Diabetes
Elizabeth Briand
High BP affects anywhere between 50% and 80% of individuals with T2D, according to NIH. For people coping with both of these conditions, the risk of cardiovascular events increases by sixfold compared to healthy individuals. However, for patients with T2D, elevated systolic BP is among the most modifiable risk factors for cardiovascular disease.
A recent study published in the November 2024 issue of NEJM sought to clarify the most beneficial target for systolic BP reduction. Specifically, the study assessed whether intensive treatment targeting a systolic BP of less than 120 mm Hg would be more effective than standard treatment which aims for a systolic BP of less than 140 mm Hg, all with a goal of reducing the risk of major cardiovascular events.
An expansive study
Nearly 13,000 patients 50 years and older with T2D, elevated systolic BP, and an increased risk of cardiovascular disease were enrolled at clinical sites across China. Half of the group received intensive treatment targeting systolic BP of less than 120 mm Hg while the other received standard treatment targeting systolic BP of less than 140 mm Hg. Over the course of 5 years, researchers examined composite data on nonfatal stroke, nonfatal myocardial infarction, treatment or hospitalization for heart failure and death from cardiovascular causes among the patients.
The intensive treatment target of less than 120 mm Hg for the systolic level was based on a previous study that showed that the lower target number “significantly reduced cardiovascular disease compared to a target of less than 140 mm Hg in patients without type 2 diabetes,” said Jiang He, professor and S. Roger and Carolyn P. Horchow chair in cardiac research at the University of Texas Southwestern Medical Center and one of the study’s authors.
“After patients entered the trial, their antihypertensive regimens were adjusted based on their blood pressure levels and assigned treatment group in order to achieve blood pressure targets,” said He. On average, patients in the intensive group received more than two antihypertensive medications and patients in the standard group received fewer than two medications.
The results showed that after a median follow up of a little over 4 years, the intensive treatment and lower targeted systolic BP were associated with a 21% reduction in major cardiovascular disease compared to the standard treatment. Specifically, the aggressive pursuit of the lower BP target helped reduce the risk of stroke, myocardial infarction, heart failure, and cardiovascular deaths, compared to the higher, standard level of 140 mm Hg.
The study notes that when pursuing intensive BP targets, patients need to be monitored for hypotension, especially at the start of BP reduction efforts. Hyperkalemia after the use of multiple antihypertensive drugs also should be watched out for during treatment.
Given the benefits in the reduction of cardiovascular events as well as stroke, which is the most common type of cardiovascular disease in China, this lower BP target may provide an invaluable roadmap for clinicians down the road. “This evidence will help develop clinical hypertension guidelines to lower the blood pressure target in patients with type 2 diabetes,” said He, adding that “hypertension clinical guidelines should be updated to recommend more intensive blood pressure control.”
Pharmacists can and should be part of the ongoing effort to reduce the risks posed by higher BP. “Many studies have shown that pharmacists can play an important role in hypertension management,” said He. “Pharmacists titrating antihypertensive medications can be even more effective than primary care physicians. Our study results can be applied to pharmacists in hypertension management and help adopt intensive blood pressure control strategies in patients with hypertension and diabetes.” ■