Gestational hypertension and preeclampsia are major contributors to perinatal morbidity and mortality. The diagnosis of gestational hypertension still relies on conventional clinic blood pressure (BP) measurements and thresholds of ≥140/90 mm Hg for systolic (SBP)/diastolic (DBP) BP. However, the correlation between BP level and target organ damage, cardiovascular disease risk, and long-term prognosis is greater for ambulatory BP monitoring (ABPM) than clinic BP measurement. Accordingly, ABPM has been suggested as the logical approach to overcoming the low sensitivity and specificity of clinic BP measurements in pregnancy. With the use of ABPM, differing predictable BP patterns throughout gestation have been identified for clinically healthy and hypertensive pregnant women. In normotensive pregnancies, BP steadily decreases up to the middle of gestation and then increases up to the day of delivery. In contrast, women who develop gestational hypertension or preeclampsia show stable BP during the first half of pregnancy and a continuous linear BP increase thereafter until delivery. Epidemiologic studies have also consistently reported sex differences in the 24-h patterns of ambulatory BP and heart rate. Typically, men exhibit a lower heart rate and higher BP than women, the differences being larger for SBP than DBP. Additionally, as early as in the first trimester of gestation, statistically significant increased 24-h SBP and DBP means characterize women complicated with gestational hypertension or preeclampsia compared with women with uncomplicated pregnancies. However, the normally lower BP in nongravid women as compared with men, additional decrease in BP during the second trimester of gestation in normotensive but not in hypertensive pregnant women, and significant differences in the 24-h BP pattern between healthy and complicated pregnancies at all gestational ages have not been taken into consideration when establishing reference BP thresholds for the diagnosis of hypertension in pregnancy. Several studies reported that use of the 24-h BP mean is not a proper test for an individualized early diagnosis of hypertension in pregnancy defined on the basis of cuff BP measurements, thus concluding that from such an awkward approach ABPM is not useful in pregnancy. The 24-h BP pattern that characterizes healthy pregnant women at all gestational ages suggests the use for diagnosis of a time-specified reference limit reflecting that mostly predictable BP variability. Once the time-varying threshold, given, for instance, by the upper limit of a tolerance interval, is available, the hyperbaric index (HBI), as a determinant of BP excess, can be calculated as the total area of any given subject's BP above the threshold. This tolerance-hyperbaric test, where diagnosis of gestational hypertension is based on the HBI calculated with reference to a time-specified tolerance limit, has been shown to provide high sensitivity and specificity for the early identification of subsequent hypertension in pregnancy, as well as a valuable approach for prediction of pregnancy outcome. ABPM during gestation, starting preferably at the time of the first obstetric check-up following positive confirmation of pregnancy, provides sensitive endpoints for use in early risk assessment and guide for establishing prophylactic or therapeutic intervention, and should thus be regarded as the required standard for the diagnosis of hypertension in pregnancy.

A number of observational studies have found that treated hypertensive patients, even those with controlled clinic blood pressure (BP), might have poorer prognosis than untreated hypertensives. Different trials have also shown that relatively low cardiovascular disease (CVD) risk cannot be achieved in high-risk hypertensive patients, leading to the belief they have a "residual CVD risk" that cannot be attenuated by conventional treatment. All these conclusions disregard the facts that the correlation between BP level and CVD risk is stronger for ambulatory than clinic BP and that the BP-lowering efficacy and effects on the 24-h BP pattern of different classes of hypertension medications exhibit statistically and clinically significant treatment-time (morning versus evening) differences. Accordingly, we evaluated the potential differential administration-time-dependent effects on CVD risk of the various classes of hypertension medications and the number of them used for therapy in the MAPEC (Monitorización Ambulatoria para Predicción de Eventos Cardiovasculares, i.e., Ambulatory Blood Pressure Monitoring for Prediction of Cardiovascular Events) study, a prospective, open-label, blinded-endpoint trial on 2156 hypertensive patients (1044 men/1112 women), 55.6 ± 13.6 (mean ± SD) yrs of age, randomized to ingest all prescribed once-a-day hypertension medications upon awakening or the entire daily dose of ≥1 of them at bedtime. Ambulatory BP was measured for 48 h at baseline, and again annually or more frequently (quarterly) when adjustment of treatment was necessary to achieve ambulatory, i.e., awake and asleep, BP control. CVD risk according to the number and classes of medications used at the final evaluation was calculated by comparison with that of 734 normotensive subjects who were identically followed and remained untreated. After a median follow-up of 5.6 yrs, CVD risk of hypertensive patients randomized to ingest all medications upon awakening was progressively higher with increase in the number of medications (adjusted hazard ratio [HR]: 1.75, 2.26, 3.02, and 4.18 in patients treated with 1, 2, 3, and ≥4 medications daily, respectively; p < .001 compared with normotensive subjects). CVD risk was markedly lower in patients ingesting ≥1 medications at bedtime (HR: .35, 1.45, .94, and 2.28 with 1, 2, 3, and ≥4 medications daily, respectively), and even lower in patients ingesting all medications at bedtime (HR: .35, .39, .87, and .79 with 1, 2, 3, and ≥4 medications daily, respectively). Patients ingesting ≥1 medications at bedtime evidenced significantly lower CVD risk than those ingesting all medications upon awakening, independent of class. Greater benefits were observed for bedtime compared with awakening treatment with angiotensin-II receptor blockers (ARBs) (HR: .29 [95% confidence interval, CI .17-.51]; p < .001) and calcium channel blockers (HR: .46 [95% CI: .31-.69]; p < .001). CVD risk was similar for all six classes of tested hypertension medications in patients randomized to ingest all of them upon awakening. Among patients randomized to ingest ≥1 medications at bedtime, however, ARBs were associated with significantly lower HR of CVD events than ingestion of any other class of medication also at bedtime (p < .017). We document significantly reduced CVD risk among hypertensive patients ingesting medications at bedtime, independent of the number of hypertension medications required to achieve proper ambulatory BP control. These findings challenge the current belief of "residual CVD risk," as a bedtime-treatment regimen of current hypertension medications, even in risk-high patients, can reduce such risk.

Many published prospective trials have reported clinically meaningful morning-evening, treatment-time differences in the blood pressure (BP)-lowering efficacy, duration of action, and safety of most classes of hypertension medications. Most important, it was recently documented that routine ingestion of the full daily dose of ≥1 hypertension medications at bedtime, compared with ingestion of all of them upon awakening, significantly reduces cardiovascular disease (CVD) events. Nocturnal hypertension and non-dipping (<10% decline in the asleep relative to the awake BP mean), as determined by ambulatory BP monitoring (ABPM), are frequent in chronic kidney disease (CKD) and both are associated with increased CVD risk. Here, we investigated the influence of hypertension treatment time on the circadian BP pattern and degree of BP control of hypertensive patients with CKD evaluated by 48-h ABPM. This cross-sectional study evaluated 2659 such patients (1585 men/1074 women), 64.9 ± 13.2 (mean ± SD) yrs of age, enrolled in the Hygia Project, involving primary care centers of northwest Spain and designed to evaluate prospectively CVD risk by ABPM; 1446 were ingesting all BP-lowering medications upon awakening, whereas 1213 patients were ingesting ≥1 medications at bedtime. Among the latter, 359 patients were ingesting all medications at bedtime, whereas 854 were ingesting the full daily dose of some medications upon awakening and the others at bedtime. Those ingesting all medications upon awakening had significantly higher total cholesterol and low-density lipoprotein (LDL) cholesterol than those ingesting ≥1 medications at bedtime. Moreover, patients ingesting all medications at bedtime had the lowest fasting glucose, serum creatinine, and uric acid. Ingestion of ≥1 medications at bedtime was significantly associated with lower asleep systolic (SBP) and diastolic (DBP) BP means than treatment with all medications upon awakening. The sleep-time relative SBP decline was significantly attenuated in patients ingesting all medications upon awakening (p < .001). Thus, the prevalence of non-dipping was significantly higher when all hypertension medications were ingested upon awakening (68.3%) than when ≥1 of them was ingested at bedtime (54.2%; p < .001 between groups), and even further attenuated (47.9%) when all of them were ingested at bedtime (p < .001). Additionally, the prevalence of a riser BP pattern, associated with highest CVD risk, was much greater (21.5%) among patients ingesting all medications upon awakening, compared with those ingesting some (15.7%) or all medications at bedtime (10.6%; p < .001 between groups), independent of CKD severity (disease stage). The latter group also showed a significantly higher prevalence of properly controlled ambulatory BP (p < .001) that was achieved by a significantly lower number of hypertension medications (p < .001) compared with patients treated upon awakening. Our findings demonstrate significantly lower asleep SBP and DBP means and attenuated prevalence of a blunted nighttime BP decline, i.e., lower prevalence of markers of CVD risk, in patients with CKD ingesting hypertension medications at bedtime than in those ingesting all of them upon awakening. These collective findings indicate that bedtime hypertension treatment, in conjunction with proper patient evaluation by ABPM to corroborate the diagnosis of hypertension and avoid treatment-induced nocturnal hypotension, should be the preferred therapeutic scheme for CKD.

Summary: Background: Several studies have demonstrated increased numbers of angiographically detectable collaterals after vascular endothelial growth factor (VEGF) gene transfer. However, VEGF appears to be insufficient for stimulating the growth of mature blood vessels. Therefore, we decided to reinvestigate in what way the VEGF gene transfer to rabbit ischaemic muscle can restore blood flow impaired by femoral artery excision.Methods: Naked DNA, either control plasmid (pSVβgal) or pSG5-VEGF165 (harbouring human VEGF cDNA), was injected into adductor magnus muscle.Results: Human VEGF165 mRNA was detected in the ischaemic muscle injected with pSG5-VEGF165, and human VEGF protein was present in the blood plasma of the same animals but not in rabbits treated with control plasmid. However, rabbit VEGF synthesis was also enhanced in ischaemic legs of both β-gal and VEGF-treated animals. In spite of the augmented generation of endogenous VEGF, the local blood flow decreased to 75 ± 13.9 % (of flow before excision) after 28 days in pSVβgal injected animals, whereas it was preserved (97.3 ± 15 %) in pSG5-VEGF165 treated rabbits (P < 0.02). Muscles of rabbits treated with pSG5-VEGF165 showed a significantly higher number of microvessels in comparison to ischaemic muscles treated with pSVβgal (230 ± 66 vessels/mm2 vs 134 ± 48; P < 0.01), but angiographic analysis did not demonstrate significant differences in the number of collaterals between animals. Conclusions: The restoration of blood flow is most probably due to increased local angiogenesis and not to the formation of stable collateral vessels. Zusammenfassung: Grundlagen: Verschiedene Studien haben eine erhöhte Anzahl an angiographisch nachweisbaren Kollateralen nach Vascular Endothelial Growth Factor (VEGF)-Gentransfer nachweisen können. Allerdings scheint VEGF allein nicht ausreichend für die Ausbildung voll entwickelter Blutgefäße zu sein. Deshalb haben wir untersucht, in welcher Weise ein VEGF-Gentransfer an einem ischämischen Kaninchenmuskel die Wiederdurchblutung nach Exzision der Arteria femoralis beeinflußt.Methodik: Die „nackte” DNA, entweder als Kontrollplasmid (pSVβgal) oder pSG5-VEGF165 (humane VEGF cDNA) wurde in den Musculus adductor magnus injiziert.Ergebnisse: Humane VEGF165 mRNA konnte in dem mit pSG5-VEGF165 behandelten Muskel und humanes VEGF-Protein im Blutplasma dieser Tiere nachgewiesen werden, nicht aber in den Kaninchen, die mit dem Kontrollplasmid behandelt wurden. Allerdings war die Synthese des Kaninchen-VEGF im ischämischen Muskel sowohl in der Therapie- als auch in der Kontrollgruppe erhöht. Im Gegensatz zu der erhöhten Bildung endogenen VEGFs sank der lokale Blutfluß nach 28 Tagen auf 75 ± 13,9 % (gegenüber dem Blutfluß vor Exzision) bei den Tieren, die pSVβgal injiziert bekommen haben. Bei den Kaninchen, die mit pSG5-VEGF165 behandelt wurden, blieb der Blutfluß (97,3 ± 15 %) erhalten (P < 0,02). Die mit pSG5-VEGF165 behandelten Muskeln zeigten eine signifikant höhere Anzahl an Mikrogefäßen im Vergleich zur pSVβgal Gruppe (230 ± 66 Gefäße/mm2 vs. 134 ± 48; P < 0,01). Die angiographische Analyse zeigte keinen signifikanten Unterschied der Anzahl an Kollateralen zwischen den Gruppen.Schlußfolgerungen: Die Verbesserung der Durchblutung ist auf eine erhöhte Mikrogefäßdichte wahrscheinlich aufgrund einer stimulierten Angiogenese zurückzuführen.

Previous chronotherapy studies have shown that the circadian pattern of blood pressure (BP) remains unchanged after either morning or evening dosing of several calcium channel blockers (CCB), including amlodipine, isradipine, verapamil, nitrendipine, and cilnidipine. This trial investigated the antihypertensive efficacy and safety profile of the slow-release, once-a-day nifedipine gastrointestinal therapeutic system (GITS) formulation administered at different times with reference to the rest-activity cycle of each participant. We studied 80 diurnally active subjects (36 men and 44 women), 52.1+/-10.7 yrs of age, with grade 1-2 essential hypertension, who were randomly assigned to receive nifedipine GITS (30 mg/day) as a monotherapy for eight weeks, either upon awakening in the morning or at bedtime at night. Patients with uncontrolled BP were up-titrated to a higher dose, 60 mg/day nifedipine GITS, for an additional eight weeks. BP was measured by ambulatory monitoring every 20 min during the day and every 30 min at night for 48 consecutive hours before and after therapy with either dose. The BP reduction after eight weeks of therapy with the lower dose of 30 mg/day was slightly, but not significantly, larger with bedtime dosing. The efficacy of 60 mg/day nifedipine GITS in non-responders to the initial 30 mg/day dose was twice as great with bedtime as compared to morning dosing. Moreover, bedtime administration of nifedipine GITS reduced the incidence of edema as an adverse event by 91%, and the total number of all adverse events by 74% as compared to morning dosing (p=0.026). Independent of the time of day of administration, a single daily dose of 30 mg/day of nifedipine GITS provides full 24 h therapeutic coverage. The dose-dependent increased efficacy and the markedly improved safety profile of bedtime as compared to morning administration of nifedipine GITS should be taken into account when prescribing this CCB in the treatment of essential hypertension.

Heme oxygenase-1 (HO-1) is an inducible enzyme that degrades heme to carbon monoxide, iron ions, and biliverdin. Its expression can be induced by 15-deoxy-Delta(12,14)prostaglandin-J(2) (15d-PGJ(2)), a natural ligand of peroxisome proliferator-activated receptor-gamma transcription factor. In macrophages and vascular smooth muscle cells, 15d-PGJ(2) up-regulates the expression of vascular endothelial growth factor (VEGF), a fundamental regulator of angiogenesis. Here we investigated the involvement of HO-1 in the 15d-PGJ(2)-mediated regulation of VEGF production by human microvascular endothelial cells (HMEC-1). Resting HMEC-1 released approximately 20 pg/ml VEGF protein after 24 h of incubation. Treatment of cells with 15d-PGJ(2) (1-10 microM) significantly and dose-dependently increased the VEGF promoter activity, mRNA expression, and protein secretion. In the same cells, 15d-PGJ(2) potently induced the expression of HO-1 protein that correlated with HO-1 promoter activity. Activation of HO-1 with hemin or ectopic overexpression of HO-1 in HMEC-1 perfectly mimicked the effect of 15d-PGJ(2) and led to increased VEGF production. Importantly, the inhibition of the HO-1 pathway by tin protoporphyrin-IX significantly reduced the stimulatory effect of 15d-PGJ(2) on VEGF synthesis. Thus, we postulate that the up-regulation of VEGF expression in response to 15d-PGJ(2 )in HMEC-1 is mediated by the activation of HO-1.

In chronic kidney disease (CKD), the prevalence of hypertension is very high, escalating with diminishing renal function. Typically, the diagnosis of hypertension and the clinical decisions regarding its treatment are based on daytime clinic blood pressure (BP) measurements. However, the correlation between BP level and target organ damage, cardiovascular risk and long-term prognosis is greater for ambulatory than clinic measurements. Moreover, evidence is consistent among numerous studies that the elevated risk and incidence of end-organ injury and fatal and non-fatal cardiovascular events are significantly associated with blunted night-time BP decline, and that the asleep BP better predicts cardiovascular events than either the awake or 24-h BP mean. The prevalence of abnormally high asleep BP is extensive in CKD, significantly increasing with its severity. In CKD, the diagnoses of hypertension and its therapeutic control are often inaccurate in the absence of complete and careful assessment of the entire 24 h, i.e. daytime and night-time, BP pattern. Accordingly, ambulatory BP monitoring should be the preferred method to comprehensively assess and decide the optimal clinical management of patients with CKD. Recent findings indicate therapeutic restoration of normal physiologic BP reduction during night-time sleep is the most significant independent predictor of decreased cardiovascular and cerebrovascular risk, both in patients with and without CKD, and is best achieved when antihypertensive medications, mainly those blocking the renin-angiotensin-aldosterone system, are routinely taken at bedtime.

Amlodipine, a calcium antagonist of the 1,4-dihydropyridine type, has been shown to be effective in reducing blood pressure (BP) throughout the day and night when given once daily. However, the potential chronopharmacologic differing effects on BP of amlodipine have only been addressed occasionally. We investigated the administration-time dependent antihypertensive efficacy of amlodipine in patients with essential hypertension. We studied 194 patients with grade 1–2 essential hypertension (101 men and 93 women), 55.3±12.1 years of age, randomly assigned to receive a single daily dose of amlodipine (5 mg/day) either upon awakening or at bedtime. BP was measured by ambulatory monitoring at 20-min intervals from 07:00 to 23:00 hours and at 30-min intervals at night for 48 hours before and after 3 months of therapy. Physical activity was simultaneously monitored every minute by wrist actigraphy to accurately calculate the diurnal and nocturnal means of BP on a per subject basis. The BP reduction after 12 weeks of therapy with amlodipine was slightly but not significantly larger after bedtime dosing (10.4 and 7.3 mm Hg reduction in the 24-hour mean of systolic and diastolic BP after amlodipine on awakening; 11.5 and 7.0 mm Hg after bedtime dosing; P>0.463 for treatment-time effect). This BP reduction was similar during both daytime activity and nighttime resting hours, independently of dosing time, indicating a full 24-hour therapeutic coverage of amlodipine administered either on awakening or at bedtime. The day/night BP ratio (calculated as the nocturnal decline of BP relative to the diurnal mean) was slightly reduced for diastolic BP after morning treatment (-1.6, P=0.037), but remained unchanged after bedtime dosing of amlodipine (increase of 0.2 and 0.7 in systolic and diastolic BP, P>0.337). Results from this trial demonstrate that amlodipine efficiently reduces BP for the entire 24 hours of the day independently of the time of its administration with respect to the rest-activity cycle of each individual patient. The similar BP reduction observed for the diurnal and nocturnal BP means indicates that amlodipine does not modify the circadian pattern of BP variability, even if administered at bedtime.

Vascular endothelial growth factor (VEGF) is the major molecule governing angiogenesis, defined as the growth of blood vessels from vascular structure. There is abundant evidence that nitric oxide (NO) is an effector molecule mediating the activity of VEGF. By binding to its receptors, VEGF initiates the signaling cascades leading to NO production and angiogenic activation of endothelial cells. Recent data show that NO induces VEGF synthesis in numerous cell types, including vascular smooth muscle cells, macrophages, keratinocytes, and tumor cells. NO enhances VEGF production by augmenting its expression through activation of Akt kinase, followed by induction of several transcription factors, of which stabilization of hypoxia-inducible factor (HIF-1) is the critical step. With respect to its effect on VEGF expression, NO mimics hypoxia, the classical activator of HIF-1 and VEGF synthesis. The effect of NO on VEGF production is also mediated by heme oxygenase, an enzyme generating carbon monoxide, which appears to stimulate VEGF release. In this review, we attempt to elucidate the molecular mechanisms underlying the effects of NO on VEGF synthesis. We also discuss some discrepant data and suggest explanations for various aspects of the NO-VEGF relationship.

Several previous studies found that too great a reduction of clinic blood pressure (BP) by treatment increased cardiovascular disease (CVD) risk, whereas moderate reduction decreased it. Thus, it has been suggested that the relationship between BP and CVD events is J-shaped, with CVD risk decreasing as BP is lowered, and then rising as BP is further decreased. Correlation between BP level and CVD risk, however, is stronger for ambulatory BP monitoring (ABPM) than clinical BP measurements. We previously established that the hypertension treatment-time regimen, upon awakening versus at bedtime, exerts differential effect on BP control during the day and nighttime, which translates into a differential degree of CVD risk prevention. We, therefore, investigated the role of hypertension treatment-time scheme on the nature of the relationship between achieved clinic and ambulatory BP and CVD risk in the MAPEC (Monitorización Ambulatoria para Predicción de Eventos Cardiovasculares, i.e., Ambulatory Blood Pressure Monitoring for Prediction of Cardiovascular Events) study, a prospective, open-label, blinded-endpoint trial on 2156 hypertensive patients (1044 men/1112 women), 55.6 ± 13.6 (mean ± SD) yrs of age, randomized to ingest all prescribed once-a-day hypertension medications upon awakening or the entire daily dose of ≥1 of them at bedtime. Ambulatory BP was measured for 48-h at baseline and annually thereafter, and more frequently (quarterly) when adjustment of treatment was necessary. After a median follow-up of 5.6 yrs, a J-shaped relationship was detected between total CVD events and clinic as well as awake BP mean, but only for the group of patients ingesting all medications upon awakening. The relationship was different in the group of patients who ingested ≥1 medications at bedtime; the risk of CVD events progressively diminished in a linear, rather than J-shaped, manner with treatment-induced decrease in awake BP mean. The adjusted hazard ratio of CVD events was significantly lower with the progressive reduction in the asleep BP mean, independent of the hypertension treatment-time regimen. There was no single major event, i.e., CVD death, myocardial infarction, or stroke, in patients who achieved an asleep systolic BP mean <103 mm Hg. Our findings indicate that bedtime hypertension treatment is not associated with a J-shaped relationship between achieved BP and CVD risk. The decreased CVD risk associated with the progressive reduction in asleep BP, more feasible by bedtime than morning hypertension treatment, has clinical implications, in particular, the need to consider the proper timing of hypertension medications, in conjunction with ABPM for proper assessment of BP control, as an improved and potentially safer means of reducing CVD risk of hypertensive patients.

Current indices used in the evaluation of antihypertensive treatment duration and homogeneity such as the trough-peak, smoothness index, and normalized smoothness index were designed to be applied to ambulatory blood pressure monitoring recordings from individual participants. Evaluation of antihypertensive treatment in populations is often carried out by calculating these individual indices for each of the participants and providing summarizing statistics about the population, such as the mean and median. We describe a new population vector index and graphical method for the statistical assessment of antihypertensive treatment reduction, duration, and homogeneity (RDH) from ambulatory blood pressure monitoring. The population (RDH) was specifically designed as a tool to evaluate and compare blood pressure coverage offered by antihypertensive drugs over 24 h in populations. The population RDH is a three-component vector index that incorporates information about the reduction, duration, and homogeneity of antihypertensive treatment, as well as their statistical significance over the 24 h period. In addition to defining the RDH index, in this paper we also demonstrate its usefulness and advantages as an index and graphical method for antihypertensive treatment duration and homogeneity assessment by using it to analyze two data sets.