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

Nature Reviews Endocrinology volume 13, pages 365–374 (2017)Cite this article

Subjects

Key Points

  • In the 2000s, international guidelines suggested a goal blood pressure (BP) of <130/80 mmHg in patients with diabetes mellitus, based mostly on observational data and trials randomizing to diastolic BP targets

  • The results of the ACCORD-BP trial suggested no benefit in reducing cardiovascular events in patients with type 2 diabetes mellitus (T2DM) randomly assigned to a systolic BP (SBP) of <120 mmHg compared with <140 mmHg, with the exception of stroke, but this trial might be limited by low statistical power

  • New guidelines have moved the target BP for patients with diabetes mellitus to a less strict target of <140/85 mmHg or <140/90 mmHg. In the SPRINT trial of patients with hypertension, lower cardiovascular events and mortality were seen in patients randomized to SBP <120 mmHg compared with <140 mmHg, which questioned appropriate BP targets

  • The EMPA-REG OUTCOME trial showed major reductions in cardiovascular events and mortality in patients with T2DM who were treated with empagliflozin; concomitant SBP reduction from 135.3 mmHg to 131.3 mmHg might also question current guidelines

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.

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Authors and Affiliations

  1. Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital,

    Pantelis A. Sarafidis

  2. 2nd Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration Hospital, Konstantinoupoleos 49, Thessaloniki, 54642, Greece

    Antonios A. Lazaridis

  3. Department of Internal Medicine, Papageorgiou Hospital, Thessaloniki, 56429, Greece

    Antonios A. Lazaridis

  4. Institute of Investigation and Hypertension Unit, Hospital 12 de Octubre, Avenida de Córdoba s/n, Madrid, 28041, Spain

    Gema Ruiz-Hurtado & Luis M. Ruilope

  5. Department of Preventive Medicine and Public Health, Universidad Autonoma, Ciudad Universitaria de Cantoblanco, Madrid, 28049, Spain

    Luis M. Ruilope

  6. School of Doctoral Studies and Research, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, 28670, Spain

    Luis M. Ruilope

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P.A.S. has received honoraria as an advisor for Boehringer Ingelheim and AstraZeneca and research grants from AstraZeneca. A.A.L., G.R.-H. and L.M.R. declare no competing interests.

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Sarafidis, P., Lazaridis, A., Ruiz-Hurtado, G. et al. Blood pressure reduction in diabetes: lessons from ACCORD, SPRINT and EMPA-REG OUTCOME. Nat Rev Endocrinol 13, 365–374 (2017). https://doi.org/10.1038/nrendo.2016.209

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