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Treating hypertension reduces CV risks in diabetes care
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People with diabetes have elevated risks for CVD and events, and these risks are compounded by hypertension, a common comorbidity. In 2017, the American College of Cardiology/American Heart Association and the American Diabetes Association released hypertension guidelines recommending different BP targets. Cardiology Today spoke with cardiologist Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASH, and endocrinologist Helena W. Rodbard, MD, FACP, MACE, about how they manage BP for patients with diabetes.
What is your target BP goal for adults with diabetes?
A cardiologist weighs in.
Based on randomized trials of adults who did not have diabetes, and on meta-analyses of trials that included persons with diabetes, the BP goal of less than 130 mm Hg/80 mm Hg is reasonable for most adults who have had diabetes for 10 years or more, especially those who are middle aged or older.
While diabetes may not be in all cases a CHD risk equivalent, it clearly increases the risk for a wide range of major CV conditions, including MI, stroke and HF. Almost all middle-aged and older adults with diabetes have a high atherosclerotic CVD risk score, suggesting that they need intensive BP reduction. Furthermore, diabetes itself is a major risk factor for HF.
The latest 2017 ACC/AHA guideline recommends a BP goal of less than 130 mm Hg/80 mm Hg, and the American Association of Clinical Endocrinologists embraced this target based on assessment of risk. The ADA continues to mention a goal of less than 140 mm Hg/90 mm Hg, but its recommendations for clinical care mention that the lower goal of less than 130 mm Hg/80 mm Hg is recommended for certain patients, such as those who have a higher risk for CVD. This is the majority of patients who are seen by a cardiologist, many of whom are already at high-risk status or have demonstrable disease.
One of the questions that arises is the strength of the evidence from clinical outcomes trials. The primary outcome of major CVD in the ACCORD trial was not reduced with lower BP. However, a subgroup of participants who had tight BP control and usual glucose control had an improvement in major CV events. A prespecified secondary outcome of stroke in ACCORD was lower with intensive BP reduction. Furthermore, although SPRINT did not include participants with diabetes, it did demonstrate the benefit of intensive BP control in high-risk patients, including those with diabetes.
One of the reasons ACCORD may not have shown reduction in primary CV outcomes with a lower BP target could have been that it was a smaller trial than SPRINT (4,733 vs. 9,361) and the population was somewhat younger (62 years vs. 68 years). We know that age itself is a powerful predictor of risk.
For the clinical cardiologist, it is reasonable to intensively treat high-risk patients — with caution, of course — to a lower BP goal of less than 130 mm Hg/80 mm Hg. The bedrock of BP control is lifestyle modification, including weight loss, physical activity, adequate sleep and avoidance of stress. Low sodium intake, especially for middle-aged and older persons, African Americans and those with obesity or any chronic kidney disease, also is extremely important to control BP.
- References:
- ACCORD Study Group. New Engl J Med. 2010;doi:10.1056/NEJMoa1001286.
- SPRINT Research Group. New Engl J Med. 2015;doi:10.1056/NEJMoa1511939.
- For more information:
- Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASH, professor of medicine at Tulane University School of Medicine and Cardiology Today Editorial Board Member.
Disclosure: Ferdinand reports no relevant financial disclosures.
An endocrinologist weighs in.
Hypertension is perhaps the most important risk factor for CVD, and it affects 46% of the adult population in the United States. Hypertension places a burden on the myocardium and leads to ventricular hypertrophy. It also increases the rate of atherogenesis. When combined with diabetes, hypertension greatly increases the risks for macrovascular disease and CV events. Further, it accelerates the progression of chronic kidney disease and may also contribute to the advancement of diabetic retinopathy. Thus, for individuals with diabetes, it is essential to maintain BP as close to normal, as possible.
The American Association of Clinical Endocrinologists and the American College of Endocrinology recommend that targets for BP be individualized, but state that a target of less than 130 mm Hg/80 mm Hg is appropriate for most patients. Less stringent goals may be appropriate for frail patients with comorbidities. More intensive BP control, such as less than 120 mm Hg/80 mm Hg, should be considered for some patients if this target can be reached safely.
The ADA recommends a BP target of less than 130 mm Hg/80 mm Hg for people with diabetes and hypertension who are at higher CV risk; that is, those with existing atherosclerotic CVD or a 10-year risk for a major CV event of more than 15%. For people with diabetes and hypertension with lower CV risk (10-year atherosclerotic CV risk of less than 15%), a target of 140 mm Hg/90 mmHg is recommended. For pregnant women with diabetes and preexisting hypertension who are being treated with antihypertensive therapy, systolic pressure targets of 120 mm Hg to 160 mm Hg and diastolic pressure targets of 80 mm Hg to 105 mm Hg are recommended to optimize long-term maternal and fetal health.
A recent study in people with type 1 diabetes presented at the ADA Scientific Sessions in June demonstrated that hypertension and hyperglycemia present similar threats for developing heart disease in young adults, with the risk for heart disease doubling when the BP exceeds 120 mm Hg/80 mm Hg.
Therefore, my personal opinion is that “the lower, the better,” as long as BP reduction can be achieved safely.
- Reference:
- Guo J, et al. Abstract 1464-P. Optimal blood pressure goals for cardiovascular health in individuals with type 1 diabetes. Presented at: American Diabetes Association 79th Scientific Sessions; June 7-11, 2019; San Francisco.
- For more information:
- Helena W. Rodbard, MD, FACP, MACE, medical director, Endocrine and Metabolic Consultants, Rockville, Maryland.
Disclosure: Rodbard reports no relevant financial disclosures.