The optimal blood pressure target in diabetes mellitus: a quest coming to an end?

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The presence of hypertension in patients with diabetes mellitus (DM) substantially increases cardiovascular risk. Blood pressure (BP) decrease in these individuals is associated with large reductions in cardiovascular morbidity and mortality, but the optimal BP levels in DM still remain a matter of important controversy. For almost 20 years, guidelines recommended an office BP target of <130/80 mmHg in diabetic individuals, following evidence from trials randomizing patients to diastolic BP levels. When the action-to-control-cardiovascular-risk-in-diabetes-blood-pressure (ACCORD-BP) study showed that systolic BP (SBP) <120 mmHg was associated with similar risk to SBP < 140 mmHg in type 2 DM, all guidelines stepped back to recommend a SBP < 140 mmHg, despite the obvious limitations of ACCORD-BP, including the surprisingly low event rate and the actual average BP of 133.5/70.5 mmHg in the “standard-target” arm. In contrast, the systolic-blood-pressure-intervention-trial (SPRINT) showed cardiovascular benefits in hypertensive patients without DM randomized to SBP<120 versus <140 mmHg and many believed that absence of between-group differences in ACCORD-BP was rather a matter of power and not of dissimilar cardiovascular profile of diabetic patients. In this regard, the American-College-of-Cardiology/American-Heart-Association 2017 BP guidelines advocated a BP target of <130/80 in all hypertensives, including those with DM. However, the 2018 American-Diabetes-Association recommendations were not in the same direction, suggesting BP goal <140/90 for most patients, with the exception of those with “high cardiovascular risk”, where a <130/80 mmHg target may apply. This review presents the evidence from old and recent trials relevant to optimal BP levels in DM, aiming to shed light in this major clinical question.

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Fig. 1


  1. 1.

    Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC practice guidelines for the management of arterial hypertension. Blood Press. 2014;23:3–16.

  2. 2.

    Perkovic V, Huxley R, Wu Y, Prabhakaran D, MacMahon S. The burden of blood pressure-related disease: a neglected priority for global health. Hypertension. 2007;50:991–7.

  3. 3.

    Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/american heart association task force on clinical practice guidelines. Hypertension. 2017 (Epub ahead of print).

  4. 4.

    World Health Organization. Global report on Diabetes. Geneva: WHO; 2016.

  5. 5.

    The Emerging Risk Factors Collaboration, Sarwar N, Gao P, SRK Seshasai, Gobin R, Kaptoge S, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375:2215–22.

  6. 6.

    Sarafidis PA, Whaley-Connell A, Sowers JR, Bakris GL. Cardiometabolic syndrome and chronic kidney disease: what is the link? J Cardiometab Syndr 2006;1:58–65.

  7. 7.

    Sarafidis PA, Alexandrou ME, Ruilope LM. A review of chemical therapies for treating diabetic hypertension. Expert Opin Pharmacother. 2017;18:909–23.

  8. 8.

    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.

  9. 9.

    Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339:229–34.

  10. 10.

    Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, 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;321:412–9.

  11. 11.

    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: 703–13.

  12. 12.

    Hansson L, Zanchetti A, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351:1755–62.

  13. 13.

    Sarafidis PA, Georgianos P, Bakris GL. Resistant hypertension—its identification and epidemiology. Nat Rev Nephrol. 2013;9:51–8.

  14. 14.

    ACCORD Study Group TAS, Cushman WC, Evans GW, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575–85.

  15. 15.

    American Diabetes Association. Standards of Medical Care in Diabetes-2013. Diabetes Care. 2013;36(Supplement 1):S11–66.

  16. 16.

    James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults. JAMA. 2014;311:507.

  17. 17.

    SPRINT Research Group TSR, Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–16.

  18. 18.

    Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373:2117–28.

  19. 19.

    American Diabetes Association. Cardiovascular disease and risk management: standards of medical care in diabetes-2018. Diabetes Care. 2018;41(Supplement 1):S86–104.

  20. 20.

    Sarafidis PA, Bakris GL. Antihypertensive therapy and the risk of new-onset diabetes. Diabetes Care. 2006;29:1167–69.

  21. 21.

    Sarafidis PA, Bakris GL. Use of a single target blood pressure level in type 2 diabetes mellitus for all cardiovascular risk reduction. Arch Intern Med. 2012;172:1304.

  22. 22.

    Sarafidis PA, Lazaridis AA, Ruiz-Hurtado G, Ruilope LM. Blood pressure reduction in diabetes: lessons from ACCORD, SPRINT and EMPA-REG OUTCOME. Nat Rev Endocrinol. 2017;13:365–74.

  23. 23.

    Sarafidis PA. Patient cases: 1. a patient with apparent compliance. High Blood Press Cardiovasc Prev. 2015;22(S1):15–8.

  24. 24.

    Sarafidis PA, Sharpe CC, Wood E, Blacklock R, Rumjon A, Al-Yassin A, et al. Prevalence, patterns of treatment, and control of hypertension in predialysis patients with chronic kidney disease. Nephron Clin Pract. 2012;120:147–55.

  25. 25.

    Patel A, MacMahon S, Chalmers J, Neal B, Woodward M, ADVANCE Collaborative Group. et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet. 2007;370:829–40.

  26. 26.

    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;304:61.

  27. 27.

    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;123:2799–810.

  28. 28.

    Reboldi G, Gentile G, Angeli F, Ambrosio G, Mancia G, Verdecchia P. Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta-analysis in 73 913 patients. J Hypertens. 2011;29:1253–69.

  29. 29.

    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. Arch Intern Med. 2012;172:1296.

  30. 30.

    Arguedas JA, Leiva V, Wright JM. Blood pressure targets for hypertension in people with diabetes mellitus. Cochrane Database Syst Rev. 2013; CD008277.

  31. 31.

    American Diabetes Association. Executive summary: standards of medical care in diabetes-2013. Diabetes Care. 2013; 36(Supplement 1): S4–10.

  32. 32.

    Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, Goff DC, Bigger JT, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545–59.

  33. 33.

    Margolis KL, O’Connor PJ, Morgan TM, Buse JB, Cohen RM, Cushman WC, et al. Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial. Diabetes Care. 2014;37:1721–8.

  34. 34.

    Sarafidis PA, Ruilope LM. Aggressive blood pressure reduction and renin-angiotensin system blochade in chronic kidney disease:time for re-evaluation? Kidney Int. 2014;85:536–46.

  35. 35.

    Khosla N, Sarafidis PA, Bakris GL. Microalbuminuria. Clinics in Laboratory Medicine 2006;26:635–53.

  36. 36.

    Ruiz-Hurtado G, Banegas JR, Sarafidis PA, Volpe M, Williams B, Ruilope LM. Has the SPRINT trial introduced a new blood-pressure goal in hypertension? Nat Rev Cardiol. 2017;14:560–6.

  37. 37.

    Cushman WC, Whelton PK, Fine LJ, Wright JT, Reboussin DM, Johnson KC, et al. SPRINT trial results. latest news in hypertension management. Hypertension. 2016;67:263–5.

  38. 38.

    Mancia G, Bertinieri G, Grassi G, Parati G, Pomidossi G, Ferrari A, et al. Effects of blood-pressure measurement by the doctor on patient’s blood pressure and heart rate. Lancet. 1983;2:695–8.

  39. 39.

    Mancia G, Parati G, Bilo G, Gao P, Fagard R, Redon J, et al. Ambulatory blood pressure values in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET). Hypertension. 2012;60:1400–6.

  40. 40.

    Esler M. SPRINT, or false start, toward a lower universal-treated blood pressure target in hypertension. Hypertension. 2016;67:266–7.

  41. 41.

    Perkovic V, Rodgers A. Redefining blood-pressure targets — SPRINT starts the marathon. N Engl J Med. 2015;373:2175–8.

  42. 42.

    Tonelli M, Muntner P, Lloyd A, Manns BJ, Klarenbach S, Pannu N, et al. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study. Lancet. 2012;380:807–14.

  43. 43.

    Cheung AK, Rahman M, Reboussin DM, Craven TE, Greene T, Kimmel PL, et al. Effects of intensive BP control in CKD. J Am Soc Nephrol. 2017;28:2812–23.

  44. 44.

    Wanner C, Inzucchi SE, Lachin JM, Fitchett D, von Eynatten M, Mattheus M, et al. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med. 2016;375:323–34.

  45. 45.

    Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377:644–57.

  46. 46.

    Abdul-Ghani M, Del Prato S, Chilton R, DeFronzo RA. SGLT2 inhibitors and cardiovascular risk: lessons learned from the EMPA-REG OUTCOME study. Diabetes Care. 2016;39:717–25.

  47. 47.

    Ferrannini E, Mark M, Mayoux E. CV protection in the EMPA-REG OUTCOME trial: a “Thrifty Substrate” hypothesis. Diabetes Care. 2016;39:1108–14.

  48. 48.

    Marx N, McGuire DK. Sodium-glucose cotransporter-2 inhibition for the reduction of cardiovascular events in high-risk patients with diabetes mellitus. Eur Heart J. 2016;37:3192–200.

  49. 49.

    Sarafidis PA, Tsapas A. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2016;374:1092–4.

  50. 50.

    Imprialos KP, Sarafidis PA, Karagiannis AI. Sodium–glucose cotransporter-2 inhibitors and blood pressure decrease. J Hypertens. 2015;33:2185–97.

  51. 51.

    Vasilakou D, Karagiannis T, Athanasiadou E, Mainou M, Liakos A, Bekiari E, et al. Sodium–glucose cotransporter 2 inhibitors for type 2 diabetes. Ann Intern Med. 2013;159:262.

  52. 52.

    Gilbert RE. Sodium–glucose linked transporter-2 inhibitors: potential for renoprotection beyond blood glucose lowering? Kidney Int. 2014;86:693–700.

  53. 53.

    Cherney DZI, Perkins BA, Soleymanlou N, Maione M, Lai V, Lee A, et al. Renal hemodynamic effect of sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetes mellitus. Circulation. 2014;129:587–97.

  54. 54.

    Pandit JA, Batlle D. Snapshot hemodynamics and clinical outcomes in hypertension. precision in the measurements is key. Hypertension. 2016;67:270–1.

  55. 55.

    Touyz RM, Dominiczak AF. Successes of SPRINT, but still some hurdles to cross. Hypertension. 2016;67:268–9.

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Correspondence to Pantelis Sarafidis.

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