Is the next STEP on the BPROAD to intensive blood pressure lowering for all type 2 diabetic patients?: consensus statements from the Korean Society of Hypertension

Recent publication of the Systolic Blood Pressure Intervention Trial (SPRINT) in close temporal proximity to 2 meta-analyses affirming the benefits of intensive blood pressure (BP) control collectively signify the need to reevaluate BP targets in hypertensive patients at high risk for cardiovascular events.1–3 This commentary discusses how this recent evidence has affected Canadian clinical practice guidelines, describes the process used to update these guidelines in light of this evidence, and outlines the major issues deliberated by Canadian Hypertension Education Program (CHEP) Task Force members during this process. In the SPRINT trial, which studied 9361 subjects aged ≥50 years at increased risk for cardiovascular events, intensive systolic BP control (to <120 mm Hg) reduced the incidence of cardiovascular events and mortality by 25% (5.2% versus 6.8%; hazard ratio 0.75; 95% confidence interval 0.64–0.89) compared with standard systolic BP control (135–139 mm Hg).1 Furthermore, a meta-analysis of 55 randomized controlled trials (265 576 subjects) demonstrated that the reduction in cardiovascular events realized from a 10-mm Hg systolic BP reduction is similar across different quintiles of baseline systolic BP (<130, 130–139, 140–149, 150–159, ≥160 mm Hg).2 In a second meta-analysis of 14 treat-to-target trials (44 989 subjects), a 7-mm Hg mean systolic BP reduction (from 140 to 133 mm Hg) led to a 14% (95% confidence interval 0.78–0.96) reduction in major cardiovascular events.3 In aggregate, these data support the implementation of intensive BP control in high-risk patients. Canadian hypertension clinical practice guidelines are crafted and disseminated by the multidisciplinary 75-member CHEP Recommendations Task Force, a process that is funded by Hypertension Canada.4 CHEP has produced annually updated recommendations for the diagnosis and management of high BP since 1999.5 The CHEP process consists of the following: 1. A Cochrane librarian conducts literature searches in collaboration with Task Force members. These searches are designed to inform …

No abstract available.

Background: Hypertension (HTN), a prevalent comorbidity in type 2 diabetes mellitus (T2DM), increases the risk of cardiovascular (CV) events, mortality, and kidney complications. However, optimal blood pressure (BP) targets in patients with T2DM remain unclear. Research Question: Does intensive BP control, compared to standard targets, reduce CV, renal, and mortality outcomes in patients with T2DM? Aims: We aim to conduct an updated meta-analysis to evaluate the effects of intensive vs. standard BP control on CV and kidney outcomes and mortality in T2DM patients. Methods: A comprehensive search of PubMed, Cochrane Library, and Scopus was conducted through December 2024 for trials comparing intensive vs. standard BP control in patients with T2DM. Outcomes assessed included all-cause mortality, CV mortality, major adverse CV events (MACE), stroke, myocardial infarction (MI), incident heart failure (HF), chronic kidney disease (CKD) development, albuminuria, and serious adverse events (SAEs). Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random effects model. Results: 28 trials encompassing 104,634 patients were included. Intensive BP control significantly reduced the risk of CV mortality (RR: 0.75, 95% CI: 0.65–0.87, P = 0.0001), all-cause mortality (RR: 0.85, 95% CI: 0.76–0.95, P = 0.004), MACE (RR: 0.81, 95% CI: 0.75–0.87, P &lt; 0.00001), stroke (RR: 0.70, 95% CI: 0.61–0.80, P &lt; 0.00001), MI (RR: 0.86, 95% CI: 0.79–0.94, P = 0.001), HF (RR: 0.78, 95% CI: 0.64–0.96, P = 0.02), and albuminuria (RR: 0.89, 95% CI: 0.82–0.97, P = 0.005). There were no significant differences in CKD development (RR: 1.08, 95% CI: 0.92–1.26, P = 0.36) or SAEs (RR: 1.16, 95% CI: 0.97–1.40, P = 0.10). Conclusions: Intensive BP control in patients with T2DM was associated with a lower risk of all-cause mortality, CV mortality, MACE, stroke, MI, HF, and albuminuria as compared to standard control, without an increased risk of serious adverse events.

Preventable Coronary Heart Disease Events from Control of Cardiovascular Risk Factors in US Adults With Diabetes (Projections from Utilizing the UKPDS Risk Engine)

The Impact of APOL1 on Chronic Kidney Disease and Hypertension.

One of the great successes of modern medicine is the development of effective pharmacological treatments to lower blood pressure (BP). Of the modifiable risk factors for cardiovascular disease, elevated BP or hypertension has the highest population attributable risk,1 and a near continuous relationship with rates of stroke and coronary heart disease from levels of 115 mm Hg systolic and 75 mm Hg diastolic BP.2 Overviews of randomized trials are consistent in showing that lowering systolic BP by 5 to 10 mm Hg reduces the risk of stroke by one third, irrespective of disease history, initial BP level, or type of agent used.3–5 Moreover, more intensive long-term BP lowering can result in additional benefits proportional to the size of fall in BP.4–6 Despite this body of evidence, there has been longstanding controversy (and consternation) over the levels to which BP should be brought down by treatment for the prevention of cardiovascular disease. Because there has been limited randomized evidence, guideline committees have been challenged in defining BP targets below 130 to 140 mm Hg to manage individual patients.7 Concerns over diminishing net benefit being overtaking by excessive harm with increasing reductions in BP is supported by a physiological argument over critical thresholds for organ perfusion and secondary analysis of randomized trials suggesting a J-shaped relationship with cardiovascular events.8 Moreover, recent trials of more intensive BP lowering, including the Action to Control Cardiovascular Risk on Type 2 Diabetes (ACCORD)9 and Secondary Prevention of Small Subcortical Strokes (SPS3),10 failed to show significant reductions in rates of ischemic stroke with systolic BP reductions below 120 and 130 mm Hg, respectively. The main result of the Systolic …

Benefit-harm trade-offs of intensive blood pressure control versus standard blood pressure control on cardiovascular and renal outcomes: an individual participant data analysis of randomised controlled trials.

HYPERTENSION––AT A CRITICAL CROSSROADS? Hypertension (HTN), through its high incidence, prevalence, and dire consequences, remains a major contributor to the global burden of disease. The noncommunicable disease burden now exceeds that of infectious disease even in the developing world, with precious few resources anywhere to manage this burgeoning challenge. Nevertheless, HTN control rates remain unacceptably low. Currently, approximately 73 million Americans have HTN, and blood pressure (BP) is controlled in only around 50% of the cases. Between 1988–1994 and 2007–2010, the prevalence of uncontrolled high BP declined for all age groups. However, in 2007–2010, nearly one half of adults with HTN continued to have uncontrolled high BP. Good, clear guidance about how to screen for, detect, and treat HTN is needed for patients, health-care providers, insurance companies, public health bodies, agencies, and governments. The question we posed in 2014 was whether we have this guidance or whether the multiple overlapping and sometimes even contradictory statements recently issued do not in fact provide a perfect storm of confusion.

What should the optimal blood pressure goal be in patients with diabetes mellitus or chronic kidney disease?

Editorial What should the optimal blood pressure goal be in patients with diabetes mellitus or chronic kidney disease?

Blood Pressure Goals: How Low Is Safe in CKD?

Older patients with hypertension receiving intensive systolic blood pressure control (110-130 mm Hg) have lower incidences of cardiovascular events than those receiving standard control (130-150 mm Hg). Nevertheless, the mortality reduction is insignificant, and intensive blood pressure management results in more medical costs from treatments and subsequent adverse events. To examine the incremental lifetime outcomes, costs, and cost-effectiveness of intensive vs standard blood pressure control in older patients with hypertension from the health care payer's perspective. This economic analysis was conducted with a Markov model to examine the cost-effectiveness of intensive blood pressure management among patients aged 60 to 80 years with hypertension. Treatment outcome data from the Trial of Intensive Blood-Pressure Control in Older Patients With Hypertension (STEP trial) and different cardiovascular risk assessment models for a hypothetical cohort of STEP-eligible patients were used. Costs and utilities were obtained from published sources. The incremental cost-effectiveness ratio (ICER) against the willingness-to-pay threshold was used to evaluate whether the management was cost-effective. Extensive sensitivity, subgroup, and scenario analyses were performed to address uncertainty. The US and UK population using race-specific cardiovascular risk models were conducted in the generalizability analysis. Data for the STEP trial were collected from February 10 to March 10, 2022, and were analyzed for the present study from March 10 to May 15, 2022. Hypertension treatments with a systolic blood pressure target of 110 to 130 mm Hg or 130 to 150 mm Hg. Incremental lifetime quality-adjusted life-years (QALYs), costs, and ICER are discounted at the given rates annually. After simulating 10 000 STEP-eligible patients assumed to be 66 years of age (4650 men [46.5%] and 5350 women [53.5%]) in the model, the ICER values were ¥51 675 ($12 362) per QALY gained in China, $25 417 per QALY gained in the US, and £4679 ($7004) per QALY gained in the UK. Simulations projected that the intensive management in China being cost-effective were 94.3% and 100% below the willingness-to-pay thresholds of 1 time (¥89 300 [$21 364]/QALY) and 3 times (¥267 900 [$64 090]/QALY) the gross domestic product per capita, respectively. The US had 86.9% and 95.6% probabilities of cost-effectiveness at $50 000/QALY and $100 000/QALY, respectively, and the UK had 99.1% and 100% of probabilities of cost-effectiveness at £20 000 ($29 940)/QALY and £30 000 ($44 910)/QALY, respectively. In this economic evaluation, the intensive systolic blood pressure control in older patients produced fewer cardiovascular events and had acceptable costs per QALY gained, well below the typical willingness-to-pay thresholds. The cost-effective advantages of intensive blood pressure management in older patients were consistent over various clinical scenarios across different countries.

It is currently unknown whether intensive blood pressure (BP) lowering beyond that recommended would lead to more lowering of the risk of left ventricular hypertrophy (LVH) in patients with hypertension and whether reducing the risk of LVH explains the reported cardiovascular disease (CVD) benefits of intensive BP lowering in this population. This analysis included 8164 participants (mean age, 67.9 years; 35.3% women; 31.2% blacks) with hypertension but no diabetes mellitus from the SPRINT trial (Systolic Blood Pressure Intervention Trial): 4086 randomly assigned to intensive BP lowering (target SBP <120 mm Hg) and 4078 assigned to standard BP lowering (target SBP <140 mm Hg). Progression and regression of LVH as defined by Cornell voltage criteria derived from standard 12-lead ECGs recorded at baseline and biannually were compared between treatment arms during a median follow-up of 3.81 years. The effect of intensive (versus standard) BP lowering on the SPRINT primary CVD outcome (a composite of myocardial infarction, acute coronary syndrome, stroke, heart failure, and CVD death) was compared before and after adjustment for LVH as a time-varying covariate. Among SPRINT participants without baseline LVH (n=7559), intensive (versus standard) BP lowering was associated with a 46% lower risk of developing LVH (hazard ratio=0.54; 95% confidence interval, 0.43-0.68). Similarly, among SPRINT participants with baseline LVH (n=605, 7.4%), those assigned to the intensive (versus standard) BP lowering were 66% more likely to regress/improve their LVH (hazard ratio=1.66; 95% confidence interval, 1.31-2.11). Adjustment for LVH as a time-varying covariate did not substantially attenuate the effect of intensive BP therapy on CVD events (hazard ratio of intensive versus standard BP lowering on CVD, 0.76 [95% confidence interval, 0.64-0.90] and 0.77 [95% confidence interval, 0.65-0.91] before and after adjustment for LVH as a time-varying covariate, respectively). Among patients with hypertension but no diabetes mellitus, intensive BP lowering (target systolic BP <120 mm Hg) compared with standard BP lowering (target systolic BP <140 mm Hg) resulted in lower rates of developing new LVH in those without LVH and higher rates of regression of LVH in those with existing LVH. This favorable effect on LVH did not explain most of the reduction in CVD events associated with intensive BP lowering in the SPRINT trial. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.

To appreciate the importance of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial,1 one needs to remember that the systolic blood pressure (BP) target currently recommended by major guidelines for diabetic patients, that is, 130 mm Hg, except in the Appropriate Blood Pressure Control in Diabetes Study (ABCD) normotensive trial,7 which consisted of only a few hundred patients and had changes in creatinine clearance as the primary end point. Thus, ACCORD represents the only large-scale randomized trial that provides information on what happens to the cardiovascular risk of diabetic patients when SBP is reduced to 130 mm Hg as a result of randomization to the usual (rather than the tight) BP control treatment strategy. Thus, the message from ACCORD to guidelines and clinical practice is that in diabetic patients it is not necessary to adopt …

Aim: To verify if intensive antihypertensive treatment (systolic blood pressure <130mmHg) has beneficial effects on cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus and hypertension, compared with standard antihypertensive treatment (systolic blood pressure <140mmHg). Data sources: National Guideline Clearinghouse, NHS Evidence, CMA InfoBase, Cochrane, DARE, MEDLINE/PubMed. Review methods: Meta-analyses (MA), systematic reviews, randomized controlled trials (RCT) and guidelines in English and Portuguese, published between 2006 and 2016 were searched, using the MeSH terms ‘antihypertensive agents’, ‘diabetes mellitus’, and ‘blood pressure’. The Strength of Recommendation Taxonomy (SORT) scale from the American Family Physician was used to evaluate the levels of evidence (LE) and the strength of recommendation (SR). Results: A total of 662 articles were obtained, amongst which 12 fulfilled the inclusion criteria: three MA, one RCT and eight guidelines. MA showed that intensive blood pressure (BP) control reduces the risk of stroke, microalbuminuria and nephropa-thy in diabetic patients (LE 2). However, intensive BP control was associated with an increased risk of adverse effects in these patients, and seems to increase cardiovascular mortality (LE 2). The RCT has only shown a reduction on the risk of development of microalbuminuria (LE 2). Finally, most guidelines do not recommend intensive BP control in diabetic patients and advise that the BP control should be more intensive only in young diabetic patients, in those with target organ damage, or those with more than one risk factor for atherosclerotic cardiovascular disease. Conclusions: According to the evidence available, intensive BP control in patients with type 2 diabetes should not be recommended, except in young diabetic patients and in certain risk groups (SR B). Nevertheless, this study reinforces the importance of BP control in these patients, and highlights the key role of the family physician in the individualized assessment of the risks and benefits of intensive BP treatment.