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The essential benefit of the management of hypertension is derived from the blood pressure (BP) lowering per se, indicating the importance of BP throughout 24 hours. Recent guidelines stressed the importance of home BP for the diagnosis and management of hypertension. It is well-known that cardiovascular events occur more frequently in the morning BP levels have been shown to increase during the period from night to early morning. Clinical research using ambulatory BP monitoring (ABPM) or home BP monitoring has clarified that morning BP and BP surge are more closely related to the cardiovascular risk than office BP (Kario et al. Circulation 2003;107:1401–1406).

The importance of on-treatment HBPM for the cardiovascular prognosis of hypertensive individuals was recently revealed in the largest real-world prospective study, the Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study which enrolled more than 21 000 hypertensive patient. In prospective results of the HONEST study, in hypertensive patients treated with antihypertensive medication, even patients whose office BP is well-controlled, on-treatment uncontrolled morning hypertension prior to taking medication frequently remains high risk for both stroke and coronary disease (Kario, et al. Hypertension 2014;64:989–996; J Am Coll Cardiol 2016;67:1519–1527). In our nationwide Japanese cohort, the Japan Morning Surge Home Blood Pressure (J-HOP) Study, morning home BP was the best predictor of stroke event (Hoshide, Kario, et al. Hypertension 2016;68:54–61). Since Asians show greater morning BP surges (Hoshide, Kario, Parati et al. Hypertension 2016;68:54–61), it is particularly important for Asians to control morning BP as the first step to achieve ‘perfect 24-hr BP control,’ i.e., the 24-hr BP level, nocturnal BP dipping, and BP variability including morning surge (Kario. Ann Glob Health 2016;82:254–273).

The first definition of “morning hypertension” was defined as the average of morning BPs >135 mmHg for systolic BP, or >85mmHg for diastolic BP, regardless of office BPs with the definition of morning BP >135/85 mmHg regardless office BP in Clinician's Manual on Early Morning Risk Management in Hypertension in 2004 (Science Press, London, UK, 2004). “Masked morning hypertension” may be used for morning hypertension with office BP <140/90 mmHg. Morning BP could be measured by both ABPM (2 hour-average of ambulatory BPs after arsing) and home BP monitoring (the average of 2 measurements in the morning during 3 or more days). Morning hypertension could be diagnosed not only by home BP monitoring, but also by ABPM (ambulatory morning hypertension). When information on the time of arising is not available, the highest 1 hour moving average of consecutive systolic BPs between 6am and 10am could be calculate as the “Moving peak morning systolic BP” (Kario. Essential manual of 24 hour blood pressure management. Wiley, UK, pp.1–158.2015). The risk of morning BP surge may be underestimated by BP monitoring device with intermittent measurements. The innovation of wearable “surge” BP monitoring which could measure BP continuously will clarify the risk of morning BP surge (Kario. Prog Cardiovasc Dis 2016, in press).

We are now proposing a three-step strategy for the morning BP-guided management of hypertension using home BP monitoring as follows. Step 1: Morning systolic BP <145 mmHg should be achieved by treatment; Step 2: The guideline level of 135 mmHg morning systolic BP should then be reached, and Step 3: Approx. 125 mmHg or less, which presents the lowest risk of cardiovascular events, should be achieved and maintained (Kario. Essential manual of 24 hour blood pressure management. Wiley, UK, pp.1–158.,2015). Non-specific medication for controlling morning hypertension includes long-acting drugs. Once-daily dosing antihypertensive agents, now widely used as conventional antihypertensive medication, has decreased the patient burden and contributed to increased patient compliance. However, conventional antihypertensive medication using once-daily use of antihypertensive drugs was insufficient for controlling morning hypertension. Specific treatment includes the time of dosing of antihypertensive drugs and selecting the specific class of antihypertensive drugs, such as inhibitors of sympathetic activity or the renin-angiotensin system (RAS). Practically, bedtime dosing of antihypertensive drug, especially calcium channel blocker, alpha-blocker, RAS inhibitors suppress exaggerated morning BP surge without excessive nocturnal hypotension during sleep. These treatments also effective for nocturnal hypertension. On the other hand, specific drug for reducing nocturnal BP is diuretics including thiazide-type diuretics, indapamide, and aldosterone blockers. These drugs are effective for morning hypertension with non-dipper/riser pattern of nocturnal BP. The renal denervation is effective for reducing morning BP and the moving peak morning BP in the combination analysis of the HTN-3 and the HTN-Japan as well as nocturnal BP (Kario, Bakris, et al. Hypertension 2015;66:1130–1137).

The morning BP-guided approach using home BP monitoring is the most promising first step leading to the “anticipation medicine” for the most effective antihypertensive treatment for cardiovascular disease (Kario. Prog Cardiovasc Dis 2016, in press).

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