Timing of blood pressure medication may not matter for reducing CV event risk
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Key takeaways:
- The timing of when patients took their blood pressure medication made no difference in risk for CV events.
- The findings were consistent between the general population and frail older adults.
The timing of when a patient takes their blood pressure medication does not appear to matter for reducing CV event risk, according to two trials and a meta-analysis presented at the European Society of Cardiology Congress.
“The reason that this came up is that one research group out of Spain has twice reported a large reduction in death, stroke and heart attack if blood pressure medications are taken at bedtime as compared to conventional morning use,” Scott Garrison, MD, PhD, professor of medicine at the University of Alberta in Calgary, Canada, and founder of the Pragmatic Trials Collaborative, said during a press conference. “We are now the second of two teams of independent investigators to refute that finding.”
The theory behind taking BP medications at night is that nighttime BP is more predictive of CV events than daytime BP, and most BP medications are more active soon after being taken, he said.
The Spanish trials were MAPEC, published in 2010, and Hygia, published in 2019. In MAPEC, there was a 61% reduction in death, MI or stroke when BP medications were taken at night compared with in the morning, and in Hygia, taking BP medications in the morning was associated with a 45% reduction in CV death, MI or stroke, Garrison said. However, he said, the TIME trial, presented at ESC in 2022, found no difference in CV outcomes based on timing of BP medications.
BedMed and BedMed-Frail
Garrison and colleagues conducted two pragmatic randomized trials of bedtime dosing vs. morning dosing of BP medications in patients with hypertension. One, BedMed, included 3,357 patients recruited from 436 primary care practices in five Canadian provinces. The other, BedMed-Frail, included 776 residents of 17 continuing-care facilities in Alberta.
“The reason for this second trial is our belief that the risks and benefits of most things we do are probably going to be different in frail older adults,” Garrison said during the press conference. “Most randomized trials that guide everyone’s care underrepresent that population.”
The primary outcome of death or hospitalization for ACS, stroke or HF did not differ between the groups at 6 years in the BedMed trial (HR = 0.96; 95% CI, 0.77-1.19) or at 3 years in the BedMed-Frail trial (HR = 0.88; 95% CI, 0.71-1.11), Garrison said during the press conference.
“We found the benefits and risks of antihypertensive medications do not vary by the time of day that they are used,” Garrison said during the press conference. “If you’re a physician, you don’t need to spend time promoting bedtime blood pressure medications. For the average person who has hypertension ... if you have a particular reason to want to take [medications] at a particular time, you are the best person to make judgment on when is the best time to take them.”
Meta-analysis
A meta-analysis of all five of the BP medication timing trials — MAPEC, Hygia, TIME, BedMed and BedMed-Frail, showed no difference in CV outcomes based on morning or bedtime dosing of BP medications, Ricky Turgeon, PharmD, pharmacist and researcher at the University of British Columbia in Vancouver, British Columbia, Canada, said during the press conference.
The five trials totaled more than 46,000 patients. The researchers assessed each trial for risk for bias and conducted a meta-analysis to pool their results.
The primary outcome of death, MI, stroke or HF did not differ between patients who took their BP medications at bedtime and those who took them in the morning, when all five trials were analyzed, and especially when the three trials with low risk for bias (TIME, BedMed and BedMed-Frail) were analyzed (HR = 0.94; 95% CI, 0.85-1.04; I2 = 0%), Turgeon said.
The researchers also found no differences in the individual outcomes of death, MI, stroke, HF, hospitalizations, fractures, glaucoma or cognitive impairment.
“The bottom line is that taking blood pressure medications at night, as compared to taking them in the morning, does not reduce the risk of cardiovascular events including death, heart attack, stroke and heart failure, and does not alter the risk of safety events,” Turgeon said. “In terms of advising and prescribing, patients can take [BP medications] at whatever time best suits them for their schedule and routine. Whatever helps to maximize their adherence.”
Reference:
- Turgeon R, et al. Hot line 2. Presented at: European Society of Cardiology Congress; Aug. 30-Sept. 2, 2024; London (hybrid meeting).
Perspective
Back to TopThis important study’s results remind us that the primary take-home message is that we have to get patients to take their BP medicine. The studies identified that whether they take it in the morning or in the evening, the most important thing is that we have to get them to be compliant and take it. This is a critical message that needs to be widely distributed to ensure that all our patients are aware. We have to manage hypertension much better than we are.
It was also interesting that this trial was conducted with an older, frail, more vulnerable population; this segment of our patients is rarely included in research and including them is notable. That we didn’t see a big difference in that population either highlighted the critical takeaway message that patients just have to be compliant and take their medication. Patients in an extended-care facility usually have their medications managed for them, so that is not as much of an issue. The bigger issue with compliance is out in the community.
Another key message is to make sure that people know their BP. I don’t think we have solved that problem yet in the U.S. or globally. Every individual, including high school students (who in turn will ask their family), should know their BP. This is a major component of our efforts to prevent CAD; we have to start with the very basics.
If you are diagnosed with hypertension, make sure you follow the guidelines, are on optimal medical therapy and have your BP at target rates. This includes implementing the lifestyle components we recommend, including exercise and diet.
We should be making sure we use team-based care to manage hypertension, which is especially important during a time of workforce shortages and equitable access issues. We need to maximize our CV team in all that we do, with hypertension as a key focus.
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Garrison S, et al. Hot line 2. Presented at: European Society of Cardiology Congress; Aug. 30-Sept. 2, 2024; London (hybrid meeting).
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