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Blood pressure, diabetes, and the usefulness of segmentation

The Canadian Journal of Diabetes just released a review of blood pressure targets for people with type 2 diabetes.  About 70% of people with type 2 diabetes have high blood pressure, and clinical studies tell us that blood pressure has two to three times the impact of A1C on diabetes-related complications. So where should the blood pressure target be? Blood pressure guidelines have been undulating recently, based on both clinical trial results, and the interpretation of these clinical trial results. Two recent large clinical studies (both non-pharmaceutical industry vased) suggested different goals. The ACCORD study found no benefits for a systolic blood pressure goal below 120 mm Hg, compared to a goal of below 140 mm Hg. However, the SPRINT study, more recent and even larger, showed clear benefit to a blood pressure goal of below 120 mm Hg. I think that part of our confusion results from a lack of segmentation of the population of people with high blood pressure. The ACCORD study recruited only people with type 2 diabetes who had evidence of cardiovascular disease. The average age was over 60 years, and the average duration of diabetes was about 10 years. The SPRINT study group was similar in age, had a generally lower risk of cardiovascular disease, and notably, excluded people with diabetes. This study showed clear benefit for a systolic blood pressure target under 120 mm Hg. Although these studies seemingly have different findings, a recent analysis of an ACCORD subgroup receiving standard glucose therapy and meeting the SPRINT inclusion criteria showed that these ACCORD participants, all of course having diabetes, had clear benefit from a blood pressure target below 120 mm Hg. So, where does that leave us? I refer you to the article for a fuller discussion, but they convincingly support the Canadian Diabetes Association blood pressure goal of less than 130/80 mm Hg as a general target. For those with diabetes of longer duration with more evidence of cardiovascular disease, a systolic goal of under 140 might be more appropriate. Segmentation should also include what current level of blood pressure treatment a person is receiving. It probably brings more benefit to add a blood pressure medication when someone is on no or one blood pressure lowering medication than it does to those who are on two or more medications. This is certainly a good discussion for a people with diabetes and their doctors, and a chance to personalize the approach.

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