Should blood pressure medications be taken at bedtime?

Hypertension is a common problem that increases cardiovascular risk. A recent large trial suggests the timing of treatment can make a difference to outcomes.

Current guidelines on the management of hypertension do not mention the timing of treatments. The UK’s National Institute for Health and Care Excellence (NICE), for example, has no recommendations on the timing of treatments. Having just updated its guidance in August 2019, the timing of hypertensives was also not in NICE’s research recommendations. Similarly, the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines makes no specific recommendations on timing, but do state ‘the dosing of multidrug regimens, occasionally including night-time dosing, maybe best optimised by hypertension specialists.’

EBM Verdict on: Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. Eur Heart J. 2019: ehz754. doi: 10.1093/eurheartj/ehz754.

Taking at least one hypertensive at bedtime appears to lead to reductions in night-time blood pressure and significant reductions in cardiovascular events.

One of the strengths of the study was its multicentre design and that it was embedded into routine primary care. Other strengths include the use of 48hours ABPM, the independent blinded adjudication of the outcomes and the minimal losses to follow-up (99.6% of patients enrolled were included in the final evaluated population).

The study had some weaknesses, including the lack of generalisability to ethnic groups: the trial included only Spanish people of a white ethnic background. The class effects of different medications on night-time BP could also not be determined as participants were free to choose which hypertensive agent they took at night and not assigned to specific classes of drugs. The open-label trial meant patients could not be blinded to the timing of their treatments, and researchers were also made aware of the timings. The blinded adjudication of endpoints was, therefore, essential 

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