Recognizing Non-Dippers


MEDICINE IS NOT AN EXACT SCIENCE

RAMON F. ABARQUEZ, JR., MD, EFACC, FASCC, FPCP, FPCC, CSPSH

Dr. Ramon F. Abarquez, Jr. has been one of the most prolific consultant writers of H&L and its sister publication, Vital Signs. Highly esteemed in the medical community, he is an emeritus professor of the University of the Philippines College of Medicine, and an academician of the National Academy of Science and Technology.

For comments, ramonfabarquezjr@yahoo.com.ph


Blunted sleep time, orthostatic hypotension, obstructed sleep apnea, “lazy legs” during sleep, restlessness upon waking up in the morning can suggest a non-dipper BP characteristics. Any other non-dipper clues?

Reversed non-dipper personality

Agreeableness and conscientiousness were associated with more nocturnal BP dipping (ß = .05 [p = .025] and ß = .07 [p < .001], respectively) and lower systolic blood pressure at night (ß = -.05 [p = .018] and ß = -.03 [p = .072], respectively).

Non-dippers were particularly more impulsive (p = .009), less trusting (p = .004), and less self-disciplined (p = .001). The associations were stronger when comparing extreme dippers (nighttime drop = 20 percent) to reverse dippers (nighttime increase in blood pressure).

Conscientiousness was associated with approximately 40 percent reduced risk of reverse dipping (OR = 1.43, 1.08-1.91). Reduced nighttime BP dipping is associated with antagonism and impulsivity-related traits, but not with measures of emotional vulnerability. (Cucca, Psychosom Med. 2014 Apr;76(3):237-43)

Will psychiatrists agree to relate personality profiles to cardiovascular risk profiling via non-dipper assessment?

Pediatric ABPM

Although much experience with pediatric ABPM has been gained since publication of the 2008 AHA scientific statement, much more work needs to be done. Specifically, there is an urgent need for more comprehensive normative ABPM data across sex, race, and age. Devices that can measure DBP more accurately may be useful in determining the true increase in DBP over age, because current norms indicate a flat DBP curve.

Recognizing Non-Dippers 2Better data linking ABPM patterns to target-organ damage are also needed to improve our characterization of BP, because children with abnormal load, dipping, or a circadian pattern may be at risk for cardiovascular disease despite normal ABPM mean levels. Finally, additional data evaluating the efficacy of ABPM in measuring the effect of interventions and effectiveness of ABPM-driven BP control in reversing target-organ damage are need. (Flynn, Hypertension. 2014 May;63(5):1116-35.)

Non-dipper in childhood

Do children and adolescents who have obesity (Ob) or type 2 diabetes (T2DM) of relatively short duration have already impaired cardiovascular function compared with lean subjects by using 24-hour ambulatory blood pressure as a surrogate measure of evaluation? Mean 24-hour, daytime and nighttime systolic blood pressure was significantly higher in Ob and T2DM compared with lean subjects (mean 24-hour 117 and 120 vs. 109 mm Hg; daytime 121 and 123 vs. 113 mm Hg; and nighttime 109 and 115 vs. 101 mm Hg; p < 0.01 for all time periods). The nocturnal systolic dip in Ob and T2DM did not differ from that of lean, whereas nocturnal diastolic dip decreased significantly in Ob and T2DM compared to lean (11.5 and 10.4 vs. 20.6 mm Hg; p < 0.01). Mean pulse pressure was significantly increased in the Ob and T2DM groups compared to lean subjects (51 and 54 vs. 45 mm Hg; p < 0.01). Adolescent Ob and T2DM groups share adverse risk factors, which may be harbingers of adult cardiovascular events. (Shikha, Cardiorenal Med. 2015 Jun;5(3):183-90.)

Recognizing Non-Dippers 3Non-dipper in diabetes

Hypertension is a highly prevalent risk factor for cardiovascular disease in patients with type 1 diabetes mellitus. Elevated blood pressure (BP) as a risk factor, can promote the development and progression of microvascular complications, (nephropathy and retinopathy). The purpose of this study was to identify and detect early BP changes in diabetic children and adolescents, aiming for the early prediction of future renal and cardiovascular disease risk during childhood to adulthood. All parameters of BP (dippers, non-dippers, early morning surges) were highly significantly increased in diabetic patients compared with controlled group (P<0.0001).

The frequency of non-dipping was greater and highly significant in micro-albuminuric diabetic patients (P<0.0001). Regression analysis revealed that BP parameters were significantly related to albumin/creatinine ratio, glycated hemoglobin, insulin dose, and body mass index. A clear link between the nocturnal BP type and microalbuminuria mandates BP follow-up via ambulatory BP monitoring with therapeutic intervention to prevent renal and cardiovascular diabetic complications in adulthood. (Shalaby, Ther Clin Risk Manag. 2015 Oct 5;11:1531-7). A simple positive micral testing is an early clue that a diabetic child is at a future macro-micro cardiovascular risk till adulthood.