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What is the optimal blood pressure target for patients with diabetes?
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Target should be ≤140 mm Hg
The totality of the evidence supports that the general population should strive for substantially less than 140 mm Hg approaching 130 mm Hg, but not less than 130 mm Hg. There are two possible exceptions: people with very high risk for stroke and people with proteinuric kidney disease. For those people, the evidence does support less than 130 mm Hg.
The risk for CV events dramatically increases with systolic BP above 140 mm Hg, but levels off once the patient reaches less than 140 mm Hg. While the risk may be slightly less at 130 mm Hg, one would have to treat 1 million people to actually see a difference. Looking at ACCORD and INVEST and other randomized trials that examined different levels of BP control, no trial has shown that less than 130 mm Hg is better than less than 140 mm Hg for the general population with diabetes. As we found out in INVEST, if a patient has high pulse pressure and stiff arteries, the patient will be at higher risk if you get them well below 130 mm Hg because of lowering the diastolic BP too much. A number of papers have showed that the CV risk actually increases with diastolic pressure below 60 mm Hg, regardless of systolic BP.
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The Sixth and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recommended a BP target of less than 130 mm Hg. We were afraid that if we recommended less than 140 mm Hg for everybody, physicians would assume that a BP in the neighborhood of 140 mm Hg was OK — and that is not the correct approach. We know about physician inertia, we know patients do not want to take more medicine and we know physicians do not have time to explain all of this, so we run the risk of getting worse control overall at the 140 mm Hg mark if we were not to recommend less than 130 mm Hg. Can we prove that? No. But, available data gave us good reason to fear that. The next guidelines, the Eighth Report of the Joint National Committee, will be nothing like previous reports, as the results will all be based on results of Cochrane analyses to specific questions posed.
George Bakris, MD, is Professor of Medicine and Director of the Hypertensive Diseases Unit at the University of Chicago, Pritzker School of Medicine, and is a Member of the Endocrine Today Editorial Board.
Target should be ≤130 mm Hg
Current guidelines for BP management from the American Diabetes Association, Joint National Committee and other organizations recommend a systolic BP target of less than 130 mm Hg, based on data from epidemiologic studies and retrospective analyses of clinical trials, and were by and large developed by consensus. Based on these same analyses and smaller clinical trials, high-risk patients with a prior history of stroke, the highest risk for CVD or significant renal disease may benefit from even lower targets. Although ACCORD failed to demonstrate substantial benefit in targeting lower targets, at present, guidelines have not changed.
The ADA will review the results of ACCORD, not just in isolation but in the context of myriad clinical trials, including the Systolic Hypertension in the Elderly Program and Hypertension Optimal Treatment study and others that suggested lower BP targets may be of benefit for high-risk diabetes patients. Both ACCORD and ADVANCE suggested that BP targets in the mid-130 mm Hg range are suitable for the majority of patients with diabetes. However, the ACCORD BP trial achieved a mean systolic BP of less 120 mm Hg in patients assigned to the intensive target; those in the standard treatment group achieved a systolic BP in the low- to mid-130 mm Hg range while targeting systolic BP less than 140 mm Hg. ADVANCE investigators achieved a systolic BP of 135 mm Hg in the more aggressive treatment arm compared with values of approximately 140 mm Hg in the comparison group. Based on these and other results, the BP target supported by current clinical trials seems to fall somewhere between 130 mm Hg and 140 mm Hg.
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Overall, ADA guidelines support the notion that achieving good BP control in the vast majority of patients with diabetes is of benefit. Recent results do not recuse clinicians from managing BP appropriately in diabetes patients. The precise treatment target driving the maximal number of patients to good control is still a point of discussion. One fear of ‘relaxing’ current guidelines is that one runs the risk of sending the message that BP control is unimportant — and none of the recent trials would support this contention. Rather, these findings suggest that the ADA and other organizations must look carefully at recent studies, as well as previous clinical trials, to identify targets that ensure the majority of patients with diabetes and elevated BP are treated appropriately.
David M. Kendall, MD, is Chief Scientific & Medical Officer for the American Diabetes Association.