This site is intended for healthcare professionals only


Diabetes Digest

Issue:

Share this article

New targets for treatment of hypertension in diabetes?

Jiten Vora

It is well recognised that treatment of hypertension in people with diabetes reduces macrovascular and microvascular complications. Consequently, many guidelines recommend that blood pressure treatment targets should be more aggressive in people with diabetes (<130/80 mmHg) compared with those without diabetes (<140/90 mmHg; Mancia et al, 2007; American Diabetes Association, 2012).

More recently, however, these treatment targets in T2D guidelines are being questioned. This relates specifically to more contemporaneous evaluations of the relationship between hypertension in diabetes with coronary artery disease and the effect of intensive blood pressure control. These recent evaluations do not corroborate the data for aggressive blood pressure producing a reduction in coronary heart disease (Cooper-DeHoff et al 2010; Cushman et al, 2010).

Indeed, in some studies, increases in adverse cardiovascular outcomes have been reported with low blood pressure (Berl et al, 2005; Van Hateren et al, 2010). A recent analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study did not confirm beneficial effects with intensive blood pressure treatment (systolic blood pressure <120 mmHg) compared with systolic blood pressure of <140 mmHg, though there was a clear and significant reduction in the incidence of stroke (Cushman et al, 2010).

Studies have demonstrated an inverse association with blood pressure and cardiovascular mortality, particularly amongst older people with diabetes (Ronnback et al, 2006; Zhao et al, 2013). In an article described in this edition of Cardio Digest are the results from a prospective cohort study (2000–2009) on individuals with diabetes including 17536 African American and 12618 Caucasian people (Zhao et al, 2013). This study suggests that in this large hospital-based cohort, aggressive blood pressure control (systolic <120 mmHg and diastolic <70 mmHg) was associated with increased risk of coronary heart disease amongst African American and white Caucasian people with T2D. Furthermore, in this study, the harm of lower blood pressures was greater in older people.

Thus, there is no robust evidence available to support intensive lowering of blood pressure levels to <130/80 mmHg in patients with diabetes, except in those with nephropathy. Consequently, it may be appropriate to modify the treatment targets associated with guidelines, potentially to between 130–139 mmHg and 80–89 mmHg.

It is well recognised that treatment of hypertension in people with diabetes reduces macrovascular and microvascular complications. Consequently, many guidelines recommend that blood pressure treatment targets should be more aggressive in people with diabetes (<130/80 mmHg) compared with those without diabetes (<140/90 mmHg; Mancia et al, 2007; American Diabetes Association, 2012).

More recently, however, these treatment targets in T2D guidelines are being questioned. This relates specifically to more contemporaneous evaluations of the relationship between hypertension in diabetes with coronary artery disease and the effect of intensive blood pressure control. These recent evaluations do not corroborate the data for aggressive blood pressure producing a reduction in coronary heart disease (Cooper-DeHoff et al 2010; Cushman et al, 2010).

Indeed, in some studies, increases in adverse cardiovascular outcomes have been reported with low blood pressure (Berl et al, 2005; Van Hateren et al, 2010). A recent analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study did not confirm beneficial effects with intensive blood pressure treatment (systolic blood pressure <120 mmHg) compared with systolic blood pressure of <140 mmHg, though there was a clear and significant reduction in the incidence of stroke (Cushman et al, 2010).

Studies have demonstrated an inverse association with blood pressure and cardiovascular mortality, particularly amongst older people with diabetes (Ronnback et al, 2006; Zhao et al, 2013). In an article described in this edition of Cardio Digest are the results from a prospective cohort study (2000–2009) on individuals with diabetes including 17536 African American and 12618 Caucasian people (Zhao et al, 2013). This study suggests that in this large hospital-based cohort, aggressive blood pressure control (systolic <120 mmHg and diastolic <70 mmHg) was associated with increased risk of coronary heart disease amongst African American and white Caucasian people with T2D. Furthermore, in this study, the harm of lower blood pressures was greater in older people.

Thus, there is no robust evidence available to support intensive lowering of blood pressure levels to <130/80 mmHg in patients with diabetes, except in those with nephropathy. Consequently, it may be appropriate to modify the treatment targets associated with guidelines, potentially to between 130–139 mmHg and 80–89 mmHg.

REFERENCES:

American Diabetes Association (2012) Standards of Care in Diabetes. Diabetes Care 35: S11–63
Berl T, Hunsicker LG, Lewis JB et al (2005) Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. J Am Soc Nephrol 16: 2170–9
Cooper-DeHoff RM, Gong Y, Handberg EM et al (2010) Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 304: 61–8
Cushman WC, Evans GW, Byington RP et al (2010) Effects of intensive blood pressure control in type 2 diabetes mellitus. N Engl J Med 362: 1575–85
Mancia G, De Backer G, Dominiczak et al (2007) The task force for the management of arterial hypertension of the European Society of Hypertension, European Society of Hypertension and European Society of Cardiology. Eur Heart J 28: 1462–536
Ronnback M, Isomaa B, Fagerudd J et al (2006) Complex relationship between blood pressure and mortality in type 2 diabetic patients: a follow-up of the Botnia Study. Hypertension 47: 168–73
Van Hateren KJ, Landman GW, Kleefstra N et al (2010) Lower blood pressure associated with higher mortality in elderly diabetic patients (ZODIAC-12). Age Ageing 39: 603–9
Zhao W, Katzmarzyk PT, Horswell R et al (2013) Aggressive blood pressure control increases coronary heart disease among diabetic patients. Diabetes Care 11 Jun [Epub ahead of print]

Related content
;
Free for all UK & Ireland healthcare professionals

Sign up to all DiabetesontheNet journals

 

By clicking ‘Subscribe’, you are agreeing that DiabetesontheNet.com are able to email you periodic newsletters. You may unsubscribe from these at any time. Your info is safe with us and we will never sell or trade your details. For information please review our Privacy Policy.

Are you a healthcare professional? This website is for healthcare professionals only. To continue, please confirm that you are a healthcare professional below.

We use cookies responsibly to ensure that we give you the best experience on our website. If you continue without changing your browser settings, we’ll assume that you are happy to receive all cookies on this website. Read about how we use cookies.