Understated Concepts in Hypertension Focus on BP Variability Dr.N.Praveen Final yr DM PG
Understated Concepts in Hypertension
Focus on BP Variability
Dr.N.PraveenFinal yr DM PG
Outline
• Hypertension and CV Risk: Where Do We Stand?
• Variability of BP and Cardiovascular Risk
• Key Considerations for Variability of BP
Hypertension and Cardiovascular Risk
Where Do We Stand?
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;380:2224-60Adapted 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.
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.
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 CriticalThe Lower, The Better
2 mm Hg decrease in mean SBP 10% reduction in
risk of stroke mortality
7% reduction in risk of IHD mortality
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
Hypertension in IndiaMet-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.
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
Blood Pressure MeasurementBeyond the Office Horizon
Certain Factors Independently Increase CV Risk, Beyond Clinical Blood Pressure
BP Variability
Masked HTCentral BP and Stiffness
Variability of BP and
Cardiovascular Risk
Prof. Gianfranco Parati, MD
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;58:133-1352. Rothwell. Lancet 2010;375:938-948.3. Mancia et al. J Hypertension 2013;31:1281-1357
PHYSIOLOGICAL VARIATION IN BLOOD PRESSURE
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 2012Krantz et al ,Pschyol Bulletin 1984;96:435-464
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.
Types of BP VariabilityDeterminants 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
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
Blo
od p
ress
ure
(mm
Hg)
1 2 3
SBP
DBP
40
60
80
100
120
140
160
180
200
220
Blo
od p
ress
ure
(mm
Hg)
1 2 3Weeks
Higher mean BPoverall
24-hr BPV and TOD: Cross-sectional Evidence
Adapted from Parati et al. Nat Rev Cardiol 2013;10:143-155
24-hr BPV and TOD: 7.4 yrs Follow-up
Adapted from Parati et al. Nat Rev Cardiol 2013;10:143-155
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.
BP VariabilityHazard 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
Definitions of Hypertension Office and Out-of-office BP Levels (mmHg)
Clinic Daytime (ABPM / HBPM)
Nighttime (ABPM)
24-hour (ABPM)0
35
70
105
140
175
140 135120
130
90 8570
80
Systolic BP Diastolic BP
BP Measurement Category
Blo
od P
ress
ure
(mm
Hg)
ABPM: Ambulatory BP Monitoring; HBPM: Home BP MonitoringMancia et al. J Hypertension 2013;31:1281-1357. Franklin SS et al. Hypertension. 2015;65(1):16-20.
WHY / WHERE ARE WE MISSING ?
Identifying HypertensionCategories of Blood Pressure
Masked Hypertension
(≈ 70% ↑↑ CV risk)
Sustained Hypertension
Normotension White-coat Hypertension
Clinic BP
Out
of C
linic
BP
JSH. Hypertension Research. 2009;32:70-7.
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.
DIPPERS NON DIPPERS
Nocturnal HypertensionInfluencing 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.
Sleep-time BP: prognostic marker of type 2 diabetes and therapeutic target for preventionRamón 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.
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.
MESSAGE
• Diabetes risk fell by 57% in patients taking
medication before bed
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.
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
Central Blood PressureAorta as a Reservoir
Cavalcante JL et al. J Am Coll Cardiol. 2011 Apr 5;57(14):1511-22.
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)
Insults Resulting in Increasing Aortic Stiffness
Cavalcante JL et al. J Am Coll Cardiol. 2011 Apr 5;57(14):1511-22.
BP Variability is Related to Arterial Stiffness
Schillaci G et al. Hypertension. 2012 Aug;60(2):369-77.
AVERAGE REAL VARIABILITY
HOW TO TACKLE ?
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 problemo 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 yearo 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
Home BP MonitoringJSH Recommendations, 2009
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.
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.
Therapeutic Considerationsfor
Variability of BP
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”
TRIAL EVIDENCE
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 BPHR = 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;9:469-48012. MRC Working Party. BMJ 1992;304:404-4123. Dahlof et al. Lancet 2005;366:895-9064. Poulter et al. Lancet 2005;366:907-913
ASCOT BPLAStudy 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)
ASCOT BPLABP Reduction over Follow-up
Amlodipine-Based Regimen Better for Total CV End-points and Procedures
In All Patient Subgroups
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
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
BP Variability and Stroke RiskEffect 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
Conduit Artery Function Evaluation (CAFE) Sub-study of ASCOT TRIAL
HEAD TO HEAD COMPARISON OF AMLODIPINE WITH OTHER
ANTIHYPERTENSIVES EFFECT ON BPV
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
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.
Changes in SBP with Amlodipine and Cilnidipine
24-hr SBP Daytime SBP Nighttime SBP Morning SBP-20
-16
-12
-8
-4
0
-14-16
-12-14
-11-13
-8.2-9.3
Amlodipine Cilnidipine24-hour ABPM Parameters
Redu
ction
in S
BP (m
m H
g)
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.
Changes in BP with Amlodipine and CilnidipineIndian Evidence
Daytime SBP Daytime DBP Nighttime SBP
Nighttime DBP
Morning SBP Morning DBP-18
-14
-11
-7
-4
0
-14
-8
-12
-6
-14
-5
-12
-8 -8
-4
-10
-4
Reduction in BP
Amlodipine Cilnidipine
Redu
ction
in S
BP (m
m H
g)
BP Reductions from baseline were significant in both groups
Zaman ZA et al. Int J Basic Clin Pharmacol 2013;2:160-4.
In Diabetic Hypertensives with Maximal RAS Blockade,Nebivolol Offered No Significant Advantage Over Metoprolol for Aortic BP
ALLHAT Trial Follow-upChlorthalidone, 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
ALLHAT StudyUnexplained Observations
ALLHAT Investigators. Curr Hypertens Rep. 2003 Aug;5(4):293-4.
Parameter OutcomeBP 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 Trial2nd 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.
ACCOMPLISH TrialDelay of CKD Progression
Significantly Superior With Amlodipine
Bakris GL et al. Lancet. 2010;375(9721):1173-81.
N Engl J Med 2008;359:2417-28
ACCOMPLISH TrialCardiovascular Events
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). IIn 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.
PLEIOTROPIC EFFECTS OF AMLODIPINE
Benefits Beyond BP ControlAmlodipine’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.
SYNERGISM
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.
Antihypertensive Drugs and CombinationsControl of BP Variability
Telmisartan / Amlodipine combination
(all doses)
Telmisartan 80mg
Amlodipine 10mg
Valsartan 160mg
Ramipril 10mg
Placebo-1.5
-0.5
0.5
-1.06
-0.05
-1.37
0.45 0.47
0.24
-0.82
-0.16
-0.54 -0.59
0.27
0.05
24-hour BPV Daytime BPV Nighttime BPV
Mea
n R
educ
tion
in B
P V
aria
bilit
y (S
D)
SD: Standard DeviationN = 10 studiesParati G et al. J Hypertens. 2014 Jun;32(6):1326-33.
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
Thank You