Intensive blood pressure control in patients with type 2 diabetes reduced cardiovascular risk over nine years of follow-up despite a lack of between-group difference in blood pressure, a post hoc analysis found.
Researchers used data from Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD) participants in the standard glucose control arm who had established cardiovascular disease, had chronic kidney disease, were 75 years of age or older, and had a 10-year coronary heart risk of 15% or more. Participants had been randomized to either intensive (systolic BP <120 mm Hg; n=652) or standard (systolic BP <140 mm Hg, n=632) BP control for an average of five years. Observational follow-up occurred for an average of four more years through the ACCORDION study.
The main outcome of interest was the composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. Other outcomes included the individual components of the main outcome, any death, heart failure, and the composite of coronary death, nonfatal myocardial infarction, and unstable angina. Results were published March 2 by Diabetes, Obesity and Metabolism.
During the ACCORD trial, mean achieved systolic BP in the intensive BP control arm was 120±14 mm Hg compared to 134±16 mm Hg in the standard BP control arm (P<0.001). Systolic BP did not differ between groups during ACCORDION follow-up (132±17 mm Hg in the intensive group vs. 134±16 mm Hg in the standard group; P=0.14). Treatment-related adverse events occurred more frequently in the intensive BP control arm than in the standard BP control arm (4.1% vs. 2.1%; P=0.003).
The intensive group had lower rates of the main outcome compared to the standard group over the nine-year follow-up period (2.70%/y vs. 3.63%/y; hazard ratio [HR], 0.75; 95% CI, 0.60 to 0.95; P=0.015). The composite of coronary death, nonfatal myocardial infarction, and unstable angina was significantly lower with intensive BP control (2.77%/y vs. 3.81%/y; HR, 0.74; 95% CI, 0.58 to 0.92; P=0.008). The reduction in the main composite outcome was driven by a statistically significant reduction in nonfatal myocardial infarction (1.32%/y vs. 2.00%/y; HR, 0.66; 95% CI, 0.48 to 0.91; P=0.01). There were no statistically significant differences in the remaining outcomes.
An editorial noted, “Admittedly there is no randomized control trial that unequivocally demonstrates the benefit of aiming for an office SBP<130 mm Hg in patients with diabetes, and the recent [American College of Cardiology/American Heart Association] hypertension guidelines are not without limitations. The data from ACCORDION taken together with more recent meta-analyses and systematic reviews summarized in the [American Diabetes Association] BP guidelines clearly support a BP level of <130/80 mm Hg in people with high CV risk and diabetes.”