Published Online
on March 26, 2007

A more recent version of this article appeared on June 1, 2007

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Submitted on January 11, 2007
Revised on January 30, 2007

Predictors of All-Cause Mortality in Clinical Ambulatory Monitoring. Unique Aspects of Blood Pressure During Sleep

Iddo Z. Ben-Dov^*; Jeremy D. Kark; Drori Ben-Ishay; Judith Mekler; Liora Ben-Arie; and Michael Bursztyn

From the Nephrology and Hypertension (I.Z.B.-D.), Epidemiology Unit (J.D.K.), and Mount-Scopus Internal Medicine Department (D.B.-I., J.M., L.B.-A., M.B.), Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

^* To whom correspondence should be addressed. E-mail: bendovi{at}md.huji.ac.il.

Abstract--The prognostic value of sleep blood pressure reported by recent studies is variable. Our aim was to examine the relationship of sleep blood pressure, measured by 24-hour ambulatory blood pressure monitoring, with all-cause mortality. We studied a cohort of 3957 patients aged 55±16 (58% treated) referred for ambulatory monitoring (1991-2005). Sleep, including daytime sleep, was recorded by diary. Linkage with the national population register identified 303 deaths during 27 750 person-years of follow-up. Hazard ratios (HRs) for mortality in Cox proportional hazards models that included age, sex, hypertension, and diabetes treatment were 1.32 (95% CI: 0.99 to 1.76) for awake hypertension (135/85 mm Hg), and 1.67 (95% CI: 1.25 to 2.23) for sleep hypertension (120/70 mm Hg). By quintile analysis, the upper fifths of systolic and diastolic dipping during sleep were associated with adjusted HRs of 0.58 (95% CI: 0.41 to 0.82) and 0.68 (95% CI: 0.48 to 0.96), respectively. In a model controlling for awake systolic blood pressure, hazards associated with reduced systolic dipping increased from dippers (>10%; HR: 1.0), through nondippers (0% to 9.9%; HR: 1.30; 95% CI: 1.00 to 1.69) to risers (<0%; HR: 1.96; 95% CI: 1.43 to 2.96). Thus, in practice, ambulatory blood pressure predicts mortality significantly better than clinic blood pressure. The availability of blood pressure measures during sleep and, in particular, the pattern of dipping add clinically predictive information and provide further justification for the use of ambulatory monitoring in patient management.

Key words: ambulatory blood pressure monitoring • dipping • mortality • cohort • sleep blood pressure

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