As part of the ACCORD trial, more than 4,000 patients with type 2 diabetes, hypertension and cardiovascular disease (CVD) or CVD risk factors were randomized to a systolic blood pressure (BP) target of less than 120 mm Hg or less than 140 mm Hg (as well as intensive and standard glycemic targets). After about four years of follow-up, no significant difference was seen between blood pressure groups on the primary composite outcome of renal failure, retinal photocoagulation or vitrectomy for retinopathy. Authors concluded that intensive blood pressure control did not reduce microvascular events more than standard control, regardless of intensity of glycemic control.
The study was published by Kidney International on March 2. The following commentary by Juan P. Brito, MD, and ACP Member Victor M. Montori, MD, MSc, was published in the ACP Journal Club section of the Oct. 16 Annals of Internal Medicine.
How far should BP be lowered to prevent microvascular complications in patients with type 2 diabetes? Favorable results from the UK Prospective Diabetes Study, which sought a BP target < 150/85 mm Hg, and from the Appropriate Blood Pressure Control in Diabetes trial, which sought a BP target < 130/80 mm Hg, supported the notion that “lower is better.” However, the ACCORD-BP trial failed to find favorable results with a target systolic BP < 120 mm Hg. New microalbuminuria events were reduced by 16% (hazard ratio 0.84), but intensive BP control did not reduce the incidence of advanced kidney or eye disease, regardless of intensity of glycemic control.
These results strongly suggest that compared with more modest targets, lowering BP to < 120/80 mm Hg with current therapies may offer no benefits that patients would value but could cause serious adverse effects.
Only 124 patients developed renal failure in this study (which makes the results imprecise), and about half of those who developed renal failure and had follow-up albumin measures did not have micro- or macroalbuminuria at baseline or develop these markers during follow-up. Therefore, microalbuminuria may not be as reliable a surrogate for advanced renal outcomes as previously believed.
Although BP and glycemic control continue to play an important role in the management of patients with type 2 diabetes and hypertension, current evidence supports moderate targets and avoiding overtreatment.