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Should Lower Blood Pressure Targets for Diabetic Patients be Adopted?

ACCORD trial suggests lowering blood-pressure to a target of <120 mm Hg systolic.

According to the American Diabetes Association, hypertension is affecting about 20-60% of patients with diabetes. Right now the target blood pressure for diabetic patients is less than 140/90 mmHg, recommended by the American Heart Association. Hypertension increases the risk of both macrovascular and microvascular complications in diabetic patients. Many clinical trials provided evidence to support the aggressive treatment of hypertension in diabetic patients.

In the new SPRINT trial, new results showed the benefits of intensive blood-pressure aimed at a target of <120 mm Hg systolic for patients at high cardiovascular risk. Dr. William C. Cushman, ACCORD lead investigator, suggested this result should also be extended to diabetic patients.

This conclusion is a secondary analysis in the ACCORD trial. In the trial, 3,957 patients were followed for an additional 54 to 60 months. Dr. Cushman pointed out the result of the interaction between blood pressure and glycemia interventions was significant, with p value 0.037, and it also showed evidence of benefit in participants with standard glycemia therapy. He suggested these long-term results should be considered important when viewing the SPRINT results.

Now there is no level-A evidence to support treating diabetic patients to a target of 120 mm Hg. However, when healthcare providers make a decision for diabetic patients with hypertension, it is appropriate to recommend an intensive blood-pressure control treatment.

Comment from Dr. George Bakris (Advisory Board Member):

George Bakris, MD, specializes in the diagnosis and reduction of high blood pressure, particularly in complicated and refractory cases. He is also skilled in the treatment of kidney disease, with special expertise in diabetes-related kidney disease. (Dr. Bakris is a board member of the National Kidney Foundation.)

DIC: There’s been so many changes when it comes to blood pressure and there are many organizations that come out with guidelines that differ, which makes it really confusing.

Dr. Bakris: Yeah, I understand that and I think the good news is that if you had to select one number based  on the data that we have available to us on outcomes, if you wanted a single number, if you said less than 140/90, you would be correct in almost all guidelines as they exist today. Now, it depends on what you want to view as the evidence. Guidelines, you have to understand, guidelines are  developed to provide guidance. They are not edicts. They are not stone tablets from Moses. They are, in fact, guidelines. In fact, the original concept of a guideline was many, many, many years ago when people were climbing mountains and they were uncharted territories, ropes would be provided as a guide to help get you to where you need to be. And that’s what these are. They are ropes to help get you to where you need to be. They are not edicts and they are not must do’s or should not do’s. They are guidances.

Now, if you look at what has happened in both the world of diabetes and nondiabetic disease for cardiovascular risk, the guidance probably is going to be changed to less than 130. The evidence for diabetes is not quite as strong as it is for nondiabetic disease but nevertheless, it’s going to be less than 130/80. Right now, if you read the latest guidelines, you’re going to find everybody talking about less than 140/90. It was 130/80, then some hard-core people got in there and said well, you can’t absolutely mandate that because the evidence is weak. Well, the evidence is stronger now and there are papers that are going to be coming out that were presented at national meetings, and some have already come out, showing that in fact, for risk of stroke and in stroke reduction and for cardiovascular risk in general, less than 130/80 is perfectly reasonable for most people. And in fact, in the latest Up to Date Cardio Newsletter, we’ve taken the stance to say listen, we’re not physicists. This is not a single digit –“if you are at 129, you’re in big trouble; if you’re at 131, you’re going to die.” There’s nothing like that. But in fact they are given ranges now. So you’re probably better off if you are in the range between 125 and 130 and on the lower end, as long as you are above 60 and below 80, you are in pretty good shape.  So that’s kind of the range you want to be in.

And yes, it’s a little more difficult than having a single number but if you want a single number, you can say less than 130/80 because with the advent of SPRINT, with the long-term follow-up of the ACCORD, the so-called ACCORDIAN trial, and with other data into very, very large med analyses that were just published (one is in press and the other one was just published in January) the data are overwhelming. In over 140,000 people, talking about diabetes, that less than 130/80 is probably where you need to be.

Practice Pearls:

  • This study examined whether lowering blood pressure to a target of <120 mm Hg systolic should be extended to diabetic patients.
  • These long-term results should be considered important when viewing the SPRINT results.
  • Intensive blood pressure control treatments can be considered in diabetic patients with hypertension.
  • There is no one number that is for everyone, but a range of lower blood pressure targets for diabetic patients should be considered.

Cushman WC, Evans GW, Cutler JA. Long-term cardiovascular effects of 4.9 years of intensive blood pressure control in type 2 diabetes mellitus: The Action to Control Cardiovascular Risk in Diabetes follow-on blood-pressure study. American Heart Association 2015 Scientific Sessions; November 10, 2015; Orlando, FL.