Blood Pressure Targets in Diabetes: Is This the Time for Change?

Following the publication of the Action to Control Cardiovascular Risk in Diabetes (ACCORD)1 blood pressure (BP) trial results in early 2010, many were contemplating whether the longstanding recommendations for BP targets in diabetes were in need of modification. Prior to the ACCORD trial, there was a general consensus that BP targets in diabetes should be lower (140 mm Hg. Such an approach would also have to encourage regular use of combination therapy, because, in general, two drugs were required to achieve “standard” targets in the ACCORD trial. Second, we must consider whether comparable rates of major CVD events alone provide sufficient evidence for a change in BP treatment targets. As noted, the risk of nonfatal and total stroke was significantly lower with the more intensive treatment strategy. In addition, this strategy was associated with reductions in markers of progressive renal disease. If this is the case, is the current target not more acceptable? In a recent review,10 Mancia summarizes this point, stating that if: maximal protection is achieved at BP values lower for the brain (and kidney) than for the heart, then an important question is what BP-lowering strategy should be recommended in clinical practice. One might argue that if an aggressive BP reduction leads to cerebrovascular protection without substantially increasing the risk of coronary events (as suggested by the ACCORD trial), this strategy deserves to be adopted. Third, consider whether the adverse effects of more intensive therapy were substantial enough to support a significant change in BP targets. As noted in the original report,1 serious adverse events were twice as common with more intensive BP control (although this occurred in an effort to achieve SBP 140 mm Hg.11 Now is not the time for change. The burden of diabetes—and its complications—continues to grow. Optimized care of diabetes warrants careful consideration of all treatment targets. While the evidence base may provide more exacting targets over time, targets must also be considered for what they are: a reflection of optimal care, not a simple acceptable standard. More intensive lowering of BP in diabetes results in a significant reduction in stroke risk1 and limits the progression of renal disease in patients with significant chronic kidney disease. To take into full account the broad evidence base supporting these benefits, including the ACCORD trial results, supports maintaining current BP targets as established. Disclosures: The views presented in this manuscript do not necessarily reflect those of the American Diabetes Association. Dr Kendall served as an investigator for the ACCORD trial from 1999 to 2005 and again from 2008 to 2009. Dr Kendall receives no honoraria, research support, or other payments from outside interests. His spouse is currently employed by Genentech, Inc.