What question did this study set out to answer?

To evaluate the effects of intensive blood pressure lowering on all-cause mortality, cardiovascular outcomes, and renal outcomes in individuals with type 2 diabetes mellitus.

April 12, 2019PLoS ONEOpen Access

Effects of intensive blood pressure lowering on mortality and cardiovascular and renal outcomes in type 2 diabetic patients: A meta-analysis

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Why the study?

Whether intensive blood pressure lowering treatment is associated with mortality reductions and vascular protection in patients with type 2 diabetes mellitus remained unknown.

Does intensive blood pressure lowering reduce mortality and cardiovascular events in patients with type 2 diabetes mellitus?

Key Points

To evaluate the effects of intensive blood pressure lowering on all-cause mortality, cardiovascular outcomes, and renal outcomes in individuals with type 2 diabetes mellitus.
Systematically searched PubMed, EMBASE, Science Citation Index, and Cochrane Library databases for randomized controlled trials meeting specific eligibility criteria.
Identified and analyzed 16 randomized controlled trials comparing intensive blood pressure lowering treatment against less intensive treatment regimens.
Extracted outcome data and calculated pooled effect estimates using a random-effects model.
Intensive blood pressure lowering significantly decreased all-cause mortality (RR 0.82; 95% CI, 0.70–0.96), major cardiovascular events (RR 0.82; 95% CI, 0.73–0.92), myocardial infarction (RR 0.86; 95% CI, 0.77–0.96), stroke (RR 0.72; 95% CI, 0.60–0.88), cardiovascular death (RR 0.73; 95% CI, 0.58–0.92), and albuminuria progression (RR 0.91; 95% CI, 0.84–0.98).
No clear effects were observed for non-cardiovascular death (RR 0.97; 95% CI, 0.79–1.20), heart failure (RR 0.88; 95% CI, 0.71–1.08), or end-stage kidney disease (RR 1.00; 95% CI, 0.75–1.33).
All-cause mortality reduction was pronounced in patients with baseline cardiovascular risk ≥10% (RR 0.77; 95% CI, 0.64–0.91) but not in those with risk <10% (RR 1.04; 95% CI, 0.84–1.29; P_heterogeneity = 0.028).

Structured PICO

Does intensive blood pressure lowering reduce mortality and cardiovascular events in patients with type 2 diabetes mellitus?

Population

Patients with type 2 diabetes mellitus (16 RCTs)

Intervention

Intensive blood pressure lowering treatment

Comparator

Less intensive blood pressure lowering treatment

Outcome

All-cause mortalityhard clinical

Intensive blood pressure lowering in patients with type 2 diabetes mellitus significantly reduces all-cause mortality and major cardiovascular events, particularly in those with higher baseline cardiovascular risk.

Implication

Supports intensive BP lowering in T2DM; reinforces RCT meta-evidence for mortality and CV event reduction.

Abstract

BACKGROUND: Previous studies have demonstrated that intensive blood pressure (BP) lowering treatment reduces the risk of all-cause mortality and provides greater vascular protection for patients with hypertension. Whether intensive BP lowering treatment is associated with such benefits in patients with type 2 diabetes mellitus remain unknown. We aimed to clarify these benefits by method of meta-analysis. METHODS: The PubMed, EMBASE, Science Citation Index and Cochrane Library databases were searched to identify randomized controlled trials (RCT) that fulfilled study inclusion criteria. Two investigators independently extracted and summarized the relevant data of the included trials. Random-effects model was applied to calculate the estimates of all effect measures. RESULTS: We included 16 RCTs and our meta-analysis showed that intensive BP lowering treatment vs less intensive BP lowering treatment resulted in significant reductions in the all-cause mortality risk [relative risk (RR), 0.82; 95% CI, 0.70-0.96], major CV events (RR, 0.82; 95% CI, 0.73-0.92, MI (RR, 0.86; 95% CI, 0.77-0.96), stroke (RR, 0.72; 95% CI, 0.60-0.88, CV death (RR, 0.73; 95% CI, 0.58-0.92) and albuminuria progression (RR, 0.91 95% CI, 0.84-0.98). However, intensive BP lowering treatment had no clear effect on non-CV death (RR, 0.97; 95% CI, 0.79-1.20), heart failure (HF) (RR, 0.88; 95% CI, 0.71-1.08) or end-stage kidney disease (ESKD) (RR, 1.00; 95% CI, 0.75-1.33). Subgroup analysis showed that the reduction in all cause-mortality was consistent across most patient groups, and intensive BP lowering treatment had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg. However, the benefit differed in patients with different CV risk (≥10%: RR, 0.77, 95%CI, 0.64-0.91; <10%: RR, 1.04, 95%CI, 0.84-1.29; Phetero = 0.028). CONCLUSIONS: Our data indicate that intensive BP lowering treatment provides greater benefits than less intensive treatment among patients with type 2 diabetes mellitus. Further studies are required to more clearly evaluate the benefits and harms of BP targets below those currently recommended with intensive BP lowering treatment.