AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Differential Prognostic Impact of Nighttime Blood Pressure According to Cardiovascular-Kidney-Metabolic Stage
By Fukuda T, Fujiwara T, Hoshide S et al.
Background: Nighttime blood pressure (BP) has been shown to be a stronger predictor of cardiovascular disease (CVD) events than office or daytime BP. The recently proposed Cardiovascular-Kidney-Metabolic (CKM) syndrome framework integrates metabolic, renal, and cardiovascular risk, but the prognostic significance of nighttime BP across CKM stages remains unclear. Hypothesis: We hypothesized that the association between nighttime BP and CVD risk would be stronger in advanced CKM stages. Methods: We used data from the J-HOP (Japan Morning Surge-Home Blood Pressure) Nocturnal BP Study, which recruited 2,745 high-cardiovascular-risk participants (mean [SD] age, 63.6 [10.4] years; 48.7% men; 82.7% on antihypertensive medications). Nighttime BP was measured at 2:00, 3:00, and 4:00 AM for 14 consecutive days using a validated, automated home BP device (mean [SD] number of measurements, 17.1 [13.5]). Participants were categorized according to nighttime systolic BP (SBP): <120, 120-129, 130-139, and ≥140 mmHg. CKM stages were grouped as early (stages 0-2) and advanced (stages 3-4). Associations between nighttime SBP and incident CVD events (coronary artery disease, stroke, and heart failure) were evaluated using Cox proportional hazards models. Risk reclassification was evaluated using category-free net reclassification improvement (NRI). Results: During a mean follow-up of 4.5±2.4 years, 185 CVD events occurred. A trend toward interaction between nighttime SBP and CKM stage was observed (p for interaction = 0.087). Among participants with advanced CKM stages (n=1,515), each 10-mmHg increase in nighttime SBP was significantly associated with a higher risk of CVD (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.15-1.40), and risk increased progressively across SBP categories (Figure). In contrast, no significant association was observed in participants with early CKM stages (n=1,230) (HR, 0.99; 95% CI, 0.80-1.23). In participants with advanced CKM stages, both daytime and nighttime SBP independently predicted CVD risk. However, adding nighttime SBP to a daytime SBP model significantly improved risk reclassification (NRI, 0.279; 95% CI, 0.054-0.496), whereas adding daytime SBP to a nighttime SBP model did not (NRI, 0.187; 95% CI, –0.025 to 0.407). Conclusions: The prognostic impact of nighttime BP differs according to CKM stage. Elevated nighttime BP is particularly associated with increased CVD risk in individuals with advanced CKM stages and may provide incremental prognostic information beyond daytime BP, suggesting that nighttime BP assessment may be especially important for risk stratification in this high-risk population.