Farah Raymond, Makhoul Nicola, Arraf Zaher, Khamisy-Farah Rola
Internal Medicine B Department, Ziv Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
Blood Press Monit. 2013 Aug;18(4):227-31. doi: 10.1097/MBP.0b013e3283624aed.
Uncontrolled hypertension is present in most patients treated with only a single morning dose or fixed dose drug combination; usually a third of them have a high prevalence of a nondipper blood pressure pattern, especially patients with chronic illness. In most cases, nondipping is related partly to the absence of 24-h therapeutic coverage of the single morning doses. We have investigated the usefulness of shifting therapy to evening instead of the morning.
The aim of the study was to better control blood pressure and convert patients with a nondipping pattern to a dipper pattern without the need to increase the dose of their drugs or the addition of any other family of drugs.
Among 200 hypertensive patients, we investigated the impact of treatment time on the blood pressure pattern in 60 patients (33.3%) with uncontrolled hypertension with a nondipper pattern on the basis of clinic measurements who were studied by 24-h ambulatory monitoring during 2 and 4 months of follow-up; all of them received their treatment in the morning. This group of patients was divided randomly into two groups of 30 patients each; one group continued to receive the medication on awakening and the other took their medication at bedtime. Most of the treatment involved calcium channel blockers and other angiotensin-converting-enzyme inhibitors (ACEI), and 20 patients were taking one tablet of combined treatment (calcium blocker with ACEI).
The percentage of patients with controlled ambulatory blood pressure was 0.86 among patients taking the drug at bedtime (P=0.005). Twenty-six patients with uncontrolled hypertension, receiving one drug or combined therapy at bedtime, showed a significant reduction in the 24-h mean systolic and diastolic blood pressure (6.2 and 2.6 mmHg, respectively; P<0.009). This reduction was more prominent during night-time (8.3 and 5.0 mmHg; P<0.001). In addition, all 26 patients showed normal blood pressure less than 140/90 during clinic measurement at daytime. Only four patients treated with monotherapy in the morning were unresponsive to the switching, and their blood pressure was controlled by the addition of a second drug at bedtime. The control group (who continued taking therapy in the morning) showed no reduction in blood pressure during night-time and remained with uncontrolled hypertension as they were at the beginning of the study.
In patients with uncontrolled hypertension, switching of therapy to bedtime should be considered to improve control and to avoid the nondipper pattern before any attempt is made to increase the dose or add more drugs. We need other research studies with long time follow-up to verify the efficacy of switching therapy.
大多数仅接受单一晨起剂量或固定剂量药物组合治疗的患者存在血压控制不佳的情况；其中通常有三分之一的患者非勺型血压模式的患病率较高，尤其是慢性病患者。在大多数情况下，非勺型部分与晨起单一剂量缺乏24小时治疗覆盖有关。我们研究了将治疗时间改为晚上而非早晨的有效性。
本研究的目的是更好地控制血压，并将非勺型模式的患者转变为勺型模式，而无需增加药物剂量或添加任何其他类别的药物。
在200例高血压患者中，我们对60例（33.3%）血压控制不佳且基于临床测量显示为非勺型模式的患者，在2至4个月的随访期间通过24小时动态血压监测研究了治疗时间对血压模式的影响；他们均在早晨接受治疗。这组患者被随机分为两组，每组30例；一组继续在醒来时服药，另一组在睡前服药。大多数治疗涉及钙通道阻滞剂和其他血管紧张素转换酶抑制剂（ACEI），20例患者服用联合治疗药物（钙通道阻滞剂与ACEI）。
睡前服药患者中动态血压得到控制的患者百分比为0.86（P = 0.005）。26例血压控制不佳的高血压患者在睡前接受单一药物或联合治疗，其24小时平均收缩压和舒张压显著降低（分别为6.2和2.6 mmHg；P < 0.009）。夜间降低更为显著（8.3和5.0 mmHg；P < 0.001）。此外，所有26例患者在白天临床测量时血压均正常，低于140/90。只有4例早晨接受单一疗法的患者对换药无反应，他们的血压通过在睡前添加第二种药物得到控制。对照组（继续在早晨接受治疗）夜间血压未降低，且仍处于研究开始时血压控制不佳的状态。
对于血压控制不佳的患者，在尝试增加剂量或添加更多药物之前，应考虑将治疗改为睡前服药，以改善血压控制并避免非勺型模式。我们需要其他长期随访的研究来验证换药治疗的疗效。
