Influence of Time of Day of Blood Pressure-Lowering Treatment on Cardiovascular Risk in Hypertensive Patients With Type 2 Diabetes

OBJECTIVE-We prospectively investigated in hypertensive patients with type 2 diabetes if bedtime treatment with >= 1 hypertension medications exerts better blood pressure control and cardiovascular risk reduction than conventional therapy, in which all medications are ingested in the morning. RESEARCH DESIGN AND METHODS-We conducted a prospective, randomized, open-label, blinded end point trial on 448 hypertensive patients with type 2 diabetes, 255 men/193 women, mean +/- SD age 62.5 +/- 10.8 years, randomized to ingest all their prescribed hypertension medications upon awakening or >= 1 of them at bedtime. Ambulatory blood pressure was measured for 48 h at baseline and again annually or even more frequently (quarterly) after adjustments in treatment. RESULTS-After a median follow-up of 5.4 years, patients ingesting >= 1 hypertension medications at bedtime showed a significantly lower cardiovascular risk (adjusted by age and sex) than subjects ingesting all medications upon awakening (hazard ratio 0.33[95% Cl 0.21-0.54]; P < 0.001). The difference between groups in the adjusted risk of major events (cardiovascular death, myocardial infarction, and stroke) was also statistically significant (0.25 [0.10-0.61]; P = 0.003). Patients treated at bedtime showed significantly lower sleep time blood pressure mean and higher prevalence of controlled ambulatory blood pressure (62.5 vs. 50.9%; P = 0.013). There was a significant 12% cardiovascular risk reduction per each 5 mmHg decrease in asleep systolic blood pressure during follow-up (P < 0.001). CONCLUSIONS-Among patients with diabetes, treatment with >= 1 hypertension medications at bedtime, compared with all medications upon waking, resulted in improved ambulatory blood pressure control and significantly reduced cardiovascular morbidity and mortality.