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Meta-Analysis
. 2013 Oct 30;2013(10):CD008277.
doi: 10.1002/14651858.CD008277.pub2.

Blood pressure targets for hypertension in people with diabetes mellitus

Jose Agustin Arguedas  1 , Viriam Leiva, James M Wright
Affiliations
Meta-Analysis

Blood pressure targets for hypertension in people with diabetes mellitus

Jose Agustin Arguedas et al. Cochrane Database Syst Rev. .

Abstract

Background: When treating elevated blood pressure (BP), doctors often want to know what blood pressure target they should try to achieve. The standard blood pressure target in clinical practice for some time has been less than 140 - 160/90 - 100 mmHg for the general population of people with elevated blood pressure. Several clinical guidelines published in recent years have recommended lower targets (less than 130/80 mmHg) for people with diabetes mellitus. It is not known whether attempting to achieve targets lower than the standard target reduces mortality and morbidity in those with elevated blood pressure and diabetes.

Objectives: To determine if 'lower' BP targets (any target less than 130/85 mmHg) are associated with reduction in mortality and morbidity compared with 'standard' BP targets (less than 140 - 160/90 - 100 mmHg) in people with diabetes.

Search methods: We searched the Database of Abstracts of Reviews of Effectiveness (DARE) and the Cochrane Database of Systematic Reviews for related reviews. We conducted electronic searches of the Hypertension Group Specialised Register (January 1946 - October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE (January 1946 - October 2013), EMBASE (January 1974 - October 2013) and ClinicalTrials.gov. The most recent search was performed on October 4, 2013.Other search sources were the International Clinical Trials Registry Platform (WHO ICTRP), and reference lists of all papers and relevant reviews.

Selection criteria: Randomized controlled trials comparing people with diabetes randomized to lower or to standard BP targets as previously defined, and providing data on any of the primary outcomes below.

Data collection and analysis: Two review authors independently assessed and established the included trials and data entry. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure and end-stage renal disease. Secondary outcomes were achieved mean systolic and diastolic BP, and withdrawals due to adverse effects.

Main results: We found five randomized trials, recruiting a total of 7314 participants and with a mean follow-up of 4.5 years. Only one trial (ACCORD) compared outcomes associated with 'lower' (< 120 mmHg) or 'standard' (< 140 mmHg) systolic blood pressure targets in 4734 participants. Despite achieving a significantly lower BP (119.3/64.4 mmHg vs 133.5/70.5 mmHg, P < 0.0001), and using more antihypertensive medications, the only significant benefit in the group assigned to 'lower' systolic blood pressure (SBP) was a reduction in the incidence of stroke: risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.88, P = 0.009, absolute risk reduction 1.1%. The effect of SBP targets on mortality was compatible with both a reduction and increase in risk: RR 1.05 CI 0.84 to 1.30, low quality evidence. Trying to achieve the 'lower' SBP target was associated with a significant increase in the number of other serious adverse events: RR 2.58, 95% CI 1.70 to 3.91, P < 0.00001, absolute risk increase 2.0%.Four trials (ABCD-H, ABCD-N, ABCD-2V, and a subgroup of HOT) specifically compared clinical outcomes associated with 'lower' versus 'standard' targets for diastolic blood pressure (DBP) in people with diabetes. The total number of participants included in the DBP target analysis was 2580. Participants assigned to 'lower' DBP had a significantly lower achieved BP: 128/76 mmHg vs 135/83 mmHg, P < 0.0001. There was a trend towards reduction in total mortality in the group assigned to the 'lower' DBP target (RR 0.73, 95% CI 0.53 to 1.01), mainly due to a trend to lower non-cardiovascular mortality. There was no difference in stroke (RR 0.67, 95% CI 0.42 to 1.05), in myocardial infarction (RR 0.95, 95% CI 0.64 to 1.40) or in congestive heart failure (RR 1.06, 95% CI 0.58 to 1.92), low quality evidence. End-stage renal failure and total serious adverse events were not reported in any of the trials. A sensitivity analysis of trials comparing DBP targets < 80 mmHg (as suggested in clinical guidelines) versus < 90 mmHg showed similar results. There was a high risk of selection bias for every outcome analyzed in favor of the 'lower' target in the trials included for the analysis of DBP targets.

Authors' conclusions: At the present time, evidence from randomized trials does not support blood pressure targets lower than the standard targets in people with elevated blood pressure and diabetes. More randomized controlled trials are needed, with future trials reporting total mortality, total serious adverse events as well as cardiovascular and renal events.

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Conflict of interest statement

None known.

Figures

1
1
Results of the search.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Systolic blood pressure, Outcome 1 Total mortality.
1.2
1.2. Analysis
Comparison 1 Systolic blood pressure, Outcome 2 Cardiovascular mortality.
1.3
1.3. Analysis
Comparison 1 Systolic blood pressure, Outcome 3 Non‐CV mortality.
1.4
1.4. Analysis
Comparison 1 Systolic blood pressure, Outcome 4 Total serious adverse events.
1.5
1.5. Analysis
Comparison 1 Systolic blood pressure, Outcome 5 Myocardial infarction.
1.6
1.6. Analysis
Comparison 1 Systolic blood pressure, Outcome 6 Stroke.
1.7
1.7. Analysis
Comparison 1 Systolic blood pressure, Outcome 7 Congestive heart failure.
1.8
1.8. Analysis
Comparison 1 Systolic blood pressure, Outcome 8 End‐stage renal failure.
1.9
1.9. Analysis
Comparison 1 Systolic blood pressure, Outcome 9 All other serious adverse events.
1.10
1.10. Analysis
Comparison 1 Systolic blood pressure, Outcome 10 Systolic blood pressure achieved.
1.11
1.11. Analysis
Comparison 1 Systolic blood pressure, Outcome 11 Diastolic blood pressure achieved.
1.13
1.13. Analysis
Comparison 1 Systolic blood pressure, Outcome 13 Number of antihypertensive drugs needed per patient.
2.1
2.1. Analysis
Comparison 2 Diastolic blood pressure, Outcome 1 Total mortality.
2.2
2.2. Analysis
Comparison 2 Diastolic blood pressure, Outcome 2 Cardiovascular mortality.
2.3
2.3. Analysis
Comparison 2 Diastolic blood pressure, Outcome 3 Non‐CV mortality.
2.5
2.5. Analysis
Comparison 2 Diastolic blood pressure, Outcome 5 Myocardial infarction.
2.6
2.6. Analysis
Comparison 2 Diastolic blood pressure, Outcome 6 Stroke.
2.7
2.7. Analysis
Comparison 2 Diastolic blood pressure, Outcome 7 Congestive heart failure.
2.10
2.10. Analysis
Comparison 2 Diastolic blood pressure, Outcome 10 Systolic blood presure achieved.
2.11
2.11. Analysis
Comparison 2 Diastolic blood pressure, Outcome 11 Diastolic blood pressure achieved.
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References

References to studies included in this review

ABCD‐2V 2006 {published data only}
    1. Estacio RO, Coll JR, Tran ZV, Schrier RW. Effect of intensive blood pressure control with valsartan on urinary albumin excretion in normotensive patients with type 2 diabetes. American Journal of Hypertension 2006;19(12):1241‐8. - PubMed
ABCD‐H 1998 {published data only}
    1. Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff Sl, Gifford N, Schrier RW. The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non‐insulin‐dependent diabetes and hypertension. New England Journal of Medicine 1998;338(10):645‐52. - PubMed
ABCD‐N 2002 {published data only}
    1. Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney International 2002;61(3):1086‐97. - PubMed
ACCORD BP 2010 {published data only}
    1. The ACCORD Study Group. Effects of intensive blood‐pressure control in type 2 diabetes mellitus. New England Journal of Medicine 2010;362(17):1575‐85. - PMC - PubMed
HOT 1998 {published data only}
    1. Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt B, Julius S, et al. Effects of intensive blood‐pressure lowering and low‐dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. HOT Stdy Group. Lancet 1998;351(9118):1755‐62. - PubMed

References to studies excluded from this review

HDS 1996 {published data only}
    1. Anon. Hypertension in Diabetes Study IV. Therapeutic requirements to maintain tight blood presure control [Erratum]. Diabetologia 1997;40(3):366. - PubMed
    1. Hypertension in Diabetes Study Group. Hypertension in Diabetes Study IV. Therapeutic requirements to maintain tight blood presure control. Diabetologia 1996;39(12):1554‐61. - PubMed
Lewis 1999 {published data only}
    1. Lewis JB, Berl T, Bain RP, Rohde RD, Lewis EJ. Effect on intensive blood pressure control on the course of type 1 diabetic nephropathy. American Journal of Kidney Diseases 1999;34(5):809‐17. - PubMed
SANDS 2008 {published data only}
    1. Howard BV, Roman MJ, Devereux RB, Fleg JL, Galloway JM, Henderson JA, et al. Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes. JAMA 2008;299(14):1678‐89. - PMC - PubMed
Steno‐2 2003 {published data only}
    1. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. New England Journal of Medicine 2003;348(5):383‐93. - PubMed
UKPDS 38 1998 {published data only}
    1. Anon. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38 [Erratum]. BMJ 1999;318(7175):29. - PMC - PubMed
    1. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317(7160):703‐13. - PMC - PubMed

Additional references

ABCD 2007
    1. Schrier RW, Estacio RO, Mehler PS, Hiatt WR. Appropriate blood pressure control in hypertensive and normotensive type 2 diabetes mellitus: a summary of the ABCD trial. Nature Clinical Practice: Nephrology 2007;3(8):428‐38. - PubMed
ABCD‐H 2000
    1. Estacio RO, Gifford N, Jeffers BW, Schrier RW. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care 2000;23(Suppl 2):B54‐64. - PubMed
ADA 2012
    1. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2012;35(Suppl 1):S11‐63. - PMC - PubMed
ADA 2013
    1. American Diabetes Association. Standards of medical care in diabetes 2013. Diabetes Care 2013;36(Suppl 1):S11‐66. - PMC - PubMed
Adler 2000
    1. Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews CR, Cull CA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000;321(7258):412‐9. - PMC - PubMed
AHA 2007
    1. Rosendorff C, Black HR, Cannon CP, Gersh BJ, Gore J, Izzo JL Jr, et al. Treatment of hypertension in the prevention and management of ischemic heart disease. A scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007;115(21):2761‐88. - PubMed
Arguedas 2009
    1. Arguedas JA, Perez MI, Wright JM. Treatment blood pressure targets for hypertension. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD004349.pub2] - DOI - PubMed
Arguedas 2010
    1. Arguedas JA. Blood pressure targets: are clinical guidelines wrong?. Current Opinion in Cardiology 2010;25(4):350‐4. - PubMed
Bangalore 2010
    1. Bangalore S, Messerli FH, Wun CC, Zuckerman AL, DeMicco D, Kostis JB, et al. J‐curve revisited: an analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. European Heart Journal 2010;31(23):2897‐908. - PubMed
Bangalore 2011
    1. Bangalore S, Kumar S, Lobach I, Messerli FH. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose. Observations from traditional and Bayesian random‐effects meta‐analyses of randomized trials. Circulation 2011;123(24):2799‐810. - PubMed
BHS 2004
    1. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. British Hypertension Society guidelines for hypertension management 2004 (BHS‐IV): summary. BMJ 2004;328(7440):634‐40. - PMC - PubMed
Boissel 2005
    1. Boissel JP, Gueyffier F, Boutitie F, Pocock S, Fagard R. Apparent effect on blood pressure is only partly responsible for the risk reduction due to antihypertensive treatments. Fundamental & Clinical Pharmacology 2005;19(5):579‐84. - PubMed
BPLTTC 2003
    1. Turnbull F, Blood Pressure Lowering Treatment Trialists´ Collaboration. Effects of different blood‐pressure‐lowering regimens on major cardiovascular events: results of prospectively‐designed overviews of randomised trials. Lancet 2003;362(9395):1527‐35. - PubMed
CHEP 2011
    1. Rabi DM, Daskalopoulou SS, Padwal RS, Khan NA, Grover SA, Hackam DG, et al. The 2011 Canadian Hypertension Education Program recommendations for the management of hypertension: blood pressure measurement, diagnosis, assessment of risk, and therapy. Canadian Journal of Cardiology 2011;27(4):415‐33. - PubMed
Cooper‐DeHoff 2010
    1. Cooper‐DeHoff RM, Gong Y, Handberg EM, Bavry AA, Denardo SJ, Bakris GL, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010;304(1):61‐8. - PMC - PubMed
Deedwania 2011
    1. Deedwania PC. Blood pressure control in diabetes mellitus. Is lower always better, and how low it should go?. Circulation 2011;123(24):2776‐8. - PubMed
Dorresteijn 2012
    1. Dorresteijn JA, Graaf Y, Spiering W, Grobbee DE, Bots ML, Visseren FL, Secondary Manifestations of Arterial Disease Study Group. Relation between blood pressure and vascular events and mortality in patients with manifest vascular disease. J‐curve revisited. Hypertension 2012;59(1):14‐21. - PubMed
ESH‐ESC 2007
    1. Mancia G, Backer G, Domiiczak A, Cifkova R, Fagard R, Germano G, et al. 2007 Guidelines for the management of arterial hypertension. The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Journal of Hypertension 2007;25(6):1105‐87. - PubMed
ESH/ESC2013
    1. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). European Heart Journal 2013;34(28):2159‐219. - PubMed
Farnett 1991
    1. Farnett L, Mulrow CD, Linn WD, Lucey CR, Tuley MR. The J‐curve phenomenon and the treatment of hypertension. Is there a point beyond which pressure reduction is dangerous?. JAMA 1991;265(4):489‐95. - PubMed
Filippone 2011
    1. Filippone EJ, Foy A, Newman E. Goal‐directed antihypertensive therapy: lower may not always be better. Cleveland Clinic Journal of Medicine 2011;78(2):123‐33. - PubMed
Grossman 2011
    1. Grossman E. Blood pressure: the lower, the better. The con side. Diabetes Care 2011;34(Suppl 2):308‐12. - PMC - PubMed
Higgins 2003
    1. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327(7414):557‐60. - PMC - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
JNC 7 2003
    1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. The JNC 7 report. JAMA 2003;289(19):2560‐72. - PubMed
Kannel 1996
    1. Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA 1996;275(20):1571‐6. - PubMed
LA 2009
    1. Sánchez RA, Ayala M, Baglivo H, et al. Latin American Expert Group. Latin American Guidelines on Hypertension. J Hypertens 2009;27:905‐22. - PubMed
Laurent 2004
    1. Laurent S. Guidelines from the British Hypertension Society. The lower the pressure the better. BMJ 2004;328(7440):593‐4. - PMC - PubMed
MacMahon 1990
    1. MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, et al. Blood pressure, stroke and CHD. Part 1. Prolonged differences in blood pressure: prospective observational studies collected for the regression dilution blas. Lancet 1990;335(8692):765‐74. - PubMed
Mancia 2011
    1. Mancia G, Grassi G, Zanchetti A. Antihypertensive treatment and blood pressure in diabetic and nondiabetic patients. The lower, the better?. Diabetes Care 2011;34(Suppl 2):304‐7. - PMC - PubMed
McBrien 2012
    1. McBrien K, Rabi DM, Campbell N, Barnieh L, Clement F, Hemmelgarn BR, et al. Intensive and standard blood pressure targets in patients with type 2 diabetes mellitus. Systematic review and meta‐analysis. Archives of Internal Medicine 2012;172(17):1296‐303. - PubMed
Messerli 2006
    1. Messerli FH, Mancia G, Conti CR, Hewkin AC, Kupfer S, Champion A, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous?. Annals of Internal Medicine 2006;144(12):884‐93. - PubMed
NICE 2011
    1. National Institute for Health and Clinical Excellence. Hypertension. Clinical management of primary hypertension in adults. NICE clinical guideline 127 2011:1‐36.
Oparil 2003
    1. Oparil S, Zaman MA, Calhoun DA. Pathogenesis of hypertension. Annals of Internal Medicine 2003;139(9):761‐76. - PubMed
Parati 2011
    1. Parati G, Bilo G, Ochoa JE. Benefits of tight blood pressure control in diabetic patients with hypertension. Importance of early and sustained implementation of effective treatment strategies. Diabetes Care 2011;34(Suppl 2):S297‐303. - PMC - PubMed
Prospective Studies 2002
    1. Lewington S, Clarke R, Qisilbash N, Peto R, Collins R, Prospective Studies Collaboration. Age‐specific relevance of usual blood pressure to vascular mortality: a meta‐analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360(9349):1903‐13. - PubMed
Reboldi 2011
    1. Reboldi G, Gentile G, Angeli F, Ambrosio G, Mancia G, Verdecchia P, et al . Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta‐analysis in 73913 patients. Journal of Hypertension 2011;29(7):1253‐69. - PubMed
RevMan 2012 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012.
Sleight 2009
    1. Sleight P, Redon J, Verdecchia P, Mancia G, Gao P, Fagard R, et al. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial study. Journal of Hypertension 2009;27(7):1360‐9. - PubMed
Stamler 1993
    1. Stamler J, Stamler R, Neaton JD. Blood Pressure, systolic and diastolic and cardiovascular risk. US population data. Archives of Internal Medicine 1993;153(5):598‐615. - PubMed
Stamler 1993b
    1. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12‐yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993;16:434‐44. - PubMed
Vokó 1999
    1. Vokó Z, Bots ML, Hofman A, Koudstaal PJ, Witteman JC, Breteler MM. J‐shaped relation between blood pressure and stroke in treated hypertensives. Hypertension 1999;34(6):1181‐7. - PubMed
WHO/ISH 2003
    1. Whitworth JA, World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO/International Society of Hypertension (ISH) statement on management of hypertension. Journal of Hypertension 2003;21(11):1983‐92. - PubMed
Zanchetti 2003
    1. Zanchetti A, Hansson L, Clement D, Elmfeldt D, Julius S, Rosenthal T, et al. HOT Study Group. Benefits and risks of more intensive blood pressure lowering in hypertensive patients of the HOT study with different risk‐profiles: does a J‐shaped curve exist in smokers?. Journal of Hypertension 2003;21(4):797‐804. - PubMed
Zanchetti 2009
    1. Zanchetti A. Bottom blood pressure or bottom cardiovascular risk? How far can cardiovascular risk be reduced?. Journal of Hypertension 2009;27(8):1509‐20. - PubMed

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