Blood Pressure Variability and Outcomes Across Antihypertensive Regimens.

backgroundBlood pressure (BP) variability (BPV) is associated with cardiovascular risk beyond mean BP. Whether first-line antihypertensive regimens differentially affect BPV and cardiovascular outcomes remains uncertain.

methodsWe conducted a target trial emulation using pooled individual participant data from 2 randomized trials: ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure) and SPRINT (Systolic Blood Pressure Intervention Trial). Propensity score matching was used for pairwise comparisons of RAS (renin-angiotensin system) inhibitors, calcium channel blockers (CCBs), and diuretics, as monotherapy or in combination. Follow-up was initiated at a predefined baseline medication assessment. The primary outcome was visit-to-visit systolic BPV, assessed using variation independent of the mean. Secondary outcomes included major adverse cardiovascular events and its individual components.

resultsThe final cohort included 5779 participants (median of 12 BP measurements and median follow-up of 3.5 years), among whom 2754 were included in the matched analysis. CCB-based regimens were consistently associated with significantly lower systolic BPV compared with both RAS inhibitor-based and diuretic-based regimens. This association was consistent across monotherapy (CCB versus RAS: β=-1.341 [95% CI, -1.930 to -0.752];

conclusionsAmong high-risk hypertensive patients receiving target-driven BP management, CCB-based regimens were associated with lower visit-to-visit systolic BPV compared with RAS inhibitor-based and diuretic-based regimens. However, these differences were not accompanied by detectable differences in cardiovascular outcomes.