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BP reduction in type 2 diabetes may lower CVD risks at levels below guideline recommendations
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A lower risk for cardiovascular disease and coronary heart disease events, as well as improved mortality, was found among patients with type 2 diabetes assigned blood pressure-lowering therapies, according to findings published in JAMA.
Kazem Rahimi, DM, MSc, and colleagues from The George Institute for Global Health conducted a systematic review and meta-analysis of randomized controlled trials of BP-lowering treatment that included patients with diabetes to determine the effects of treatment on vascular disease among patients with type 2 diabetes.
Forty trials (100,354 participants) were included for analysis, and main outcomes included all-cause mortality, CV events, CHD events, stroke, heart failure, retinopathy, new or worsening albuminuria and renal failure.
A significantly lower risk for all-cause mortality (RR = 0.87; 95% CI, 0.78-0.96), CVD events (RR = 0.89; 95% CI, 0.83-0.95), CHD events (RR = 0.88; 95% CI, 0.8-0.98), stroke events (RR = 0.73; 95% CI, 0.64-0.83), retinopathy (RR = 0.87; 95% CI, 0.76-0.99) and albuminuria (RR = 0.83; 95% CI, 0.79-0.87) were all associated with a 10-mm Hg decrease in systolic BP.
Lower risks for stroke, retinopathy and albuminuria were found even when baseline systolic blood pressure was lower than 140 mm Hg or when it was reduced to below 130 mm Hg.
“Among patients with type 2 diabetes, BP lowering was associated with improved mortality and other clinical outcomes,” the researchers wrote. “These findings support the use of medications for BP lowering in these patients. Although proportional associations of BP lowering treatment for most outcomes studies were attenuated below a systolic BP level of 140 mm Hg, data indicate that further reduction below 130 mm Hg is associated with a lower risk of stroke, retinopathy, and albuminuria, potentially leading to net benefits for many individuals at high risk for those outcomes.”
In an accompanying editorial, Bryan Williams, MD, of the University College London, wrote that the findings support current guidelines that recommend health care providers “consider offering patients with type 2 diabetes antihypertensive therapy when their systolic BP is 140 mm Hg or greater, aiming for a target systolic BP toward 130 mm Hg but not usually lower than this.”
“However, the findings of the study by Emdin [and colleagues] suggest that for some patients, these treatment thresholds and targets might be too conservative, especially for optimally reducing the risk of stroke and the development or progression of albuminuria,” Williams wrote. “This conundrum highlights the problem with clinic overreliance on guidelines and guideline overdependence on an often uncritical adoption of evidence, despite the limitations of the clinical trials. Guidelines are just that, and are necessarily conservative in providing population-based recommendations that physicians must interpret in the context of the individual patient being treated.” – by Amber Cox
Disclosure: Rahimi reports no relevant financial disclosures. The George Institute for Global Health has received grants from several pharmaceutical companies. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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