Establishing target systolic and diastolic blood pressure in diabetic patients with hypertension: what do we need to consider?

ABSTRACT

Introduction

The optimum target for systolic and diastolic blood pressure remains divisive. In particular, the conflicting outcomes of the SPRINT and ACCORD trials have led to a divergence of guideline-recommended blood pressure targets for adults with diabetes.

Areas covered

Here, we review the existing recommendations for blood pressure targets in diabetes, discussing the evidence base behind them and their limitations. We start by outlining the risks and benefits of lower systolic blood pressure targets among diabetics. We then follow with a separate appraisal of diastolic blood pressure targets, which necessitates examination of the ‘J curve’ and isolated diastolic hypertension.

Expert opinion

Current and emerging evidence supports, on balance, a blood pressure therapeutic target of < 130/90 mmHg in adults at increased risk for cardiovascular disease, including diabetics. Whether certain diabetics with systolic BPs of 120–130 and/or diastolic BPs 80–90 mmHg require drug treatment to a target of <120/80 mmHg is less clear and requires more research.

KEYWORDS:

• Hypertension
• Type 2 diabetes
• systolic blood pressure
• diastolic blood pressure
• guidelines
• adults
• cardiovascular risk

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Article highlights

• Recommended blood pressure targets in patients with diabetes differ internationally.

• Recent guideline trends in targeting Systolic Blood Pressure to <130 mmHg, precipitated by the SPRINT trial, are now also supported in the diabetes population with the STEP trial and other RCT metanalyses.

• The evidence for a Systolic Blood Pressure target of <120 mmHg is less strong and requires further trials, particularly in diabetes.

• Evidence for lowering of Diastolic Blood Pressure Targets is much sparser and no randomized data from adults with diabetes have shown that a diastolic BP target of <80 is more efficacious in reducing CVD than a target of <90 mmHg.

• We believe that targeting blood pressure in diabetes patients to <130/90 mmHg, lowers cardiovascular disease risk as established in trials while avoiding overtreating patients with isolated diastolic hypertension, which has not been associated with a significantly increased of cardiovascular disease.