Intensive Systolic Blood Pressure Control May Not Reduce Mortality in Patients with Diabetes

DynaMed Weekly Update - Volume 5, Issue 13

Current guidelines from the American Diabetes Association (ADA) and other organizations recommend a blood pressure target < 130/80 mm Hg for patients with diabetes (Diabetes Care 2010 Jan;33 Suppl 1:S11). To date, there has been little experimental data to guide blood pressure target recommendations, but a new trial directly compared 2 different blood pressure goals. The Action to Control Cardiovascular Risk in Diabetes blood pressure trial (ACCORD BP) compared intensive systolic blood pressure control (target < 120 mm Hg) vs. standard control (target < 140 mm Hg) in 4,733 patients. While the trial did not stipulate specific antihypertensive regimens, patients in both groups were required to receive a drug class associated with reduction in cardiovascular events in patients with diabetes (ACE inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, or diuretics). They could also receive other medications as necessary. Mean systolic blood pressure from the end of first year to end of follow-up was 119.3 mm Hg for the intensive group and 133.5 mm Hg for the standard group. Systolic blood pressure target < 120 mm Hg does not reduce mortality or myocardial infarction but does reduce nonfatal stroke compared to target < 140 mm Hg (level 1 [mid-level] evidence). During a mean follow-up of 4.7 years, cardiovascular mortality was 2.5% in each group. There were no significant differences in all-cause mortality (6.3% vs. 6.1%), nonfatal myocardial infarction (5.3% vs. 6.2%), or heart failure (3.5% vs. 3.8%). Stroke occurred in 1.7% of the intensive group compared to 2.6% of the standard group (p = 0.01, NNT 84). However, the risk of serious adverse events from treatment was increased for the intensive group (3.3% vs. 1.3%, p < 0.001, NNH 50). Adverse events reported (not all individually significant) included hypotension, syncope, bradycardia or other arrhythmia, hyperkalemia, angioedema, and renal failure (N Engl J Med. 2010 Apr 29;362(17):1575).

For more information, see the Hypertension treatment in patients with diabetes topic in DynaMed.