Does our understanding of blood pressure targets in diabetics need rethinking?

For many years the main strategy in the treatment of arterial hypertension has been based on blood pressure targets. Those targets are the levels of blood pressure considered as the goals to be achieved with therapy because they are thought to represent the values below which the greatest clinical benefit of antihypertensive treatment is obtained. During recent years the traditional target of less than 140/90 mmHg was modified by ‘the lower, the better’ strategy, based on recommendations from many clinical guidelines suggesting that blood pressure should be decreased as much as tolerated. The intensified treatment approach was especially recommended for people with diabetes, in whom a stricter target of less than 130/80 mmHg was usually defined based on the idea that the combination of both conditions will possibly hasten the development and progression of complications [1]. However, all of these targets were based on observational or indirect data, and supported by scant evidence from prospective randomized trials [2]. Besides some concerns regarding the possibility of a J-curve phenomenon [3], ‘the lower, the better’ strategy was formally questioned in a Cochrane meta-analysis of randomized trials that showed no clinical benefits in mortality or cardiovascular morbidity when a lower blood pressure target was compared with the traditional target in the general population of individuals with hypertension [4]. Similar results have been obtained when the comparison was restricted to individuals with diabetes, with the only exceptions of a significant but quantitatively small reduction in strokes and a significant increase in other serious adverse events a ssociated with a lower systolic target [4–7]. Although not designed to test outcomes associated with different blood pressure targets, the results of some randomized trials including people with diabetes or “It can be argued that conventional blood pressure measurement has a poorer prognostic significance compared with other strategies that provide information on blood pressure variability during a certain period of time.”