Good BP control as important as glucose control in T2D

Intensive antihypertensive therapy in patients with type 2 diabetes reduces mortality and major vascular events irrespective of baseline blood pressure or cardiovascular disease (CVD) risk, Australian research shows.

A post-hoc analysis of the ADVANCE trial data showed treatment with a fixed-dose combination of perindopril-indapamide reduced all-cause mortality (HR 0.86) and major microvascular and macrovascular events (HR 0.91) compared to placebo.

The study comprised more than 10,000 patients with type 2 diabetes and a history of CVD or at least one other CVD risk factor. During a mean follow-up of 4.3 years there were 837 deaths and 966 major vascular events.

There was no evidence of heterogeneity in the effect of blood pressure lowering treatment across sub-groups of patients on the basis of baseline systolic blood pressure (SBP), diastolic blood pressure or ASCVD score.

“For those with baseline SBP <140 mm Hg, most of the benefit for more intensive therapy was driven by the group with baseline SBP of 130 to 139 mm Hg – a finding that supports current American College of Cardiology/American Heart Association guidelines,” the study said.

However an intensive blood pressure goal in patients with diabetes has remained controversial.

The study authors said that their findings support those of a meta-analysis showing a reduction in ASCVD events from intensive blood pressure-lowering treatment in patients with diabetes mellitus and a mean SBP of <140 mm Hg.

“Taken together with the results from the current study, this suggests that most adults with type 2 diabetes mellitus taking antihypertensive medication would benefit from a BP goal of <130/80 mm Hg, thus raising the possibility that the current American Diabetes Association guidelines may be too conservative.”

The study also found adverse events were ‘negligible, compared with clinical events’.

Co-author Professor John Chalmers, from The George Institute for Global Health, told the limbic it was safe to lower blood pressure in patients who warrant the treatment.

“There is a risk of over-treatment, but in general in the American guidelines, they recommend for most people who have no other risk factors, it should be lifestyle factors in the first instance before they are exposed to drugs.”

He said people with diabetes were at a much higher risk.

“It’s always very much more difficult in patients with diabetes; they have so many more hurdles to overcome. They have to watch their weight, they have to watch their glucose, they have to watch their blood pressure. It’s quite tough.”

“Good control of blood pressure is very important in diabetes; it is at least as important as good glucose control.”

However there was a ‘package of considerations’ in addition to blood pressure goals.

“Good control of blood pressure is one essential component in the context of treating people with diabetes but it is one component. The other things are good lifestyle management, good weight control, good glucose control, control of fats and cholesterol, and smoking cessation.”

The study said it remains unclear how intensive glycaemic control interacts with intensive blood pressure management, especially with newer medications such as SGLT2 inhibitors.

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