Cor Vasa 2010, 52(11-12):700-705 | DOI: 10.33678/cor.2010.175

What are the optimal values of systolic blood pressure in patients with diabetes? The ACCORD Blood Pressure study completed

Jiří Widimský

Klinika kardiologie, Institut klinické a experimentální medicíny, Praha, Česká republika

The presence of hypertension dramatically increases the cardiovascular risk of patients with type-2 diabetes mellitus. The 2007 European guidelines for the management of arterial hypertension recommend to decrease systolic blood pressure (BP) to < 130 mmHg in hypertensive patients with diabetes. However, this recommendation is not based on data obtained from a randomized prospective study. Mean systolic BP levels of 135/74 mmHg were only reported in a group of patients with diabetes treated with a fixed perindopril/indapamid combination in the ADVANCE study.
A retrospective analysis of ONTARGET showed a J-curve relation between systolic BP and the primary endpoint (nonfatal myocardial infarction, nonfatal stroke, and cardiovascular mortality). However, no J-curve phenomenon was seen with stroke.
The ACCORD study sought to determine whether a decrease in systolic BP to < 120 mmHg would result in a greater reduction in the incidence of cardiovascular complications compared with a decrease in systolic BP to < 140 mmHg.
A decrease in systolic BP to < 120 mmHg (mean BP during therapy 119.3/64.4 mmHg) did not result in a significant decrease in the composite primary endpoint (nonfatal myocardial infarction, nonfatal stroke, and cardiovascular mortality) or a decrease in cardiovascular or total mortality compared with standard therapy (mean BP during therapy 133.5/70.5 mmHg). However, there was a significant decrease in the incidence of stroke in the group with target systolic BP < 120 mmHg. Signs of renal dysfunction were also favourably affected in the group achieving intensive systolic BP control.
Hence, there is no rationale for decreasing systolic BP < 130 mmHg in all patients with type-2 diabetes mellitus in terms of total and cardiovascular mortality. In patients at high risk for stroke, i.e., primarily in the elderly patients and in individuals after a stroke, it is advisable to decrease systolic BP to < 130 mmHg.
The 2009 Reappraisal of the European guidelines on hypertension management, as if foreseeing the results of the ACCORD Blood Pressure study, BP, recommended target systolic BP levels of 130-139 mmHg for patients with diabetes, consistent with results of the ADVANCE study. Results of the prospective ACCORD Blood Pressure study were supported by retrospective analysis of data of patients with diabetes in the INVEST study involving hypertensives with coronary heart disease and type-2 diabetes.

Keywords: Target systolic BP; Type-2 diabetes mellitus; Intensive vs. standard management of hypertension in diabetes

Published: November 1, 2010  Show citation