Calcium Channel Blockers Linked to Lower Blood Pressure Variability

A target trial emulation pooling individual-participant data from the ACCORD-BP and SPRINT trials found that calcium channel blocker (CCB) based antihypertensive regimens were associated with lower visit-to-visit systolic blood pressure variability than renin-angiotensin system (RAS) inhibitor based regimens, despite similar achieved mean blood pressure. The difference was not accompanied by a difference in major adverse cardiovascular events (MACE) across treatment strategies.¹

Yue Qiao, of China, presented the findings at the World Stroke Congress (WSC 2026), held October 21-23, 2026, in Seoul, Republic of Korea. For context, a target trial emulation is an analytic method designed to approximate the results of a hypothetical randomized trial using existing data, in this case individual-participant data pooled from 2 previously completed randomized trials rather than new clinical trial enrollment.

Researchers used propensity score matching to compare 3 first-line antihypertensive drug classes, used as monotherapy or in combination: RAS inhibitors, calcium channel blockers, and diuretics. The primary outcome was visit-to-visit systolic blood pressure variability (BPV), measured using variation independent of the mean (VIM); MACE and its individual components were assessed as secondary outcomes.

Among 5779 eligible participants (mean age, 65.9 years; 39.7% female) drawn from ACCORD-BP (77 sites in North America) and SPRINT (102 sites in the United States), 2754 were included in matched analyses, with a median follow-up of 3.5 years. CCB-based regimens were consistently associated with lower systolic BPV than RAS inhibitor-based regimens, both as monotherapy (β=-1.341; 95% CI, -1.930 to -0.752) and in combination therapy (β=-1.299; 95% CI, -1.852 to -0.747; both P <.001), despite comparable achieved mean blood pressure between groups. RAS inhibitor-based and diuretic-based regimens showed similar BPV profiles.¹

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A total of 215 MACE events (3.7%) occurred across the matched cohort, with no significant differences in MACE rates across the antihypertensive strategies compared (all P >.05). The investigators concluded that among high-risk hypertensive patients receiving target-driven blood pressure management, CCB-based regimens were associated with lower visit-to-visit systolic BPV than RAS inhibitor-based or diuretic-based regimens, but that this difference was not accompanied by detectable differences in cardiovascular outcomes.

ACCORD-BP was a component of the larger ACCORD trial, which randomized 4733 participants with type 2 diabetes to a systolic blood pressure target of less than 120 mm Hg or less than 140 mm Hg. Over a mean follow-up of 4.7 years, the primary composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke did not differ significantly between groups (1.9% vs 2.1% per year; P =.20), though stroke occurred less frequently with the intensive target (0.3% vs 0.5% per year; P =.01). Serious adverse events, hypokalemia, and elevated serum creatinine were all more common with intensive treatment.²

SPRINT randomized more than 9300 adults aged 50 years and older with hypertension and elevated cardiovascular risk, but without diabetes, to the same 2 systolic blood pressure targets. The trial was stopped about 1 year early after an interim analysis found that intensive treatment reduced its composite cardiovascular outcome by about 25% and all-cause mortality by about 27%, compared with standard treatment; intensive treatment was also associated with higher rates of hypotension, syncope, and acute kidney injury.³

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REFERENCES
1. Qiao Y, et al. Visit-to-visit blood pressure variability and cardiovascular outcomes across antihypertensive regimens: a target trial emulation study. Presented at: World Stroke Congress 2026 (WSC 2026); October 21-23, 2026; Seoul, Republic of Korea.
2. ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-1585.
3. SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103-2116.