Blood pressure targets for hypertension in patients with type 2 diabetes

Background: Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus. Methods: We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120–140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50–0.92], fatal (RR =0.41; 95% CI, 0.20–0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43–0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80–90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality. Conclusions: We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120–130/80 mmHg, with close monitoring for all drug-related harms.