Friday, February 17, 2012

JOURNAL CLUB: Bedtime dosing of anti hypertensives

Studies have shown now that blood pressure follows a circadian rhythm and a normal pattern demonstrates a night time dipping effect.  Some are Non dippers or reverse dippers and have altered BP patterns at night time.  A growing body of literature supports that absence of night time dipping is likely to have high risk of CVD and stroke. There is an increase prevalence of MI in the first several hours after awakening.  A recent study published in JASN examined the effect of administration of BP medications at night time vs daytime (chronotherapy) and ABPM for 48 hours was used.  695 patients with CKD (GFR<60 and some albuminuria for 3 months) were assessed from 2000-2007 and 661 were selected.  One group received night time medication change and other had no change in medications. There was no overlap of medications. It was a PROBE protocol, so prospective, randomized, open label, blinded end point.  The groups were divided into 2 groups: 1 all BP meds in AM and other, 1 or more meds at night.
They should that bedtime dosing of BP meds leads to lower risk of composite CVD events and major CVD events. Bedtime dosing of meds leads to better sleep time BP.  A greater proportion of patients with bedtime dosing had controlled daytime BP.

Is this practice change? Its the first randomized prospective trial to date on this topic with significant outcomes changes.  There was good follow up for 5 years but would the benefit been decreased if followed up for 10years?. It might be not applicable to all CKD patients( especially late stages) but perhaps more general population and early CKD.  The technique was good here and they used 48 hours monitoring.  Is this applicable to the USA population that is a more heterogenous group rather than the investigators in Spain.

Uptodate is listing this study as one of the practice changing study?

Do you agree?


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