Nocturnal blood pressure: pathophysiology, measurement and clinical implications. Position paper of the European Society of Hypertension
ESH · 2025 · Europe
Source and licence
- Authors
- Gianfranco Parati, Martino F Pengo, Alberto Avolio et al.
- Title
- Nocturnal blood pressure: pathophysiology, measurement and clinical implications. Position paper of the European Society of Hypertension
- Journal
- Journal of Hypertension, 2025
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC12237141
Licence statement of the original publication
This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0
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Abstract
Interest in the pathophysiology, measurement, and clinical implications of nocturnal blood pressure (BP) has significantly increased due to its strong association with cardiovascular risk, and its importance was recognized by the 2023 European Society of Hypertension (ESH) guidelines. Nocturnal BP regulation is complex and multifactorial, involving sleep-wake cycle, circadian rhythms, autonomic nervous system, renin-angiotensin-aldosterone system, and renal mechanisms.
24-h ambulatory blood pressure monitoring is currently the reference method for nocturnal BP assessment. Home BP monitoring, with specially designed, validated devices with nocturnal BP measuring function, may also be used, while new cuffless and wearable technologies hold great potential but require further validation.
Nocturnal BP phenotypes of clinical interest include nocturnal hypertension, increased nocturnal BP variability and altered day-night BP fluctuations. Among those, isolated nocturnal hypertension may be considered a type of masked hypertension. BP variability has prognostic relevance, as do the day-night BP changes, i.e. the nocturnal BP “dipping”.
Nocturnal hypertension and nondipping are particularly prevalent in individuals with autonomic neuropathies, sleep disorders (e.g., obstructive sleep apnoea), kidney disease, and metabolic or endocrine disorders, and are linked to hypertension mediated organ damage and cardiovascular risk.
Therapeutic strategies targeting nocturnal BP remain debated. Chronotherapy (evening dosing of antihypertensives) has shown inconsistent results in clinical trials. Renal denervation and treatment of sleep-related breathing disorders may lower nocturnal BP and improve sleep quality. More research is needed to further clarify pathophysiology, measurement, therapeutic interventions, and overall management of nocturnal hypertension, issues on which this ESH position paper offers an in-depth review.
Contents of the original publication
The section headings of the original.
- INTRODUCTION
- PHYSIOLOGY AND PATHOPHYSIOLOGY OF NOCTURNAL BP
- Role of sleep and circadian rhythm in determining night-time BP
- Sodium and water handling
- The renin-angiotensin system
- The autonomic nervous system
- CURRENT METHODS OF NOCTURNAL BP ASSESSMENT
- Defining nocturnal BP
- Discontinuous 24-h ambulatory blood pressure monitoring
- Wearables and multiparametric sleep monitoring
- CLINICAL IMPLICATIONS
- Implications for hypertension diagnosis (masked hypertension due to isolated nocturnal hypertension)
- Relationship with organ damage
- Relationship with cardiovascular outcomes
- Nocturnal hypertension vs. nondipping
- SPECIAL POPULATIONS
- Neurological disorders
- Patients with sleep disorders
- Relationship with kidney disorders
- Relationship with metabolic and endocrine disorders
- THERAPEUTIC ASPECTS
- Pharmacological antihypertensive treatment: role for chronotherapy?
- Renal denervation
- Improving sleep quality and duration
- Treating sleep apnoea to reduce nocturnal BP
- CONCLUSION
- Nocturnal BP in recent guidelines
- Knowledge gaps
- Key issues for future research
- TAKE HOME MESSAGGES FOR DAILY PRACTICE, BASED ON CURRENT EVIDENCE
- Mechanisms of day-night BP changes, relevant for clinical practice
- Indications on how to perform nocturnal BP measurement in clinical practice
- How to define wake and sleep periods
- Importance of nocturnal BP assessment in relation with outcome
- Dipping vs. nocturnal hypertension
- Special populations in which nocturnal BP assessment is indicated because of high prevalence of nocturnal BP alterations
- Therapeutic aspects
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