Proposal of RAS-diuretic vs. RAS-calcium antagonist strategies in high-risk hypertension: insight from the 24-hour ambulatory blood pressure profile and central pressure

I here propose an individualized renin angiotensin system (RAS) inhibitor-based combination therapy with calcium-channel blockers (CCBs) or with diuretics, based on the 24-hr ambulatory blood pressure (BP) profiles and central pressure in relation to the target organ damage in high-risk hypertensive patients. For high-risk patients with increased circulating volume, such as that caused by chronic kidney disease (CKD) or congestive heart failure (CHF), who are likely to exhibit a non-dipper/riser pattern of nocturnal BP fall, diuretics are recommended in combination with a RAS inhibitor to reduce nocturnal BP preferentially. For high-risk patients with arterial diseases such as cardiovascular disease and increased arterial stiffness, who are likely to exhibit exaggerated BP variability, such as morning BP surge and day-to-day BP variability, a CCB is recommended for use in combination with a RAS inhibitor to reduce BP variability and central BP. In particular, bedtime dosing of a RAS inhibitor targeting sleep-early morning activation of RAS may be particularly effective for cardiorenal protection.