BPROAD — End of the Road for Debate on Systolic Blood-Pressure Goals in Type 2 Diabetes?

BACKGROUND

Elevated blood pressure mediates much of the organ toxicity affecting persons with type 2 diabetes. The management of hypertension occupies as much clinical attention as that of dysglycemia, yet the recommended blood-pressure target in type 2 diabetes remains controversial.

METHODS

The Systolic Blood Pressure Intervention Trial (SPRINT; 9361 participants), which excluded persons with type 2 diabetes, showed that a systolic blood-pressure target of less than 120 mm Hg led to a lower incidence of major cardiovascular events or death than a target of less than 140 mm Hg. Some national society guidelines recommend a systolic blood-pressure goal of less than 130 mm Hg in persons with hypertension, including in those with concomitant type 2 diabetes, but controversy persists because randomized trials showing a benefit of intensive blood-pressure targets in persons with type 2 diabetes have been lacking.

RESULTS

In the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial, a 2-by-2 factorial design was used to compare intensive therapy targeting a systolic blood pressure of less than 120 mm Hg with standard therapy targeting a systolic blood pressure of less than 140 mm Hg and to compare intensive with standard blood-glucose targets among 4733 persons with type 2 diabetes. The trial showed no significant difference in the incidence of primary-outcome events (nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes) between the intensive and standard therapies. Although the risk of stroke was lower with intensive therapy than with standard therapy, the incidence of adverse events, including hypotension, syncope, bradycardia, arrhythmia, hypokalemia, and renal impairment, was higher with intensive therapy.

CONCLUSIONS

The results of the BPROAD trial provide strong support for using intensive blood-pressure treatment targets in persons with diabetes. The results are broadly applicable because many persons with diabetes would fulfill at least one of the trial eligibility criteria; for example, 63% of persons with diabetes in the United States also have obesity, and 30% have chronic kidney disease. With the BPROAD trial reinforcing SPRINT and STEP findings, strong evidence now supports a lower systolic blood-pressure target for adults with hypertension at high risk for cardiovascular disease with or without type 2 diabetes.

BACKGROUND

Elevated blood pressure mediates much of the organ toxicity affecting persons with type 2 diabetes. The management of hypertension occupies as much clinical attention as that of dysglycemia, yet the recommended blood-pressure target in type 2 diabetes remains controversial.

METHODS

The Systolic Blood Pressure Intervention Trial (SPRINT; 9361 participants), which excluded persons with type 2 diabetes, showed that a systolic blood-pressure target of less than 120 mm Hg led to a lower incidence of major cardiovascular events or death than a target of less than 140 mm Hg. Some national society guidelines recommend a systolic blood-pressure goal of less than 130 mm Hg in persons with hypertension, including in those with concomitant type 2 diabetes, but controversy persists because randomized trials showing a benefit of intensive blood-pressure targets in persons with type 2 diabetes have been lacking.

RESULTS

In the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial, a 2-by-2 factorial design was used to compare intensive therapy targeting a systolic blood pressure of less than 120 mm Hg with standard therapy targeting a systolic blood pressure of less than 140 mm Hg and to compare intensive with standard blood-glucose targets among 4733 persons with type 2 diabetes. The trial showed no significant difference in the incidence of primary-outcome events (nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes) between the intensive and standard therapies. Although the risk of stroke was lower with intensive therapy than with standard therapy, the incidence of adverse events, including hypotension, syncope, bradycardia, arrhythmia, hypokalemia, and renal impairment, was higher with intensive therapy.

CONCLUSIONS

The results of the BPROAD trial provide strong support for using intensive blood-pressure treatment targets in persons with diabetes. The results are broadly applicable because many persons with diabetes would fulfill at least one of the trial eligibility criteria; for example, 63% of persons with diabetes in the United States also have obesity, and 30% have chronic kidney disease. With the BPROAD trial reinforcing SPRINT and STEP findings, strong evidence now supports a lower systolic blood-pressure target for adults with hypertension at high risk for cardiovascular disease with or without type 2 diabetes.