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01-20-2017 | Hypertension | Review | Article

Blood pressure reduction in diabetes: lessons from ACCORD, SPRINT and EMPA-REG OUTCOME

Authors:
Pantelis Sarafidis, Antonios Lazaridis, Gema Ruiz-Hurtado, Luis Ruilope

Abstract

In patients with diabetes mellitus, the presence of hypertension substantially increases the risk of cardiovascular events, and reductions in blood pressure (BP) can reduce cardiovascular morbidity and mortality. Following evidence from trials randomizing patients to diastolic BP levels, previous guidelines recommended an office BP target of <130/80 mmHg in individuals with diabetes mellitus. However, the evidence for this systolic BP (SBP) target was derived from observational studies. When the results of the ACCORD-BP study showed that those individuals with diabetes mellitus and a target BP of <120 mmHg had a cardiovascular risk that is similar to those with <140 mmHg, all guidelines returned to a recommended SBP of <140 mmHg. However, the ACCORD-BP trial was limited by the low number of cardiovascular events observed, whereas the mean SBP in the 'conventional' arm was 133 mmHg. The SPRINT study, showing cardiovascular benefits in hypertensive patients without diabetes mellitus randomized to SBP <120 mmHg versus those randomized to <140 mmHg, came in contrast with the ACCORD-BP, but a detailed evaluation reveals many similarities between the two trials. Finally, the EMPA-REG OUTCOME study, with impressive cardiovascular mortality reduction with empagliflozin, suggested that reduction of SBP to around 130 mmHg is safe and might explain part of these beneficial results. In this Review, we evaluate the implications of the ACCORD-BP, SPRINT and EMPA-REG OUTCOME trials and previous studies for the optimal BP target in diabetes mellitus.

Diabetes mellitus is a major issue of public health and a leading cause of morbidity and mortality. The prevalence of diabetes mellitus in the general adult population is estimated at ~8%, a number that is predicted to double by 2030. Type 2 diabetes mellitus (T2DM) accounts for >90% of these patients1. Diabetes mellitus is a major cardiovascular risk factor, and patients have a risk of death that is twice as high as the risk in those without the disease and equal to those who have had a previous myocardial infarction2, 3. The increased incidence of macrovascular and microvascular complications in diabetes mellitus leads to a huge economic burden for health systems worldwide4. Hypertension is also a leading cause of death, affecting nearly 30% of the adult population in Western countries, and is responsible for 49% of cases of ischaemic cardiac disease, 69% of cerebrovascular disease and 7.1 million deaths per year worldwide5, 6, 7. As the control of hypertension is very poor in most countries, the effective management of high blood pressure (BP) is a major target of public health strategies.

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