Target blood pressure in diabetes patients with hypertension--what is the accumulated evidence in 2011?

Abstract

There is overwhelming evidence that hypertension is an important risk factor for both macrovascular and microvascular complications in patients with diabetes, but the problem remains to identify appropriate goals for preventive therapies. A number of guidelines (the European Society of Cardiology (ESC)/European Association for the Study of Diabetes (EASD) 2007, the Joint National Committee (JNC)-VII 2003, the American Diabetes Association (ADA) 2011) have for example advocated a blood pressure goal of less than 130/80 mmHg, but this suggestion has been challenged by findings in recent trials and meta-analyses (2011). The European Society of Hypertension (ESH) therefore recommends a systolic blood pressure goal of "well below" 140 mmHg. Based on evidence from both randomized controlled trials (hypertension optimal treatment (HOT), action in diabetes and vascular disease: preterax and diamicron MR controlled evaluation (ADVANCE), action to control cardiovascular risk in diabetes (ACCORD)) and observational studies (ongoing telmisartan alone and in combination with ramipril global endpoint trial (ONTARGET), international verapamil-trandolapril study (INVEST), treat to new targets (TNT), and the National Diabetes Register (NDR)), it has been shown that the benefit for stroke reduction remains even at lower achieved blood pressure levels, but the risk of coronary events may be uninfluenced or even increased at lower systolic blood pressure levels. In a recent meta-analysis, it was therefore concluded that the new recommended goal should be 130-135 mmHg systolic blood pressure for most patients with type 2 diabetes. Other risk factors should also be controlled with a more ambitious strategy applied in the younger patients with shorter diabetes duration, but a more cautious approach in the elderly and frail patients with a number of vascular or non-vascular co-morbidities. In patients from East Asia, such as China, the stroke risk is relatively higher than the risk of coronary events. This must also be taken into consideration for individualized goal setting in relation to total risk, for example in patients from stroke-prone families. In conclusion, the current strategy is to have a more individualized approach to risk factor control in patients with type 2 diabetes, also relevant for blood pressure control.

Fig. 1

Adjusted hazard ratios for fatal/nonfatal CHD by intervals of updated mean SBP Data are from the National Diabetes Register (NDR) of Sweden including 12 751 patients with type 2 diabetes treated with antihypertensive drugs (Nilsson et al., 2011a)

Fig. 2

Different ways to graphically present the same data for CHD risk by use of varying spline models Adjustment for age, sex, diabetes duration, HbA1c, body mass index (BMI), smoker, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, albuminuria, atrial fibrillation, a history of CVD, and hypoglycemic treatment (Nilsson et al., 2011a)

Fig. 3

Adjusted hazard ratios for fatal/nonfatal stroke by intervals of updated mean SBP (Nilsson et al., 2011a)

Fig. 4

Different ways to graphically present the same data for stroke risk by use of varying spline models Adjustment for age, sex, diabetes duration, HbA1c, body mass index (BMI), smoker, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, albuminuria, atrial fibrillation, a history of CVD, and hypoglycemic treatment (Nilsson et al., 2011a)

Fig. 5

SBP levels in 57 645 patients with type 2 diabetes and treatment with antihypertensive drug therapy followed individually 2005 to 2009 in the NDR Adapted from data presented in (Nilsson et al., 2011b)