Differential Effects of Antihypertensive Drug Classes on Home and Office Blood Pressure Variability

Blood pressure (BP) variability provides prognostic information beyond mean BP. However, the class-specific associations of antihypertensive medications with BP variability remain uncertain, and few studies have directly contrasted home and office BP variability within the same patients while accounting for the white-coat effect.

In a multicenter prospective registry, patients with hypertension and adequate measurements (≥ 10 home and ≥ 5 office readings) were analyzed. The primary outcomes were systolic and diastolic average real variability (ARV) of home and office BP. Associations of renin-angiotensin system inhibitors, beta-blockers, dihydropyridine calcium channel blockers (DHP-CCBs), and diuretics with BP variability were estimated using inverse probability of treatment weighting (IPTW) and doubly robust models. The white-coat effect was further adjusted using both a continuous office-home mean difference and a guideline-based white-coat definition. A true-monotherapy subcohort sensitivity analysis and class-by-class interaction tests were additionally performed.

Among 495 participants, home ARV differed minimally by antihypertensive class; a small beta-blocker-associated increase in home systolic BP (SBP)-ARV was attenuated with additional adjustment. In contrast, office BP ARV was higher with DHP-CCBs and diuretics, although the beta-blocker association was weakened after further adjustment. Following white-coat effect adjustment, home BP ARV remained neutral across drug classes, whereas DHP-CCB remained associated with higher office SBP-ARV and diuretics with higher office diastolic BP ARV. DHP-CCBs were also associated with a lower probability of office BP control. Home BP control rates did not differ significantly by antihypertensive class.

In this cross-sectional observational cohort, antihypertensive medication classes showed context-dependent associations with BP variability, which were minimal for home BP but more pronounced for office BP, partially independent of the white-coat effect. Given potential residual confounding by indication, these hypothesis-generating findings warrant prospective confirmation.