Morning hypertension for stroke and cardiovascular: clinical pearls for primary care

Main Article Content

Al Rasyid
Elvan Wiyarta


Hypertension is the world’s leading cause of mortality and morbidity. One of the phenomena that commonly occur in hypertensive as well as normotensive patients, is morning hypertension. Blood pressure (BP) follows a diurnal rhythm, reaching its highest level during the morning hours and dropping to the lowest level at midnight. Transient increases in BP in morning hypertension plus persistent stressors within 24 hours are thought to increase target organ damage and trigger cardiovascular events. Therefore, ambulatory BP monitoring or morning home BP monitoring is recommended as a strong predictor of cardiovascular events. There are two types of morning hypertension according to its underlying mechanisms; the first one is called nocturnal hypertensive morning hypertension, and the other one is morning-surge hypertension. Numerous studies have proved that this phenomenon often leads to several acute cardiovascular events, such as stroke, coronary artery disease, and peripheral artery disease. To prevent these complications, cost-effective management is needed, especially for identifying accurate diagnostic tools, as well as creating specific regimens. Therefore, to achieve appropriate management of hypertension, including morning hypertension, long-acting antihypertensive drugs should be used, at full doses and in the form of combination therapy. The clinical usefulness of antihypertensive drugs with specific mechanisms for morning BP or split or timed dosing of long-acting drugs in controlling morning BP remains under investigation. More studies are needed, especially looking for other clinical evidence of the benefits of lowering BP in the morning. Home BP monitoring is recommended as a good choice for BP measurements, especially in the primary care setting.

Article Details

How to Cite
Rasyid, A., & Wiyarta, E. . (2021). Morning hypertension for stroke and cardiovascular: clinical pearls for primary care. Universa Medicina, 40(3), 270–278.
Review Article


Bilo G, Grillo A, Guida V, Parati G. Morning blood pressure surge: pathophysiology, clinical relevance and therapeutic aspects. Integr Blood Press Control 2018;11:47-56. doi: 10.2147/IBPC.S130277.

Oh J, Lee CJ, Kim IC, et al. Association of morning hypertension subtype with vascular target organ damage and ventral hemodynamics. J Am Heart Assoc 2017;6:e005424. doi: 10.1161/JAHA. 116.005424.

Wang JG, Kario K, Chen CH, et al. Management of morning hypertension: a consensus statement of an Asian expert panel. J Clin Hypertens (Greenwich) 2018;20:39-44. doi: 10.1111/jch.13140.

Oparil S, Acelajado MC, Bakris GL, et al. Hypertension. Nat Rev Dis Primers 2018;4:18014. doi: 10.1038/nrdp.2018.14.

NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet 2017;389:37-55. DOI:

Pena-Hernandez C, Nugent K, Tuncel M. Twenty-four-hour ambulatory blood pressure monitoring. J Prim Care Community Health 2020;11: 2150132720940519. doi: 10.1177/21501327209 40519.

Turner JR, Viera AJ, Shimbo D. Ambulatory blood pressure monitoring in clinical practice: a review. Am J Med 2015;128:14-20. doi: 10.1016/j.amjmed. 2014.07.021.

Katritsis DG, Gersh BJ, Camm AJ. A clinical perspective on sudden cardiac death. Arrhythm Electrophysiol Rev 2016;5:177-82. doi: 10.15420/aer.2016:11:2.

Marijon E, Uy-Evanado A, Dumas F, et al. Warning symptoms are associated with survival from sudden cardiac arrest. Ann Intern Med 2016; 164:23-9. doi: 10.7326/M14-2342.

Kario K. Morning surge in blood pressure and cardiovascular risk: evidence and perspectives. Hypertension 2010;56:765-73.

Sogunuru GP, Kario K, Shin J, et al. Morning surge in blood pressure and blood pressure variability in Asia: evidence and statement from the HOPE Asia Network. J Clin Hypertens (Greenwich) 2019;21:324-34. doi: 10.1111/jch.13451.

Booth JN, Jaeger BC, Huang L, et al. Morning blood pressure surge and cardiovascular disease events and all-cause mortality in Blacks: the Jackson heart study. Hypertension 2020;75:835-43. AHA.119.14233

Houle SKD, Padwal R, Poirier L, Tsuyuki RT. The 2015 Canadian Hypertension Education Program (CHEP) guidelines for pharmacists: an update. Can Pharm J (Ott) 2015;148:180-6. doi: 10.1177/1715163515586847.

Kario K, Saito I, Kushiro T, et al. Morning home blood pressure is a strong predictor of coronary artery disease: the HONEST study. J Am Coll Cardiol 2016;67:1519-27. doi: 10.1016/j.jacc.2016. 01.037.

Kario K. Home blood pressure monitoring: current status and new developments. Am J Hypertens 2021;34:783-94.

Kim HJ, Shin YU, Lee Y, et al. Increasing incidence of macular edema in excessive morning blood pressure surge in patients with retinal vein occlusion. Sci Rep 2020;10:4420.

Shimamoto K, Ando K, Fujita T, et al. The Japanese Society of Hypertension Guidelines for the management of hypertension (JSH 2014). Hypertens Res 2014;37:253-390. doi: 10.1038/hr.2014.20.

Mills KT, Bundy JD, Kelly TN, et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation 2016; 134:441-50. doi: 10.1161/CIRCULATIONAHA. 115.018912.

Wang JG, Kario K, Park JB, Chen CH. Morning blood pressure monitoring in the management of hypertension. J Hypertens 2017;35:1554-63. doi: 10.1097/HJH.0000000000001379.

Sheppard JP, Hodgkinson J, Riley R, Martin U, Bayliss S, McManus RJ. Prognostic significance of the morning blood pressure surge in clinical practice: a systematic review. Am J Hypertens 2015;28:30-41. doi: 10.1093/ajh/hpu104.

Bowles NP, Thosar SS, Herzig MX, Shea SA. Chronotherapy for hypertension. Curr Hypertens Rep 2018;20:97. doi: 10.1007/s11906-018-0897-4.

Hoshide S, Kario K. Early morning hypertension/morning blood pressure surge. Nihon Rinsho 2014;72:1395-9.

Zhang P, Jin MY, Song XY, Wang Z, Jiang YH, Yang CH. Comparison of the antihypertensive efficacy of morning and bedtime dosing on reducing morning blood pressure surge: a protocol for systemic review and meta-analysis. Medicine (Baltimore) 2021;100:e24127. DOI: 10.1097/MD.0000000000024127.

Liu K, Xu Y, Gong S, et al. The disadvantage of morning blood pressure management in hypertensive patients. Medicine (Baltimore) 2020; 99:e19278. doi: 10.1097/MD.0000000000019278.

Aslanger E, Sezer M, Umman S. High blood pressure: an obscuring misnomer? Anatol J Cardiol 2016;16:713-9. doi: 10.14744/AnatolJ Cardiol.2016.7054.

Grillo A, Salvi L, Coruzzi P, Salvi P, Parati G. Sodium intake and hypertension. Nutrients 2019;11:1970. doi: 10.3390/nu11091970.

Kaur R, Kaur M, Singh J. Endothelial dysfunction and platelet hyperactivity in type 2 diabetes mellitus: molecular insights and therapeutic strategies. Cardiovasc Diabetol 2018;17:121.

Kario K, Shimada K, Pickering TG. Clinical implication of morning blood pressure surge in hypertension. J Cardiovasc Pharmacol 2003;42 Suppl 1:S87-91. DOI: 10.1097/00005344-200312001-00019.

Ames MK, Atkins CE, Pitt B. The renin-angiotensin-aldosterone system and its suppression. J Vet Intern Med 2019;33:363-82. doi: 10.1111/jvim.15454.

Shimizu K, Takahashi M, Sato S, et al. Rapid rise of cardio-ankle vascular index may be a trigger of cerebro-cardiovascular events: proposal of smooth muscle cell contraction theory for plaque rupture. Vasc Health Risk Manag 2021;17:37-47. DOI

Bonarjee VVS. Arterial stiffness: a prognostic marker in coronary heart disease. Available methods and clinical application. Front Cardiovasc Med 2018;5:64. doi: 10.3389/fcvm. 2018.00064.

Milutinoviæ A, Šuput D, Zorc-Pleskoviè R. Pathogenesis of atherosclerosis in the tunica intima, media, and adventitia of coronary arteries: an updated review. Bosn J Basic Med Sci 2020;20:21-30. doi: 10.17305/bjbms.2019.4320.

Espinosa MG, Staiculescu MC, Kim J, Marin E, Wagenseil JE. Elastic fibers and large artery mechanics in animal models of development and disease. J Biomech Eng 2018;140:0208031-3. doi: 10.1115/1.4038704.

Climie RE, van Sloten TT, Bruno RM, et al. Macrovasculature and microvasculature at the crossroads between type 2 diabetes mellitus and hypertension. Hypertension 2019;73:1138-49. 118.11769.

Kwon A, Ihm SH, Park CS. Morning blood pressure surge in the early stage of hypertensive patients impacts three-dimensional left ventricular speckle tracking echocardiography. Clin Hypertens 2021;27: 16. doi: 10.1186/s40885-021-00173-3.

Gaciong Z, Siñski M, Lewandowski J. Blood pressure control and primary prevention of stroke: summary of the recent clinical trial data and meta-analyses. Curr Hypertens Rep 2013;15:559-74. doi: 10.1007/s11906-013-0401-0.

Hoshide S, Yano Y, Haimoto H, et al. Morning and evening home blood pressure and risks of incident stroke and coronary artery disease in the Japanese general practice population. Hypertension 2016;68:54-61.

Boggia J, Thijs L, Hansen TW, et al. Ambulatory blood pressure monitoring in 9357 subjects from 11 populations highlights missed opportunities for cardiovascular prevention in women. Hypertension 2011;57:397-405. doi: 10.1161/HYPERTENSIONAHA.110.156828.

Hermida RC, Ayala DE, Mojón A, Fernández JR. Sleep-time ambulatory BP is an independent prognostic marker of CKD. J Am Soc Nephrol 2017;28:2802-11. doi: 10.1681/ASN.2016111186.

Boffa RJ, Constanti M, Floyd CN, Wierzbicki AS. Hypertension in adults: summary of updated NICE guidance. BMJ 2019;367:l5310. doi: 10.1136/bmj.l5310.

Lee HY, Shin J. Kim GH, et al. 2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension. Clinical Hypertension 2019; 25:20.

Chiang CE, Wang TD, Ueng KC, et al. 2015 guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension. J Chin Med Assoc 2015;78:1-47. doi: 10.1016/j.jcma.2014.11.005.

Mancia G, Fagard R, Narkiewicz K,et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34: 2159–219.

James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the eighth joint national committee (JNC 8). JAMA 2014;311:507. doi:10.1001/jama. 2013.284427.

Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 2020;75:1334–57.

Fares H, Di Nicolantonio JJ, O’Keefe JH, Lavie CJ. Amlodipine in hypertension: a first-line agent with efficacy for improving blood pressure and patient outcomes. Open Heart 2016;3:e000473. doi: 10.1136/openhrt-2016-000473.

Wright JM, Musini VM, Gill R. First-line drugs for hypertension. Cochrane Database Syst Rev 2018;4:Cd001841. doi: 10.1002/14651858. CD001841.pub3.

Cooper E, Flores S, Basu R. Hypertension evaluation and management. In : Stockwell JA, Kutko MC, editor, Comprehensive critical care: pediatric; 2nd ed. Mount Prospect, Illinois, USA: Society of Critical Care Medicine;2016.p. 951-61.

Hanayama Y, Uchida HA, Nakamura Y, Makino H. Losartan/hydrochlorothiazide combination therapy surpasses high-dose angiotensin receptor blocker in the reduction of morning home blood pressure in patients with morning hypertension. Acta Med Okayama 2012;66:449-59. doi: 10.18926/AMO/49041.

Omboni S, Volpe M. Angiotensin receptor blockers versus angiotensin converting enzyme inhibitors for the treatment of arterial hypertension and the role of olmesartan. Adv Ther 2019;36:278-97. doi: 10.1007/s12325-018-0859-x.

Miller AJ, Arnold AC. The renin-angiotensin system in cardiovascular autonomic control: recent developments and clinical implications. Clin Auton Res 2019;29:231-43. doi: 10.1007/s10286-018-0572-5.

Vian J, Pereira C, Chavarria V, et al. The renin–angiotensin system: a possible new target for depression. BMC Med 2017;15:144. doi: 10.1186/s12916-017-0916-3.

Gupta A, Mackay J, Whitehouse A, et al. Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial. Lancet 2018;392:1127-37. doi: 10.1016/S0140-6736(18)31776-8.