What is the optimal target blood pressure

JNC VII [19] recommends the target BP to be less than 130/85 mm Hg in diabetics who have hypertension. The ADA [22] and the CMA [23] have pushed the target even lower, with a goal for diastolic BP of less than 80 mm Hg. What is the evidence for these recommendations? Three, randomized, actively-controlled trials provided some direct evidence regarding the need for aggressive BP control (see Table 4) [3,52,75].

The intensive BP control in UKPDS 38 [3] trial was achieved at a target of 144/82 mm Hg. Compared with conventional control (BP 154/87 mm Hg), there was a 32%, 44%, and 37% reduction of diabetes-related death, stroke, and microvascular complications, respectively. For a 10 mm Hg greater reduction in systolic BP, there was a significantly greater reduction in the risk of CV end points, including MI and heart failure.

In the ABCD trial [75], 470 patients who had type 2 diabetes with a baseline BP of approximately 155/98 mm Hg were assigned randomly to intensive BP control (achieved 132/78 mm Hg) or less tight control (achieved 138/86 mm Hg). There was a 49% reduction in the intensive BP control group in all-cause mortality; however, this benefit was not due to differences in MI, cerebrovascular events, or congestive heart failure. The J-curve phenomenon was not reported in the ABCD trial; however, it is difficult to rely on this information because of the small sample size. No adverse consequence was due to tight control in the ABCD or the UKPDS; this should allay any fear of the J-curve phenomenon in diabetic, hypertensive patients.

The HOT study [52] was the largest, randomized, actively-controlled trial and 8% of participants were diabetics. BP was reduced from 170/ 105 mm Hg to 140/81 mm Hg in the group whose BP was controlled most intensively and was followed for most than 3.8 years. There were trends of benefit in all outcome categories (see Table 4). In a subgroup analysis of diabetic patients, the most significant differences were reduction of major CV events and CV mortality in target group who had diastolic BP < 80 mm Hg. The main reason for the reported benefit in the HOT study is related to the benefits that were observed in the diabetes subgroup; however, the true achieved BP in diabetic patients was not reported in the study. Thus, the results of these three recent RCTs clearly emphasize the importance of aggressive BP control in diabetic, hypertensive patients. Based on the data that are available from these studies, it seems prudent to recommend the target goal for BP to be less than 130/80 mm Hg.

What should be the target blood pressure in diabetic patients who have renal failure?

JNC VII guidelines recommend that BP should be decreased to 125/75 mm Hg in patients who have proteinuria in excess of 1 g/d, primarily based on the RCT, Modification of Diet in Renal Disease Study [76,77]. Diabetic patients who required insulin were excluded from this study and diabetics accounted for only 3% of study subjects. Nevertheless, because renal dysfunction is related clearly to the BP values, it seems reasonable to recommend the target BP of 125/ 75 mm Hg in diabetic patients who have renal insufficiency.

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