Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients With Diabetes and Coronary Artery Disease

Abstract

Context Hypertension guidelines advocate treating systolic blood pressure (BP) to less than 130 mm Hg for patients with diabetes mellitus; however, data are lacking for the growing population who also have coronary artery disease (CAD). Objective To determine the association of systolic BP control achieved and adverse cardiovascular outcomes in a cohort of patients with diabetes and CAD. Design, Setting, and Patients Observational subgroup analysis of 6400 of the 22 576 participants in the International Verapamil SR-Trandolapril Study (INVEST). For this analysis, participants were at least 50 years old and had diabetes and CAD. Participants were recruited between September 1997 and December 2000 from 862 sites in 14 countries and were followed up through March 2003 with an extended follow-up through August 2008 through the National Death Index for US participants. Intervention Patients received first-line treatment of either a calcium antagonist or β-blocker followed by angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve systolic BP of less than 130 and diastolic BP of less than 85 mm Hg. Patients were categorized as having tight control if they could maintain their systolic BP at less than 130 mm Hg; usual control if it ranged from 130 mm Hg to less than 140 mm Hg; and uncontrolled if it was 140 mm Hg or higher. Main Outcome Measures Adverse cardiovascular outcomes, including the primary outcomes which was the first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. Results During 16 893 patient-years of follow-up, 286 patients (12.7%) who maintained tight control, 249 (12.6%) who had usual control, and 431 (19.8%) who had uncontrolled systolic BP experienced a primary outcome event. Patients in the usual-control group had a cardiovascular event rate of 12.6% vs a 19.8% event rate for those in the uncontrolled group (adjusted hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25–1.71; P<.001). However, little difference existed between those with usual control and those with tight control. Their respective event rates were 12.6% vs 12.7% (adjusted HR, 1.11; 95% CI, 0.93–1.32; P=.24). The all-cause mortality rate was 11.0% in the tight-control group vs 10.2% in the usual-control group (adjusted HR, 1.20; 95% CI, 0.99–1.45; P=.06); however, when extended follow-up was included, risk of all-cause mortality was 22.8% in the tight control vs 21.8% in the usual control group (adjusted HR, 1.15; 95% CI, 1.01–1.32; P=.04). Conclusion Tight control of systolic BP among patients with diabetes and CAD was not associated with improved cardiovascular outcomes compared with usual control.

Standards of care for type 2 diabetes in China

“…There is sufficient clinical evidence that in patients with T2DM who have had cardiovascular diseases, lowering blood pressure, lowering lipids, or the proper use of aspirin therapy alone or in combination can reduce the risk of cardiovascular disease recurrence and death 35, 39, 40, 41, 42, 43. In patients with diabetic nephropathy, the use of blood pressure‐lowering agents, particularly the use of angiotensin‐converting enzyme inhibitor or angiotensin II receptor antagonist drugs, significantly reduced the risk of diabetic nephropathy progression 43.…”

Diabetes in older people: position statement of The Hong Kong Geriatrics Society and the Hong Kong Society of Endocrinology, Metabolism and Reproduction

“…[42][43][44] There is no further benefit to lowering SBP to <130 mm Hg however, as compared to SBP of 130-140 mm Hg, but may increase mortality. 45,46 Furthermore, a low diastolic blood pressure of <70 mm Hg that may result from SBP reduction is associated with higher cardiovascular disease risk. 42 Thus, the recommended target blood pressure for older diabetic patients is <140/90 mm Hg, if tolerated.…”

Therapeutic Modalities in Diabetic Nephropathy: Standard and Emerging Approaches

“…The recent ACCORD trial failed to show a reduction in cardiovascular events but increased rates of hyperkalemia and renal dysfunction when targeting a SBP<120 mmHg as compared with <140 mmHg. 53 A subgroup analysis of 6400 patients with diabetes in the INVEST study 54 and a crosssectional analysis of patients in the Swedish National Diabetes Registry 55 also failed to show a reduction in mortality in patients with SBP<130 vs. 130-139 mmHg. These recent observations do not support BP goals of <130/80 and even bring into question the need to reduce SBP below 140 mmHg.…”