How to manage morning surge hypertension?

Management of Morning Surge Hypertension

Morning surge hypertension should be managed with long-acting antihypertensive medications administered in the morning, with consistent timing to ensure 24-hour blood pressure control, rather than specifically targeting bedtime administration.

Understanding Morning Surge Hypertension

• Morning surge hypertension refers to the rapid rise in blood pressure that occurs upon awakening in the early morning hours, which is associated with increased cardiovascular risk 1
• This phenomenon is characterized by a biphasic circadian rhythm with higher blood pressure values during wakefulness and lower values during sleep, followed by a rapid rise upon awakening 2
• Morning surge is mediated at least partly by increased alpha-sympathetic activity and has been associated with more advanced silent cerebrovascular disease and higher future incidence of stroke 1

Assessment and Monitoring

• Home blood pressure monitoring is essential to identify and manage morning surge hypertension, with measurements taken in both morning and evening for at least 14 days 3
• Evaluate for potential target organ damage, including cardiac, cerebrovascular, and renal complications, as patients with morning hypertension are at increased risk of cardiovascular and renal disease 4
• Consider ambulatory blood pressure monitoring (ABPM) to fully characterize the 24-hour blood pressure profile, including nighttime patterns and morning surge 5

Pharmacological Management

• Use long-acting antihypertensive medications that provide full 24-hour coverage to control both daytime and nighttime blood pressure 6
• Single morning dosing of long-acting antihypertensive medications is generally recommended as most evidence supporting cardiovascular benefits has been derived from outcome trials with morning dosing 6
• Consider the following medication options:
  • Calcium channel blockers (e.g., long-acting dihydropyridines) are effective for controlling morning blood pressure surge 2
  • Combination therapy may be necessary to achieve adequate 24-hour blood pressure control 7
  • Fixed-dose single-pill combinations can improve medication adherence and should be considered when multiple medications are needed 7

Timing of Medication Administration

• While some studies suggest benefits of evening or bedtime dosing for controlling morning hypertension 3, current guidelines from major societies do not recommend preferential bedtime dosing 8, 7
• The International Society of Hypertension position paper states that preferred use of bedtime dosing should not be routinely recommended in clinical practice until results from ongoing well-designed trials are available 6
• Consistency in medication timing is more important than the specific time of administration to optimize adherence 8, 7

Lifestyle Modifications

• Implement salt restriction, increased intake of vegetables and fruits (potassium intake), weight management, and reduced alcohol intake 4
• For patients of African descent, additional focus on salt restriction is recommended as they may have altered renal sodium handling 4
• Consider Mediterranean or DASH eating patterns, particularly for patients with diabetes and hypertension 8

Special Populations

• For patients of African descent, first-line pharmacological therapy is recommended as a single pill combination including a thiazide-like diuretic plus calcium channel blocker or calcium channel blocker plus ARB 4
• Among RAS-inhibitors, ARBs may be preferred over ACE inhibitors in black patients as angioedema is about 3 times more likely with ACE inhibitors 4
• For patients with diabetes and hypertension, ACE inhibitors or ARBs are recommended for those with albuminuria 8

Follow-up and Monitoring

• Regular and frequent follow-up (monthly) is recommended until target blood pressure and ideally regression of hypertension-mediated organ damage has been achieved 4
• Monitor serum creatinine/eGFR and potassium levels at least annually when using ACE inhibitors, ARBs, or diuretics 8
• Adjust and simplify antihypertensive therapy paired with advice for lifestyle modification to improve adherence and long-term blood pressure control 4