Circadian Blood Pressure Pattern and Microvascular and Macrovascular Cerebral Imaging Burden

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Cerebrovascular imaging burden (white matter hyperintensities and intracranial arterial calcification) across nocturnal blood pressure dipping patterns (n=376). Intervention: Reverse dipping blood pressure pattern (<0% nocturnal SBP decline) vs. Dipper blood pressure pattern (≥10% nocturnal SBP decline). Primary outcome: White matter hyperintensity (WMH) burden assessed by ordinal Fazekas grade (0–3) (OR 2.26, 95% CI 1.13–4.56, p=0.022).

Q: What does this research mean for the field?

Reverse nocturnal blood pressure dipping is independently associated with higher white matter hyperintensity burden and intracranial arterial calcification compared to normal dipping. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Enise N. Özlem Tiryaki; Uğur Karagöz; Muhammet Mücahit Tiryaki

doi:10.3390/jcm15135038

June 28, 2026Journal of Clinical MedicineOpen Access

Circadian Blood Pressure Pattern and Microvascular and Macrovascular Cerebral Imaging Burden

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Key result

Reverse nocturnal blood pressure dipping was independently associated with higher Fazekas white matter hyperintensity grades (OR 2.26, p=0.022) and intracranial arterial calcification (OR 8.03, p=0.001) compared to normal dipping.

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Why the study?

The differential impact of non-dipping versus reverse dipping nocturnal blood pressure patterns on white matter hyperintensity burden and intracranial arterial calcification remains unclear.

Does a non-dipping or reverse dipping nocturnal blood pressure pattern increase white matter hyperintensity burden and intracranial arterial calcification compared to normal dipping in adult outpatients undergoing 24-hour ABPM and neuroimaging?

Key Points

To evaluate the differential impact of nocturnal blood pressure non-dipping versus reverse dipping on white matter hyperintensity burden and intracranial arterial calcification.
Retrospective study of 376 patients who underwent 24 h ambulatory blood pressure monitoring, brain MRI, and cranial CT.
Patients were classified by nocturnal systolic blood pressure decline into dippers (≥10%, n = 148), non-dippers (0–10%, n = 156), or reverse dippers (<0%, n = 72).
White matter hyperintensity was evaluated using the Fazekas scale (0–3) with ordinal logistic regression, and intracranial arterial calcification was assessed as present or absent, adjusting for age, sex, hypertension, diabetes, chronic kidney disease, and coronary artery disease.
Reverse dippers had significantly higher Fazekas grades (OR 2.26; 95% CI 1.13–4.56; p = 0.022) and intracranial arterial calcification prevalence (OR 8.03; 95% CI 2.42–29.18; p = 0.001) compared with dippers.
Non-dippers showed no significant association with Fazekas grade (OR 0.78; 95% CI 0.45–1.36; p = 0.386) but were independently associated with intracranial arterial calcification (OR 3.75; 95% CI 1.43–10.76; p = 0.010).
A significant dose–response trend across dipping categories was observed for intracranial arterial calcification (OR 2.89 per category; 95% CI 1.60–5.47; p = 0.001) but not for Fazekas grade (OR 1.35; 95% CI 0.97–1.90; p = 0.078).

Study Design

Type

Cross-Sectional (n=376)

Blinding

Assessor-blinded

Multicenter

No

Structured PICO

Does a non-dipping or reverse dipping nocturnal blood pressure pattern increase white matter hyperintensity burden and intracranial arterial calcification compared to normal dipping in adult outpatients undergoing 24-hour ABPM and neuroimaging?

P

Population

376 adult neurology and cardiology outpatients aged ≥18 years who underwent 24-hour ambulatory blood pressure monitoring, brain MRI, and cranial CT within one month, excluding those with confounding CNS lesions.

E

Exposure

24-hour ambulatory blood pressure monitoring (ABPM) classification of nocturnal systolic blood pressure phenotypes: non-dipping (0-10% nocturnal SBP decline) and reverse dipping (<0% nocturnal SBP decline, where mean nighttime SBP exceeded mean daytime SBP)

C

Comparator

Normal physiological dipping phenotype (dippers: ≥10% nocturnal SBP decline on 24 h ABPM, including 4 extreme dippers with >20% decline)

O

Outcome

White matter hyperintensity (WMH) burden assessed on brain MRI using the global Fazekas scale (0-3) and presence/absence of visible intracranial arterial calcification (IAC) assessed on non-contrast cranial CT, evaluated independently by two blinded clinicianssurrogate

Main Result

Odds Ratio: 2.26 (95% CI 1.13–4.56)

p-value: p=0.022

This study demonstrates that reverse nocturnal blood pressure dipping is independently associated with both microvascular (white matter hyperintensities) and macrovascular (intracranial arterial calcification) cerebral damage, whereas non-dipping is primarily linked to macrovascular calcification.

Limitations

Retrospective, single-center, cross-sectional design precludes causal inference and may limit generalizability.
Intracranial arterial calcification was assessed only as a binary variable without quantitative burden, arterial segment involvement, laterality, or severity grading.
White matter hyperintensity burden was evaluated using the ordinal Fazekas scale rather than volumetric methods.
Small number of patients with Fazekas grade 3 and wide confidence intervals in the IAC models indicate statistical imprecision.
Baseline differences existed across dipping groups, with reverse dippers being older and having a higher vascular risk burden, leaving potential for residual confounding.
Close relationship between reverse dipping and elevated nighttime BP load makes it difficult to fully disentangle whether reverse dipping is a distinct phenotype or primarily reflects nocturnal hypertension.
Sleep-related factors (sleep quality, obstructive sleep apnea, nocturnal awakenings, sedative/hypnotic use, shift-work status) were not systematically recorded.
Retrospective, single-center design precludes causal inference and may limit generalizability to community-based or asymptomatic populations.
IAC was assessed as a binary variable without quantitative calcification burden, arterial segment involvement, laterality, or severity; WMH burden was evaluated using the Fazekas scale rather than volumetric methods.
Dipping groups were not fully balanced (reverse dippers were older and had a higher vascular risk burden), so residual confounding cannot be excluded.
Sleep-related factors that may influence nocturnal BP patterns (sleep quality, obstructive sleep apnea, nocturnal awakenings, sedative/hypnotic use, shift-work status) were not systematically recorded.

Implication

Reverse dipping was associated with greater white matter hyperintensity and calcification burden; hypothesis-generating for nocturnal BP modification in cerebrovascular prevention.

Abstract

Background: Nocturnal blood pressure (BP) dipping patterns have been associated with cerebrovascular disease, but the differential impact of non-dipping versus reverse dipping on white matter hyperintensity (WMH) burden and intracranial arterial calcification (IAC) remains unclear. Methods: This retrospective study included 376 patients who underwent 24 h ambulatory BP monitoring, brain MRI, and cranial CT. Patients were classified as dipper (≥10% SBP decline, n = 148), non-dipper (0–10%, n = 156), or reverse dipper (<0%, n = 72). WMH was assessed using the Fazekas scale (0–3) and analyzed with ordinal logistic regression. IAC was scored as present/absent. Multivariable models adjusted for age, sex, hypertension, diabetes, chronic kidney disease (CKD), and coronary artery disease (CAD). Results: Reverse dippers had significantly higher Fazekas grades (OR 2.26; 95% CI 1.13–4.56; p = 0.022) and IAC prevalence (OR 8.03; 95% CI 2.42–29.18; p = 0.001) compared to dippers. Non-dippers showed no association with Fazekas (OR 0.78; 0.45–1.36; p = 0.386) but were independently associated with IAC (OR 3.75; 1.43–10.76; p = 0.010). A significant dose–response trend was observed for IAC (OR 2.89 per category; 1.60–5.47; p = 0.001) but not for Fazekas grade (OR 1.35; 0.97–1.90; p = 0.078). Age, diabetes, and CAD were also independent predictors of IAC, while female sex was protective. Conclusions: Reverse dipping was associated with both higher WMH burden and IAC, whereas non-dipping was associated mainly with IAC. These findings suggest that nocturnal BP phenotypes may be differentially associated with cerebral microvascular and macrovascular imaging markers. Further prospective studies are needed to confirm these observations.

Discussion

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Cite This Study

Tiryaki et al. (2026) conducted a cross-sectional in Cerebrovascular imaging burden (white matter hyperintensities and intracranial arterial calcification) across nocturnal blood pressure dipping patterns (n=376). Reverse dipping blood pressure pattern (<0% nocturnal SBP decline) vs. Dipper blood pressure pattern (≥10% nocturnal SBP decline) was evaluated on White matter hyperintensity (WMH) burden assessed by ordinal Fazekas grade (0–3) (OR 2.26, 95% CI 1.13–4.56, p=0.022). Reverse nocturnal blood pressure dipping was independently associated with higher Fazekas white matter hyperintensity grades (OR 2.26, p=0.022) and intracranial arterial calcification (OR 8.03, p=0.001) compared to normal dipping.

synapsesocial.com/papers/6a44af055cd2549c8bc440f7 https://doi.org/10.3390/jcm15135038

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Circadian Blood Pressure Pattern and Microvascular and Macrovascular Cerebral Imaging Burden

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Circadian Blood Pressure Pattern and Microvascular and Macrovascular Cerebral Imaging Burden

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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