Dipping Pattern of Nocturnal Blood Pressure in Patients with Hypertension

Robert H Fagard


Expert Rev Cardiovasc Ther. 2009;7(6):599-605. 

In This Article

Abstract and Introduction


Four dipping categories have been described, based on the night–day blood pressure ratio from 24-h ambulatory blood pressure recordings: extreme dippers (night–day blood pressure ratio ≤ 0.8), dippers (0.8 < ratio ≤ 0.9), nondippers (0.9 < ratio ≤ 1.0) and reverse dippers (ratio > 1.0). The main purpose of this article is to discuss the prognostic significance of these four dipping categories in hypertension, mainly based on a large meta-analysis of individual patient data. In hypertensive patients without cardiovascular disease at baseline and with statistical adjustment for confounders and 24-h blood pressure, mortality was lower in extreme dippers than in dippers, whereas the incidence of cardiovascular events was higher in reverse dippers. The worst prognosis for reverse dippers was also observed in hypertensive patients with major cardiovascular disease at baseline. Higher incidences of cardiovascular events and mortality were also found in reverse dippers in comparison with dippers in a comprehensive meta-analysis of population-based studies but outcome was not significantly different between extreme dippers and dippers. Based on these findings, there appears to be little doubt that reverse dipping is associated with a worse prognosis. Some studies suggest that prognosis is similar in nondippers and extreme dippers in comparison with dippers, but other studies suggest a somewhat worse prognosis in nondippers, or a better or worse prognosis in extreme dippers.


Blood pressure is, on average, lower during the night (sleep) than during the day (waking hours) by approximately 10–20%. However, blood pressure decreases by more than 20% in some patients with hypertension or is lowered by less than 10% in others, and some patients may even have a rise in blood pressure during the night in comparison with daytime blood pressure. Hence, patients are categorized, usually based on systolic blood pressure, as extreme dippers (night–day blood pressure ratio ≤ 0.8), dippers (0.8 < ratio ≤ 0.9), nondippers (0.9 < ratio ≤ 1.0) and reverse dippers or risers (ratio > 1.0). In this review we will report on the prognostic significance of these four dipping categories, with emphasis on the findings in patients with hypertension.