Night-Time Blood Pressure

• High blood pressure or hypertension is one of the most important modifiable risk factors for heart disease, strokes and dementia. It can be measured quite accurately and easily and can be treated very well using prescription medications and therapeutic lifestyle changes. There are 1.28 billion (yes, billion) people worldwide living with hypertension and about 46 % of them are not diagnosed. Of those people diagnosed, only 21% have their blood pressure at the target range. (Numbers from World Health Organization).

Why is hypertension not well managed?

There are multiple reasons for this:

1. Most hypertension is asymptomatic, or the symptoms, particularly in women, are attributed to other conditions like menopause.
2. Young hypertension, hypertension in people less than 40 years (this age cutoff will probably change based on more research), is undiagnosed because most young people do not think of hypertension as a problem for younger people; it's something their parents should worry about, not them.
3. Getting accurate blood pressure readings is irksome. (In this article I will share my journey in overcoming the measurement challenge).
4. Clinician inertia. Healthcare providers fail to change or increase blood pressure medications even when they detect less than optimal blood pressure in patients on medications.
5. A recent article on Medscape says, "Failing to take blood pressure measurements at the doctor's office, using incorrect techniques, and a lack of validated automated blood pressure measurement devices are three problems that converge to cloud the diagnosis and management of hypertension in the Americas."
6. Lack of information among healthcare providers about normal blood pressure thresholds.

The importance of night-time blood pressure

Multiple studies have shown the significance of high night-time blood pressure (nocturnal hypertension). Normally blood pressure is supposed to fall by 10-20% of your day-time blood pressure. You are called a non-dipper if your blood pressure doesn't fall at night. In some people, blood pressure rises at night instead of falling.

A non-dipper status raises your risk for heart disease, stroke and dementia and kidney disease even if your blood pressure is in the normal range for the rest of the day.

(Interestingly, studies in young women with PCOS have shown a non-dipper status at a young age).

You cannot measure blood pressure at night using home monitoring devices.

Measuring blood pressure:

Hypertension guidelines recommend "out of office" blood pressure measurement (meaning, measuring blood pressure outside the doctor's clinic) to diagnose and manage hypertension. There are a few ways of doing that.

1. 24 Hour Ambulatory Blood Pressure Measurement (24HABPM). You wear a specialized cuff device for 24 hours and depending on the settings, the cuff inflates every 20-30 minutes and the recordings are captured in a device you wear across your body. The report is generated after you return the device to your healthcare provider.

Pros: You get a record of night-time blood pressure and your blood pressure levels during your normal day, not just a single (Ideally using an automated device) at your doctor's clinic.

Cons: Your sleep is disturbed and you need a sufficient number of readings for it to be interpreted correctly. In the ideal world, one would need about a week's data to provide correct insight. I don't see most people (including me!) doing that. One night of poor sleep because of the irksome inflating cuff was enough for me :-)!

2. The second way to measure "out of office" blood pressure is home blood pressure measurement (HBPM). Multiple clinically validated low-cost blood pressure devices are available all over the world. (Here is a list). Yet the process of checking blood pressure at home suffers from poor user experience. It is irksome to follow the guidelines to the T. You have to sit quietly for 5 minutes, no caffeine for 1 hour before, check before medications, and take an average of 3 readings. An added bit of irritation when the device doesn't automatically take 3 measurements and you have to manually take it thrice. Next comes recording it. Not all devices have a connected app. Should you record it on paper and then take pictures? Or use an xl spreadsheet? Or use an app like BP Journal (only Android)? (Hypertension Canada guidelines for blood pressure measurement ). I gave up after several failed attempts.

3. Wearable devices like the Aktiia bracelet. In the video below I share my experience managing my blood pressure using the Aktiia device. This is not a review of the device. The bracelet is not available all over the world yet, available only in some European countries. I checked with Aktiia before ordering one to be delivered to my cousin in the UK whom I met in India. I bought the device. Aktiia did not ask me to record this video, but I am happy to share my experience because I think devices like this are game-changing in the management of hypertension.

Thank you to Madhur Kotharay for joining me in this special (video-only) episode of The Brain Podcast.

I have had hypertension for 18 years and I have been on prescription medications since the time of diagnosis. I have a strong family history of strokes (my mother's side of the family). In just one day of using the Aktiia device, I knew my blood pressure was not at an optimal level.

In the video Madhur and I talk about my journey, and we briefly go over some supplements for hypertension (Is hypertension a micronutrient deficiency?), what am I planning next with managing my night-time hypertension (you may be surprised to know the threshold for nocturnal hypertension).

Personal hypertension journey (video)

References

1. https://www.who.int/news-room/fact-sheets/detail/hypertension
2. Hinton, Thomas C., et al. "Investigation and treatment of high blood pressure in young people: too much medicine or appropriate risk reduction?."?Hypertension?75.1 (2020): 16-22.
3. https://www.medscape.com/viewarticle/992902
4. Kargili, Ayse, et al. "Association of polycystic ovary syndrome and a non-dipping blood pressure pattern in young women."?Clinics?65 (2010): 475-479.
5. Kario, Kazuomi. "Nocturnal hypertension: new technology and evidence."?Hypertension?71.6 (2018): 997-1009.