Effects of Intensive Systolic Blood Pressure Lowering on Cardiovascular Events and Mortality in Patients With Type 2 Diabetes Mellitus on Standard Glycemic Control and in Those Without Diabetes Mellitus: Reconciling Results From ACCORD BP and SPRINT

Abstract

BackgroundIntensive systolic blood pressure (SBP) lowering significantly reduced cardiovascular disease (CVD) events in SPRINT (Systolic Blood Pressure Intervention Trial) but not in ACCORD BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure).Methods and Results SPRINT tested the effects of intensive (<120 mm Hg) versus standard (<140 mm Hg) SBP goals on CVD events and all‐cause mortality. Using 2×2 factorial design, ACCORD BP tested the same SBP intervention in addition to an intensive versus standard glycemia intervention. We compared the effects of intensive SBP lowering on the composite CVD end point and all‐cause mortality in SPRINT with its effects within each of the glycemia arms in ACCORD BP. Intensive SBP lowering decreased the hazard of the composite CVD end point similarly in SPRINT (hazard ratio: 0.75; 95% confidence interval, 0.64–0.89) and in the ACCORD BP standard glycemia arm (hazard ratio: 0.77; 95% confidence interval, 0.63–0.95; interaction P=0.87). However, the effect of intensive SBP lowering on the composite CVD end point in the ACCORD BP intensive glycemia arm (hazard ratio: 1.04; 95% confidence interval, 0.83–1.29) was significantly different from SPRINT (interaction P=0.023). Patterns were similar for all‐cause mortality.ConclusionsThe effects of intensive SBP control on CVD events and all‐cause mortality were similar in patients without diabetes mellitus and in those with diabetes mellitus on standard glycemic control. An interaction between intensive SBP lowering and intensive glycemic control may have masked beneficial effects of intensive SBP lowering in ACCORD BP.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01206062, NCT00000620.

Sodium–Glucose Cotransporter 2 Inhibitors: A Case Study in Translational Research

“…It is instructive to compare these data with the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD-BP) clinical trial and Systolic Blood Pressure Intervention Trial (SPRINT) ( 55 ). In the SPRINT study of patients without diabetes, intensive blood pressure control was associated with a hazard ratio of 0.75 (95% CI 0.64–0.89) for MACE.…”

KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline

“…This hypothesis is supported by a recent reanalysis of ACCORD BP and SPRINT data. 113 Intensive SBP lowering decreased the hazard of the composite CVD end point similarly in SPRINT (HR, 0.75; 95% CI, 0.64-0.89) and the ACCORD BP standard glycemia arm (HR, 0.77; 95% CI, 0.63-0.95; interaction P = 0.87). However, the effect of intensive SBP lowering on the composite CVD end point in the ACCORD BP intensive glycemia arm (HR, 1.04; 95% CI, 0.83-1.29) was significantly different from SPRINT (interaction P=0.02).…”

“…Risk of serious adverse events attributed to intensive SBP lowering was significantly higher in the intensive as compared to standard BP lowering in the ACCORD BP trial, a finding similar to SPRINT. Given these findings of the interactions between the intensive glycemia and intensive SBP-lowering interventions in the ACCORD BP trial, 113 intensive SBP lowering should not be combined with intensive glucose lowering (hemoglobin A 1c target < 7%).…”

Barriers and Enablers of Older Patients to Deprescribing of Cardiometabolic Medication: A Focus Group Study

“…Intensive glucose and blood pressure lowering treatment can prevent long-term complications in people with diabetes and/or hypertension but it may come with an increased risk of harm ( The Diabetes Control and Complications Trial Research Group, 1993 ; Gerstein et al, 2008 ; Wright et al, 2015 ). Whether in older patients intensive glycemic and blood pressure control is more beneficial than harmful has been a matter of debate ( Bejan-Angoulvant et al, 2010 ; Cushman et al, 2010 ; Gerstein et al, 2011 ; Sue Kirkman et al, 2012 ; Vijan et al, 2014 ; Beddhu et al, 2018 ; Williamson et al, 2019 ). While some investigators argued that intensive treatment should be maintained in older patients because of shown benefits in clinical trials, others reasoned that the limitations of these trials resulted in overestimating benefits and underestimating harms, particularly for older patients ( Scott et al, 2019 ; Supiano and Williamson, 2019 ).…”