The Relationship between Abnormal Circadian Blood Pressure Rhythm and Risk of Readmission in Patients with Heart Failure with Preserved Ejection ...
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Vol. 5 No. 4 (2021) 275–282
Cardiovascular Innovations and Applications ISSN 2009-8618
DOI 10.15212/CVIA.2021.0014
RESEARCH PAPER
The Relationship between Abnormal
Circadian Blood Pressure Rhythm and Risk of
Readmission in Patients with Heart Failure with
Preserved Ejection Fraction
Diqing Wang 1
, Zhengfei He1, Sihua Chen1 and Jianlin Du 2
1
Department of Cardiology, the First People’s Hospital of Fuyang District in Hangzhou, Hangzhou, 311400, China
2
Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
Received: 19 January 2021; Revised: 16 March 2021; Accepted: 26 March 2021
Abstract
Objective: Abnormal circadian blood pressure rhythm has been revealed to be associated with hypertensive target
organ damage and cardiovascular events, but its association with readmission risk in patients with heart failure with
preserved ejection fraction (HFpEF) remains unknown. We conducted a retrospective study to explore the relationship
between circadian blood pressure rhythm and readmission risk in HFpEF patients.
Methods: We retrospectively collected baseline and follow-up data on HFpEF patients who underwent ambulatory
blood pressure monitoring (ABPM) from May 2015 to October 2019. Patient circadian blood pressure rhythms defined
by ABPM were grouped as dipper, nondipper, or riser patterns. Univariate and multivariate linear regression analyses
were performed to assess the association between circadian blood pressure rhythm and readmission risk.
Results: A total of 122 patients were enrolled in this study. The mean age and ejection fraction were 69.87 years and
61.44%, respectively, with mean the N-terminal pro-B-type natriuretic peptide (NT-proBNP) level being 1048.15 pg/mL.
There were significant differences in the 24-hour systolic blood pressure (SBP), sleep SBP, and sleep diastolic blood
pressure (DBP) among the three groups, where the 24-hour SBP, sleep SBP, and sleep DBP in the riser pattern group
were markedly higher than in the dipper pattern group. Notably, serum NT-proBNP levels, the proportion of patients
readmitted for heart failure and the mean number of admissions differed markedly among three groups. Instructively,
multivariate linear regression analysis showed that the riser pattern was a significant and independent risk factor for
increased serum NT-proBNP level (β = 929.16, 95% confidence interval 178.79–1679.53, P = 0.016). In multivariate
logistic regression analysis, the riser pattern was demonstrated to be a significant risk factor for readmission (odds ratio
11.23, 95% confidence interval 2.01–62.67, P = 0.006) in HFpEF patients.
Conclusion: The riser blood pressure pattern is a potential risk factor for elevated serum NT-proBNP level and read-
mission in HFpEF patients.
Keywords: Heart failure with preserved ejection fraction; circadian blood pressure rhythm; ambulatory blood pres-
sure monitoring; riser pattern; N-terminal pro-B-type natriuretic peptide; readmission
Correspondence: Jianlin Du, MD, PhD, Department Introduction
of Cardiology, Chongqing Medical University, 74 Linjiang
Road, Chongqing, 400010, China, Heart failure, the most common reason for hos-
E-mail: jianlindunev@cqmu.edu.cn pitalization in patients aged 65 years or older in
© 2021 Cardiovascular Innovations and Applications. Creative Commons Attribution-NonCommercial 4.0 International License276 D. Wang et al., Riser pattern and readmission risk in HFpEF
high-income countries, is a clinical syndrome asso- diagnosis of HFpEF (left ventricular ejection frac-
ciated with substantial health care resource utili- tion of 50% or greater) [11] with New York Heart
zation, poor life quality, and premature death [1]. Association (NYHA) class III or class IV heart
Epidemiological studies have indicated that up to failure at the First People’s Hospital of Fuyang
50% of patients with heart failure have a preserved District in Hangzhou from May 2015 to May 2017.
ejection fraction, and the proportion of affected The eligibility criteria for inclusion were as fol-
patients has increased over time [2, 3]. The rates of lows: (1) patients underwent ABPM at the baseline;
hospitalization and death in patients who have heart (2) sufficient clinical information, including ejec-
failure with preserved ejection fraction (HFpEF) tion fraction and N-terminal pro-B-type natriuretic
approach those who have heart failure with reduced peptide (NT-proBNP) level, was available at base-
ejection fraction. Despite advancements in therapeu- line; (3) fatal and nonfatal outcomes were available
tic strategies, rehospitalization remains a significant for 18 months of follow-up. Patients with infective
challenge in HFpEF, placing a considerable burden endocarditis, myocarditis, malignant tumors, severe
on health care systems [4]. Furthermore, heart fail- liver disease, dementia, delirium, and other severe
ure readmission carries prognostic implications, noncardiovascular diseases were excluded. Baseline
with longer hospital stays and worsening prognosis ABPM data were collected after the stabilization
[5]. Unraveling the treatable risk factors for read- of heart failure symptoms during the patients’ first
mission in patients with HFpEF may shed light on hospitalization. The study enrolled 122 patients
the development of novel therapeutic strategies. with HFpEF of NYHA class III or class IV. The cir-
Measurement of dynamic blood pressure changes cadian blood pressure rhythm was determined on
over 24 hours by ambulatory blood pressure moni- the basis of the results of ABPM, and the patients
toring (ABPM) is used to reveal an individual’s were divided into dipper pattern, nondipper pattern,
circadian blood pressure rhythm. Recent studies and riser pattern groups accordingly.
have indicated that the ABPM parameters are more For each patient, baseline characteristics, includ-
strongly associated with target organ damage and ing age, sex, body mass index (BMI), NYHA class,
cardiovascular disease than are office or clinic blood medical history, laboratory and echocardiographic
pressure parameters [6]. Abnormal circadian blood data, and medications on admission were collected.
pressure rhythm has been revealed to be associated The study was approved by the Ethics Committee
with hypertensive target organ damage and progno- of the First People’s Hospital of Fuyang District
sis [7]. In particular, the riser blood pressure pat- in Hangzhou, and informed consent was obtained
tern is a type of abnormal circadian blood pressure from all patients according to the Declaration of
rhythm in which sleep blood pressure paradoxically Helsinki’s Ethical Principles for Medical Research
exceeds awake blood pressure, and it has been dem- Involving Human Subjects.
onstrated to be a risk factor for hypertensive target
organ damage and cardiovascular events [7–10]. Definitions
However, the association between abnormal circa-
dian blood pressure rhythm and risk of readmission Heart failure readmission was defined as one or more
in patients with HFpEF is still unknown. This study admissions due to heart failure during 18 months
aimed to explore the relationship between the circa- of follow-up after discharge of the patients from
dian blood pressure rhythm and the cardiac function their first hospitalization, and the primary end point
and readmission risk in patients with HFpEF. was heart failure readmission occurrence. The
NT-proBNP levels were defined as the baseline
level. The glomerular filtration rate was estimated
Methods with the Japanese Society of Nephrology equation as
follows: estimated glomerular filtration rate (eGFR)
Study Population (mL/min/1.73 m2) = 194 × C−1.094 × A−0.287 (×0.739 for
women), where C is the serum creatine concentra-
This was a retrospective and observational study. tion and A is the age [12]. BMI was calculated as
We recruited patients who were admitted with a weight (in kilograms) divided by height (in meters)D. Wang et al., Riser pattern and readmission risk in HFpEF 277
squared. A history of hypertension was defined by (Elecsys proBNP II, Roche Diagnostics, Mannheim,
blood pressure of 140/90 mmHg or greater, on the Germany) with a Modular Analytics Evo analyzer
basis of medical records, and on the basis of use with an E170 module (Roche).
of antihypertensive medications. A history of diabe- Transthoracic two-dimensional echocardiography
tes mellitus was defined by a fasting glucose level (LOGIQ 7, GE Healthcare, Chicago, IL, USA) was
of 126 mg/dL or greater, on the basis of medical performed in all patients. The left ventricular end-
records, and on the basis of the use of antidiabetic diastolic dimension were measured in the M-mode,
medications. and the left ventricular ejection fraction was calcu-
lated by the Teichholz method.
Ambulatory Blood Pressure Monitoring
Statistical Analysis
When the patients’ heart failure symptoms were
stabilized, a single session of noninvasive ABPM Continuous variables conforming to the normal
was performed by an automatic system with electric distribution were described as means with standard
cuff inflation (model 90127, Spacelabs Healthcare, deviations, and the one-way ANOVA test was used
Snoqualmie, WA, USA), and measurements were for comparison between groups. The categorical
obtained every 20 minutes during the awake time variables were presented as numbers and percent-
and every 30 minutes during the sleep time. A mini- ages and compared with the Pearson chi-square test.
mum of 20 valid awake readings and six valid sleep Multivariate linear regression models were used to
readings were recorded to define the awake blood assess the influence of circadian blood pressure
pressure and the sleep blood pressure, but all par- rhythm on the serum NT-proBNP level, with adjust-
ticipants had more valid readings. Individuals were ment for age, sex, BMI, history of hypertension,
instructed to rest or sleep during nighttime and 24-hour SBP, sleep SBP, sleep diastolic blood pres-
maintain usual daytime activities. sure (DBP), use of β blockers, and eGFR. To evalu-
The nocturnal blood pressure fall (%) was calcu- ate the predictive value of circadian blood pressure
lated as the difference between the awake systolic rhythm for heart failure readmission, we developed
blood pressure (SBP) and the sleep SBP divided a series of logistic regression models, incorporating
by the awake SBP. Then we classified patients different circadian blood pressure rhythm indices in
into three patterns by the circadian blood pressure the presence or absence of clinical factors, includ-
rhythm: dipper pattern if the nocturnal blood pres- ing age, sex, BMI, history of hypertension, 24-hour
sure fall was greater than 10%, nondipper pattern SBP, sleep SBP, sleep DBP, use of β blockers,
if it was between 0% and 10%, and riser pattern NT-proBNP, and eGFR. P < 0.05 was considered
if it was less than 0%. As the number of patients significant. All statistical analyses were performed
with extreme dippers (nocturnal blood pressure fall with SPSS Statistics, version 22.0 (IBM, Armonk,
greater than 20%) was small (n = 4) in this study, NY, USA).
patients with extreme dippers were classified as the
dipper pattern group in the present study. A nonriser
pattern, which includes a dipper pattern and a non-
Results
dipper pattern, was defined when sleep SBP was
lower than awake SBP.
Baseline Characteristics in Patients with
HFpEF
Biochemical Analyses and
The mean (± standard deviation) age of all patients
Echocardiography
with HFpEF was 69.87 ± 11.49 years, and the pro-
Venous blood samples were collected after portion of male patients was 55.7%. We classified
patients had fasted overnight for determination of the 122 patients into dipper pattern, nondipper pat-
blood glucose and serum creatinine levels. Serum tern, and riser pattern groups on the basis of the cir-
NT-proBNP levels were measured by a two-site cadian blood pressure rhythm and compared their
sandwich electrochemiluminescence immunoassay baseline clinical characteristics (Table 1). There278 D. Wang et al., Riser pattern and readmission risk in HFpEF
were no significant differences in age, sex, BMI, for heart failure, the mean number of heart failure
and NYHA class among the three groups (Table 1), admissions, and the proportion of patients readmit-
and the biochemical indicators of eGFR and fast- ted for all causes, but not heart failure admission
ing blood glucose level did not differ significantly duration or all-cause deaths, differed significantly
among the three groups (Table 1). In addition, a among the three groups (Table 1).
history of hypertension, diabetes, and atrial fibrilla-
tion, and the prescription of angiotensin-converting ABPM Parameters in Patients with HFpEF
enzyme inhibitors, angiotensin receptor blockers,
β-receptor antagonists, Ca2+ antagonists, or diuret- As shown in Table 2, there were significant differ-
ics did not differ markedly among the three groups ences in 24-hour SBP, sleep SBP, and sleep DBP
(Table 1). Notably, there were significant differences among the three groups, with no marked changes
in serum NT-proBNP levels among the three groups in 24-hour DBP, awake SBP, and awake DBP.
(Table 1), although neither the left ventricular ejec- Moreover, 24-hour SBP, sleep SBP, and sleep DBP
tion fraction nor the left ventricular end-diastolic in the riser pattern group were significantly higher
dimension was markedly different (Table 1). Most than in the dipper pattern group (Table 2), and the
importantly, the proportion of patients readmitted sleep DBP in the nondipper pattern group was
Table 1: Baseline Characteristics of the Study Population.
Characteristic Dipper pattern Nondipper pattern Riser pattern F/χ2 P
(n = 32) (n = 58) (n = 3)
Age, years 69.81 ± 14.23 69.55 ± 10.19 70.50 ± 11.46 0.29 0.867
Male, n (%) 18 (56.3%) 30 (51.7%) 20 (62.5%) 0.49 0.784
BMI, kg/m2 22.96 ± 2.87 23.47 ± 2.16 23.11 ± 2.37 1.09 0.581
NYHA class, n (%) 0.53 0.766
III 22 (68.8%) 36 (62.1%) 18 (56.3%)
IV 10 (31.3%) 22 (37.9%) 14 (43.8%)
Comorbidity, n (%)
Hypertension 16 (50%) 28 (48.3%) 18 (56.3%) 0.268 0.875
Diabetes mellitus 6 (18.8%) 10 (17.2%) 6 (18.8%) 0.02 0.988
Atrial fibrillation 18 (56.3%) 24 (41.4%) 20 (62.5%) 2.10 0.351
Pharmacotherapy, n (%)
ACEI/ARB 24 (75.0%) 40 (69.0%) 20 (62.5%) 0.58 0.747
β blocker 14 (43.8%) 28 (48.3%) 14 (43.8%) 0.13 0.939
Ca2+ antagonist 8 (25.0%) 14 (24.1%) 7 (21.9%) 0.09 0.954
Diuretic 24 (75%) 38 (65.5%) 30 (93.8%) 4.43 0.109
eGFR, mL/min/1.73 m2 77.00 ± 20.56 75.02 ± 24.67 79.25 ± 15.89 0.09 0.958
Blood glucose, mmol/L 5.35 ± 1.16 5.30 ± 1.23 4.88 ± 0.98 2.75 0.252
NT-proBNP, pg/mL 803.51 ± 923.37 797.06 ± 716.81 1747.88 ± 1685.34 5.95 0.049
EF, % 62.06 ± 4.14 61.17 ± 0.58 61.31 ± 5.62 0.91 0.635
LVEDD, cm 4.64 ± 0.57 4.73 ± 0.58 4.69 ± 0.59 0.15 0.927
Number of HF admissions, times 1.63 ± 1.09 1.48 ± 0.99 2.00 ± 0.97 6.02 0.049
HF admission duration, days 12.88 ± 11.04 12.45 ± 11.72 17.75 ± 12.26 5.48 0.065
HF readmissions, n (%) 10 (31.3%) 16 (27.6%) 17 (53.1%) 6.20 0.045
All-cause readmissions, n (%) 13 (40.6%) 21 (36.2%) 21 (65.6%) 7.56 0.023
All-cause deaths, n (%) 1 (3.1%) 2 (3.4%) 0 1.103 0.576
Data are shown as the number and percentage or the mean ± standard deviation.
ARB, angiotensin receptor blocker; ACEI, angiotensin-converting enzyme inhibitor; BMI, body mass index; EF, ejection
fraction; eGFR, estimated glomerular filtration rate; HF, heart failure; LVEDD, left ventricular end-diastolic dimension;
NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association.D. Wang et al., Riser pattern and readmission risk in HFpEF 279
Table 2: Ambulatory Blood Pressure Parameters in Different Groups.
Blood pressure Dipper pattern Nondipper pattern Riser pattern F P
(n = 32) (n = 58) (n = 32)
24-hour SBP, mmHg 118.94 ± 14.82 120.17 ± 13.00 133.75 ± 12.18** 11.363 0.003
24-hour DBP, mmHg 68.88 ± 11.40 71.83 ± 7.92 76.44 ± 10.14 5.629 0.060
Awake SBP, mmHg 123.19 ± 14.60 121.24 ± 13.04 131.81 ± 13.82 5.479 0.065
Awake DBP, mmHg 71.38 ± 11.78 72.79 ± 8.18 76.00 ± 10.60 1.973 0.373
Sleep SBP, mmHg 107.44 ± 15.00 116.00 ± 13.11 136.94 ± 11.99** 23.407 0.000
Sleep DBP, mmHg 61.75 ± 10.59 69.41 ± 7.93** 77.00 ± 9.80** 16.52 0.000
Data are shown as the mean ± standard deviation.
DBP, diastolic blood pressure; SBP, systolic blood pressure.
**P < 0.01 versus dipper pattern.
markedly higher than in the dipper pattern group hypertension, use of β blockers, 24-hour SBP, sleep
(Table 2). SBP, sleep DBP, and eGFR, the riser pattern ver-
sus the nonriser pattern was still associated with a
The Relationship between Abnormal significantly increased serum NT-proBNP level in
Circadian Blood Pressure Rhythm and HFpEF patients (β = 929.16, 95% confidence inter-
Serum NT-proBNP Level in Patients with val 178.79–1679.53, P = 0.016), indicating its inde-
HFpEF pendent predictive value.
Univariate linear regression analysis showed that
The Relationship between Abnormal
the riser pattern versus the nonriser pattern (which
Circadian Blood Pressure Rhythm and
includes the dipper and nondipper patterns) was
Readmission Risk in Patients with HFpEF
associated with a significantly elevated serum
NT-proBNP level in patients with HFpEF (Table Univariate logistic regression analysis showed
3). However, the riser pattern versus the dipper pat- that the riser pattern versus the nonriser pattern
tern and the nondipper pattern versus the dipper was associated with a significantly increased risk
pattern were not correlated with serum NT-proBNP of readmission in patients with HFpEF (Table 4).
level in patients with HFpEF (Table 3). We then Furthermore, the riser pattern versus the dipper pat-
performed a multivariate linear regression analy- tern, but not the nondipper pattern versus the dip-
sis to investigate factors associated with elevated per pattern, was correlated with an increased risk of
serum NT-proBNP levels in patients with HFpEF. readmission in patients with HFpEF (Table 4). We
After adjustment for age, sex, BMI, history of then performed a multivariate logistic regression
Table 3: Univariate and Multivariate Linear Regression Analysis of the Relationship between Circadian Blood Pressure
Rhythm and Serum N-terminal pro-B-Type Natriuretic Peptide Level in Patients with Heart Failure with Preserved Ejection
Fraction.
Univariate analysis Multivariate analysis*
β 95% CI P β 95% CI P
Riser pattern versus nonriser pattern
†
948.53 294.13 to 1602.93 0.005 929.16 178.79 to 1679.53 0.016
Riser pattern† versus dipper pattern 472.18 −38.79 to 983.16 0.069 353.12 −360.38 to 1066.63 0.317
Nondipper pattern† versus dipper pattern −6.46 −510.86 to 497.94 0.980 101.36 −483.82 to 686.54 0.728
CI indicates confidence interval.
*Multivariate linear regression analysis with adjustment for age, sex, body mass index, history of hypertension, β-blocker
medication, 24-hour systolic blood pressure, sleep systolic blood pressure, sleep diastolic blood pressure, and estimated
glomerular filtration rate.
†
Independent variable in the linear regression analysis model.280 D. Wang et al., Riser pattern and readmission risk in HFpEF
Table 4: Univariate and Multivariate Logistic Analysis of the Relationship between Circadian Blood Pressure Rhythm and
Readmission Rates in Patients with Heart Failure with Preserved Ejection Fraction.
Univariate analysis Multivariate analysis*
OR 95% CI P OR 95% CI P
Riser pattern† versus nonriser pattern 5.42 1.57–18.68 0.007 11.23 2.01–62.67 0.006
Riser pattern† versus dipper pattern 2.20 1.04–4.65 0.039 2.84 1.00–7.87 0.047
Nondipper pattern† versus dipper pattern 0.84 0.22–3.18 0.795 0.67 0.12–3.85 0.654
CI, confidence interval; OR, odds ratio.
*Multivariate logistic regression analysis with adjustment for age, sex, body mass index, history of hypertension, β-blocker
medication, 24-hour systolic blood pressure, sleep systolic blood pressure, sleep diastolic blood pressure, N-terminal pro-B-
type natriuretic peptide, and estimated glomerular filtration rate.
†
Independent variables in the logistic regression analysis model.
analysis to investigate factors associated with and nighttime SBP and DBP is 10 to 20% [13]. The
increased readmission risk in patients with HFpEF. riser pattern is a manifestation of abnormal circa-
After adjustment for age, sex, BMI, history of dian blood pressure rhythm, and is associated with
hypertension, use of β blockers, 24-hour SBP, sleep hypertensive target organ damage and poor car-
SBP, sleep DBP, NT-proBNP, and eGFR, the riser diovascular prognosis [14, 15]. Our analysis found
pattern versus the nonriser pattern was still associ- associations between riser blood pressure pattern
ated with a significantly increased readmission risk and increased readmission risk in patients with
for HFpEF patients (odds ratio 11.23, 95% confi- HFpEF independent of 24-hour SBP and sleep SBP,
dence interval 2.01–62.67, P = 0.006). In addition, indicating a pathophysiological mechanism beyond
the riser pattern versus the dipper pattern was also blood pressure. There are three possible mecha-
associated with a markedly increased readmission nisms accounting for this phenomenon. Firstly, the
risk in patients with HFpEF (odds ratio 2.84, 95% riser pattern is associated with advanced vascular
confidence interval 1.00–7.87, P = 0.047). However, disease, such as endothelial dysfunction and accel-
the nondipper pattern versus the dipper pattern erated arterial stiffness [15]. Secondly, the riser pat-
was not associated with the risk of readmission in tern has been demonstrated to be associated with
patients with HFpEF (Table 4). increased circulating volume [16]. Thirdly, the riser
pattern is manifested as a higher sympathetic nerve
Discussion activity [17]. Recent clinical studies have shown
that renal denervation significantly reduced 24-hour
The present study demonstrates that 24-hour SBP, blood pressure, including nighttime blood pressure
nocturnal SBP, and nocturnal DBP of HFpEF [18]. All these factors contribute to the progression
patients with the riser pattern were significantly of heart failure by increasing cardiac preload or
higher than that in HFpEF patients with the dipper afterload, or directly impacting on the left ventricu-
pattern, and the riser pattern versus the nonriser pat- lar remodeling.
tern was associated with a significantly increased ABPM can be used to measure 24-hour dynamic
serum NT-proBNP level and risk of readmission due changes of blood pressure, blood pressure variabil-
to heart failure. The riser pattern constitutes an inde- ity, and circadian blood pressure rhythm. Recent
pendent risk factor for elevated serum NT-proBNP clinical studies have shown that ABPM parameters
level and readmission in patients with HFpEF. are more strongly associated with target organ
Individuals with normotension have a pronounced damage and cardiovascular disease events than
diurnal rhythm in blood pressure. Blood pressure office or clinical blood pressure parameters [6, 8].
falls to its lowest level during the first few hours Consistent with previous studies, we found that
of sleep, and then surges markedly in the morning, 24-hour SBP, sleep SBP, and sleep DBP in HFpEF
coinciding with the transition from sleep to wake- patients with the riser pattern were significantly
fulness. The average difference between daytime higher than in HFpEF patients with the dipperD. Wang et al., Riser pattern and readmission risk in HFpEF 281
pattern. In clinical practice, physicians often initi- with increased all-cause mortality, cardiovascu-
ate and intensify antihypertensive medications on lar readmission, and heart failure readmission in
the basis of office blood pressure. Thus, daytime HFpEF patients [22]. The PEPCHF (Perindopril in
blood pressure might be well controlled, but this Elderly People with Chronic Heart Failure) study
may leave a proportion of medicated patients with revealed that as the quartile of NT-proBNP level
undetected nocturnal hypertension, placing them at increased, morbidity and mortality for heart fail-
high risk of cardiovascular events. Recent studies ure patients also gradually increased [23]. In addi-
have shown that both high nocturnal blood pressure tion, the CHARM-Preserved (Candesartan in Heart
and abnormal circadian blood pressure rhythm are Failure-Assessment of Reduction in Mortality and
important risk factors for cardiovascular events [7]. Morbidity) study indicated that NT-proBNP level
Compared with daytime blood pressure, the impact greater than 600 pg/mL was the sole predictor of
of elevated nighttime blood pressure may depend cardiovascular mortality, heart failure readmission,
on the clinical stage of hypertension. In the early myocardial infarction, or stroke [24]. The present
stage of hypertension, where patients have upper study found that the riser pattern is associated with
limits of normal blood pressure or mild hyper- increased serum NT-proBNP levels in patients with
tension, daytime blood pressure may be a more HFpEF, indicating its prognostic value.
important determinant of left ventricular hyper- In summary, abnormal circadian blood pressure
trophy. Conversely, the prognostic value of noc- rhythm, especially the riser pattern, is an independ-
turnal blood pressure will increase in patients with ent risk factor for increased NT-proBNP level and
treated hypertension. ABPM is a standard method readmission in patients with HFpEF. In clinical
for measuring nighttime blood pressure, but it practice, more attention should be paid to the cir-
has not been widely used in clinical p ractice [19]. cadian blood pressure rhythm with monitoring of
Home blood pressure monitoring equipment with ambulatory blood pressure to better manage noc-
the function of monitoring nighttime blood pres- turnal blood pressure and improve the prognosis of
sure has recently become available, but is not yet patients with HFpEF.
in widespread use [20]. To better manage patients
with abnormal circadian blood pressure rhythm,
nighttime blood pressure monitoring is therefore Sources of Funding
routinely needed to reduce the risk of cardiovascu-
This study was supported by grants from the Medical
lar events in these patients.
Research Projects of the Chongqing Science and
BNP and NT-proBNP are important biomarkers
Technology Commission and Chongqing Health
for evaluating the prognosis of patients with chronic
Committee (2020FYYX047).
heart failure [21]. Compared with BNP, NT-proBNP
has a longer half-life and is more effective in pre-
dicting the risk of readmission. The I-PRESERVE Conflicts of Interest
(Irbesartan in Heart Failure with Preserved Ejection
Fraction) study found that a baseline NT-proBNP The authors declare that they have no conflicts of
level of more than 339 pg/mL was associated interest.
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