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Intensive BP control may reduce CV events in high-risk patients with type 2 diabetes
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Patients with type 2 diabetes at high risk for cardiovascular disease were 21% less likely to experience a CV outcome when assigned to an intensive blood pressure goal of 120 mm Hg or lower, according to an analysis of SPRINT-eligible patients who participated in the ACCORD-BP trial.
In ACCORD-BP, lower BP targets and combination lipid therapy failed to reduce the overall risk for CV events in patients with type 2 diabetes compared with standard treatment strategies, leading many health care professionals to reason that intensive therapy may not be better in diabetes. In contrast, researchers in the SPRINT trial observed a reduction in CV events with intensive BP control of 120 mm Hg or lower, but the study excluded patients with type 2 diabetes.
“Selection of appropriate blood pressure goals is a challenging topic — particularly among patients with diabetes,” Benjamin Van Tassell, PharmD, BCPS, FCCP, FAHA, ASH-CHC, associate professor and vice chair for clinical research at Virginia Commonwealth University School of Pharmacy, told Endocrine Today. “While many reports have highlighted the differences between results of the SPRINT and ACCORD-BP trials, our analysis describes the common ground between the studies and identifies a subgroup of high-risk diabetes patients that appears to benefit from intensive blood pressure lowering.”
In a post hoc, subgroup analysis, Van Tassell, Leo F. Buckley, PharmD, a postdoctoral fellow in the department of pharmacotherapy and outcomes science at Virginia Commonwealth University in Richmond, and colleagues identified patients from the standard glucose control arm of the ACCORD-BP trial who had the additional CV risk factors that would have made them eligible for SPRINT, had they not had type 2 diabetes. Researchers used Cox proportional hazard regression models to analyze the effect of intensive (n = 652) vs. standard BP control (n = 632) on CV outcomes, pooling SPRINT-eligible ACCORD patients with the SPRINT cohort.
Within the cohort, mean Framingham 10-year CVD risk scores were 14.5% in the intensive BP arm and 14.8% in the standard BP arm. There were no between-group differences in systolic BP at baseline (139.8 mm Hg vs. 140.8 mm Hg). Mean achieved systolic BP in the intensive arm was 120.1 mm Hg and 133.5 mm Hg in the standard arm.
Researchers found that intensive BP control reduced the risk for composite CV death, nonfatal myocardial infarction, nonfatal stroke, any revascularization or heart failure by 21% in the SPRINT-eligible ACCORD-BP patients (HR = 0.79; 95% CI, 0.65-0.96). Intensive BP control also reduced the risk for ACCORD-BP’s primary endpoint of CVD death, nonfatal MI or nonfatal stroke (HR = 0.69; 95% CI, 0.51-0.93).
After pooling the original SPRINT participants with the SPRINT-eligible ACCORD-BP patients, researchers found no evidence of heterogeneity in the effect of intensive BP control on the composite outcome of CVD death, nonfatal MI, nonfatal stroke, any revascularization or heart failure between participants with and without type 2 diabetes (P for interaction = .76). Treatment-related adverse events occurred more frequently in participants receiving intensive BP control (4.1% vs. 2.1%; P = .003).
“Interestingly, we noted that the benefits of intensive BP control manifest most evidently in SPRINT-eligible ACCORD-BP patients who were not receiving intensive glucose control,” the researchers wrote. “In the original ACCORD-BP, there was a trend toward interaction between intensive glucose control and intensive BP control, where intensive BP control appeared beneficial only in the standard glucose control arm.”
The researchers added that the findings suggest that the interaction between intensive glucose lowering and intensive BP lowering may be evident only among those with additional CV risk factors, such as the SPRINT-eligible patients, but further studies are needed to investigate any interaction.
“Our analysis suggests that the benefit of intensive blood pressure lowering is not driven by the presence (or absence) of diabetes, but by traditional cardiovascular risk factors, such as age, chronic kidney disease, prior cardiovascular disease or Framingham 10-year risk,” Van Tassell said. “Using this approach, high-risk patients with diabetes appear to benefit from intensive blood pressure lowering (< 120/80 mmHg) just as much as high-risk patients without diabetes.” – by Regina Schaffer
For more information:
Benjamin Van Tassell , PharmD, BCPS, FCCP, FAHA, ASH-CHC, can be reached at Virginia Commonwealth University School of Pharmacy, 410 North 12th Street, Rm 636, Richmond, VA 23298-0533; email: bvantassell@vcu.edu.
Disclosures: The authors report no relevant financial disclosures.
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