“Less than 140 mm Hg is the message we need to put out, and less than 130 mm Hg is probably not necessary to achieve benefit and may be harmful in certain populations,” said Rhonda M. Cooper-DeHoff, Pharm.D., associate director of the cardiovascular clinical research program at the University of Florida, Gainesville.
Dr. DeHoff presented results from a second study that also called into question a systolic blood pressure goal of less than 130 mm Hg for patients with diabetes. Her study used long-term follow-up data from the 6,400 patients with diabetes who had participated in the International Verapamil SR-Trandolapril (INVEST) study, with an overall enrollment of more than 22,000 patients that compared two different antihypertensive regimens (JAMA 2003;290:2805-16).
Using data collected during the trial plus 5 years of follow-up, Dr. DeHoff and her associates showed that the 2,255 patients with diabetes maintained at a systolic blood pressure below 130 mm Hg had cardiovascular disease event rates similar to the 1,970 patients with diabetes maintained at a systolic blood pressure of 130-139 mm Hg; patients in both groups did significantly better than did a third group of 2,175 patients with diabetes whose systolic pressure consistently remained at 140 mm Hg or higher. Among the 5,077 U.S. patients with diabetes in INVEST, those kept at a systolic pressure of less than 130 mm Hg had a significant 15% increase in the rate of all-cause death, compared with the patients kept at a systolic pressure of 130-139 mm Hg.
“Based on the results from ACCORD and INVEST, is it time to rethink lower blood pressure goals in patients with diabetes and coronary artery disease?” Dr. DeHoff asked as she concluded her report at the meeting.
To apply the ACCORD results in practice, Dr. Cushman advises physicians to prescribe for patients with diabetes a “maximum” dosage of a renin-angiotensin-aldosterone system (RAAS) blocker drug, such as an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, plus a diuretic such as chlorthalidone. He also urges physicians to prescribe other drugs with antihypertensive effects, such as certain beta-blockers or calcium channel blockers, that patients with diabetes and a high risk for cardiovascular disease events might need for specific risk indications.
If a patient's systolic pressure remains above 140 mm Hg despite these treatments, then another agent should be added; if the indicated drugs bring the patient's systolic pressure below 140 mm Hg, then additional treatments should stop. However, if the indicated drugs bring the patient's pressure moderately below 130 mm Hg, “I wouldn't back off,” and withdraw drugs that the patient might otherwise need, he said.
In this way, practice should not fully mimic the ACCORD trial design. In that trial, patients in the standard-therapy arm came off one or more of their medications if their systolic pressure fell below 130 mm Hg, noted Dr. Cushman, who also is professor of medicine at the University of Tennessee in Memphis.
Intensive blood pressure control did not reduce the rate of major cardiovascular disease events in patients with diabetes, Dr. William C. Cushman reported.
Source Courtesy Memphis VAMC
If the indicated drugs bring a patient's pressure moderately below 130 mm Hg, 'I wouldn't back off.'
Source Dr. Cushman
This Month's Talk Back Question
How low do you try to get blood pressure in your patients with diabetes?
My Take
Study Findings Diverge From Observational Data
We would have predicted that the lower a patient's blood pressure the better the outcome, and we have therefore sought to get blood pressures lower.
Normal blood pressure is less than 120/80 mm Hg, but we had no data on treating patients to blood pressures that low. Nature says that high blood pressure is not good, and we try to simulate nature by using treatments that lower blood pressure by lifestyle and drugs. There is no question that lower blood pressure benefits patients, but where is the floor? Is a pressure of 140 mm Hg good enough?
For patients with diabetes, chronic kidney disease, or dyslipidemia the guidelines set a lower target pressure. But in this large trial we did not see a difference from bringing the pressure lower. We need to look at the results further to try to explain them.
ELIJAH SAUNDERS, M.D., is professor of medicine and head of the division of hypertension at the University of Maryland in Baltimore. He has been a consultant to, served on the speakers bureau for, and has received research support from Bristol-Myers Squibb, Forest, Novartis, Pfizer, and Sanofi-Aventis.