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Bedtime instead of morning ingestion of hypertension meds = significantly more reduction in cardiovascular disease risk
Clinical Question
Does bedtime ingestion instead of morning ingestion of hypertension medications produce better cardiovascular disease risk reduction in adults with hypertension?
Bottom line
This study found a significant reduction in mortality and morbidity among patients who took their once-daily antihypertensive medications at bedtime instead of on awakening. Although no significant difference occurred in compliance rates between bedtime and awakening ingestion times in this study, individual experiences may differ in clinical practice. 1b-
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Government
Setting: Outpatient (primary care)
Synopsis
These investigators identified 19,168 adults, 18 years or older, who met standard criteria for hypertension that required prescription treatment to lower blood pressure (BP). The study participants randomly received (uncertain concealment) assignment to the intervention group and were told to ingest the entire daily dose of one or more prescribed BP-lowering medications at bedtime, or to the control group and were told to ingest the entire daily dose on awakening. Clinicians provided care without restriction to choice of BP-lowering medication approved for once-daily dosing (eg, angiotensin receptor blocker, angiotensin-converting enzyme inhibitor, calcium channel blocker, beta-blocker, and/or diuretic). Statins, aspirin, and diabetes medications were also prescribed as needed and ingested as recommended. Individuals masked to treatment group assignment assessed outcomes, including the primary composite outcome of myocardial infarction, coronary revascularization, heart failure, stroke, and CVD death. Complete follow-up occurred for more than 99% of participants at a median of 6.3 years. Using intention-to-treat analysis, significantly fewer patients in the bedtime group experienced the primary cardiovascular disease outcome (n = 1752 total) compared with the awakening group (adjusted HR = 0.55; 95% CI 0.50 - 0.61; number needed to treat = 20.3; 17.4 - 24.3). Adverse events occurred similarly in both groups. Similarly poor adherence was reported at any visit during follow-up in both groups (approximately 3%).
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Hypertension study of the decade?
This is the most important study for hypertension I've seen in a long time. Yes, that includes SPRINT. Pt-oriented outcomes, simple intervention, should be practice changing. There is an ongoing pragmatic trial underway in Alberta right now looking at this very question, I'm not sure how many subjects have been recruited.
diuretics @ night?
Great paper... but I'm amazed they managed to dose diuretics at night. They mention no increase in adverse events, but I don't see nocturia specifically measured. Is anyone able to share if this was measured?
TIME study refutes this
Great to see the new POEM on the TIME study that shows no difference in outcomes with a similar sized study:
https://joule.cmail20.com/t/j-l-ellltyk-yuiyjueiu-h/
Looking forward to seeing the Alberta (actually broader than just one province) study results which should tip the current "tie" in findings