Lower Blood Pressure Targets for Type 2 Diabetes

Medscape

2 days ago

This transcript has been edited for clarity.
Today I am going to discuss a recent paper on intensive blood pressure control in people with type 2 diabetes. This was a big study. It included over 12,000 participants who were older than age 50, and had type 2 diabetes and an increased risk for cardiovascular disease; either they'd had a prior cardiovascular event, had two or more risk factors, or had a reduced estimated glomerular filtration rate (eGFR).
The study was performed in China and it was really done to determine, potentially once and for all, what the target should be in treating patients with type 2 diabetes. The ACCORD trial tried to answer this question, but it didn't show overall improvement in outcomes with blood pressure reduction, although when they did subset analysis, they did show benefit in certain groups. It still didn't have that definitive feel, and I think this study does.
They were looking only at systolic blood pressures, and they wanted to target a systolic blood pressure of less than 120 mm Hg in the intensively treated group; in the standardly treated group, the blood pressure target was a systolic of less than 140 mm Hg. The primary endpoint was nonfatal stroke, nonfatal MI, treatment or hospitalization for heart failure, or death from cardiovascular disease causes.
In this study, 45% were women. The average age was 63.8 years. Body mass index was 26.7 and 25% smoked. The baseline blood pressure was 140/76 mm Hg and the mean blood pressure over approximately 4 years of follow-up was 121.6 mm Hg in the intensively treated group vs 133.2 mm Hg in the standard treatment group.
You basically began to see a difference between the two in terms of the primary endpoint after about a year, so you started to see this split. At the end of the study, there was a very significant difference in terms of the primary endpoint between the two groups.
I want to point out that, in my brain, those blood pressure targets that were reached are actually fairly standard. The intensively treated group was about 120 mm Hg, and that's compared with the standard treatment group, which was around 130 mm Hg.
I must say that, in my own practice, given all the changes that we've seen over the years in blood pressure targets, the results from this study have actually motivated me to lower my systolic target, at least in terms of how I treat patients in clinic, because I think they may get further benefit.
That then begs the question of how did they measure blood pressures in this study? I get patients who have what's called white coat hypertension. They come into my office, their blood pressure is higher, and then I have them test at home and it's better.
In this study, they tried to take away some of that interference. They had patients come into clinic having had no exercise, no coffee, and no cigarettes for at least 30 minutes before their appointment. The patients had 5 minutes of seated rest, and then they had three blood pressure measurements, each done 1 minute apart. There was no talking or joking around. They just sat there and had their blood pressures measured in the appropriate way.
The average systolic blood pressure was used of those three readings to determine whether treatment was changed. They followed pretty standard treatment regimens for hypertension, which are the ones we use in our ADA guidelines for the management of hypertension.
People in the intensive group ended up on one or two additional medications compared with those in the standard group. The overall rate of severe adverse events was equivalent in both groups, but there was more symptomatic hypotension and hyperkalemia in the intensively treated group.
As I said, this has actually changed how I'm treating my patients. The difference between 120 mm Hg and 133 mm Hg isn't that big in my brain, and yet there does seem to be a difference in terms of outcomes, primarily cardiovascular outcomes, as the primary endpoint.
I think that, if a patient can tolerate a lower blood pressure without symptomatic hypotension, I am going to be treating them down to a lower target. I think this was a well-done study that actually will probably inform practice and guidelines in the future because I think it helps inform us of what is potentially the best target for our patients.