Prognostic value of different circadian blood pressure patterns in ambulatory blood pressure monitoring

Background Hypertension (HTN) remains one of the most prevalent modifiable risk factors for cardiovascular disease (CVD). Despite major advances in diagnosis and therapy, blood pressure (BP) control remains suboptimal. Ambulatory blood pressure monitoring (ABPM) enables identification of circadian patterns, which have been associated with variable cardiovascular risk. Purpose This study aimed to characterize hypertensive patients according to circadian BP profiles, evaluate their association with cardiovascular outcomes, and identify predictors of major events. Methods This retrospective cohort study included patients followed at a tertiary hospital who underwent ABPM between January 2010 and July 2015, with at least 10 years of follow-up. Patients were classified by circadian BP pattern following the European Society of Hypertension criteria. Clinical, pharmacological, and ABPM data were analysed using univariate and multivariate logistic regression to identify independent predictors of major cardiovascular events, defined as ischemic or haemorrhagic stroke, transient ischemic attack, or acute myocardial infarction. Survival was estimated using Kaplan–Meier analysis. Results The study included 185 patients (mean age 56 years; 49.2% female). Most had hypertension (91.9%), dyslipidaemia (28.6%), diabetes mellitus (27.0%), or were smokers (23.2%). Regarding ABPM patterns, 58.9% were Dippers, 28.1% Non-Dippers, 7.6% Risers, and 5.4% Extreme Dippers. Over a mean follow-up of 5.4±4.0 years, 12.4% of patients died, 2.7% had ischemic stroke, 3.8% myocardial infarction, and 2.2% transient ischemic attack. Cardiovascular events and mortality were significantly more frequent among Non-Dipper and Riser profiles (p=0.033 and p=0.028, respectively). Riser and Extreme Dipper profiles exhibited the lowest survival (p=0.048). When stratified by BP control, these associations persisted but did not reach statistical significance. Age was the only independent predictor of major events or death (OR 3.67, p=0.003). Non-Dipper and Riser profiles were also more frequently associated with diabetes (p=0.001), atrial fibrillation (p=0.009) and heart failure (p=0.019). Conclusions Abnormal circadian BP profiles are linked to higher cardiovascular morbidity and mortality, whereas the Dipper pattern represents a more favourable phenotype. Advanced age, diabetes, atrial fibrillation, and heart failure cluster among patients with adverse BP patterns, contributing to their worse prognosis. These findings reinforce the clinical value of ABPM not only for hypertension diagnosis and management but also for cardiovascular risk stratification and individualized therapeutic strategies.