BLOOD PRESSURE NATURALLY IS A DYNAMIC PHENOMENON WITH VARIATION ALL ALONG THE DAY SECONDARY TO AUTONOMIC RESPONSES

1. Understated Concepts in Hypertension
Focus on BP Variability
Dr.N.Praveen
Final yr DM PG

2. Outline
• Hypertension and CV Risk: Where Do We Stand?
• Variability of BP and Cardiovascular Risk
• Key Considerations for Variability of BP

3. Hypertension and Cardiovascular Risk
Where Do We Stand?

4. BP Elevation
Multiplication of CV Risk
• BP: Leading risk factor for Global
Burden of Disease (GBD, 2010)
• HT is associated with:
– 69% of first MIs
– 74% of cases of CHD
– 77% of first strokes
– 91% of cases of HF
Global Burden of Disease Study. Lancet 2012;380:2224-60
Adapted from Thom T et al. Circulation. 2006;113:e85–e151.
BP=blood pressure; HTN=hypertension; MI=myocardial infarction;
CHD=coronary heart disease; HF=heart failure.

5. Global burden of premature CVD
Globally, decreasing the prevalence of hypertension accounted for the largest risk reduction,
followed by a reduction in tobacco smoking for men and obesity for women, but these results
varied by region. The impact of meeting all risk factor targets on CVD mortality varied widely by
region and sex.

6. Meta-analysis of 61 prospective, observational studies*
1 million adults
12.7 million person-years
*Epidemiologic studies, not clinical trials of HTN agents.
BP, blood pressure; IHD, ischemic heart disease.
Lewington S et al. Lancet 2002;360:1903-1913.
BP Reduction Is Critical
The Lower, The Better
2 mm Hg
decrease in
mean SBP 10% reduction in
risk of stroke
mortality
7% reduction in
risk of IHD
mortality

7. BENEFIT OF BP CONTROL
10 mm Hg lower systolic BP is associated with
• 50-60% lower risk of stroke death
• 40-50% lower risk of death – CAD
• 50% lower heart failure
GREATER BENEFIT IN OLDER AGES AND
AT HIGHER INITIAL BP READINGS

8. Hypertension in India
Met-analysis of 142 Studies (1950-2013)
• Overall Prevalence: 29.8%
Rural (%) Urban (%)
Prevalence 27.6 33.8
Awareness 25.3 42.0
Treatment 25.1 37.6
Control 10.7 20.2
Anchala R et al. J Hypertens. 2014 Jun;32(6):1170-7.

9. CSI CARDIAC PREVENT STUDY
• 21 states across India.(1,81,000)
• 36% population in hyderabad.(19,846)
• 25% are within the age group 31-45 yrs.
• 60% undiagnosed/unknown of hypertension.
• 42% not under control.
• 13% of deaths in CVD due to hypertension alone.
• MC profession affected is software professional.
• Average salt consumption >9-12g/day (recommended is 2-
3 g/day)
Venkat.S.Ram et al ,CSI PREVENT survey,2015

10. Blood Pressure Measurement
Beyond the Office Horizon
Certain Factors Independently Increase CV Risk,
Beyond Clinical Blood Pressure
BP
Variability
Masked HT
Central BP
and Stiffness

11. Variability of BP
and
Cardiovascular Risk
Prof. Gianfranco Parati, MD

12. What is BP Variability?
• BP normally fluctuates during day, can vary from day-to-day1
• Pronounced fluctuations in BP can occur over short / long-
term
• Episodic Hypertension is common:2
o In TIA patients, 12% had stable HT, 69% had episodic HT
(some SBP readings ≤140 mmHg, some >140 mmHg)
• Self BP monitoring widely encouraged (ESC / JSH) 3
• BPV is difficult to measure in routine clinical practice: no
clearly defined or widely adopted diagnostic definitions
or treatment goals
1. Schillaci et al. Hypertension 2011;58:133-135
2. Rothwell. Lancet 2010;375:938-948.
3. Mancia et al. J Hypertension 2013;31:1281-1357

13. PHYSIOLOGICAL VARIATION IN BLOOD
PRESSURE

15. BP REACTIVITY
• Defined as the response to environmental stressors,usually
quantiated as responses to standardized laboratory stressors.
• Hot reactors –individuals with increased reactivity.
• Difficult to quantitate – reactivity differs from stressor to stressor
and even upon retesting with same stressor.
• Suspected to be predictive of future development of
hypertension and CV risk – studies have not found this to be
true.
Blood pressure variability;how to deal? NR Rau,Medicine Update 2012
Krantz et al ,Pschyol Bulletin 1984;96:435-464

16. BP LABILITY
• Characteristic of human BP.
• No clear definition that differentiates normal from abnormal lability.
• Labile hypertension – widely used – lacks an accepted definition and
is more of a clinical impression rather than a specific diagnosis.
• Patients experience transient but substantial increases in BP.
• Likely due to sympathetic activation.
• BP usually falls without intervention.
• Risk of hypertension in future but no role of pretreatment.

17. Types of BP Variability
Determinants and Prognostic Relevance
Pronounced fluctuations in BP can occur over short- and long-term
observation periods
Parati et al. Nat Rev Cardiol 2013;10:143-155

18. BPV Differs in Extent Between Individuals
Rothwell PM. Lancet 2010;375:938-948
Patient 1 with lower BPV Patient 2 with higher BPV
Weeks
40
60
80
100
120
140
160
180
200
220
Bloodpressure
(mmHg)
1 2 3
SBP
DBP
40
60
80
100
120
140
160
180
200
220
Bloodpressure
(mmHg)
1 2 3
Weeks
Higher
mean BP
overall

19. 24-hr BPV and TOD: Cross-sectional Evidence
Adapted from Parati et al. Nat Rev Cardiol 2013;10:143-155

20. 24-hr BPV and TOD: 7.4 yrs Follow-up
Adapted from Parati et al. Nat Rev Cardiol 2013;10:143-155

21. BP Variability and CV Risk
Hansen TW, et al. Hypertension 2010;55:1049-1057.
Systolic Average Real Variability
Incidence of Mortality and CV Events in 8,938 patients
BPV, blood pressure variability; CV, cardiovascular; NCV, non CV.

22. BP Variability
Hazard Ratio for Stroke
UK TIA
aspirin trial
ASCOT
previous
TIA;
Atenolol
ASCOT
previous
TIA;
Amlodipine
ESPS-1
placebo
group
Dutch TIA
trial
Mean SBP 3.63 1.81 0.94 1.89 2.34
SD SBP
adjusted for
Mean SBP
4.84 4.29 4.39 1.78 3.35
CV SBP
adjusted for
Mean SBP
3.82 3.51 3.25 2.22 3.41
National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 127.
Available at: http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf. Accessed
Apr 23, 2015

23. Definitions of Hypertension
Office and Out-of-office BP Levels (mmHg)
140 135
120
130
90 85
70
80
0
35
70
105
140
175
Clinic Daytime (ABPM /
HBPM)
Nighttime (ABPM) 24-hour (ABPM)
(mmHg)
BP Measurement Category
Systolic BP Diastolic BP
ABPM: Ambulatory BP Monitoring; HBPM: Home BP Monitoring
Mancia et al. J Hypertension 2013;31:1281-1357. Franklin SS et al. Hypertension. 2015;65(1):16-20.

24. WHY / WHERE ARE WE MISSING ?

25. Identifying Hypertension
Categories of Blood Pressure
Masked
Hypertension
(≈ 70% ↑↑ CV risk)
Sustained
Hypertension
Normotension
White-coat
Hypertension
Clinic BP
OutofClinicBP
JSH. Hypertension Research. 2009;32:70-7.

26. Nocturnal Hypertension
Nighttime BP ≥120/70 mmHg (ABPM)
• Normally BP ↓ses by 10-20% at night (Dipping)
• Non-dipping / Reverse Dipping:
✓ ↑ risk of organ damage (brain, heart, kidney)
✓ ↑ CV events and mortality
Range of BP Dipping Class
<0% Reverse Dipping
≥0%, <10% Non-Dipping
≥10%, <20% Dipping (Normal pattern)
≥20% Extreme Dipping
JSH. Hypertension Research. 2009;32:70-7.

27. DIPPERS NON DIPPERS

29. Nocturnal Hypertension
Influencing Factors and Management
Factors Influencing Nighttime Hypertension
↑ Fluid volume Heart failure, renal insufficiency
Sleep disorders Sleep apnoea
Autonomic dysfunction Diabetes, orthostatic hypotension
Neuropsychiatric
disorders
Depression, cognitive decline,
cerebrovascular disease
JSH. Hypertension Research. 2009;32:70-7.

30. Sleep-time BP: prognostic marker of type 2 diabetes and therapeutic
target for prevention
Ramón C. Hermida, Diana E. Ayala , Artemio Mojón José R. Fernández
• We prospectively evaluated 2,656 Individuals without diabetes, 1,292 men and 1,364 women, 50.6 ± 14.3 years of age,
with baseline BP ranging from normotension to hypertension according to ABP criteria. At baseline and annually
(more frequently if hypertension treatment was adjusted based on ABP) thereafter, ABP and physical activity (wrist
actigraphy) were simultaneously monitored for 48 h to accurately derive the awake and asleep BP means.
• Results
During a 5.9-year median follow-up, 190 participants developed type 2 diabetes. The asleep systolic ABP mean was
the most significant predictor of new-onset diabetes in a Cox proportional-hazard model adjusted for age, waist
circumference, glucose, chronic kidney disease (CKD) and hypertension treatment.
Daytime clinic BP and awake or 48 h ABP mean had no predictive value when corrected by the asleep ABP mean.
Analyses of BP changes during follow-up revealed a 30% reduction in the risk of new-onset diabetes per 1-SD
decrease in asleep systolic ABP mean, independent of changes in clinic BP or awake or 48 h ABP means.
• Conclusions/interpretation
Sleep-time BP is a highly significant independent prognostic marker for new-onset diabetes. Alteration in sleep-time
BP regulation seems to precede, rather than follow, the development of new-onset diabetes. Most important, lowering
asleep BP, a novel therapeutic target requiring ABP evaluation, could be a significant method for reducing new-onset
diabetes risk.

31. Sleep-time blood pressure
• value of using blood pressure to predict new-onset diabetes,
prospectively examining 2,656 individuals of varying blood
pressure levels who did not have diabetes at the beginning of
the study.
• After an average of 5.9 years of follow-up, 190 participants had
developed T2 DM.
• This first study suggested to the researchers that lowering
sleep-time blood pressure could be a novel method for
reducing the risk of new-onset diabetes.

32. MESSAGE
• Diabetes risk fell by 57% in patients taking
medication before bed

33. Morning Hypertension(surge)
Early morning BP ≥135/85 mmHg (HBP / ABP)
Factors Influencing Morning Hypertension
Physiological BP surge ↑ Sympathetic, neuroendocrine activities
Associated conditions Stress, OSA, Drinking, Cold, Old age
Inadequate 24-hr control Loss of drug efficacy at night / over 24-hr
Patterns of Morning HT Clinical Outcomes
✓ Extension of nocturnal HT ✓ ↑ Cardiovascular risk
✓ ↑ BP Variability over 24-hr ✓ ↑ Occurrence of events
✓ Morning surge (rapid BP rise) ✓ Target organ damage
JSH. Hypertension Research. 2009;32:70-7.

34. Morning BP Surge
Kario K, et al. J Cardiovasc Pharmacol 2003;42 Suppl 1:S87-S91.
MBP, morning blood pressure.
Patients with sleep-trough surge of >55 mm Hg
were classified in the MBP surge group

35. Central Blood Pressure
Aorta as a Reservoir
Cavalcante JL et al. J Am Coll Cardiol. 2011 Apr 5;57(14):1511-22.

36. Factors Influencing Aortic Stiffness
• Hypertension
• Diabetes mellitus
• Atherosclerosis and Calcification
• Chronic Kidney Disease
• Aortic regurgitation; Valvular heart disease
• Hypertrophic cardiomyopathy
• Connective tissue disorders (Marfans, Ehlers Danlos)

37. Insults Resulting in Increasing
Aortic Stiffness
Cavalcante JL et al. J Am Coll Cardiol. 2011 Apr 5;57(14):1511-22.

38. BP Variability is Related to
Arterial Stiffness
Schillaci G et al. Hypertension. 2012 Aug;60(2):369-77.
AVERAGE REAL VARIABILITY

39. HOW TO TACKLE ?

40. Patients
Discontinue • Self-monitoring of BP
irregular therapy • Self-management by simple patient guidance system
• Establish patient population
• Strategic information
• Comprehensive intervention: Including message,
reminder, BP self-monitoring, telephone follow-up, or
working environment or pharmacy-based projects
Subject Phenomena Recommended improvements
■ Comprehensive BP management focusing on patients and combining doctors and
communities
■ Poor compliance is a global problem
o 1/3rd of patients will discontinue the initial therapy within 6 months after
treatment, and only one half of patients will continue treatment after 1 year
o Self-monitoring of BP is an important means of improving adherence
Mancia et al. J Hypertension 2013;31:1281-1357
2013 ESH / ESC Guidelines:
Self-monitoring of BP: Key Component of BP Management

41. Home BP Monitoring
JSH Recommendations, 2009

42. Is HBPM Equivalent to ABPM?
Measurement
Method
Ambulatory
(ABPM)
Home
(HBPM)
Clinic (Office)
Measurement
Supervision + - / + +
BP Patterns
Daytime;
Nighttime; 24 hr.
Daytime only In clinic only
BP Variability
24 hr. (intraday);
Visit-to-visit
Day-to-day Visit-to-visit
Prediction of
Outcome
Best; nighttime
HT crucial
Superior to Clinic
BPM
Standard
measure
Guidance to
Drug treatment
Most complete;
24 hr. control
Limited; better
than Clinic BPM
Limited and poor
Improving
Compliance
Maybe helpful Best evidence Minor influence
O'Brien E et al. J Hypertens. 2013 Sep;31(9):1731-68.

43. ABPM Recommended in High Risk Groups
✓ Ongoing antihypertensive treatment
✓ High-normal BP (130-139 / 85-89 mmHg)
✓ Smoking / DM / Obesity / Metabolic syndrome / CVD
✓ ↑sed drinking / stress / physical activity / heart rate
✓ Abnormal orthostatic changes in the BP
✓ Organ damage (LVH, ↑ carotid intima-media thickness)
Clinical Suspicion is Essential in these high-risk patients
JSH. Hypertension Research. 2009;32:70-7.

44. Therapeutic Considerations
for
Variability of BP

45. Guidelines on BPV
• NICE 20111
– Whatever the underlying mechanisms, SBP variability appears to be an
important independent predictor of clinical outcomes
– BPV most effectively reduced by CCBs, closely followed by thiazide-type
diuretics. Beta-blockers were the least effective and may actually
increase blood pressure variability.
• ESC/ESH guidelines 20132
– Consideration should be given to the evidence that visit-to-visit BPV may
be a determinant of CV risk, independently of the mean BP levels
achieved during long-term treatment
– CV protection may be greater in patients with consistent BP control
1. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 127. Available at: http://www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf. 2.
Mancia G, et al. Eur Heart J 2013;34:2159-2219.
“Updated guidance recommends the best available evidence-based
treatment options to suppress BPV in people with hypertension”

46. TRIAL EVIDENCE

47. CV Outcomes Relate to BPV
and Antihypertensive Treatment
ASCOT-BPLA Trial1,3,4
▪ Lower risk of stroke with amlodipine vs
atenolol
HR = 0.78 (0.67 ‒ 0.90)
▪ Partly attenuated by adjusting for
mean systolic BP
HR = 0.84 (0.72 ‒ 0.98)
▪ Abolished by adjusting for
within-individual systolic BPV
HR = 0.99 (0.85 ‒ 1.16)
▪ Reduced daytime systolic BPV in
amlodipine group partly accounted for
reduced risk of CV events, but reduced
visit-to-visit clinic systolic BPV had a
greater effect
MRC Trial1,2
▪ Temporal trends in BPV with atenolol
correlated with trends in risk of stroke
▪ Risk of stroke higher with atenolol vs
placebo over the first 2 years when
systolic BPV was higher despite lower
mean systolic BP
HR = 1.31 (0.81 ‒ 2.10)
▪ After 2 years when systolic BPV no
longer differed from placebo, but
mean systolic BP was still reduced,
the risk of stroke with atenolol was
reduced
HR = 0.62 (0.40 ‒ 0.94)
1. Rothwell et al. Lancet Neurol 2010;9:469-4801
2. MRC Working Party. BMJ 1992;304:404-412
3. Dahlof et al. Lancet 2005;366:895-906
4. Poulter et al. Lancet 2005;366:907-913

49. ASCOT BPLA
Study Design and Treatment Algorithm
• Age 40 - 79 yrs with untreated / treated HT
• At least 3 additional CV risk factors (male sex, smoker, age 55 years, LVH, ischemic
ECG abnormalities, T2DM, PVD, cerebrovascular disease, microalbuminuria or
proteinuria, Total : HDL cholesterol ratio 6, family history)
• Total patients 19,257; median follow-up 5.5 yrs (106,153 pt-yrs of observation)

50. ASCOT BPLA
BP Reduction over Follow-up

51. Amlodipine-Based Regimen Better for
Total CV End-points and Procedures
In All Patient Subgroups

52. Benefits Beyond BP Control?
Difference in SBP between treatment groups
• 2.7 mm Hg (average, throughout ASCOT BPLA)
Expected to generate a difference in outcomes of:
• 4 - 8% in coronary events
• 11 - 14% in strokes
Observed Difference in Outcomes is Greater than
Anticipated with BP Lowering Alone

53. SPRINT trial -RESULTS
• show a 12% reduction in the cardiovascular outcome
• 25% reduction in allcause mortality
• the full results are not yet available
• halted early (September 2015)
• clinical implications of this trial have not been determined

54. BP Variability and Stroke Risk
Effect of Drug Classes on SBP Variability
Meta-analysis of 389 trials; ≈1 year of follow-up
Adapted from: Webb AJ et al. Lancet. 2010 Mar 13;375(9718):906-15.
↓ BP Variability with drug class ≡ ↓ Stroke Risk, independent of BP

55. Conduit Artery Function Evaluation (CAFE)
Sub-study of ASCOT TRIAL

56. HEAD TO HEAD COMPARISON OF
AMLODIPINE WITH OTHER
ANTIHYPERTENSIVES EFFECT ON BPV

57. Improved Long-term BPV with
Amlodipine vs Other Antihypertensives
Wang JG, et al. J Am Soc Hypertens 2014. doi: 10.1016/j.jash.2014.02.004.
ACEI, angiotensin-converting enzyme inhibitor; BPV, blood pressure variability; CI, confidence interview; SD, standard deviation.
SD-based BPV analysis (mm Hg) in individual studies
and from a meta-analysis

58. Amlodipine vs Nifedipine GITS
Effect on MBP Surge
• Open-label, controlled crossover study
• 40 patients with mild to moderate essential hypertension, receive amlodipine (5
mg/day) or nifedipine GITS (30 mg/day) for 12 weeks
• Evaluated reduction in ABPM with amlodipine and nifedipine GITS
Ferrucci A, et al. Clin. Drug Invest 1997;13(Suppl 1):67-72.
ABPM, Ambulatory BP monitoring; BP, blood pressure; BPV, BP variability; Gits, gastrointestinal therapeutic system; MBP, morning BP.

59. Changes in SBP with Amlodipine and Cilnidipine
-14
-16
-12
-14
-11.
-13.
-8.2
-9.3
-20.
-16.
-12.
-8.
-4.
0.
24-hr SBP Daytime SBP Nighttime SBP Morning SBP
ReductioninSBP(mmHg)
24-hour ABPM Parameters
Amlodipine Cilnidipine
Doses of Drugs Used in Study:
Amlodipine: 2.5 to 5 mg OD (Less - than Maximum Anti-HT Dose)
Cilnidipine: 10 to 20 mg OD (Maximum Anti-HT Dose)
BP Reductions from baseline
were significant in both groups,
nonsignificant between groups
Hoshide S et al. Hypertens
Res. 2005 Dec;28(12):1003-8.

60. Changes in BP with Amlodipine and Cilnidipine
Indian Evidence
-14
-8
-12
-6
-14
-5
-12
-8 -8
-4
-10
-4
-18
-14
-11
-7
-4
0
Daytime SBP Daytime DBP Nighttime
SBP
Nighttime
DBP
Morning SBP Morning DBP
ReductioninSBP(mmHg)
Reduction in BP
Amlodipine Cilnidipine
BP Reductions from baseline
were significant in both groups
Zaman ZA et al. Int J Basic Clin
Pharmacol 2013;2:160-4.

61. In Diabetic Hypertensives with Maximal RAS Blockade,
Nebivolol Offered No Significant Advantage Over Metoprolol for Aortic BP

62. ALLHAT Trial Follow-up
Chlorthalidone, Amlodipine, Lisinopril
Prevention of Fatal / Non-fatal Stroke
Yamal JM et al. J Am Soc Hypertens. 2014;8(11):808–819.
During trial, diuretic and CCB
were superior to ACE-I

63. ALLHAT Study
Unexplained Observations
ALLHAT Investigators. Curr Hypertens Rep. 2003 Aug;5(4):293-4.

64. Parameter Outcome
BP Reduction Equivalent Reduction in SBP and DBP, and
control of BP through study period
Proteinuria Reduction Significantly Superior with
Hydrochlorothiazide, relative to Amlodipine
Delay in Progression of
CKD
Significantly Superior with Amlodipine,
relative to Hydrochlorothiazide
ACCOMPLISH Trial
2nd Add-on Antihypertensive Class
ACCOMPLISH Trial:
Effect of Drug Combinations on CKD Outcomes
Study Groups:
• Benazepril plus Amlodipine (5,744 patients)
• Benazepril plus Hydrochlorothiazide (5,762 patients)
Mean follow-up: 2.9 years
Bakris GL et al. Lancet. 2010;375(9721):1173-81.

65. ACCOMPLISH Trial
Delay of CKD Progression
Significantly Superior With Amlodipine
Bakris GL et al. Lancet. 2010;375(9721):1173-81.

66. N Engl J Med 2008;359:2417-28
ACCOMPLISH Trial
Cardiovascular Events

67. However, the reduction in BPV by amlodipine was significantly associated with the reduction in
BP (P0.006) and the reduction in HR variability (P0.02), whereas the corresponding reduction by
indapamide sustained release was only associated with the reduction in HR variability at night
(P0.004). I
In summary, 3-month amlodipine or indapamide sustained release treatment was associated with
a significant reduction in BPV, and the mechanism of those reductions was
possibly attributable to lowering BP or ameliorating the autonomic
nervous system regulation or both. The combination of the 2 agents might help to
optimize such properties.

68. PLEIOTROPIC EFFECTS OF AMLODIPINE

69. Benefits Beyond BP Control
Amlodipine’s Chemical Structure and Pleiotropic Effects
Anti-atherogenesis; Plaque stabilization
• ↓ Platelet aggregation (↓ p-selectin levels)
• Antioxidant action
• ↓ smooth muscle cell proliferation
• Remodeling of atherosclerotic membrane structure
• ↑ endothelial nitric oxide production
Mason RP et al. Atherosclerosis. 2002; 165:191-199. Tiryaki O et al. Clin Exp Hypertens. 2012;34(2):145-52.
Umemoto S et al. Hypertens Res. 2006 Mar;29(3):179-86. Pitt B et al. Circulation 2000;102:1503-10.
Jorgensen B et al. J Am Coll Cardiol 2000;35:592-9. Nissen SE et al. JAMA. 2004 Nov 10;292(18):2217-25.
Meta-analysis (87,257 patients): Amlodipine and CV Outcomes
“Amlodipine reduced the risk of total cardiovascular events as well
as all-cause mortality compared with non-CCB-based regimens,
indicating its benefit for high-risk cardiac patients.”
Lee SA et al. Korean J Intern Med. 2014 May;29(3):315-24.

71. SYNERGISM

72. Synergism Between
RAS Inhibitors and Amlodipine
• CCBs are usually combined with an ACEI or an ARB that target the renin-
angiotensin system1
– ACEI or ARB is favorable since they can be used at higher doses to increase efficacy
without compromising tolerability2
• ARB-based combinations may be more desirable than ACEI-based combinations
due to their superior tolerability3
• The use of CCB/ARB combinations has been shown to be ‘capable of most
effectively reducing even severe hypertension’3
1. Mancia G, et al. Eur Heart J 2013;34:2159-2219. 2. Kreutz R. Vasc Health Risk Manag 2011;7:183-192. 3. Erdine S. Ther Adv Cardiovasc Dis 2012;6:31-44.
Anchored drug to
target BPV control:
Amlodipine
ARB?
ACEI?
+ OR
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BPV, BP variability; CCB, calcium channel blocker.

73. Antihypertensive Drugs and Combinations
Control of BP Variability
-1.06
-0.05
-1.37
0.45 0.47
0.24
-0.82
-0.16
-0.54 -0.59
0.27
0.05
-1.5
-0.5
0.5
Telmisartan /
Amlodipine
combination
(all doses)
Telmisartan
80mg
Amlodipine
10mg
Valsartan
160mg
Ramipril
10mg
Placebo
MeanReductioninBPVariability
(SD)
24-hour BPV Daytime BPV Nighttime BPV
SD: Standard Deviation
N = 10 studiesParati G et al. J Hypertens. 2014 Jun;32(6):1326-33.

74. Summary
• BPV control should be considered as a goal to guide choice
of initial antihypertensive treatments
• MBP should be monitored as it is a potential marker for
BPV
• CCBs are the antihypertensive class of choice for BPV
control
• Among CCBs, amlodipine as initial monotherapy has
proven efficacy in reducing BPV and MBP surge
• Synergism between long acting CCBs and ARBs