Guidelines for blood pressure treatment in patients with hypertension and diabetes

Diabetes
blood pressure treatment

A new study assessed whether intensive treatment in patients with high blood pressure and diabetes can reduce risk of adverse events or death.

Hypertension, or high blood pressure, is a well-established risk factor for the development and progression of cardiovascular disease. High blood pressure is associated with increased risk of adverse cardiovascular events, including heart attack and stroke, and death. While there are many anti-hypertensive drugs available, there is no consensus on when these drugs should be initiated and what the target blood pressure for these patients should be. Recent trials suggest that the blood pressure targets should be lower than previously advised. For instance, in the SPRINT (Systolic Blood Pressure Intervention Trial), researchers found that individuals that had their systolic blood pressure reduced to less than 120 mmHg with therapeutic intervention had significantly lower rates of adverse events and death, compared to those who had their systolic blood pressure lowered to less than 140 mmHg. Similarly, in the HOPE-3 (Heart Outcomes Prevention Evaluation-3) trial, patients with more substantial blood pressure reduction had a lower risk of negative cardiovascular events.

While the SPRINT and HOPE-3 clinical trials collectively demonstrate that setting lower targets for blood pressure may benefit hypertensive patients, it is unclear whether these guidelines can be applied to people with hypertension and type 2 diabetes. For example, in contrast to the SPRINT trial, the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial found no difference in patient outcomes whether their systolic blood pressures were restricted to less than 120 or 140 mmHg. These conflicting studies have led to organizations setting different guidelines for when to initiate treatment and what target blood pressure to achieve in diabetic, hypertensive patients.

A recent trial, called ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation), analyzed outcomes from nearly 11,000 patients to determine whether intensive blood pressure treatment is effective in patients with both hypertension and diabetes. Rates of overall death, major vascular events like heart attack and stroke, and diabetes-related kidney and eye damage were compared between patients receiving intensive blood-pressure treatment and those receiving a placebo control. The study found that regardless of the patient’s baseline blood pressure, using an intensive treatment regimen to maintain low blood pressure targets was associated with 9% fewer adverse events and 14% fewer deaths. In conclusion, the ADVANCE trial provides additional evidence to support using intensive blood pressure treatments in patients with both hypertension and diabetes.

Written by Haisam Shah, BSc

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Reference: Rahman, F., McEvoy, J. W., Ohkuma, T., Marre, M., Hamet, P., Harrap, S., … & Muntner, P. (2019). Effects of Blood Pressure Lowering on Clinical Outcomes According to Baseline Blood Pressure and Cardiovascular Risk in Patients With Type 2 Diabetes Mellitus: The ADVANCE Trial. Hypertension, HYPERTENSIONAHA-118.

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