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EASD: No Microvascular Benefit with Intense BP, Glucose Control

Sep 23, 2011

Aggressively lowering blood pressure and blood glucose together won’t provide any microvascular benefits to type 2 diabetes patients, researchers said….

Patrick O’Connor, MD, of HealthPartners Research Foundation in Minneapolis, reported that, in an analysis of data from the ACCORD trial, neither intense glycemic management nor intense blood pressure control reduced the risk of a composite of microvascular outcomes.

There was no interaction between the two treatments on that outcome; nor did the combination have significant effects on a host of individual microvascular outcomes including microalbuminuria, macroalbuminuria, or renal failure.

O’Connor stated that, “None of the prespecified outcomes were further significantly reduced in those intensively treated for both glycemia and blood pressure compared with either regimen alone, signifying the lack of an additional beneficial effect from combined intensive management.”

Some work has shown that lowering blood pressure and blood glucose individually diminish some microvascular complications of type 2 diabetes, but there are few data on the combined effects of these interventions.

O’Connor and colleagues analyzed data from the ACCORD blood pressure trial, totaling 4,733 adults with type 2 diabetes and hypertension.

Patients were randomized to either intensive blood pressure control, with a systolic target of 120 mm Hg or less, or standard control of 140 mm Hg or less. They were also separately randomized to either intense blood glucose management (HbA1c under 6%) or a standard target (HbA1c 7% to 7.9%).

Prespecified outcomes included one composite microvascular outcome measure — dialysis or renal transplantation, high serum creatinine, and retinal photocoagulation or virectomy — and nine single measures of kidney, eye, or peripheral nerve function.

The researchers looked at two-way interactions between glycemia and blood pressure treatment.

They found that over a mean of 4.7 years, the primary microvascular outcome occurred in 11.4% of those in the intensive blood pressure arm and 10.9% of those in the standard blood pressure arm.

Overall, neither intensive intervention had any effect on whether patients reached the primary composite outcome of microvascular disease. Nor were there many significant effects on the nine individual markers of microvascular disease, except those on intensive blood pressure management were less likely to develop microalbuminuria (HR 0.84, P=0.02).

Moreover, those on intensive glycemic management had a reduced risk of three outcomes: macroalbuminuria (HR 0.68, P=0.002), loss of vibratory sensation (HR 0.89, P=0.02), and loss of pressure sensation (HR 0.76, P=0.001).

O’Connor and colleagues found no significant interactions between intensive blood pressure and glycemic management for any of the outcomes. O’Connor stated that, “The benefits seen on the one hand with blood pressure control, or on the other hand with glucose control, were not amplified by an interaction.”

In regression analyses, assignment to either intensive program was not a predictor of renal failure as defined by initiation of dialysis or end-stage renal disease. The only significant predictors were serum creatinine and albuminuria at baseline. O’Connor noted, however, that the low proportions of patients who achieved the primary endpoint could have reduced the power of the analysis.

“The short duration of the study doesn’t permit for the full assessment of the impact of the interventions,” he said.

Practice Pearls:

  • Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
  • Explain that the combination of intensive blood pressure and glucose management did not protect against microvascular endpoint measures compared with standard care in a study of type 2 diabetics.
  • Note that the combination of intensive therapies also did not affect single markers of microvascular disease compared with either therapy alone.

O’Connor PJ, et al “Microvascular effects of intensive blood pressure control and its relation to glycemic control in the ACCORD blood pressure trial” EASD 2011; Abstract OP07-40.