardiovascular events. J Hypertens Suppl. 2006;24(2):S11-16.
  5. Pol?nia J, Amado P, Barbosa L, et al. Morning rise, morning surge and daytime variability of blood pressure and cardiovascular target organ damage. A cross-sectional study in 743 subjects. Rev Port Cardiol. 2005;24(1):65-78.
  6. Marfella R, Siniscalchi M, Nappo F, et al. Regression of carotid atherosclerosis by control of morning blood pressure peak in newly diagnosed hypertensive patients. Am J Hypertens. 2005;18(3):308-318.
  7. Kario K, Ishikawa J, Pickering TG, et al. Morning hypertension: the strongest independent risk factor for stroke in elderly hypertensive patients. Hypertens Res. 2006;29(8):581-587.
  8. Ohkubo T, Imai Y, Tsuji I, et al. Relation between nocturnal decline in blood pressure and mortality. The Ohasama Study. Am J Hypertens. 1997;10(11):1201-1207.
  9. White WB. Clinical assessment of early morning blood pressure in patients with hypertension. Prev Cardiol. 2007;10(4):210-214.
  10. Kario K, Shimada K. Risers and extreme-dippers of nocturnal blood pressure in hypertension: antihypertensive strategy for nocturnal blood pressure. Clin Exp Hypertens. 2004;26(2):177-189.
  11. Sica DA. What are the influences of salt, potassium, the sympathetic nervous system, and the renin-angiotensin system on the circadian variation in blood pressure? Blood Press Monit. 1999;4(Suppl 2):S9-S16.
  12. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52(1):1-9.
  13. Ishikawa J, Hoshide S, Shibasaki S, et al. Relationship between morning hypertension identified by home blood pressure monitoring and brain natriuretic peptide and estimated glomerular filtration rate: the Japan Morning Surge 1 (JMS-1) Study. J Clin Hypertens (Greenwich). 2008;10(1):34-42.
  14. Mengden T, Battig B, Schubert M, et al. Comparison of casual, ambulatory and self-measured blood pressure in a study of nitrendipine vs bisoprolol. Eur J Clin Pharmacol. 1992;42(6):569-575.
  15. White WB, Sica DA, Calhoun D, Mansoor GA, Anders RJ. Preventing increases in early-morning blood pressure, heart rate, and the rate-pressure product with controlled onset extended release verapamil at bedtime versus enalapril, losartan, and placebo on arising. Am Heart J. 2002;144(4):657-665.
  16. Glasser SP, Neutel JM, Gana TJ, Albert KS. Efficacy and safety of a once daily graded-release diltiazem formulation in essential hypertension. Am J Hypertens. 2003;16(1):51-58.
  17. Eguchi K, Kario K, Hoshide Y, et al. Comparison of valsartan and amlodipine on ambulatory and morning blood pressure in hypertensive patients. Am J Hypertens. 2004;17(2):112-117.
  18. White WB, Lacourciere Y, Davidai G. Effects of the angiotensin II receptor blockers telmisartan versus valsartan on the circadian variation of blood pressure: impact on the early morning period. Am J Hypertens. 2004;17(4):347-353.
  19. White WB, Lacourciere Y, Gana T, et al. Effects of graded-release diltiazem versus ramipril, dosed at bedtime, on early morning blood pressure, heart rate, and the rate-pressure product. Am Heart J. 2004;148(4):628-634.
  20. Kamoi K, Ikarashi T. The bedtime administration of doxazosin controls morning hypertension and albuminuria in patients with type-2 diabetes: evaluation using home-based blood pressure measurements. Clin Exp Hypertens. 2005;27(4):369-376.
  21. Lacourciere Y, Neutel JM, Davidai G, Koval S. A multicenter, 14-week study of telmisartan and ramipril in patients with mild-to-moderate hypertension using ambulatory blood pressure monitoring. Am J Hypertens. 2006;19(1):104-112.
  22. Williams B, Gosse P, Lowe L, Harper R; PRISMA I Study Group. The prospective, randomized investigation of the safety and efficacy of telmisartan versus ramipril using ambulatory blood pressure monitoring (PRISMA I). J Hypertens. 2006;24(1):193-200.
  23. Gosse P, Neutel JM, Schumacher H, et al. The effect of telmisartan and ramipril on early morning blood pressure surge: a pooled analysis of two randomized clinical trials. Blood Press Monit. 2007;12(3):141-147.
  24. Wright JT, Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008;168(2):207-217.