Department of Pharmacy Practice, Texas Tech University Health Sciences Center (TTUHSC) School of Pharmacy (Drs. MacLaughlin and Young); Department of Family and Community Medicine (Drs. MacLaughlin, Slaton, and Young) and Department of Internal Medicine (Dr. MacLaughlin), TTUHSC School of Medicine, Amarillo, Tex; PinnacleHealth CardioVascular Institute, Wormleysburg, Pa (Dr. DePalma); Director of Regulatory and Professional Practice, American Academy of Physician Assistants, Alexandria, Va (Dr. DePalma) Eric.MacLaughlin@ttuhsc.edu
Drs. MacLaughlin and DePalma were members of the Guideline Writing Committee for the 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. This manuscript does not reflect the views or opinions of the Guideline Writing Committee.
Drs. Slaton and Young reported no potential conflict of interest relevant to this article.
The most appropriate BP goal for patients with diabetes has been the subject of much debate, with different goals recommended in different guidelines (TABLE 21,2,6). The most recent American Diabetes Association guideline recommends a BP goal <140/90 mm Hg for most patients, with lower targets (<130/80 mm Hg) for patients at high CV risk if it is achievable without undue treatment burden,28 whereas the 2017 ACC/AHA guideline recommends a BP goal <130/80 mm Hg for all adults with diabetes.1
The ACCORD trial.There is limited evidence to suggest which BP goal is most appropriate for patients with diabetes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is the only RCT specifically designed to assess the impact of intensive vs standard BP goals in patients with diabetes.29 In ACCORD, 4733 patients with type 2 diabetes were randomized to either an intensive BP-lowering group (SBP <120 mm Hg) or a standard BP-lowering group (SBP <140 mm Hg). After a mean follow-up of 4.7 years, there was no difference in the primary composite endpoint of nonfatal MI, nonfatal stroke, or death from CV causes. However, the risk of stroke was reduced (NNT=89). Interpretation of ACCORD is limited due to its factorial design and because the trial was significantly underpowered.
Systematic reviews and meta-analyses.Literature supporting lower BP goals in patients with diabetes primarily comes from systematic reviews and meta-analyses.30 In the evidence-based review performed for the 2017 ACC/AHA guidelines, more intensive treatment was associated with a decrease in fatal or nonfatal stroke.8 The results from the ACCORD trial and SPRINT are consistent,31 and a sub-study of SPRINT patients with pre-diabetes showed preservation of CV benefit.32 Also, a meta-analysis of subgroups of trial participants with diabetes showed that more intensive BP lowering in patients is associated with a decrease in major CV events.14
Treating patients with chronic kidney disease
As with diabetes and older patients, recommended goals for patients with CKD have varied (TABLE 21,2,6). The Kidney Disease Improving Global Outcomes (KDIGO) 2012 guideline recommended the same target BP as JNC 7 and the 2017 ACC/AHA guideline: ≤130/80 mm Hg in patients with CKD and urine albumin excretion ≥30 mg/24 hours (or equivalent).1,2,33 KDIGO recommended a more relaxed target (≤140/90 mm Hg), however, for patients with CKD and urine albumin excretion <30 mg/24 hours.1,33
Scant data exist from RCTs designed to assess the CV effects of intensive BP targets in patients with CKD. In SPRINT, where 28% of patients had stage 3 or 4 CKD, benefits of more intensive therapy were similar to those observed in the overall cohort.16,34 While some RCTs have assessed the effect of more intensive BP lowering on progression of CKD, they were not specifically designed or powered to address CV outcomes.35,36
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