The Residual Hemodynamic Gap in Clinical Practice: A Comparative Study Using Ambulatory Blood Pressure Monitoring

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Hypertension (n=540). Intervention: Treated hypertension (monotherapy, dual, and triple antihypertensive regimens) vs. Normotensive controls. Primary outcome: 24-hour systolic blood pressure load (%) (p=<0.001).

Q: What does this research mean for the field?

Treated hypertensive patients exhibit a significant residual hemodynamic gap compared to normotensives, marked by elevated systolic load, increased arterial stiffness, and pathological non-dipper and riser circadian patterns. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Lilianny del Carmen Pineda Chopite; Jorge L. Hernández; Jorge Dominguez; Cristina López-Sánchez; Joliette Alvarado; Paola Brigli

doi:10.21203/rs.3.rs-11243012/v1

October 5, 2026Open Access

The Residual Hemodynamic Gap in Clinical Practice: A Comparative Study Using Ambulatory Blood Pressure Monitoring

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Key result

Treated hypertensive patients exhibited a significant residual hemodynamic gap compared to normotensive controls, with higher systolic load and non-dipper/riser profiles.

Why the study?

Hypertension management relies heavily on mean BP targets, yet persistent advanced vascular and chronobiological abnormalities despite controlled average BP remain a clinical challenge.

Does antihypertensive therapy across monotherapy, dual, and triple regimens normalize advanced 24-hour ABPM hemodynamic parameters (systolic load, variability, pulse pressure, arterial stiffness, and circadian patterns) compared to normotensive controls?

Key Points

To characterize the residual hemodynamic gap—persistent vascular and chronobiological abnormalities despite controlled average blood pressure—in treated hypertensive patients compared to normotensive controls.
Observational study involving 540 subjects (169 normotensives and 371 hypertensives categorized into monotherapy [n=151], dual therapy [n=123], and triple therapy [n=58] regimens).
Evaluated 24-hour ambulatory blood pressure monitoring (ABPM) markers including pulse pressure, systolic load, blood pressure variability, and circadian dipping profiles.
Conducted multivariate analysis of covariance (MANCOVA) and multiple linear regression controlling for age, sex, diabetes, and smoking status.
Pathological circadian profiles predominated in treated hypertensive patients, with non-dipper (32–42%) and riser (19–29%) patterns occurring significantly more frequently than in normotensive controls (p = 0.011).
Hypertensive subjects demonstrated significantly greater systolic load (30 ± 26.44% vs. 17 ± 19.84%, p < 0.001), pulse pressure (53 ± 11.04 vs. 48 ± 7.76 mmHg, p < 0.001), and arterial stiffness index (AASI 0.44 ± 0.20 vs. 0.37 ± 0.17, p < 0.001) than normotensives, with no significant differences across monotherapy, dual, or triple regimens.
Age was an independent predictor of pulse pressure (β = 0.20, p < 0.001) and arterial stiffness (β = 0.002, p = 0.015), serving as the primary covariate driving the global hemodynamic profile (Pillai’s Trace = 0.107, p < 0.001), whereas sex (p = 0.600), diabetes (p = 0.891), and smoking (p = 0.196) showed no significant multivariate effects.

Study Design

Type

Cross-Sectional (n=540)

Multicenter

No

Structured PICO

Does antihypertensive therapy across monotherapy, dual, and triple regimens normalize advanced 24-hour ABPM hemodynamic parameters (systolic load, variability, pulse pressure, arterial stiffness, and circadian patterns) compared to normotensive controls?

P

Population

540 adults (mean age 54.6 years, 65% female), comprising 371 treated hypertensive patients on stable monotherapy, dual, or triple regimens for at least 4 weeks and 169 normotensive controls, evaluated via 24-hour ambulatory blood pressure monitoring.

E

Exposure

Antihypertensive pharmacological regimens stratified by intensity: monotherapy (n=151, 28%), dual therapy (n=123, 23%), and triple therapy (n=58, 11%), maintained without changes for at least 4 weeks, evaluated via 24-hour Ambulatory Blood Pressure Monitoring (ABPM). Drug classes included angiotensin receptor blockers (64%), calcium channel blockers (33%), beta-blockers (23%), thiazides (21%), ACE inhibitors (9%), and alpha-agonists (3%).

C

Comparator

Normotensive control group (n=169, 31%) and inter-regimen comparisons across monotherapy, dual therapy, and triple therapy.

O

Outcome

24-hour average blood pressure and advanced hemodynamic parameters via ABPM: systolic load (% of readings ≥135 mmHg daytime and ≥120 mmHg nighttime), 24-hour systolic variability (SD), pulse pressure (PP), Ambulatory Arterial Stiffness Index (AASI), and circadian blood pressure dipping patterns (dipper, non-dipper, riser, over-dipper).surrogate

Main Result

Absolute Event Rate: 30% vs 17%

p-value: p=<0.001

Despite achieving controlled 24-hour average blood pressure across monotherapy, dual, and triple regimens, treated hypertensive patients retain a substantial residual hemodynamic gap—characterized by elevated pulse pressure, systolic load, arterial stiffness, and non-dipper/riser circadian profiles primarily driven by age—highlighting the need to target advanced ABPM parameters beyond mean BP.

Limitations

Observational and cross-sectional design precludes establishing direct causality or evaluating longitudinal trajectories of hemodynamic parameters.
Confounding by indication bias when comparing monotherapy against combination therapy subgroups.
Extended data collection period (2008–2026) spans multiple clinical guideline updates, potentially introducing heterogeneity in historical treatment decisions.
Lack of detailed data on exact hypertension duration, long-term medication adherence beyond 4 weeks, dietary sodium intake, and direct imaging or biomarker indicators of target organ damage.

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Implication

Residual hemodynamic gaps persist on ABPM despite treated hypertension; leaves open whether age-driven patterns warrant targeted interventions.

Abstract

Hypertension management relies heavily on mean blood pressure (BP) targets. However, a "residual hemodynamic gap"—persistent advanced vascular and chronobiological abnormalities despite controlled average BP—remains a clinical challenge. An observational study characterized this gap in 540 subjects (169 normotensives; 371 hypertensives across monotherapy, dual, and triple regimens) using 24-hour Ambulatory Blood Pressure Monitoring (ABPM). Evaluated parameters included pulse pressure (PP), systolic load, variability, and circadian patterns. A Multivariate Analysis of Covariance (MANCOVA) within the hypertensive cohort assessed the impact of sex, diabetes, and smoking, adjusting for age. Hypertensive patients exhibited a profound residual hemodynamic gap compared to controls. Pathological circadian patterns predominated, with non-dipper (32–42%) and riser (19–29%) profiles being highly prevalent (𝑝 = 0.011). Multiple linear regression identified age as an independent predictor of elevated PP (𝛽 = 0.20; 𝑝< 0.001) and arterial stiffness (𝛽 = 0.002; 𝑝 = 0.015). In the MANCOVA model, age emerged as the dominant independent covariate driving the global hemodynamic profile (Pillai’s Trace = 0.107; 𝑝< 0.001). After controlling for age, no significant multivariate main effects were observed for sex (Pillai’s Trace = 0.008; 𝑝 = 0.600), diabetes (Pillai’s Trace = 0.003; 𝑝 = 0.891), or smoking status (Pillai’s Trace = 0.017; 𝑝 = 0.196). This study concludes that a substantial residual hemodynamic gap persists in treated hypertensive patients. Hypertension success metrics must shift from simple average BP control toward assessing and targeting these advanced, residual hemodynamic abnormalities via ABPM, to achieve true cardiovascular protection.

Discussion

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Cite This Study

Chopite et al. (2026) conducted a cross-sectional in Hypertension (n=540). Treated hypertension (monotherapy, dual, and triple antihypertensive regimens) vs. Normotensive controls was evaluated on 24-hour systolic blood pressure load (%) (p=<0.001). Treated hypertensive patients exhibited a significant residual hemodynamic gap compared to normotensive controls, with higher systolic load and non-dipper/riser profiles.

synapsesocial.com/papers/6ae28f48cbadf70daf6c44be https://doi.org/10.21203/rs.3.rs-11243012/v1

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The Residual Hemodynamic Gap in Clinical Practice: A Comparative Study Using Ambulatory Blood Pressure Monitoring

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

The Residual Hemodynamic Gap in Clinical Practice: A Comparative Study Using Ambulatory Blood Pressure Monitoring

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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