TABLE
Dosing of BP meds: A look at outcomes
| Events/1000 patient-years | Morning dosing | Bedtime dosing | P between groups |
|---|---|---|---|
| overall (n=2201)1 | |||
| Total events* | 27.80 | 11.95 | <.001 |
| CVd death | 2.08 | 0.53 | .006 |
| Cardiovascular events | 11.00 | 5.27 | <.001 |
| Cerebrovascular events | 3.57 | 1.23 | .001 |
| Diabetes subgroup (n=448)2 | |||
| Total events* | 54.24 | 19.80 | <.001 |
| CVd death | 4.79 | 0.86 | .038 |
| Cardiovascular events | 15.95 | 6.89 | .008 |
| Cerebrovascular events | 6.38 | 0.86 | .010 |
| *Includes death from all causes and cardiovascular and cerebrovascular events. BP, blood pressure; CVD, cardiovascular disease. | |||
WHAT’S NEW: Advantages of preventing nondipping are clearly established
We’ve known that a nondipping pattern is associated with higher cardiovascular risks and that taking antihypertensives at bedtime decreases the prevalence of nondipping patterns. The MAPEC study, however, is the first prospective trial to show that bedtime dosing of BP medications lowers the risk of CVD events and death.
CAVEATS: Methodology, non-US guidelines raise questions about applicability here
MAPEC was an open-label study, meaning that the physicians adjusting BP medications were aware of the treatment groups to which their patients were allocated. Physicians were given guidelines for the titration of medications, but it is unclear whether they treated patients in both treatment groups identically. Patients were also aware of their treatment group, which creates the potential for bias if one group adhered to their medications more closely than the other.
The study was a single-center trial conducted in Spain, which may limit its generalizability to the United States. Notably, Spain’s medication guidelines differ from ours, with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and calcium channel blockers as first-line medications and hydrochlorothiazide as a second-line option.
While ABPM appears to be a better indicator of CVD risk compared with clinic BP monitoring, most US physicians still rely on readings taken in their office for diagnosing and managing hypertension. How ambulatory BP translates to clinic BP is somewhat unclear.
CHALLENGES TO IMPLEMENTATION: Some patients and providers may resist the switch
We see few challenges to implementing bedtime dosing of BP medications for patients with uncontrolled hypertension. It is possible, however, that patients who have a long-standing routine of taking their medications in the morning may be resistant to change. Also, pharmacists and nurses, as well as some physicians, may continue recommending morning dosing, which could be confusing for patients.
Acknowledgement
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.