Summary: In an analysis of the ASCOT trial, higher visit-to-visit blood pressure variability was strongly associated with worse cardiovascular and renal outcomes, especially in patients with diabetes, and an amlodipine-based regimen reduced events partly by lowering that variability.
PICO Summary
| Element | Detail |
|---|---|
| Population | 18,528 ASCOT participants (4,910 with diabetes, 13,618 without) followed about 5 years; analysis of randomised-trial data, UK. |
| Intervention | Amlodipine-based (long-acting calcium-channel-blocker) regimen, examined for its effect on systolic blood pressure variability. |
| Comparison | Atenolol-based regimen, and groups stratified by level of blood pressure variability. |
| Outcome | In diabetes, high variability was associated with higher risks of nonfatal MI and fatal CHD (HR 1.76), stroke (HR 2.41), total cardiovascular events (HR 2.39), renal impairment (HR 1.69), and mortality (HR 1.52); associations persisted after adjustment. Even with well-controlled systolic pressure (≤135 mmHg), high variability carried residual risk. The amlodipine-based regimen reduced stroke (HR 0.74) and total cardiovascular events (HR 0.81) versus atenolol, partly attributable to reduced variability. |
Amlodipine- vs atenolol-based regimen (ASCOT)
RCT analysis · hypertension · ~5 years
An amlodipine-based regimen significantly cut stroke and total cardiovascular events versus atenolol, an effect partly attributable to reduced blood pressure variability.
Expert Commentary
This is a substantial and clinically thought-provoking analysis from a major hypertension trial, and its scale lends weight to a concept that is increasingly hard to ignore, that how much blood pressure swings between visits matters independently of the average. The diabetic findings are striking, with high variability associated with roughly doubled stroke and total cardiovascular risk and meaningful excess renal and mortality risk, and the persistence of residual risk even when mean pressure was well controlled is the practically important message: a good average does not guarantee a good prognosis if readings are erratic. The mechanistic thread, that long-acting calcium-channel blockade smooths the profile and that part of amlodipine’s benefit over atenolol was mediated through reduced variability, is biologically coherent. The essential caveat, which the analysis itself implies, is that this is observational and post hoc within a trial, so it demonstrates strong association and mediation rather than proof that targeting variability changes outcomes. Can I use this with my patients? Yes, as a prompt rather than a protocol. For diabetic patients with erratic readings, it reinforces favouring agents that give smooth 24-hour control, such as long-acting calcium-channel blockers, and paying attention to consistency across visits, while formal variability targets await prospective trials.
References
Rostamian S, Kaura A, Ariti C, et al. The impact of blood pressure variability on cardiovascular and renal outcomes in patients with and without diabetes: insights from the Anglo-Scandinavian Cardiac Outcomes Trial. J Hypertens. 2025;43(12):2033–2041. doi:10.1097/HJH.0000000000004153