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Canadian Journal of Cardiology

Blood Pressure–Lowering Targets in Patients With Diabetes Mellitus

Published:November 03, 2017DOI:https://doi.org/10.1016/j.cjca.2017.10.024

      Abstract

      Diabetes is a highly prevalent medical condition that commonly coexists with hypertension. The presence of diabetes and hypertension significantly increases the risk of adverse cardiovascular events. Although compelling evidence exists from randomized controlled trials demonstrating that blood pressure (BP) reduction effectively prevents cardiovascular complications, optimal BP targets remain uncertain and continue to be the subject of ongoing controversy. Until recently, most major clinical practice guidelines recommended a BP target of < 130/80 mm Hg, but some expert panels have raised their recommended treatment targets in recent years. The primary benefit of more intensive BP reduction appears to be prevention of stroke, but this is balanced against an increase in treatment burden, side effects, and cost. The purpose of this review is to summarize the global body of evidence evaluating BP targets as well as to compare the recommendations from different clinical practice guidelines, which inform the treatment of patients with hypertension and diabetes.

      Résumé

      Le diabète est une maladie très répandue qui coexiste fréquemment avec l’hypertension. La présence du diabète et de l’hypertension augmente significativement le risque d’événements cardiovasculaires indésirables. Bien que les données probantes irréfutables proviennent d’essais cliniques à répartition aléatoire qui démontrent que la réduction de la pression artérielle (PA) prévient de manière efficace les complications cardiovasculaires, les valeurs cibles optimales de la PA demeurent incertaines et font actuellement l’objet d’une controverse. Jusqu’à récemment, les valeurs cibles de la PA recommandées par la plupart des principales lignes directrices de pratique clinique étaient < 130/80 mm Hg, mais certains groupes d’experts ont revu à la hausse les cibles de traitement recommandées au cours des dernières années. Il semble que l’avantage principal d’une plus grande réduction de la PA soit la prévention de l’accident vasculaire cérébral, mais en contrepartie, on retrouve un fardeau de traitement plus lourd, des effets secondaires plus nombreux et des coûts plus élevés. L’objectif de la présente revue est de faire la synthèse de l’ensemble des données probantes qui permettent d’évaluer les valeurs cibles de la PA et de comparer les recommandations des diverses lignes directrices de pratique clinique, dont l’objet est de renseigner sur le traitement des patients hypertendues et diabétiques.
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      References

        • Public Health Agency of Canada
        Diabetes in Canada: Facts and figures from a public health perspective.
        (Ottawa, Canada)2011
        • Haffner S.M.
        • Lehto S.
        • Ronnemaa T.
        • Pyorala 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: 229-234
        • Kabakov E.
        • Norymberg C.
        • Osher E.
        • et al.
        Prevalence of hypertension in type 2 diabetes mellitus: impact of the tightening definition of high blood pressure and association with confounding risk factors.
        J Cardiometab Syndr. 2006; 1: 95-101
        • Stamler J.
        • Vaccaro O.
        • Neaton J.D.
        • 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: 434-444
      1. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group.
        Lancet. 1998; 352: 837-853
        • Duckworth W.
        • Abraira C.
        • Moritz T.
        • et al.
        Glucose control and vascular complications in veterans with type 2 diabetes.
        N Engl J Med. 2009; 360: 129-139
        • Group A.C.
        • Patel A.
        • MacMahon S.
        • et al.
        Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.
        N Engl J Med. 2008; 358: 2560-2572
        • CDC Diabetes Cost-effectiveness Group
        Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes.
        JAMA. 2002; 287: 2542-2551
      2. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group.
        BMJ. 1998; 317: 703-713
        • Bangalore S.
        • Kumar S.
        • Lobach I.
        • Messerli F.H.
        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 (9 p following 810): 2799-2810
        • Gaede P.
        • Vedel P.
        • Larsen N.
        • et al.
        Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.
        N Engl J Med. 2003; 348: 383-393
        • Cushman W.C.
        • Evans G.W.
        • et al.
        • ACCORD Study Group
        Effects of intensive blood-pressure control in type 2 diabetes mellitus.
        N Engl J Med. 2010; 362: 1575-1585
        • Hansson L.
        • Zanchetti A.
        • Carruthers S.G.
        • 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: 1755-1762
        • Reboldi G.
        • Gentile G.
        • Angeli F.
        • et al.
        Effects of intensive blood pressure reduction on myocardial infarction and stroke in diabetes: a meta-analysis in 73,913 patients.
        J Hypertens. 2011; 29: 1253-1269
        • Schrier R.W.
        • Estacio R.O.
        • Esler A.
        • Mehler P.
        Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes.
        Kidney Int. 2002; 61: 1086-1097
        • Patel A.
        • MacMahon S.
        • et al.
        • ADVANCE Collaborative Group
        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: 829-840
        • 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: 1527-1535
        • Thomopoulos C.
        • Parati G.
        • Zanchetti A.
        Effects of blood-pressure-lowering treatment on outcome incidence in hypertension: 10-Should blood pressure management differ in hypertensive patients with and without diabetes mellitus? Overview and meta-analyses of randomized trials.
        J Hypertens. 2017; 35: 922-944
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • 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: 2560-2572
        • Dasgupta K.
        • Quinn R.R.
        • Zarnke K.B.
        • et al.
        The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.
        Can J Cardiol. 2014; 30: 485-501
        • American Diabetes Association
        Executive summary: Standards of medical care in diabetes—2012.
        Diabetes Care. 2012; 35: S4-10
        • Canadian Diabetes Association Clinical Practice Guidelines Expert Committee
        • Gilbert R.E.
        • Rabi D.
        • et al.
        Treatment of hypertension.
        Can J Diabetes. 2013; 37: S117-S118
        • Chalmers J.
        • MacMahon S.
        • Mancia G.
        • et al.
        1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization.
        Clin Exp Hypertens. 1999; 21: 1009-1060
        • Cifkova R.
        • Erdine S.
        • Fagard R.
        • et al.
        Practice guidelines for primary care physicians: 2003 ESH/ESC hypertension guidelines.
        J Hypertens. 2003; 21: 1779-1786
        • Williams B.
        • Poulter N.R.
        • Brown M.J.
        • et al.
        Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV.
        J Hum Hypertens. 2004; 18: 139-185
        • James P.A.
        • Oparil S.
        • Carter B.L.
        • et al.
        2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
        JAMA. 2014; 311: 507-520
        • Weber M.A.
        • Schiffrin E.L.
        • White W.B.
        • et al.
        Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension.
        J Hypertens. 2014; 32: 3-15
        • Mancia G.
        • Fagard R.
        • Narkiewicz K.
        • 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).
        Eur Heart J. 2013; 34: 2159-2219
        • American Diabetes Association
        Standards of medical care in diabetes—2013.
        Diabetes Care. 2013; 36: S11-S66
        • Leung A.A.
        • Daskalopoulou S.S.
        • Dasgupta K.
        • et al.
        Hypertension Canada's 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults.
        Can J Cardiol. 2017; 33: 557-576
        • Adler A.I.
        • Stratton I.M.
        • Neil H.A.
        • et al.
        Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study.
        BMJ. 2000; 321: 412-419
        • Orchard T.J.
        • Forrest K.Y.
        • Kuller L.H.
        • Becker D.J.
        • Pittsburgh Epidemiology of Diabetes Complications Study
        Lipid and blood pressure treatment goals for type 1 diabetes: 10-year incidence data from the Pittsburgh Epidemiology of Diabetes Complications Study.
        Diabetes Care. 2001; 24: 1053-1059
        • Lewington S.
        • Clarke R.
        • Qizilbash 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: 1903-1913
        • American Diabetes Association
        Cardiovascular disease and risk management.
        Diabetes Care. 2017; 40: S75-87
        • Rabi D.M.
        • Padwal R.
        • Tobe S.W.
        • et al.
        Risks and benefits of intensive blood pressure lowering in patients with type 2 diabetes.
        CMAJ. 2013; 185: 963-967
        • Action to Control Cardiovascular Risk in Diabetes Study Group
        • Gerstein H.C.
        • Miller M.E.
        • et al.
        Effects of intensive glucose lowering in type 2 diabetes.
        N Engl J Med. 2008; 358: 2545-2559
        • McAlister F.A.
        • Straus S.E.
        • Sackett D.L.
        • Altman D.G.
        Analysis and reporting of factorial trials: a systematic review.
        JAMA. 2003; 289: 2545-2553
        • Margolis K.L.
        • O'Connor P.J.
        • Morgan T.M.
        • et al.
        Outcomes of combined cardiovascular risk factor management strategies in type 2 diabetes: the ACCORD randomized trial.
        Diabetes Care. 2014; 37: 1721-1728
      3. The Hypertension Optimal Treatment study (the HOT study). 2. Blood Press, 1993: 62-68
        • Arguedas J.A.
        • Leiva V.
        • Wright J.M.
        Blood pressure targets for hypertension in people with diabetes mellitus.
        Cochrane Database Syst Rev. 2013; : CD008277
        • Wright Jr., J.T.
        • Williamson J.D.
        • Whelton P.K.
        • et al.
        A randomized trial of intensive versus standard blood-pressure control.
        N Engl J Med. 2015; 373: 2103-2116
        • Berlowitz D.R.
        • Foy C.G.
        • Kazis L.E.
        • et al.
        Effect of intensive blood-pressure treatment on patient-reported outcomes.
        N Engl J Med. 2017; 377: 733-744
        • American Diabetes Association
        Standards of medical care in diabetes—2014.
        Diabetes Care. 2014; 37: S14-80
        • American Diabetes Association
        Cardiovascular disease and risk management.
        Diabetes Care. 2015; 38: S49-57
        • American Diabetes Association
        Cardiovascular disease and risk management.
        Diabetes Care. 2016; 39: S60-71
        • Padwal R.
        • Rabi D.M.
        • Schiffrin E.L.
        Recommendations for intensive blood pressure lowering in high-risk patients, the Canadian viewpoint.
        Hypertension. 2016; 68: 3-5
        • McBrien K.
        • Rabi D.M.
        • Campbell N.
        • et al.
        Intensive and standard blood pressure targets in patients with type 2 diabetes mellitus: systematic review and meta-analysis.
        Arch Intern Med. 2012; 172: 1296-1303
        • Adamsson Eryd S.
        • Gudbjornsdottir S.
        • Manhem K.
        • et al.
        Blood pressure and complications in individuals with type 2 diabetes and no previous cardiovascular disease: national population based cohort study.
        BMJ. 2016; 354: i4070
        • Lonn E.M.
        • Yusuf S.
        Should patients with cardiovascular risk factors receive intensive treatment of hypertension to <120/80 mm Hg target? An antagonist view from the HOPE-3 trial (Heart Outcomes Evaluation-3).
        Circulation. 2016; 134: 1311-1313
        • Oparil S.
        • Lewis C.E.
        Should patients with cardiovascular risk factors receive intensive treatment of hypertension to <120/80 mm Hg target? A protagonist view from the SPRINT Trial (Systolic Blood Pressure Intervention Trial).
        Circulation. 2016; 134: 1308-1310
        • Wright Jr., J.T.
        • Fine L.J.
        • Lackland D.T.
        • et al.
        Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view.
        Ann Intern Med. 2014; 160: 499-503

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