Prognostic Value of the Morning Blood Pressure Surge in 5645 Subjects From 8 Populations

Yan Li, Lutgarde Thijs, Tine W. Hansen, Masahiro Kikuya, Jose Boggia, Tom Richart, Hirohito Metoki, Takayoshi Ohkubo, Christian Torp-Pedersen, Tatiana Kuznetsova, Katarzyna Stolarz-Skrzypek, Valerie Tikhonoff, Sofia Malyutina, Edoardo Casiglia, Yuri Nikitin, Edgardo Sandoya, Kalina Kawecka-Jaszcz, Hans Ibsen, Yutaka Imai, Jiguang WangJan A. Staessen*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Previous studies on the prognostic significance of the morning blood pressure surge (MS) produced inconsistent results. Using the International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcome, we analyzed 5645 subjects (mean age: 53.0 years; 54.0% women) randomly recruited in 8 countries. The sleep-through and the preawakening MS were the differences in the morning blood pressure with the lowest nighttime blood pressure and the preawakening blood pressure, respectively. We computed multivariable-adjusted hazard ratios comparing the risk in ethnic- and sex-specific deciles of the MS relative to the average risk in the whole study population. During follow-up (median: 11.4 years), 785 deaths and 611 fatal and nonfatal cardiovascular events occurred. While accounting for covariables and the night: day ratio of systolic pressure, the hazard ratio of all-cause mortality was 1.32 (95% CI: 1.09 to 1.59; P=0.004) in the top decile of the systolic sleep-through MS (>= 37.0 mm Hg). For cardiovascular and noncardiovascular death, these hazard ratios were 1.18 (95% CI: 0.87 to 1.61; P=0.30) and 1.42 (95% CI: 1.11 to 1.80; P=0.005). For all cardiovascular, cardiac, coronary, and cerebrovascular events, the hazard ratios in the top decile of the systolic sleep-through MS were 1.30 (95% CI: 1.06 to 1.60; P=0.01), 1.52 (95% CI: 1.15 to 2.00; P=0.004), 1.45 (95% CI: 1.04 to 2.03; P=0.03), and 0.95 (95% CI: 0.68 to 1.32; P=0.74), respectively. Analysis of the preawakening systolic MS and the diastolic MS generated consistent results. In conclusion, a MS above the 90th percentile significantly and independently predicted cardiovascular outcome and might contribute to risk stratification by ambulatory blood pressure monitoring. (Hypertension. 2010;55:1040-1048.)
Original languageEnglish
Pages (from-to)1040-1048
Issue number4
Publication statusPublished - Apr 2010


  • ambulatory blood pressure
  • blood pressure measurement
  • morning surge
  • epidemiology
  • population science

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